J Head Trauma Rehabil

Vol. 32, No. 5, pp. 354–365

Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved.

Improving Emotion Regulation

Following Web-Based Group
Intervention for Individuals With
Traumatic Brain Injury
Theodore Tsaousides, PhD; Lisa Spielman, PhD; Maria Kajankova, PhD;
Gabrielle Guetta, BA; Wayne Gordon, PhD; Kristen Dams-O’Connor, PhD

Objective: Preliminary evaluation of the efficacy of a Web-based group intervention (Online EmReg) to improve
emotion regulation (ER) in individuals with traumatic brain injury (TBI). Design: Pre-/post-within-subject design
with baseline, end-of-treatment, and 12-week follow-up assessments. Participants: Ninety-one individuals with TBI
and deficits in ER. Intervention: Twenty-four sessions of training in ER skills delivered by group videoconference.
Measures: Difficulties in Emotion Regulation Scale (DERS), Positive Affect Negative Affect Schedule (PANAS),
Satisfaction With Life Scale (SWLS), Problem Solving Inventory (PSI), Social Problem Solving Inventory-Revised:
Short Form (SPSI-R:S), and Dysexecutive Questionnaire (DEX). Results: Significant changes with large effect sizes
were found for the DERS at the 12-week follow-up assessment. Significant and moderate changes were found on
the SWLS, DEX, PSI, and subscales of the PANAS and SPSI-R:S. Conclusions: Online EmReg appears to be a
promising method of delivering a group intervention to improve ER following TBI. Key words: emotion regulation,
group treatment, telerehabilitation, traumatic brain injury, videoconferencing

E MOTION REGULATION (ER) refers to a set

of heterogeneous neuropsychological processes in-
volved in monitoring, evaluating, and modifying emo-
tional reactions.1 Well-developed ER skills enable in-
dividuals to modify their emotional and behavioral
responses at will and according to goal objectives
and situational demands.2 Deficits in ER are common
among individuals with traumatic brain injury (TBI)3,4
and are associated with a broad range of symptoms,
Author Affiliations: Department of Rehabilitation Medicine, Icahn
School of Medicine at Mount Sinai, New York.
This research was funded by National Institute on Disability, Independent
Living and Rehabilitation Research (grant H133A120084) and carried out
at the Brain Injury Research Center, Department of Rehabilitation Medicine,
Icahn School of Medicine at Mount Sinai.
The authors extend their gratitude to the following individuals for their intel-
lectual contribution and technical support: Emily D’Antonio, Colette Elliott,
Erica Kaplan, William Lu, Nicole Murray, and Melissa Paretsky, who served
as the therapists who delivered Online EmReg; Jennifer Oswald, who served
as the research assistant for partial duration of the project and who subse-
quently coded the exit interviews; and Jason Krellman, for providing clinical
supervision and support to the therapists for partial duration of the project.
The authors declare no conflicts of interest.
Corresponding Author: Theodore Tsaousides, PhD, Department of Rehabil-
itation Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L.
Levy Pl, Box 1240, New York, NY 10029 (theodore.tsaousides@mssm.edu).
DOI: 10.1097/HTR.0000000000000345
including failures in executive functioning (eg, im-
pairments in goal-directed behavior, failed problem-
solving),5–8 emotional and behavioral disinhibition (eg,
aggression, irritability, impulsive behavior, socially in-
appropriate conduct), and reduced emotional awareness
and expression (eg, alexithymia, passivity, apathy).2,7,9
Deficits in ER can neutralize the potential benefit of
other rehabilitation treatments by affecting attendance
and participation, reducing capacity for engagement and
rapport building, and consuming already compromised
cognitive resources necessary for processing new infor-
mation and learning new skills. For example, Spikman
et al7 demonstrated that impaired emotion recognition
prior to treatment onset was negatively associated with
outcomes on executive function measures for patients
with acquired brain injury. The multitude of problems
related to reduced capacity for ER highlight the impor-
tance of developing interventions to improve ER skills.
Nevertheless, there are limited reports in the literature
of such interventions.
Existing approaches to emotional problems follow-
ing TBI focus on specific symptoms and behaviors
(eg, agitation,10 irritability,11 anger,12,13 impulsivity,14
disinhibition),15 psychiatric diagnoses (eg, anxiety,16,17
depression18,19 ), or global outcomes (eg, coping skills,
psychological well-being, quality of life, and social

