Emotion regulation and mental health: current evidence and beyond

The concept of emotion regulation (ER) is receiving considerable attention in research on psychiatric disorders and their treatment. The popularity of the concept is largely rooted in its premise that deficits in adaptive responses toward undesired affective states contribute to the development and maintenance of most forms of psychopathology.

This appears obvious when considering psychiatric disorders that are primarily defined by an excess of undesired affective states (e.g., anxiety and mood disorders). For these conditions, it follows almost by definition that the perpetuation or escalation of undesired affective states results from the individual's inability to regulate them.

However, given that many behavioral and cognitive symptoms of other psychiatric disorders can also be conceptualized as dysfunctional ER strategies, the scope of this paradigm extends much further. Consider, for example, when avoidance is used to reduce anxiety, when alcohol is consumed to numb loneliness, when binge eating serves to distract from emotional anguish, or when appraising a situation as uncontrollable and hopeless is used to reduce the pressure to solve one's problems or to shield oneself from further disappointment. In all these scenarios, behavioral or cognitive strategies yield short-lived relief from undesired affective states. Since the immediate ameliorating effects of these maladaptive strategies reinforce their usage, individuals tend to progressively increase their adoption until criteria for an anxiety, alcohol use, eating or mood disorder, etc. are met.

Importantly, this trajectory is preventable if the individual realizes the negative mid- and long-term consequences of maladaptive strategies, and pivots to more adaptive ways of coping with undesired affective states. However, any such shift will fail to the extent that the individual lacks effective ER skills. Since all psychiatric disorders are arguably maintained by behaviors and cognitions that initially reduce negative affect, and since a distressed individual is more likely to utilize those strategies in the absence of more adaptive alternatives, it can be hypothesized that all psychiatric disorders are, to a significant degree, perpetuated by insufficient ER skills.

Drawing on this framework, it can be deduced that patients with psychiatric disorders should benefit from treatments that systematically enhance effective ER skills. Evidence-based ER frameworks, such as the Adaptive Coping with Emotions Model¹, posit that such treatments should foster the ability to modify the intensity and duration of undesired affective states, as well as the ability to accept and tolerate such states when modification is not possible.

Additionally, these treatments should foster so-called preparatory ER skills that facilitate the successful utilization of modification- and acceptance-focused ER skills. Examples of such preparatory skills include the ability to become aware of one's feelings, to adequately identify and label one's feelings, and to develop a mental model explaining how one's present feelings are maintained, preferably in a manner that validates and destigmatizes one's experience, while also proposing concrete tools to promote successful change/acceptance.

Finally, it is noteworthy that all adaptive ER strategies reviewed so far may initially increase negative affect^{1, 2}. Thus, treatments focusing on ER should also strengthen self-support skills that enable patients to persistently commit to adaptive strategies, despite their likely initial exacerbation of negative affect.

Regarding empirical evidence for these theoretical premises, salient deficits in ER skills have been reported for various psychiatric disorders³. Moreover, a significant number of longitudinal and experimental studies suggest that this association results from ER deficits impacting mental health, and not (exclusively) vice versa³. Regarding the importance of specific ER skills, substantial evidence supports the efficacy of reappraisal, acceptance, and self-compassion^{4, 5}.

Further studies yield evidence that treatments explicitly focusing on enhancing ER skills (e.g., dialectical behavioral therapy) are effective in treating a wide range of psychiatric disorders. More specific evidence in the literature shows that interventions exclusively focusing on enhancing ER skills (e.g., affect regulation training, emotion regulation therapy) are effective treatments for several disorders^{2, 6}. Finally, significant mediation effects observed across these studies suggest that ER skill improvement is the main driver of symptom severity reduction^{7, 8}.

While these findings are encouraging, ER research in the context of psychopathology remains fraught with several challenges. First of all, conceptual definition of key terms lacks sufficient clarity, beginning with the term emotion, which is ubiquitously used for various affective states even though more specific definitions have been proposed (i.e., emotion refers to a rather short-lived experience that has an identifiable trigger; mood is comparably more protracted, often with a vague trigger; stress is an unspecific response to threats thwarting attainment of one's goals; urges are motivational impulses; feelings are the subjective experience of affective states; and affect is an umbrella term for all of the above).

Further ambiguity plagues the term regulation, which implies that actions must be undertaken to change an affective state. However, in some instances, a conscious decision not to regulate an emotion, but rather simply observe it and allow it to run its course, could be the most adaptive response. Thus, terms such as adaptive/maladaptive response toward an undesired affective state could represent useful alternatives to regulation when conceptual clarity is deemed crucial.

Another challenge arises when researchers try to identify the most effective ER strategies. Obviously, there is no silver bullet for successfully regulating all undesired affective states under all circumstances. The number of variables moderating the efficacy of a particular ER strategy in a specific situation is too large to allow for a systematic comparison of the efficacy of multiple ER strategies for all possible constellations of potential moderators. Nevertheless, research should develop and validate rules of thumb that take significant moderators into account (e.g., “use acceptance if your chances of modifying the emotion are slim”, or “use exposure to cope with fear, but distraction to cope with anger”).

A related challenge results from the likelihood that combinations of ER strategies are more effective than any single ER strategy. For example, it has been shown that encouraging patients to practice self-compassion prior to engaging in reappraisal augments the potency of the latter⁹. Thus, future studies should elucidate effective combinations of ER strategies.

Moreover, it is evident that present research tends to focus on comparatively broad skill categories. For instance, many studies demonstrate the efficacy of the general ER skill represented by reappraisal. However, there are many ways by which an individual can reappraise a salient problem, and these different approaches may differ significantly in their effects on undesired emotions. Thus, future research should also compare the efficacy of different ways of applying ER strategies from the same ER skill domain.

Regarding intervention studies, treatments focusing exclusively on ER skill enhancement have previously only been evaluated for a relatively limited set of mental disorders. Thus, future research should evaluate the efficacy of such ER-focused interventions for a broader range of psychiatric conditions. Since, according to preliminary evidence, ER interventions may, at best, match the effect sizes of disorder-specific treatments, researchers might choose to prioritize the evaluation of treatment formats that capitalize on the unique practical and economic advantages of ER-focused treatments – particularly their transdiagnostic applicability.

More specifically, investigators might examine the incremental effects to be achieved when disorder-specific individual therapy is augmented with transdiagnostic group-based interventions focusing exclusively on ER skill promotion. Such combinations would ensure the crucial targeting of disorder-specific maintaining factors, while also exploiting the increased ease of organizing group therapy sessions for diagnostically diverse patients.