Enhancing emotion regulation

Figures & data

Figure 1. Flow diagram of the study selection process.

Table I. Studies of immediate and intermediate outcomes of emotion regulation methods.

Study	Sample	Measures of ASR, Outcomes, Moderators	Results
Stalikas and Fitzpatrick (1996)	3 archival single sessions with 3 clients all from the U.S., and 1 RET, 1 client-centered, 1 gestalt therapist who is from South Africa.	Measure of Therapist: HCVRCS-R (Friedlander, 1982) as coded by trained judges from transcripts. 8 categories were collapsed into three categories in terms of degree of structure. Measure of immediate in-session outcome: Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Intermediate Outcomes No relation was significant between degrees of structure of therapist responses and experiencing (= box score).
Gazzola and Stalikas (1997)	6 single Sessions conducted by Carl Rogers 2 male and 4 female clients, all apparently from the U.S.	Measure of Therapist: The category of Interpretation in HCVRCS-R (Friedlander, 1982) as coded by trained judges from transcripts: Consensual qualitative research. A group of three judges independently described in writing about the nature of interpretation, the manner in which it was delivered, and the client immediate reactions following interpretation. Measure of immediate in-session outcome: The Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcomes Interpretations occurred 17 times and in 13 times they were followed by the occurrence of a higher experiencing (+ box score) Interpretations that were followed by client experiencing: (a) referred to specific client feelings, (b) were phrased tentatively, (c) delivered using the voice of the client, and (d) addressed immediate feelings.
Hill et al. (1988)	Eight case studies of 12-session courses of psychotherapy in the U.S. The 8 clients were adult and female and were depressed, anxious, and had self-esteem and relationship problems. The experienced therapists (4 male, 4 female, all White) came from a range of theoretical orientations.	Measure of Therapist Method: HCVRCS (Hill, 1985, 1986) as coded by trained judges from transcripts which has 8 categories: approval, information, direct, guidance, closed question, open question, paraphrase, interpretation, confrontation, and self-disclosure. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcomes Ratings of client experiencing following speaking turns that included therapist self-disclosure averaged 2.49 (SD = 0.73) on a 7-point scale (7 = high) (+ box score). Followed by open question (m = 2.40, SD = .65), approval (m = 2.36, SD = .65), Paraphrase (m = 2.34, SD = .65) and interpretation (m = 2.34, SD = .67). (= box score for interpretation)
Silberschatz et al. (1986)	Three adult patients with good, moderate, and poor outcome in a 16-session individual psychotherapy from the Mount Zion Brief Therapy Research Project. Therapists were experienced psychodynamic therapists. A multiple case study	Measure of Therapist Method: Transference interpretations were classified using the Malan intervention typology defined as any interpretation directed toward the patient’s feelings about the therapist or the therapy. Plan compatibility of intervention scale was used to measure the extent to which a therapist response is suited to case formulation of the patient’s plan on a 7-point Likert scale as coded by trained judges from audiotapes and transcripts. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding)	Immediate In-Session Outcome The degree to which the therapist passed tests was significantly and positively related to the client experiencing immediately following the therapist statement in both cases. (+ box score for plan compatible interpretation)
Silberschatz and Curtis (1993)	Two adult patients with dysthymic disorder in a 16-session individual psychotherapy from the Mount Zion Brief Therapy Research Project. Therapists were experienced psychodynamic therapists. Both had an excellent outcome. A multiple case study	Measure of therapist method: Patient test scale was used to identify segments of patient’s testing the therapist. Patient test scale was used to identify segments which had included testing of a central pathogenic beliefs in the therapeutic relationship. Therapist Scale was then used to rate the extent to which the therapist passed or failed the patient’s test on a 7-point Likert scale. Measure of immediate in-session outcome: Client Experiencing scale (Klein et al., 1986) rated by trained judges using a 7-point scale (1 = impersonal, avoided, 7 = feelings are attended to and used for problem resolution and self-understanding). The Relaxation Scale (Curtis et al., 1986) was used to measure the patients’ state of freedom, realization, and comfort (versus anxiety, drivenness on a 5-point scale). Measures of moderators: None	Immediate In-Session Outcome The degree to which the therapist passed tests was significantly and positively related to the client experiencing immediately following the therapist statement in both cases (r = .67, .62). (+ box score for plan compatible interpretation) The degree to which the therapist passed tests was significantly and positively related to the following patient relaxation in one case (r = .55). (+ box score for plan compatible interpretation)