354

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 Online EmReg for Emotion Regulation in TBI
integration).20,21 Although these interventions are ef-
fective in reducing specific symptoms, their impact on a
person’s overall capacity for ER (volitional up- or down-
regulation of emotion) has not been addressed. While
deficits in ER are often found in a broad range of psychi-
atric disorders (eg, mood and anxiety disorders, border-
line personality disorder, posttraumatic stress disorder),
problems with ER can occur in the absence of overt
psychopathology.22 Consequently, treatments targeting
psychiatric symptoms or diagnoses following TBI may
not be sufficient for improving ER skills.
Only a small number of studies have included ER as
a treatment target or outcome in brain injury research,
with promising results. For example, Neuman et al23 re-
ported improvements on a measure of ER after 8 individ-
ual sessions of emotional self-awareness training. Three
more studies have incorporated training in ER as a com-
ponent of group treatment aimed at improving execu-
tive functioning.24–26 Rath et al24 offered participants 12
hourly sessions of “emotional self-regulation,” followed
by 12 hourly sessions of “clear thinking,” and found
improvements for the experimental group on a self-
regulation subscale of a problem-solving questionnaire.
Tornås et al25 incorporated ER training in a Goal Man-
agement Training protocol and reported improvements
after eight 2-hour group sessions. Cantor et al26 tested
the efficacy of a day treatment program to improve ex-
ecutive functioning consisting of a problem-solving in-
tervention (SWAPS) and an ER intervention (EmReg).
The authors found significant changes on measures of
executive functioning and problem solving. While they
found no significant changes on a measure of ER, only
about a third of the 98 participants reported clinically
significant ER deficits at treatment onset. EmReg was
designed to be delivered as a stand-alone intervention
to improve ER in individuals with TBI.26 To date, how-
ever, its effectiveness has not been investigated.
DELIVERY INNOVATION
Access to healthcare is a significant challenge for in-
dividuals with TBI. Limited proximity to medical cen-
ters, scarcity of specialized professionals, limited trans-
portation options, and limited finances are some of the
barriers that limit access to appropriate rehabilitation
services.27–31 One way to address these barriers is to
identify alternatives to the traditional in-person format
of most rehabilitation interventions. Telerehabilitation
(TR), the delivery of rehabilitation services via infor-
mation and communication technologies,32 is a viable
option because it is not constrained geographically and
could therefore increase access to high-quality care and
improve the welfare of individuals with TBI.
In the last decade, interest in TBI TR interventions
has grown considerably, as reflected in the number of
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355
published studies and reviews.33–37 TR interventions
have targeted cognitive,37–40 emotional,41–44 and so-
cial and vocational functioning.45 Videoconference is
a promising TR approach. In non-TBI samples, stud-
ies employing videoconference have reported clinical
outcomes and therapeutic alliance similar to those of
face-to-face studies.46 The use of videoconferencing in
TBI TR is promising as well.47–49
Advances in videoconference technology make pos-
sible the participation in an online meeting of mul-
tiple people at once. Until recently, however, lim-
ited research existed on the use of videoconference
to deliver group interventions in both TBI and non-
TBI samples.36,46,50,51 To test the feasibility of de-
livering a group intervention to individuals with
TBI through Web-based videoconferencing, Tsaousides
et al36 adopted and modified EmReg, the ER interven-
tion created by Cantor et al,26 for online delivery (On-
line EmReg) and conducted a pilot study with 7 par-
ticipants. Participants in their study showed excellent
attendance (only 5 sessions missed across all partici-
pants), acquired the skills taught (all obtained >80 on
a content-based quiz), were able to complete the study
measures online (83% of 28 surveys per person), and re-
ported high satisfaction with treatment (5.3/6 and 5.9/6
for treatment modality and therapist, respectively). Exit
interviews with each participant supported the feasibil-
ity and appeal of the intervention further. This was the
first report in the literature of a group TR intervention
for individuals with TBI and provided the groundwork
for the current study.
CURRENT STUDY OBJECTIVES
The objective of this study was to evaluate the effi-
cacy of Online EmReg. Our main hypothesis was that
Online EmReg would lead to statistically significant im-
provements in ER, change of 0.5 standard deviation
(SD) or higher on the primary outcome measure, the
Difficulties in Emotion Regulation Scale [DERS]52 ), by
the end of treatment and at follow-up. Three additional
research questions were explored: (a) Do participants
report improvements on measures of subjective well-
being and executive function following Online EmReg?
(b) Do participants report improvements on their indi-
vidual treatment goals? and (c) Do participants report
satisfaction with the intervention?
METHODS
Participants
Participants were recruited through ClinicalTri-
als.gov, announcements on our Web site and social me-
dia, mailings to participants in past studies, flyers posted
in designated areas throughout the institution, and
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356 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2017

