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In the last chapter, we explored the origins of emotion regulation skills deficits and discussed the empirical and theoretical support for the ways in which these deficits contribute to the development of mental disorders. Therefore, it can be hypothesized that enhancing emotion regulation skills should be an important target in the treatment of mental health problems. In this chapter, we will provide an overview of the current state of psychological orientations and treatments that in various ways target emotion regulation skills.

Virtually all forms of psychotherapy implicitly or explicitly strive to improve affect regulation skills. In some therapies, such as person-centered or psychodynamic psychotherapy, affect regulation skills are not explicitly targeted but can be assumed to be enhanced through general techniques used in the process of therapy. For example, unconditional positive regard for the patient is a classic technique of person-centered therapy, while psychodynamic therapists help patients gain insight into unresolved family-of-origin issues. Through these two techniques, patients may learn to accept undesired emotions as they follow the therapist’s example or find an explanation for their affective responses.

In other treatments, such as cognitive behavior therapy (CBT), therapists explicitly work to enhance emotion regulation skills. Consistently, such skills have been shown to improve during CBT (Berking et al., 2008). In CBT, a therapist mostly focuses on a patient’s thoughts and behaviors in order to modify the affective state that is related to the patient’s symptoms. This focus of CBT, in its traditional form, may limit the inclusion of other potentially effective techniques (e.g., the empty chair technique). Also, while CBT encourages patients to apply cognitive behavioral skills to other distressing emotions, the focus of treatment is primarily on the patient’s presenting problem and not on enhancing the patient’s general emotion regulation capabilities.

With increasing evidence that emotion regulation skills are important for mental health, several “third wave” (Hayes, 2004) cognitive and behavioral therapies have been developed that focus more on enhancing emotion regulation skills. For example, dialectical behavior therapy (DBT, Linehan, 1993) is arguably one of the first and most influential treatments to explicitly teach patients adaptive emotion regulation skills, such as identifying, accepting, and modifying emotions. Another such “third wave” therapy is acceptance and commitment therapy (ACT; Hayes, Strohsal, & Wilson, 1999), which focuses on reducing experiential avoidance of aversive experiences, such as undesired emotions, and facilitates the pursuit and attainment of important personal goals. A final example is mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2013). Originally designed as a group intervention to prevent relapses of depression, MBCT encourages patients to become more aware of mental phenomena, such as their feelings, and to view them as “…mental events rather than as aspects of the self or as necessarily accurate reflections of reality” (Teasdale et al., 2000, p. 616).

The stronger focus on emotion regulation that characterizes the development of psychotherapeutic interventions in the past decade is, however, not limited to the so-called third wave of CBT (e.g., DBT, ACT, MBCT). Even traditional CBT treatments are now more frequently targeting affect regulation skills in a very explicit and integrative fashion. For example, Keuthen and Sprich developed and investigated the efficacy of a CBT program that included “…instruction in skills to further enhance awareness and address problematic emotion regulation and distress tolerance” (Keuthen & Sprich, 2012, p. 373) as a treatment intervention for trichotillomania. As hypothesized, the authors found significant pre- to post-treatment improvement in emotion regulation occurred, and this improvement was correlated with reductions in hair pulling severity (Keuthen et al., 2010). Significant improvement from baseline at 3- and 6-month follow-up was also found on the measures of hair pulling severity and total scale scores for emotion regulation measures (Keuthen et al., 2011).

In another study of a CBT-based program with an explicit focus on affect regulation (Slee, Spinhoven, Garnefski, & Arensman, 2008), 90 people who exhibited deliberate self-harm behaviors were assigned to one of two treatment groups. One group consisted of any treatment desired by the participant such as CBT, interpersonal psychotherapy, or social skills training. The second treatment group involved CBT that was directed at “developing emotion regulation skills for coping with situations that interfere with effective emotion regulation” (p. 206). Those who received the emotion regulation-enhanced CBT treatment reported significantly lower measures for deliberate self-harm, emotion regulation difficulties, depression, anxiety, and suicidal cognitions. Mediation analysis showed that changes in deliberate self-harm behavior among the study participants were partially mediated by changes in emotion regulation difficulties. Since depression, anxiety, and suicidal cognitions were reduced in those who received the emotion regulation-enhanced CBT treatment, this study suggests treatment that targets emotion regulation difficulties can help reduce symptom severity as well as deliberate self-harm behaviors.