Town et al. (2012)	24 10-minute segments from 6 adult patients with cluster C personality disorder receiving Short-term psychodynamic psychotherapy for 36- to 60 sessions (mean 47 sessions). (4 female therapists, 2 male therapists; all White). The therapist, who was the originator of the STDP, treated all patients.	Measure of therapist ER method: The PICS Psychotherapy Interactional Coding System as coded by trained judges from videotapes and transcripts has 8 categories: question, information, self-disclosure, clarification, directive, support, interpretation, and confrontation. The four content categories are: defenses, anxieties, impulse/feeling, and no content. Measure of immediate ER outcome: Affect Experiencing Scale taken from the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003), a 6-point scale (1 = no affect arousal no report of feeling, 6 = full and complete affective arousal) rated by a group of 8 judges.	Immediate In-Session Outcomes The highest predicted levels of patient immediate affect experiencing were provided by Confrontation-feeling (an average of 2.49, SD = 1.10). (+ box score) followed by confrontation-defense (M = 2.33, SD = .96) (+ box score) and then facilitative responses such as support (m = 2.39, SD = 1.10) (+ box score) and Clarification (m = 2.13, SD = 1.05). (+ box score)
Ulvenes et al. (2014)	Fifty Norwegian patients with cluster C personality disorders in the RCT receiving either 40 session CT or STDP. 19 with major depression, 19 with dysthymia, 5 with anic disorder, 5 with agoraphobia, 7 with OCD, 28 with GAD, 4 with somatoform disorder. Eight dynamic therapists and 6 CBT therapists. Therapists had about 10 years of clinical experience, had one training case, and conducted their therapy according to the treatment manuals. Eight dynamic therapists and 6 CBT therapists.	Measure of therapist ER method: Psychotherapy Q-Sort as coded by trained judges from videotapes and transcripts has 100 items. Nine items associated with Affect-focused interventions were selected to form Affect Orientation Scale such as “Th drawing attention to patient’s non-verbal behavior,” “Th sensitive to the patient’s feelings, attuned to the patient,” and “Th points out patient’s attempts to ward off feelings” Measure of immediate ER outcome: Affect Experiencing Scale taken from the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003), a 10-point scale (1 = no affect arousal no report of feeling, 10 = full and complete affective arousal) rated by a group of trained judges for every 10 min of therapy. Moderator: Patient’s sense of self which is the interpersonal sense of self and ranges from a maladaptive negative view to an adaptive positive view of the self (1 = individuals deny or ignore their wants and needs and have little or no ability to identify their strengths and weaknesses, 10 = individuals acknowledge and affirm their wants and needs and are realistic about their strengths and weaknesses).	As therapy progressed, the therapists orienting the patient to affect increasingly elicited affect (+ box score) The patients whose therapist was orienting more to affect generally exhibited more activation of affect (Between-patients level) When a therapist attempted to orient more to affect than what was normal for this particular patient (i.e., vis-à-vis the mean level of TAO for that patient), the patient exhibited more activation (within patient level). Patients who had a higher sense of self than what they started therapy with were able to experience affect when the therapist oriented them to affect more than was typical for that patient.