referrals from Brain Injury Associations throughout the
United States and other rehabilitation specialists. Eligi-
bility criteria included 18 years of age or older; English-
speaking; documented TBI of any severity; at least
6 months postinjury; emotional dysregulation defined
by a score of 0.5 SD above published means on the
DERS52 (a cutoff score of 88 for females and 90 for
males); access and ability to use a device that supports
videoconferencing (desktop, laptop, tablet); access to
high-speed Internet; absence of substance/alcohol abuse
or psychosis in the past 6 months; and absence of
active suicidality as assessed using the Mini Interna-
tional Neuropsychiatric Interview (MINI).53 Presence,
history, and severity of TBI were assessed using medi-
cal records, the Brain Injury Screening Questionnaire
(BISQ),54 and American Congress of Rehabilitation
Medicine criteria.55
Power calculations based on a treatment effect size of
δ = 0.4 indicated that 70 participants were required to
detect treatment effects with 90% power. Of 154 individ-
uals screened for eligibility, 110 met inclusion criteria,
91 began treatment, 81 completed treatment, and 75
completed the follow-up assessment (see Figure 1).
Demographic and injury characteristics for the final
sample are included in Table 1. The sample de-
mographics are similar to those recruited in other
community-based TBI trials of psychosocial interven-
tions for TBI.18,24,26 Approval for the study was granted
by our institutional review board. Informed consent
was obtained from all participants via telephone.
Measures
Primary outcome measure
Difficulties in Emotion Regulation Scale52
The DERS is a 36-item self-report questionnaire as-
sessing a range of ER skills. It yields a total score and 6
subscales scores: Nonacceptance (negative self-appraisal
when experiencing negative emotion); Goals (inability
to engage in goal-directed behavior when experienc-
ing negative emotions); Impulse (difficulty controlling
impulsive behavior when experiencing negative emo-
tions); Awareness (lack of awareness or interest in one’s
emotions); Clarity (ability to identify and differentiate

Figure 1. Online EmReg enrollment flowchart. DERS indicates Difficulties in Emotion Regulation Scale; TBI, traumatic brain
injury.

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 Online EmReg for Emotion Regulation in TBI 357

TABLE 1 Demographic and clinical characteristics

Participant characteristics Mean (SD) na %
a
Age 47.08 (11.84)
Gender
Female 51 56.04
Race
White 72 79.12
Black 7 7.69
Asian/Pacific Islander 1 1.10
Hispanic 6 6.59
Other 5 5.49
Annual household income
$0-$9999 8 8.79
$10 000-$19 999 15 16.48
$20 000-$39 999 22 24.18
$40 000-$59 999 7 7.69
$60 000-$99 999 14 15.38
≥$100 000 15 16.48
Unknown 10 10.99
Marital status
Single, never married 32 35.16
Widowed/divorced/separated 19 20.88
Married 40 43.96
Years of education 15.54 (2.32)
Employment status
Not working 44 48.35
Volunteering 23 25.27
Part-time worker 13 14.29
Full-time worker 11 12.09
Injury severityb
Mild 43 47.25
Moderate 10 10.99
Severe 30 32.97
Don’t know/remember 8 8.79
Months since injuryc 119.24 (129.67)

aN = 91.
severity was defined using American Congress of Rehabilitation Medicine criteria for loss of consciousness (0-30 minutes =
b Injury

mild; >30 minutes and <24 hours = moderate; >24 hours = severe).
c Months since injury was calculated by subtracting the date of screening from the date of most serious brain injury.

