Is Emotion Regulation Training More Effective Than Self-Help For Mental Disorders?

Emotion regulation training is a skills-based intervention that teaches people strategies to manage difficult emotions.

It focuses specifically on enhancing abilities in identifying emotions, selecting appropriate regulation techniques like reappraisal or acceptance, and implementing those strategies effectively.

The goal is to improve regulation in daily life to reduce distress, improve wellbeing, and prevent progression to future mental health problems when experienced regularly over time.

Wittkamp, M. F., Krkovic, K., & Lincoln, T. M. (2023). Effectiveness of a transdiagnostic emotion regulation training in an at‐risk sample: a randomized‐controlled trial of group‐based training versus self‐help bibliotherapy. British Journal of Clinical Psychology, 62(2), 411-430. https://doi.org/10.1111/bjc.12415

Key Points

• The study tested whether group-based emotion regulation training (ART) would be more effective than self-help bibliotherapy (BT) in reducing distress and preventing mental disorders in a sample at risk for developing psychotic, depressive, or anxiety disorders.
• Participants in the ART condition showed greater improvement in emotion regulation skills in daily life compared to BT, but ART was not superior to BT in preventing transitions to mental disorders at 12-month follow-up.
• There were significant reductions in general psychopathology and symptoms from pre- to post-intervention, but no difference between ART and BT groups.
• The study was limited by its focus on a German sample and lack of active control condition, but provides initial evidence that group ART may not provide enough additional benefit over self-help to justify its substantially higher resource requirements.

Rationale

Prior research shows that subclinical symptoms of psychosis, depression, and anxiety are common, co-occur, influence each other, and confer heightened risk for developing mental disorders (Lewinsohn et al., 2000; McGrath et al., 2015; Regeer et al., 2006; Bosman et al., 2019).

These symptoms are suggested to form a “transdiagnostic at-risk state” underpinned by shared risk factors like emotion dysregulation (McGorry et al., 2018; Lynch et al., 2021).

Teaching emotion regulation skills early could potentially prevent the progression of mental disorders (Guloksuz & van Os, 2018).

While some clinical interventions successfully target emotion regulation (Cludius et al., 2020), it is unknown if resource-intensive group training is more effective for at-risk individuals than self-help approaches. Comparing interventions can inform resource allocation in prevention.

Method

This randomized controlled trial recruited 138 participants with subclinical symptoms of psychosis, depression, or anxiety.

Participants were randomly allocated to either 8 sessions of group-based ART (Springer, New York) focused on teaching emotion regulation skills, or 8 weeks of self-help BT.

• Group-based emotion regulation training (ART) covers six modules teaching different emotion regulation skills: muscle and breathing relaxation techniques, mindfulness and awareness of emotions, acceptance of emotions, self-compassion, analyzing emotions, and strategies for modifying emotions. It is delivered by a trained provider.
• Self-help bibliotherapy (BT) typically refers to using books, workbooks, or other written materials to help guide people in managing psychological or mental health issues independently.

Participants completed biweekly measures during the intervention, 6-month, and 12-month follow-ups.

Primary outcomes were differences in rates of transitions to mental disorders between groups at 12 months and changes in emotion regulation in daily life measured through experience-sampling.

Secondary symptoms and psychopathology outcomes were also examined.

Sample

The 138 German participants were predominately female (62%), Caucasian (92%) and had an average age of 25 years. Most were college students.

Statistical Analysis

Binary logistic regression analyzed the difference in 12-month transition rates between groups. Mixed model ANOVAs and ANCOVAs evaluated changes in psychopathology, symptoms, and emotion regulation over time points between groups.

Results

ART participants showed significantly greater pre-post improvement in emotion regulation in daily life compared to BT (p = .012). However, rates of transitions to mental disorders did not differ between groups at 12 months.

From pre- to post-intervention, both groups showed significant reductions in general psychopathology, depression, anxiety, and eccentric behavior (p < .001), with no difference between groups.

Insight

While group-based ART enhanced daily life emotion regulation skills more than self-help BT, it did not prevent substantially more transitions to mental disorders.

Both interventions produced similar improvements in a range of symptom and psychopathology outcomes.

The resource-intensive ART may, therefore, not provide enough additional clinical benefit over BT to justify its requirements in at-risk samples, at least based on the outcomes measured here.

Strengths

• Randomized controlled design with adequate statistical power
• Included both clinical endpoints and process measures
• Assessed outcomes through multiple methods like questionnaires and experience sampling
• Followed participants 12 months to assess disorder transitions

Limitations

• Single study with predominately Caucasian, female German college students, limiting generalizability
• No active control condition accounts for non-specific treatment factors
• Self-report measures can be biased
• Did not include biological measures of emotion regulation

Implications

The lack of difference in transition rates and most clinical outcomes suggests self-help approaches may deserve greater prioritization over intensive, specialized group trainings for emotion regulation enhancement and prevention in at-risk populations.

The choice of treatment approach may depend on the specific emotion regulation difficulties individuals exhibit, however. Stepped care models, which only provide intensive interventions if self-help fails, could be economical.