Emotion regulation therapy (ERT; Mennin & Fresco, 2014) is another example of CBT-based treatment that targets emotion regulation. ERT was originally developed for generalized anxiety disorder and conceptualizes this disorder as deficits in a variety of emotion regulation skills. This treatment therefore focuses on enhancing emotion regulation skills such as identifying emotions, accepting emotions, and managing emotions in adaptive ways without the use of avoidance (Mennin, 2006).

Emotion-focused CBT (ECBT) is yet another example of a CBT-based treatment modified to account for the recent research findings on the importance of affect regulation. ECBT (Kendall & Suveg, 2005) was specifically developed to strengthen emotion regulation skills in children with anxiety disorders. The program includes standard CBT content and adds emotion-specific components, such as exposure to emotion-evoking situations, as well as instruction regarding the recognition and management of emotions. While standard CBT treatment for anxiety tends to focus specifically on the treatment of anxious emotions, treatment of anxious children with ECBT addresses any emotions (e.g., guilt or anger) that pose difficulty for the child. In one study that evaluated ECBT, the majority of children showed improvements in both their anxious symptoms and their ability to understand and regulate emotions (Suveg, Kendall, Comer, & Robin, 2006).

The notable shift of focus onto emotion regulation has not only occurred in CBT-based treatments. Psychodynamic treatments, which have a long tradition of addressing affect and the management of it (Blagys & Hilsenroth, 2000), have also recently been developed to specifically target emotion regulation. One such treatment, developed by Fosha (2001), is accelerated experiential dynamic psychotherapy, which helps patients fully experience their emotions and use “… emotionally significant relationships to regulate affective experiences that are too intense or painful for the individual to manage alone” (Fosha, 2001, pp. 227–228). Furthermore, some newer humanistic approaches, such as emotion-focused therapy (EFT; Greenberg, 2004), have begun to emphasize emotion regulation. For example, in EFT, therapists operate as “emotional coaches” to help patients manage and utilize their emotions in helpful ways by increasing their emotional awareness and helping them make sense of their emotional experiences.

Finally, various clinicians not affiliated with a particular therapeutic tradition have developed programs aimed at enhancing affect regulation. For example, Izard and colleagues (2008) developed the emotion-based prevention (EBP) program. The goal of EBP is to “…increase young children’s ability to understand and regulate emotions, utilize modulated emotions, and reduce maladaptive behavior” (p. 373). In an efficacy study, the authors compared this treatment with the standard Head Start program (a federal program that prepares children from low-income families to enter school) and found that children who received EBP had greater increases in knowledge of emotions and emotion regulation than children participating in the standard Head Start program. Interestingly, children receiving EBP also showed greater decreases in negative emotional expression, aggression, anxious and depressed behavior, and negative interactions with peers and adults.

Additionally, Gratz and Gunderson (2006) developed an acceptance-based emotion regulation therapy for borderline personality disorder (BPD). In a pilot study, women with BPD who also exhibited self-harming behaviors were treated with either their current outpatient group therapy or the same group therapy plus Gratz and Gunderson’s acceptance-based emotion regulation group therapy. There were significant differences between the treatment groups. The women who received the adjunctive intervention showed significant improvement in emotion regulation and significant decreases in emotional avoidance, frequency of self-harm, BPD symptoms, depression, anxiety, and stress (Gratz & Gunderson, 2006). A mediation analysis of the data revealed that changes in self-harm were mediated by changes in emotion dysregulation and emotional avoidance (Gratz & Tull, 2010).

As demonstrated in this chapter, there are a variety of current theories and treatments that focus on emotion regulation skills. The available treatments, however, are not without limitations. For example, many of the types of treatment just described were designed for specific disorders such as borderline personality disorder or generalized anxiety disorder, and may not be appropriate across a broad spectrum of disorders. Additionally, many of the treatments just described do not focus exclusively on emotion regulation or do not focus on building a wide repertoire of emotion regulation skills. Instead, many of the existing treatment options aim to enhance a patient’s emotion regulation capacity along with various other therapeutic goals, while other treatments only target limited aspects of emotion regulation. To address these limitations in available treatments, we will describe, in the next chapter, another intervention for enhancing emotion regulation.