Nakamura and Iwakabe (2018)	Six episodes of corrective emotional experiences (CEE) taken from individual affect-focused therapy with adult patients (female = 4; male = 2) all Japanese. All patients achieved reliable change index on ER. One experienced therapist. A qualitative study	Measure of therapist ER method: Task analysis of episodes of CEE. Two researchers repeatedly watched videotaped segments and identified therapist methods to facilitate patient’s CEE. Measure of therapist ER method: Task analysis of episodes of CEEs. Two researchers watched videotaped segments and identified the essential patient steps toward the resolution of an emotional conflict from a distressed and dysregulated state to a positive emotionally regulated state.	Two groups of therapist methods were identified. One is experiential methods consisting of empathic understanding, focusing on emotional/somatic experiences, and experiential directing (+ box score). The other is relational methods consisting of affirming/valuing the client, creating/maintaining a relational focus, reciprocating disclosure, and co-creating a relational meaning. (+ box score) Patients started out from a state of secondary distress or emotional avoidance. Patients increasingly experienced and expressed more painful emotions and associated negative beliefs. Grief and self-soothing or self-compassion followed in which the patients projected warmth to themselves, which led to a sense of relief. This intrapersonal change process was followed by interpersonal change process in which the therapist and the patient shared their in-session experience. Mutual disclosure and sharing of positive emotions led to a sense of closeness and the patient articulated their experience in relation to their previous hurtful experiences.
Bentley et al. (2017)	Ten adults with NSSI (non-suicidal Self-Injuries) between 19- to 30- years old (female = 9; male = 1) (Caucasian = 6; others = 4) All had comorbidity (MDD, GAD, SOC). Four were on medication. Multiple case experiments The therapist was a master student whose adherence was monitored.	Measure of therapist ER method: Adherence was monitored during weekly supervision meetings and 20% of session audio recordings were randomly selected and rated for adherence and competency by the lead developer of the UP treatment. Average adherence rating was 4.8 out of 5 (excellent). Two modules were differentiated mindful emotional awareness and cognitive appraisal. Measure of intermediate ER outcome: The SMQ Southampton Mindfulness Questionnaire (Chadwick et al., 2008) is a 16-item self-report measure of mindful emotion awareness. Higher scores on the SMQ reflect greater levels of mindful awareness. The Emotion Regulation Questionnaire (Gross & John, 2003) is one of the most widely used research tools that classifies ER strategies into two subcategories each with 10 items: cognitive reappraisal and expressive suppression.	Nine of 10 patients demonstrated clinically reliable changes in at least one of the two emotion regulation skills. Two patients showed module specificity of change based on visual inspection of changes in mindful emotion awareness and cognitive reappraisal. six patients who received only one intervention, three showed reliable change in only the targeted skill and three showed reliable change in both skills (= box score).
Abasi et al. (2021)	Four patients with SAD with comorbidity of depression. All Iranian (female = 1; Male = 3) Multiple case experiments. Therapist was a doctoral candidate under supervision.	Measure of therapist ER method: A treatment manual for Emotion Regulation Therapy was used and the treatment adherence was monitored by weekly supervision. ERT consists of 4 modules: awareness skills, emotion regulation skills, experiential exposure to promote the new contextual learning, and consolidating gains and relapse preventions. Measure of intermediate ER outcome: Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004) is a 36-item scale that assesses 6 facets of emotion dysregulation: non-acceptance of emotional responses; difficulties in engaging in goal direction; impulse control difficulties; lack of emotional awareness; limited access to emotion regulation strategies; and lack of emotional clarity on a 5-point Likert scale. Affect Intensity Measure (AIM; Larsen et al., 1986): the AIM is a self-report 40-item measure rated on a 6-point Likert scale (never = 1 to always = 6). Negative emotional subscale was used. The Emotion Regulation Questionnaire (Gross & John, 2003) is one of the most widely used research tools that classifies ER strategies into two subcategories each with 10 items: cognitive reappraisal and expressive suppression.	ER was measured weekly using DERS, ERQ, and AIM. All four patients achieved RCI on their ER by the end of treatment. No patient showed module specificity of change based on visual inspection of changes in DERS, ERQ, and AIM. The introduction of ER skills training in the mid-phase of treatment was not associated with the increased improvement of ER skills (= box score).