between emotions); and Strategies (access to effective ER
strategies). Items are rated on a 5-point Likert scale rang-
ing from 1 (almost never) to 5 (almost always). Higher
scores indicate more difficulties in ER. The DERS has
been used in ER research both in non-TBI56–58 and TBI
samples.23,26
Secondary outcome measures
Affect and subjective well-being
Positive Affect Negative Affect Schedule59
The Positive Affect Negative Affect Schedule
(PANAS) consists of 20 emotion adjectives (10 positive,
10 negative). Participants are asked to state the degree to
which they feel each of the emotions described by the
adjectives on a scale from 1 (not at all) to 5 (extremely).
Scoring the PANAS yields 2 independent scales:
Positive Affect and Negative Affect. The PANAS has
been previously used in TBI research60,61 and has good
psychometric properties.
Satisfaction With Life Scale62
The Satisfaction With Life Scale (SWLS) is a 5-item
measure of global satisfaction with life. Participants rate
the 5 items on a 7-point scale ranging from 1 (strongly
disagree) to 7 (strongly agree). The SWLS is psycho-
metrically sound63 and used frequently in research on
quality of life following TBI.64
Executive functioning and problem solving
Problem Solving Inventory65
The Problem Solving Inventory (PSI) is a 35-item self-
report measure of problem-solving capabilities. Items are
rated on a 6-point Likert scale ranging from 1 (strongly
agree) to 6 (strongly disagree). The PSI yields 3 subscale
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358 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2017
scores: Confidence, Approach Avoidance, and Personal
Control.
Social Problem Solving Inventory-Revised: Short Form66
The Social Problem Solving Inventory-Revised: Short
Form (SPSI-R:S) is a 25-item self-report instrument that
assesses problem solving in everyday living. Items are
rated on a 5-point Likert scale ranging from 0 (not at all
true of me) to 4 (extremely true of me). The SPSI-R:S
yields 5 subscales (Positive Problem Orientation, Neg-
ative Problem Orientation, Rational Problem Solving,
Impulsivity/Carelessness, and Avoidance Style). Higher
scores indicate more effective problem solving. Both
the SPSI-R:S and the PSI are psychometrically sound
and are used frequently in TBI research on problem
solving.24,40,67
Dysexecutive Questionnaire68
The Dysexecutive Questionnaire (DEX) is a 20-item
questionnaire used to assess everyday problems with ex-
ecutive functioning. Items are rated on a 5-point Likert
scale ranging from 0 (never) to 4 (very often). The DEX
is often used in brain injury research.69,70
Individual treatment goals
Progress toward goals
During the first session, we asked participants to set 3
to 5 personal goals related to ER and its impact on their
daily lives (eg, “I would like to feel more calm when
there is a list of things to do,” “I would like to be less
angry and frustrated with myself,” “I would like to be
more patient”). Participants rated how much progress
they made toward these goals on a 7-point scale ranging
from 1 (no progress at all) to 7 (very significant progress
at the end of week 2 of treatment, end of treatment, and
end of follow-up).
Transition ratings71,72
This scale is used to assess change on problems that are
treatment targets, from the participants’ point of view,
by reporting how much better/worse the problem being
treated seems to be compared with how challenging it
was at treatment onset. Transition ratings on problems
related to ER were obtained at the end of treatment and
at follow-up.
Satisfaction with treatment
73
Satisfaction with Therapy and Therapist Scale
The Satisfaction with Therapy and Therapist Scale
(STTS) assesses satisfaction with treatment and therapist,
has good psychometric properties, and has been used
extensively in studies evaluating psychological interven-
tions for mood disorders, including TBI samples.18 The
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STTS was adapted to reflect satisfaction with the online
delivery of the intervention.
Exit Interview
To obtain qualitative data, research assistants who
were not involved in the study in any other capacity (ie,
had no prior contact with participant) administered an
exit interview focused on participants’ subjective experi-
ence with the virtual nature of meetings, the content of
the training, and the online assessment procedures. Par-
ticipants were also asked to report challenges and barriers
they encountered during the study (eg, technical prob-
lems, quality of online group interactions, scheduling)
and make suggestions for improvements.
Assessment timeline
The study included a 4-week baseline, a 12-week in-
tervention, and a 12-week follow-up phase. All measures
were administered via an online data collection service
(surveymonkey.com), thus enabling us to deliver the en-
tire study remotely, eliminating the need for participants
to travel. Primary and secondary measures were admin-
istered at baseline, at the end of treatment, and at the
12-week follow-up time point. Individual treatment goal
measures were administered at the end of week 2, at the
end of treatment, and at the 12-week follow-up assess-
ment. The STTS was administered at the end of treat-
ment. The exit interview was conducted by phone within
2 weeks from the end of treatment. Initially, we designed
the study to allow 4 assessments: baseline (4 weeks before
starting treatment), treatment onset (immediately prior
to treatment), end-of-treatment (1 week after treatment),
and follow-up (12 weeks after treatment completion).
However, because of the recruitment pattern, the need
to minimize wait times for individuals seeking treat-
ment, and the need to create groups of adequate size
to begin treatment, participants completed the second
assessment (treatment onset) after treatment began. As a
result, we used only the baseline assessment to compare
pre- and posttreatment responses, since some partici-
pants had already received up to 4 treatment sessions by
the time the treatment-onset assessment was adminis-
tered. However, a comparison between the assessments
showed that all participants continued to be above the
cutoff score for participation (+0.5 SD) by the second
assessment.