References

Bosman, R. C., ten Have, M., de Graaf, R., Muntingh, A. D., van Balkom, A. J., & Batelaan, N. M. (2019). Prevalence and course of subthreshold anxiety disorder in the general population: A three-year follow-up study. Journal of Affective Disorders, 247, 105–113. https://doi.org/10.1016/j.jad.2019.01.018

Cludius, B., Mennin, D., & Ehring, T. (2020). Emotion regulation as a transdiagnostic, emotion regulation as a transdiagnostic process process. Emotion, 20(1), 37. https://doi.org/10.1037/emo0000646

Gross, J. J. (2015). The extended process model of emotion regulation: Elaborations, applications, and future directions. Psychological Inquiry, 26(1), 130–137. https://doi.org/10.1080/1047840x.2015.989751

Guloksuz, S., & van Os, J. (2018). Need for evidence-based early intervention programmes: A public health perspective. Evidence-Based Mental Health, 21(4), 128–130. https://doi.org/10.1136/ebmental-2018-300030

Hartmann, J. A., Nelson, B., Ratheesh, A., Treen, D., & McGorry, P. D. (2019). At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: A scoping review in the context of clinical staging. Psychological Medicine, 49(2), 177–189. https://doi.org/10.1017/S0033291718001435

Lewinsohn, P. M., Solomon, A., Seeley, J. R., & Zeiss, A. (2000). Clinical implications of “subthreshold” depressive symptoms. Journal of Abnormal Psychology, 109(2), 345–351. https://doi.org/10.1037/0021-843X.109.2.345

Ludwig, L., Werner, D., & Lincoln, T. M. (2019). The relevance of cognitive emotion regulation to psychotic symptoms—A systematic review and meta-analysis. Clinical Psychology Review, 72, 101746. https://doi.org/10.1016/j.cpr.2019.101746

Lynch, S. J., Sunderland, M., Newton, N. C., & Chapman, C. (2021). A systematic review of transdiagnostic risk and protective factors for general and specific psychopathology in young people. Clinical Psychology Review, 87, 102036. https://doi.org/10.1016/j.cpr.2021.102036

McGorry, P. D., Hartmann, J. A., Spooner, R., & Nelson, B. (2018). Beyond the “at risk mental state” concept: Transitioning to transdiagnostic psychiatry. World Psychiatry, 17(2), 133–142. https://doi.org/10.1002/wps.20514

McGrath, J. J., Saha, S., Al-Hamzawi, A., Alonso, J., Bromet, E. J., Bruffaerts, R., Caldas-de-Almeida, J. M., Chiu, W. T., de Jonge, P., Fayyad, J., Florescu, S., Gureje, O., Haro, J. M., Hu, C., Kovess-Masfety, V., Lepine, J. P., Lim, C. C. W., Mora, M. E. M., Navarro-Mateu, F., … Kessler, R. C. (2015). Psychotic experiences in the general population: A cross-National Analysis Based on 31 261 respondents from 18 countries. JAMA Psychiatry, 72(7), 697–705. https://doi.org/10.1001/jamapsychiatry.2015.0

Regeer, E. J., Krabbendam, L., Graaf, R. D., Have, M. T., Nolen, W. A., & Os, J. V. (2006). A prospective study of the transition rates of subthreshold (hypo)mania and depression in the general population. Psychological Medicine, 36(5), 619–627. https://doi.org/10.1017/S0033291705006823

Scott, J., Martin, N. G., Parker, R., Couvy-Duchesne, B., Medland, S. E., & Hickie, I. (2021). Prevalence of self-reported subthreshold phenotypes of major mental disorders and their association with functional impairment, treatment and full-threshold syndromes in a community-residing cohort of young adults. Early Intervention in Psychiatry, 15(2), 306–313. https://doi.org/10.1111/eip.12942

Stochl, J., Khandaker, G. M., Lewis, G., Perez, J., Goodyer, I. M., Zammit, S., Sullivan, S., Croudace, T. J., & Jones, P. B. (2015). Mood, anxiety and psychotic phenomena measure a common psychopathological factor. Psychological Medicine, 45(7), 1483–1493. https://doi.org/10.1017/S003329171400261X

van Os, J. (2013). The dynamics of subthreshold psychopathology: Implications for diagnosis and treatment. American Journal of Psychiatry, 170(7), 695–698. https://doi.org/10.1176/appi.ajp.2013.13040474

Keep Learning

• Does the lack of difference between ART and BT groups in preventing disorder transitions and reducing symptoms suggest teaching emotion regulation skills is ineffective for at-risk individuals? Why or why not?
• The study population was mostly Caucasian female German college students. How might results differ in more diverse or clinical at-risk samples?
• Besides transitions to disorders, what other important outcomes should future studies on at-risk samples measure when assessing preventative interventions?
• Why might measuring biological indicators of emotion regulation like cortisol or heart rate variability provide useful additional information when comparing interventions?
• Should we prioritize self-help approaches over specialized therapies for all at-risk individuals, or might certain subgroups still benefit more from intensive trainings?
• How might incorporating principles from positive psychology or resilience research improve early interventions for at-risk populations?
• If both ART and BT produced roughly equal improvements in symptoms, what factors should drive choice between them – clinical benefit, acceptability, or resources required?