Note. HCVRCS = Hill Counselor Verbal Response Mode Category System (Hill, 1985, 1986). HCVRCS-R = Hill Counselor Verbal Response Mode Category System-Revised (Friedlander, 1982).

Table II. Studies included in meta-analysis of treatment distal effects on patient emotion regulation.

First author, Year	Design	Treatment Characteristics						ER Outcomes					Effect Size ^a	Association
		Disorder	Intervention	ER treatment components	Session	N		ER Measure	Pre Mean (SD)		Post/Follow-Up Mean (SD)
						Treatment	Control		Treatment	Control	Treatment	Control
Dalrymple (2007)	Open trial	SAD	ACT	Mindfulness	12 × 60-min weekly sessions	19		AAQ-9	41.21 (7.74)		33.46 (8.86)		Pre-Post d = 0.93	Earlier changes in the AAQ predicted later changes in symptom severity (β = -.48, p < .05).
											3-month 34.92 (8.91)		Pre-3-month d = 0.75
Petersen and Zettle (2009)	Random assignment	AUD	ACT vs TAU; Common therapeutic interventions (e.g., group therapy)	Mindfulness	Mean 5.2 × 30-min bi-weekly sessions	12	12	AAQ-9	44.8 (5.1)	45.5 (6.3)	34.4 (10.6)	44.1 (5.7)	ACT d = 1.32	Reductions in AAQ scores were significantly correlated with improvement on the HRS (r = .57, p = .05), but not the BDI-II (r = .32, p = . 31).
Twohig et al. (2010)	RCT	OCD	ACT vs PRT	contact with the present moment or mindfulness exercises	8 × 60-min weekly sessions	41	38	AAQ-16	59.76 (11.36)	57.16 (11.67)	73.69 (13.22)	63.81 (7.69)	Pre-Post ACT d = 1.06 PRT d = 0.47
											3-month 73.37 (14.44)	67.13 (10.74)	Pre-3-month ACT d = .86 PRT d = .64
Arch et al. (2012)	RCT	Anxiety disorder	ACT vs CBT	acceptance, mindfulness	12 × 60-min weekly sessions	57	71	AAQ-16	59.01 (12.35)	58.49 (11.84)	70.82 (13.14)	69.43 (14.75)	Pre-Post ACT d = 1.16 CBT d = 0.90
											6-month 72.14 (10.86)	6-month 68.38 (13.76)	Post-6-month ACT d = 0.63 CBT d = 0.45
											12-month 71.71 (11.42)	12-month 68.43 (11.65)	6-month-12-month ACT d = 0.10 CBT d = 0.00
Dehlin et al. (2013)	Case reports	OCD	ACT	acceptance, mindfulness	8 × 60–90-min weekly sessions	5		AAQ-II	36.2 (5.2)		21.6 (4.8)		[Pre-Post g = 2.32]	When graphed, declining AAQ-II slopes appear to generally co-occur with declines in both compulsions and avoided valued activities.
											3-month 20.6 (8.4)		[Pre-3-month g = 1.49]
Walser et al. (2015)	Open trial	Depression	ACT	acceptance, mindfulness	12–16 sessions	926		AAQ-II	30.93 (10.246)		38.92 (11.742)		[g = 0.71]	Interaction of time with experiential acceptance to predict depression severity was not significant (b = 0.05, p = .362).
Khoramnia et al. (2020)	RCT	SAD	ACT vs WL	acceptance, mindfulness	12 × 90-min sessions	12	12	AAQ-II	79.72 (9.55)	82.27 (13.10)	94.45 (7.28)	83.00 (12.73)	MANCOVA ES = 0.43 [Pre-Post g = 1.96]
											2-month 83.02 (16.46)	2-month 75.18 (15.89)	ES = 0.627 [Pre-2-month g = 1.02]
								SCS	78.18 (12.70)	84.27 (14.93)	94.81 (6.21)	81.27 (10.09)	ES = 0.38 [Pre-Post g = 2.71]
											2-month 96.77 (16.98)	2-month 83.54 (16.57)	ES = 0.435 [Pre-2-month g = 2.85]
								DERS	115.5 (13.71)	117.36 (9.78)	101.36 (9.26)	117.00 (10.86)	ES = 0.311 [Pre-Post g = 1.80]
											2-month 98.54 (15.77)	2-month 120.18 (10.60)	ES = 0.301 [Pre-2-month g = 2.40]
Roemer and Orsillo (2007)	Open trial	GAD	ABBT	a variety of mindfulness practices, diaphragmatic breathing and progressive muscle relaxation	16 × 60- to 90-min weekly to bi-weekly sessions	16		AAQ-9	44.56 (5.99)		29.81 (7.41)		univariate ANOVA ηp^2 = 0.76 [Pre-Post g = 2.04]
											3-month 34.17 (7.76)		ηp^2 = 0.58 [Pre-3-month g = 1.38]
Kumar et al. (2008)	Open trial	Depression	EBCT	mindfulness	20–24 sessions	29		AAQ-16	75.33 (13.30)		67.37 (12.94)		d = .61