Videoconference application
We used GoToMeeting (GTM) to deliver Online Em-
Reg. GTM is a user-friendly, commercially available,
Web-based videoconferencing application that allows
synchronous audiovisual interaction and desktop shar-
ing for up to 6 participants simultaneously. GTM pro-
vides high-security encryption and password protection
 Online EmReg for Emotion Regulation in TBI
to ensure user privacy and confidentiality. To partici-
pate in GTM online meetings, participants can access
the application on the Web or download the applica-
tion on a computer or smart device. Setting up an ac-
count is not required to join a GTM meeting, which
makes access easy, protects confidentiality further, and
is completely cost-free. The meeting organizer (thera-
pist) invites attendees (participants) to join an online
meeting at a prespecified time and date by e-mail. The
e-mail contains a link granting access to that particular
meeting. When running GTM, participants can con-
trol several display features on their own devices (eg,
turning webcam on/off, size of GTM window). GTM
allowed us to maintain important aspects of the origi-
nal EmReg intervention, including the use of a visual-
contextual model, and to maximize the benefits associ-
ated with group interventions (eg, collaborative learning,
increased self-awareness, and emotional support).74,75
Intervention
EmReg is a comprehensive, skill-based intervention
that combines didactics, metacognitive strategies, and
experiential training. It is based on theories of emo-
tions and ER and cognitive-behavioral therapy and em-
phasizes the acquisition and generalization of ER skills
through examination of past, present, and anticipated
incidents of unwanted emotional or behavioral reactiv-
ity. The intervention was delivered by postdoctoral fel-
lows who were trained and supervised by rehabilitation
neuropsychologists with extensive clinical experience in
TBI. Participants received twenty-four 1-hour group ses-
sions twice weekly over 12 weeks. Online EmReg was
divided into 2 parts. Sessions 1 to 8 were dedicated to
psychoeducation. The therapist introduced participants
to the objectives, terminology, and strategies of EmReg
and discussed the role of brain injury in ER and the
need for cognitive supports (eg, use of memory aids)
to facilitate skill development. Sessions 9 to 24 were
focused on skill practice. Participants learned specific
EmReg strategies26 and practiced them in session with
the guidance of the therapist and feedback from the
group. To promote generalization, homework was as-
signed and reviewed regularly. Participants were asked
to identify instances of emotional dysregulation in real-
life contexts, to apply EmReg strategies, and to review
the results in session. We provided participants with a
workbook to use during and between sessions, which
contained didactic information, the EmReg strategies,
and homework assignments.
Procedure
During the initial contact, a research assistant ob-
tained informed consent and conducted a screening in-
terview to determine eligibility. During the interview,
the research assistant obtained information about the
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359
presence, history, and severity of TBI, administered the
BISQ, and requested medical records to cross-refer the
information obtained in the interview. The research as-
sistant asked participants whether they had access to
the technology required to participate (Internet, device
that supports videoconference, private space). Finally,
the research assistant administered the DERS to en-
sure that participants obtained a score of 0.5 SD above
the means published by the instrument developers.52 A
doctoral-level psychologist administered the MINI dur-
ing screening. We assigned participants to groups in
the order in which they enrolled. At treatment onset,
all groups consisted of 4 or 5 participants. By the end
of treatment, a small number of groups had fewer than
4 participants because of unanticipated attrition. Shortly
before treatment onset, each participant received writ-
ten instructions on using GTM and had an individual
GTM meeting with the therapist of his or her assigned
group to test his or her equipment and learn how to
use GTM. During the treatment phase, the therapist
e-mailed participants the meeting access link 2 hours
prior to each session. Twenty minutes prior to each ses-
sion, the therapist launched the GTM meeting to give
participants time to join in and settle. At the end of the
hour, the therapist ended the GTM meeting. This pro-
cedure was repeated for each session. We never used the
same meeting link twice. We generated a new meeting
link for each session to protect privacy and confidential-
ity. During session 1, the therapist reviewed a set of rules
for appropriate conduct in an online group meeting
(eg, respectful behavior, appropriate language, privacy
during the online session, maintaining confidentiality),
which we developed specifically for Online EmReg. We
used GTM’s screen-sharing feature as a visual aid during
sessions to display the EmReg instructional materials
and to use as a writing surface during the session, the
same way a whiteboard would be used in an in-person
meeting. If participants were experiencing technical dif-
ficulties prior to or during an online meeting, a research
assistant was available to help them troubleshoot.
Statistical analysis
We examined change over time using fully within-
subjects, repeated-measures analysis of variance. Gender,
age, and time since injury were examined as potential co-
variates. A priori contrasts were built into each model,
examining change between baseline and posttreatment
assessments and between posttreatment and 12-week
follow-up assessments. In addition to significance test-
ing, we examined effect sizes (η2 ) for each comparison.
Analyses were conducted using SPSS v. 22.76 Before
conducting the main analyses, we examined the stan-
dardized DERS Total and subscale scores at each of
the 3 assessment periods for deviations from normality.
Of the 21 distributions, the Kolmogorov-Smirnov test
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360 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2017

