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An Overview of Emotion Regulation Transdiagnostic Systemically Bound with Recommendations for Treatment

By: Amanda Edwards Stewart, Ph.D., ABPP

Image of two soldiers standing together
U.S. Army photo by Gertrud Zach

Emotion regulation is a person’s attempt to influence their positive and negative emotions, as they occur, within a given situation1. Regulating emotions is both a conscious and implicit process. Regulating emotions consciously aligns to a specific goal of an individual1. A regulation goal may be either increasing or decreasing a pleasant or unpleasant emotional state2. An individual’s emotion regulation goal is influenced by the context in which the feeling occurs, personality3, family of origin4, age5, as well as race and ethnicity6.

From my clinical experience, I have found that dysregulated emotions are either a primary feature or one of the symptoms found in borderline personality disorder, trauma-related disorders, mood and anxiety disorders, substance use and eating disorders, and insomnia. Problems with emotion regulation occurring across multiple disorders has led researchers to labeling emotion dysregulation as a transdiagnostic process7,8. Transdiagnostic processes cut across disorders instead of being a disorder-specific feature7. For example, depression is characterized by a decrease in positive affect (loss of pleasure) and an increase in negative affect (depressed mood most of the day). Researchers9 summarized that individuals suffering from depression show a marked preference for reducing positive emotions; they do this by habitually using emotion regulation strategies for decreasing positive emotions and sustaining negative affect. Specifically, those with depressive symptoms tend to ruminate on negative life events or thoughts (endorsing items such as “Think, ‘I don’t deserve this,’” or “Think about things that have not gone well for you.’” Those with depressive symptoms also have been found to suppress both positive and negative affect (i.e., hiding a smile, or stopping crying when they are sad)9.

Researchers have theorized that the process of emotion regulation is rooted in childhood development and a family-systems context. In a review of emotion regulation as a family-level phenomena, researchers10 identify how family interactions from childhood to young adulthood can contribute to an individual’s emotion regulation skills. Initially, children are highly dependent on caregivers to help them exert control over their emotional lives and learn how to regulate their emotions by how caregivers react to a child’s emotions. As children grow, they learn from watching how both caregivers and peers handle potentially dysregulating situations such as a disagreement with a friend or sibling. It is theorized that attachment style11 is linked with emotion regulation skills where secure attachment leads to adaptive emotion regulation strategies (e.g., positive reframing, active coping, effective cognitive reappraisal, positive rumination, mindfulness, acceptance, and problem solving) and insecure attachments lead to maladaptive strategies (e.g., negative rumination, dampening positive affective, suppression, behavioral disengagement, and denial). It should be noted that one systematic review found that ethnoracial minorities (U.S. white vs. non-white) may be motivated to dampen emotional expressions as they often prioritize the needs of the group over the individual and may prefer to down-regulate emotional experiences, suppressing emotional experiences, to maintain group harmony12.

Lastly, there are a variety of treatments that can help patients with emotion dysregulation. In a meta-analysis of treatment effects on emotion regulation, many emotion regulation methods were found to be effective. Specifically, treatments which help patients generally include undoing avoidance of negative emotions, enhance emotional awareness, feeling the full experience of negative emotions, learning to cognitively reappraise effectively, and learning behavioral and action strategies to modulate negative emotions. Such treatments were classified as structured psychoeducation or affective-focused, experiential treatments13. Structured psychoeducation are treatments rooted in the cognitive-behavioral tradition and include:

  • The Unified Protocol14,
  • Acceptance and Commitment Therapy15,
  • Dialectical Behavior Therapy16,
  • Mindfulness-based Cognitive Therapy17,
  • Skills training in affect and interpersonal regulation18,
  • Acceptance-based Behavioral Therapy19
  • Affect regulation training20

Treatments that are affect-focused, experiential treatments include:

  • Emotion-Focused Therapy21
  • Accelerated Experiential Dynamic Psychotherapy22
  • Affect Phobia Therapy23
  • Intensive Short-term Dynamic Psychotherapy24,25

A meta-analysis of 26 studies pre/post emotion regulation treatments found an average large effect size (g = 0.82)26. While more research is needed on the effectiveness of specific components or therapist methods to improve emotion regulation skills, it is recommended that providers help enhance a patient’s capacity to feel a variety of emotions. Patients should be encouraged to undo avoidant strategies, while enhancing their awareness of their own feelings, identify the meaning of their feelings, and how to positively cope when they are in distress. A provider should approach their patient in an empathic, validating, and supportive way to help model adaptive emotion regulation. It is helpful to educate patients on when they might be using fearful avoidance and suppression. Providers should also note that when patients are experiencing negative affect, they often don’t recognize positive aspects of themselves or a situation and that their cultural identity and family system can also influence a patient’s emotional regulation habits26.