Price et al. (2019)	RCT	SUD	MABT + TAU vs WHE + TAU vs TAU only (including group sessions)	developing the capacity to sustain interoceptive awareness as a mindful process to facilitate appraisal of interoceptive experiences	8–10 × 90-min sessions	74	WHE 46	DERS	87.3 (25.1)	WHE 88.2 (27.0)	77.4 (24.2)	WHE 85.7 (28.0)	[MABT vs TAU g = 0.76]
							TAU 67			TAU 83.8 (27.3)		TAU 83.6 (27.5)
Axelrod et al. (2011)	Open trial	BPD & substance dependence	DBT		60-min weekly individual sessions and 90-min weekly group sessions for 20 weeks	24		DERS	118.00 (18.47)		94.80 (17.89)		[g = 1.23]	Significant interactions were observed with frequency of substance use and emotion regulation, F(1, 21) = 8.202, p = .009, with changes in substance use losing significance when controlling for improvement in emotion regulation F(1, 21) = .112, ns.
Goodman et al. (2014)	Open trial	BPD	DBT vs healthy controls		50–60-min weekly individual sessions and 90-min weekly group sessions for 12 months	11	11	DERS	120.5 (24.2)	56.6 (14.9)	101.5 (25.7)	54.8 (14.4)	MANOVA ƞ^2 = 0.21 [g = 1.64]	Reduction in amygdala activity to repeated unpleasant pictures following DBT was associated with improved emotion regulation as measured by the change in total DERS score (r = 0.70, p < 0.02).
Bianchini et al. (2019)	RCT (a pilot study)	BPD	DBT vs TAU	core mindfulness skills, distress tolerance, emotional regulation	60-min weekly individual sessions and 120-min weekly group sessions for 12 months	10	11	DERS	56.6 (11.77)	52.9 (19.52)	65.6 (9.40)	65.1 (15.57)	[g = 0.39]
Ito et al. (2016)	Open trial	Depressive and anxiety disorders	UP		Mean 18.13 × 50- to 90-min weekly sessions	17		ERQ: Reappraisal	16.2 (6.9)		23.8 (7.7)		Pre-Post g = −0.92
											3-month 25.4 (4.9)		Pre-3-month g = −1.37
								ERQ: Suppression	13.9 (6.0)		13.8 (3.5)		Pre-Post g = 0.09
											3-month 13.4 (3.4)		Pre-3-month g = 0.15
Sauer-Zavala et al. (2016)	Case reports	BPD and comorbid anxiety and mood disorders	UP	mindfulness (present-focused and non-judgmental attention)	16–20 weekly sessions	5		DERS	112.00 (16.26)		84.40 (24.85)		ESsg = 1.29 [g = 0.83]
Beaumont et al. (2012)	Random assignment	Trauma-related symptoms	CBT + CMT vs CBT	developing empathy for themselves and acceptance of their distress	12 sessions	16	16	SCS-SF	2.13 (0.75)	1.94 (0.51)	3.72 (0.57)	3.21 (0.57)	[g = 0.66]
Wonderlich et al. (2014)	RCT	BN	ICAT vs CBT-E		21 × 50-min sessions for 19 weeks	40	40	DERS	100.6 (18.4)	98.4 (17.6)	88.9 (13.2)	90.5 (13.7)	[Pre-Post g = 0.42]
											4-moth 90.0 (13.8)	4-month 93.0 (13.3)	[Pre-4-month g = 0.58]
MacDonald et al. (2017)	RCT	ED	CBT-RR vs MI; day hospital including CBT group therapy	distress tolerance; emotion regulation	4 × 60-min weekly sessions	23	21	DERS: Nonacceptance	20.87 (6.50)	20.10 (7.17)	14.56 (4.93)	15.41 (6.34)	univariate time by condition interactions [g = 0.32]
								DERS: Goals	20.52 (5.00)	19.33 (4.76)	15.90 (4.30)	19.15 (4.31)	[g = 1.19]
								DERS: Impulse	27.57 (6.21)	27.48 (7.80)	20.55 (5.43)	24.01 (8.74)	[g = 0.53]
								DERS: Awareness	16.52 (4.57)	15.24 (4.23)	13.02 (3.99)	15.23 (4.39)	partial η^2= .16 [g = 0.99]
								DERS: Strategies	19.74 (6.05)	20.04 (7.68)	15.11 (4.77)	18.62 (6.98)	[g = 1.00]
								DERS: Clarity	20.65 (3.93)	20.71 (3.66)	15.74 (3.89)	18.88 (5.10)	partial η^2= .19 [g = 1.09]
Zalaznik et al. (2019)	Open trial	PDA	CBT	therapist encourages exploration of experiences of bodily sensations without suppression or avoidance	12 sessions	31		ERQ: Suppression	3.78 (1.29)		2.87 (1.28)		[g = 0.69]
Monell et al. (2022)	Open trial	ED	CBT or Other therapies		12-month 44% Treatment terminated 56% Treatment ongoing	307		DERS	101.80 (25.45)		87.60 (29.58)		d = −0.59	Change in emotion dysregulation primarily had an indirect effect (through change in self-image), while change in self- image had a direct effect, on change in ED psychopathology improvement.