revealed significant nonnormality for 5 (Non-
Acceptance posttreatment and at follow-up, Goals at
follow-up, and Strategies posttreatment and at follow-
up). The remaining 16 distributions did not deviate from
normality. Because analysis of variance is robust to mod-
erate deviations from normality, with several studies77–79
finding no inflation of the false-positive rate, we did not
perform any transformations to the data.
RESULTS
Primary outcome measure
Our main hypothesis was that Online EmReg would
lead to statistically significant changes in ER. Repeated-
measures multivariate analysis of variance revealed
significant improvements on the DERS Total score
(F1.7,74 = 16.08, P < .001, η2 = 0.18, Greenhouse-
Geiser corrected). Means and standard deviations for
the DERS Total and for each subscale score are shown
in Table 2. By the end of the 12-week follow-up, par-
ticipants’ average DERS Total scores decreased by 0.73
SD. We found significant differences in DERS Total
scores both between the baseline and end-of-treatment
assessments (FT1-T2 = 14.18, P < .001, η2 = .16) and
between the end-of-treatment and 12-week follow-up as-
sessments (FT2-T3 = 4.43, P = .04, η2 = 0.06), which indi-
cates that participants continued to improve beyond the
treatment period. None of the potential covariates were
significantly associated with outcome and were not in-
cluded in the models.