References

  1. McRae, K., & Gross, J. J. (2020). Emotion regulation. Emotion, 20(1), 1-9. http://dx.doi.org/10.1037/emo0000703
  2. Tamir, M., Vishkin, A., & Gutentag, T. (2020). Emotion regulation is motivated. Emotion, 20(1), 115-119. https://dx.doi.org/10.1037/emo0000635
  3. Hughes, D. J., Kratsiotis, I. K., Niven, K., & Holman, D. (2020). Personality traits and emotion regulation: A targeted review and recommendations. Emotion, 20(1), 63-67. https://dx.doi.org/10.1037/em0000644
  4. Lindsey, E.W. (2020). Relationship context and emotion regulation across the life span. Emotion, 20(1), 59-62. https://dx.doi.org/10.1037emo0000666
  5. Crowell, J. A. (2021). Development of emotion regulation in typically developing children. Child and Adolescent Psychiatric Clinics of North America, 30, 467-474. https://doi.org/10.1016/j.chc.2021.04.001
  6. Weiss, N. H., Thomas, E. D., Schick, M. R., Reyes, M. E., & Contractor, A. A. (2022). Racial and ethnic differences in emotion regulation: A systematic review. Journal of Clinical Psychology, 78(5), 785-808. https://doi.org/10.1002/jclp.23284
  7. Cludius, B., Mennin, D., & Ehring, T. (2020). Emotion regulation as a transdiagnostic process. Emotion, 20(1), 37-42. https://dx.doi.org/10.1037/em0000646
  8. Timpano, K. R., & Port, J. H. (2021). Object attachment and emotion (Dsy)regulation across development and clinical populations. Current Opinion in Psychology, 39, 109-114. https://doi.org/10.1016/j.copsyc.2020.08.013
  9. Vanderlind, W. M., Millgram, Y., Baskin-Sommers, A. R., Clark, M. S., & Joormann, J. (2020). Understanding positive emotion deficits in depression: From emotion preferences to emotion regulation. Clinical Psychology Review, 76, 101826. https://doi.org/10.1016/j.cpr.2020.101826
  10. Paley, B., & Hajal, N. J. (2022). Conceptualizing emotion regulation and coregulation as family-level phenomena. Clinical Child and Family Psychology Review, 25, 19-43. https://doi.org/10.1007/s10567-022-00378-4
  11. Bowlby, J. (1969, 1973). Attachment and loss. Attachment (Vol. 1, Vol. 2). Basic Books.
  12. Weiss, N. H., Thomas, E. D., Schick, M. R., Reyes, M. E., & Contractor, A. A. (2022). Racial and ethnic differences in emotion regulation: A systematic review. Journal of Clinical Psychology, 78(5), 785-808. https://doi.org/10.1002/jclp.23284
  13. Iwakabe, S., Nakamura, K., & Thoma, N. C. (2023). Enhancing emotion regulation. Psychotherapy Research, 33(7), 918-945. https://doi.org/10.1080/10503307.2023.2183155
  14. Barlow, D. H., Farchione, T. J., Suer-Zavala, S., Murray-Latin, H., Ellard, K. K., Bullis, J. R., Bentley, K., Boettcher, H., & Cassiello-Robbins, C. (2018). Unified protocol for transdiagnostic treatment of emotional disorders Therapist guide (2nd ed.) Oxford University Press.
  15. Hayes, S. C. (2004). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35(4), 639-665. https://doi.org/10.1016/S0005-7894(04)80013-3
  16. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
  17. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Guilford Press.
  18. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067-1074. https://doi.org/10.1037/0022-006x.70.5.1067
  19. Roemer, L., & Orsillo, S. M. (2007). An open trial of an acceptance-based behavior therapy for generalized anxiety disorder. Behavior Therapy, 38(1), 72-85. https://doi.org/10.1016/j.beth.2006.04.004
  20. Berking, M., & Lukas, C. A. (2015). The affect regulation training (ART): A transdiagnostic approach to the prevention and treatment of mental disorders. Current Opinions in Psychology, 3, 64-69. https://doi.org/10.1016/j.copsyc.2015.02.002
  21. Greenberg, L. S. (2021). Changing emotion with emotion: A practitioner’s guide. American Psychological Association. https://doi.org/10.1037/0000248-000
  22. Fosha, D., (2021). Undoing aloneness & the transformation of suffering into flourishing: ARDP 2.0. American Psychological Association. https://doi.org/10.1037/0000232-000
  23. McCullough, L., Larsen, A. E., Schanche, E., Andrews, S., Kuhn, N., & Hurley, C. L. (2003). Achievement of therapeutic objectives scale. Short-term psychotherapy research program at Harvard Medical School. http://affectphobia.com
  24. Abbass, A. (2015). Reaching through resistance: Advanced psychotherapy techniques. Seven Leaves Press.
  25. Frederickson, J. J., Messina, L., & Grecucci, A. (2018). Dysregulated anxiety and dysregulating defenses: Toward an emotion regulation informed dynamic psychotherapy. Frontiers in Psychology, 9, 2054. https://doi.org/10.3389/fpsyg.2018.02054
  26. Iwakabe, S., Nakamura, K., & Thoma, N. C. (2023). Enhancing emotion regulation. Psychotherapy Research, 33(7), 918-945. https://doi.org/10.1080/10503307.2023.2183155

Dr. Edwards-Stewart is a board certified, licensed clinical psychologist with clinical expertise in the areas of trauma, the process of change, personality assessments, and couples. She is the government lead of the Practice-Base Implementation Network at the Psychological Health Center of Excellence.

Last Updated: December 13, 2023
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