Jain et al. (2020)	RCT	PTSD or Depression	STAIR vs TAU	emotion regulation skills, Self-compassion	5 × 60-min sessions	13	13	DERS	103.9 (21.1)	110.5 (25.4)	79.3 (17.2)	104.1 (21.4)	Pre-Post STAIR g = 1.38 TAU g = 0.30
											3-month 85.3 (19.0)	3-month 102.7 (20.2)	Pre-3-month STAIR g = 0.90 TAU g = 0.44
Doorn et al. (2014)	Open trial	Moderate to severe emotional problems	EDT	the therapist helps the patient to gradually experience more underlying feeling while regulating anxiety and reducing defensive behaviors	one 2- to 3-hour initial session	31		SCS-SF	24.88 (8.10)		27.16 (7.85)		d = 0.38
Chavooshi et al. (2017)	RCT	MUP	ISTDP online vs in-person ^b	emotional awareness, tolerate and experience emotions	16 × 60-min weekly sessions	Online 39	In-person 42	ERQ: Reappraisal	16.2 (6.5)	17.91 (6.5)	16.2 (5.7)	24.12 (4.8)	Pre-Post Online d = 0.48 In-persion d = 0.77
											12-month 15.4 (5.6)	12-month 24.1 (6.3)	Pre-12-month Online d = 0.49 In-persion d = 0.74
								ERQ: Suppression	12.3 (8.5)	11.15 (7.9)	11.9 (7.5)	5.52 (3.4)	Pre-Post Online d = 0.48 In-persion d = 0.94
											12-month 11.3 (7.2)	12-month 7.51 (3.5)	Pre-12-month Online d = 0.42 In-persion d = 0.73
Iwakabe et al. (2022)	Open trial	Transdiagnostic	AEDP	dyadic affect regulation	16 × 60-min sessions	63		DERS	94.62 (22.93)		76.97 (21.25)		Pre-Post d = −0.77
											6-month 74.13 (22.48)		Pre-6-month d = −1.03
											12-month 71.02 (21.16)		Pre-12-month d = −0.92
								SCS	15.53 (3.93)		19.44 (4.73)		Pre-Post d = 0.99
											6-month 19.98 (5.00)		Pre-6-month d = 1.32
											12-month 19.71 (4.69)		Pre-12-month d = 0.94
								AAQ-II	30.57 (6.61)		21.82 (8.24)		Pre-Post d = −1.25
											6-month 19.90 (7.74)		Pre-6-month d = −1.77
											12-month 19.75 (8.63)		Pre-12-month d = −1.46
Glisenti et al. (2018)	Case reports	BED	EFT	Phase 1: promoting awareness of emotions, welcoming and accepting emotions, putting emotions into words, identifying primary emotions Phase 2: evaluating whether the primary emotion was adaptive or maladaptive, identifying destructive emotion schemes, accessing other adaptive emotions and needs, and transforming maladaptive emotion schemes	12 × 60-min weekly sessions	6		DERS	101.23 (18.75)		53.67 (8.69)		[g = 1.66]
Normann-Eide et al. (2015)	Open trial	BPD or APD	Step-down treatment or outpatient treatment		Step-down treatment ^c: Median 45 individual session Outpatient treatment: Median 46 individual session	52		ACI: Global AC	3.58 (0.50)		3-year 4.00 (0.58)		d = 0.84	The AC change explained 7.7% of the variance in CIP (p = .033), 8.6% of the variance in Identity Integration (p = .026), and 8.7% of the variance in Relational Capacities (p = .005) at 3-year.
Mennin et al. (2018)	RCT	GAD	ERT vs MAC	patients were encouraged to deploy regulation skills during in-session and out-of-session exposures	20 × 60- to 90-min weekly sessions	28	25	ERQ: Reappraisal	22.6 (6.2)	21.6 (9.2)	Mid 26.4 (5.2) Post 29.7 (4.4)	Mid 21.6 (9.7) Post 24.0 (9.9)	g = 0.54	All proposed mediators showed an indirect effect of group on the primary outcomes. For example, GAD CSR was mediated by ERQ Reappraisal (B = -.27, p < .05) and DERS (B = -.39, p < .05).
								DERS	98.2 (23.1)	104.8 (22.4)	Mid 82.3 (20.3) Post 74.6 (19.0)	Mid 102.2 (23.2) Post 96.0 (22.0)	g = 0.80
O'Toole et al. (2019)	Open trial	GAD	ERT	the cultivation of emotion regulation skills	16 × 60- to 90-min weekly sessions	31		ERQ: Reappraisal	20.8 (7.8)		29.2 (7.3)		d = 0.9	Changes in cognitive reappraisal temporally preceded changes in all three outcomes (PSWQ, z = −2.37, p = .018, r = .42; STAI-7, z = −2.43, p = .016, r = .43; GAD-7, z = −2.19, p = .029, r = .39).

Note. ER: Emotion Regulation.

Disorder: SAD; Social Anxiety Disorder; AUD; Alcohol Use Disorder; OCD; Obsessive Compulsive Disorder; GAD; Generalized Anxiety Disorder; SUD; Substance Use Disorder; BPD; Borderline Personality Disorder; BN; Bulimia Nervosa; ED; Eating Disorder; PDA; Panic Disorder with Agoraphobia; PTSD; Posttraumatic Stress Disorder; MUP; Medically Unexplained Pain; APD; Avoidant Personality Disorder; BED; Binge-Eating Disorder.

Intervention: ACT: Acceptance and Commitment Therapy; TAU: Treatment As Usual; PRT: Progressive Relaxation Training; CBT: Cognitive Behavioral Therapy; WL: Waiting List; ABBT: Acceptance-Based Behavior Therapy; EBCT: Exposure-Based Cognitive Therapy; MABT: Mindful Awareness in Body-oriented Therapy; WHE: Women’s Health Education; DBT: Dialectical Behaviour Therapy; UP: Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders; CMT: Compassionate Mind Training; ICAT: Integrative Cognitive-Affective Therapy; CBT-E: Cognitive-Behavioral Therapy-Enhanced; CBT-RR: Cognitive Behavior Therapy for Rapid Response; MI: Motivational interviewing; STAIR: Skills Training in Affective and Interpersonal Regulation; EDT: Experiential Dynamic Therapy; ISDP: Intensive Shortterm Dynamic Psychotherapy; AEDP: Accelerated Experiential Dynamic Psychotherapy; EFT: Emotion-Focused Therapy; ERT: Emotion Regulation Therapy; MAC: Modified Attention Control.

Outcome measure: AAQ: Action and Acceptance Questionnaire; SCS: Self-Compassion Scale; DERS: Difficulty in Emotion Regulation Scale; ERQ: Emotion Regulation Questionnaire; SCS-SF: Self-Compassion Scale-Short Form; ACI: Affect Consciousness Interview; HRS: Hamilton Rating Scale; BDI-II: Beck Depression Inventory-II; CIP: Circumplex of Interpersonal Problems (A 48-item version of the Inventory of Interpersonal Problems); CSR: Clinician’s Severity Rating from the Anxiety Disorders Interview Schedule for DSM-IV; Lifetime Version, PSWQ: Penn State Worry Questionnaire; STAI-7: State Trait Anxiety Inventory-7; GAD-7: Generalized Anxiety Disorder-7.

^a Effect sizes shown in [] were calculated by the authors.

^b This meta-analysis used in-person data only.

^c 18-week day-hospital treatment and then 90-min weekly group therapy for a maximum of 4 years and weekly individual therapy for a maximum of 2.5 years.

Figure 2. Funnel plot of treatment effects on emotion regulation outcomes.

Table III. Effect sizes by outcome assessment timet, ER measure, treatment package, control group, disorder.

Comparison	Number Studies	Hedges's g and 95% confidence interval				Heterogeneity
		Point estimate	Lower limit	Upper limit	P-value	Q-value	df (Q)	P-value	I-squared
Time Point
Pre-Post	28	0.82	0.71	0.93	<.001	155.68	27	< .001	82.66
Pre-2- to 6-month follow-up	10	0.86	0.59	1.14	<.001	34.69	9	< .001	74.06
Pre-12-month follow-up	3	0.71	0.26	1.15	.002	18.81	2	<.001	89.37
Post-2- to 6-month follow-up	10	−0.07	−0.26	0.12	.456	21.44	9	.011	58.02
Post-12-month follow-up	3	0.03	−0.29	0.35	.871	11.85	2	.003	83.12
ER measure
AAQ	10	0.97	0.70	1.24	<.001	60.75	9	<.001	85.18
DERS	13	0.96	0.74	1.19	<.001	82.11	12	<.001	85.39
ERQ-Reappraisal	4	1.00	0.81	1.19	<.001	0.99	3	.804	0.00
ERQ-Suppression	3	0.49	0.08	0.90	.020	10.94	2	.004	81.72
SCS	4	0.86	0.35	1.38	.001	25.51	3	<.001	88.24
Treatment package
ACT	7	0.95	0.57	1.32	<.001	33.46	6	<.001	82.07
DBT	3	1.11	0.54	1.67	<.001	4.55	2	.103	56.03
UP (ERQ-Combined and DERS)	2	0.66	0.34	0.98	<.001	1.20	1	.273	16.95
UP (ERQ-Reappraisal and DERS)	2	0.90	0.60	1.21	<.001	0.25	1	.619	0.00
CBT	3	0.56	0.40	0.72	<.001	2.83	2	.244	29.19
ERT	2	1.07	0.78	1.37	<.001	0.01	1	.909	0.00
Experiential (EDT, ISTDP, AEDP, and EFT)	4	0.87	0.47	1.26	<.001	25.29	3	<.001	88.14
Control
Active control	9	0.67	0.39	0.94	<.001	18.71	8	.016	57.24
Waiting list	3	1.51	0.85	2.18	<.001	4.00	2	.135	50.03
No control	16	0.83	0.70	0.96	<.001	121.56	15	<.001	87.66
Disorder
Depression/Anxiety	10	0.82	0.60	1.05	<.001	42.16	9	<.001	78.65
OCD	2	1.46	−0.09	3.01	.064	8.21	1	.004	87.82
PD	5	0.93	0.61	1.26	<.001	16.04	4	.003	75.06
ED	4	0.81	0.34	1.27	.001	17.44	3	.001	82.80
SUD	2	0.85	0.47	1.23	<.001	1.15	1	.283	13.14

ER: Emotion Regulation; AAQ: Action and Acceptance Questionnaire; DERS: Difficulty in Emotion Regulation Scale; ERQ: Emotion Regulation Questionnaire; SCS: Self-Compassion Scale; ACT: Acceptance and Commitment Therapy; DBT: Dialectical Behaviour Therapy; UP: Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders; CBT: Cognitive-Behavioral Therapy; ERT: Emotion Regulation Therapy; EDT: Experiential Dynamic Therapy; ISDP: Intensive Shortterm Dynamic Psychotherapy; AEDP: Accelerated Experiential Dynamic Psychotherapy; EFT: Emotion-Focused Therapy; OCD: Obsessive Compulsive Disorder; PD: Personality Disorder; ED: Eating Disorder; SUD: Substance Use Disorder.

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