TABLE 2 Means and standard deviations at baseline, end-of-treatment, and 12-week

follow-up of primary and secondary outcome measures
Assessment point
Baseline, End of treatment, 12-wk follow-up,
Outcome measuresa mean (SD) mean (SD) mean (SD)
DERSb
Total 104.20 (26.01) 93.79 (24.86) 89.68 (26.32)
Nonacceptance 17.55 (6.63) 15.79 (6.86) 15.08 (6.92)
Goals 18.99 (4.69) 17.05 (4.56) 17.06 (5.40)
Impulse 16.33 (5.89) 13.46 (5.08) 12.54 (4.63)
Awareness 15.74 (4.71) 15.17 (5.06) 14.24 (5.10)
Strategies 22.86 (7.68) 20.34 (7.49) 19.44 (7.38)
Clarity 12.72 (4.71) 11.96 (3.84) 11.30 (3.88)
PANASc
Positive Affect 26.55 (8.66) 27.22 (9.74) 28.85 (10.12)
Negative Affect 23.48 (10.20) 19.15 (9.64) 19.83 (9.09)
SWLSd 15.34 (6.38) 17.90 (7.25) 20.00 (6.98)
DEXe 16.00 (6.10) 26.94 (13.73) 23.36 (11.94)
PSIf
Total 118.81 (25.14) 131.38 (27.01) 131.56 (31.58)
Approach Avoidance 55.63 (14.87) 61.75 (15.96) 61.53 (18.32)
Confidence 39.23 (9.58) 43.67 (9.78) 43.5 (11.32)
Personal Control 12.90 (4.83) 15.68 (5.64) 16.15 (6.51)
SPSI-R:Sg
Total 88.92 (18.03) 91.49 (16.36) 92.42 (20.68)
Positive Problem Orientation 89.63 (17.47) 88.70 (17.65) 92.11 (19.77)
Negative Problem Orientation 114.55 (19.31) 106.97 (16.64) 108.04 (20.65)
Rational Problem Solving 92.18 (16.57) 90.36 (15.89) 93.56 (20.45)
Impulsivity/Carelessness 106.39 (17.93) 104.02 (16.65) 105.32 (20.90)
Avoidance Style 104.97 (17.75) 102.11 (16.90) 103.42 (19.02)

Abbreviations: DERS, Difficulties in Emotion Regulation Scale; DEX, Dysexecutive Questionnaire; NA, Negative Affect; PA, Positive
Affect; PANAS, Positive Affect Negative Affect Schedule; PSI, Problem Solving Inventory; SPSI-R:S, Social Problem Solving Inventory-
Revised: Short Form; SWLS, Satisfaction With Life Scale.
a Higher scores on DERS, PANAS-NA indicate more deficits; higher scores on PANAS-PA, SWLS, DEX, PSI, SPSI-R:S indicate fewer

deficits.
b N = 75.
c N = 67.
d N = 50.
e N = 38.
f N = 60.
g N = 71.

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 Online EmReg for Emotion Regulation in TBI
There were significant changes across all 6 DERS sub-
scales of medium to large effect sizes. In order of mag-
nitude by effect size, significant changes were found for
Impulse (F1.7,74 = 24.26, P < .001, η2 = 0.25), Strategies
(F1.8,74 = 12.32, P < .001, η2 = 0.14), Goals (F1.8,74 =
8.24, P < .001, η2 = 0.10), Nonacceptance (F1.7,74 =
6.80, P < .001, η2 = 0.08), Clarity (F1.8,74 = 5.87, P <
.01, η2 = 0.07), and Awareness (F1.9,74 = 4.37, P < .05,
η2 = 0.06), all Greenhouse-Geisser corrected.
Secondary outcome measures
Means and standard deviations on the PANAS,
SWLS, SPSI-R:S, and PSI are shown in Table 2, which
illustrate the mixed results we found with respect to
participants’ baseline and posttreatment scores on these
measures.
Positive Affect Negative Affect Schedule
Participants’ scores on the Positive Affect subscale
of the PANAS improved but not significantly (F2,132 =
2.7, ns). Scores on the Negative Affect subscale decreased
significantly (F2,132 = 6.4, P = .002, η2 = 0.088).
Satisfaction With Life Scale
Participants reported significantly higher levels of sat-
isfaction with life by the end of the study (SWLS F2,98
= 10.65, P < .001, η2 = 0.18). Participants’ scores
on the SWLS improved from pretreatment to end-of-
treatment assessments (FT1-T2 = 5.59, P = .022, η2 =
0.10) and continued to improve significantly between
end-of-treatment and follow-up assessments (FT2-T3 =
6.32, P = .015, η2 = 0.11).
Measures of executive function
Significant improvements of large effect size were ob-
served on the DEX (F2,74 = 20.90, P < .001, η2 = 0.28).
Participants showed significant improvements on the
PSI (F2,118 = 14.54, P < .001, η2 = 0.20) and all of
the PSI subscales (Table 2). We observed a trend toward
improvement on the SPSI-R:S as well, but the changes
were not statistically significant. However, we found sig-
nificant changes on the Negative Problem Orientation
subscale of the SPSI-R:S (F2,140 = 12.52, P < .001, η2 =
0.152).
Individual treatment goals
Progress toward goals
Participants’ own ratings of their progress toward the
goals they set for themselves at the onset of Online
EmReg changed significantly over time (F2,102 = 59.87,
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
361
P < .001, η2 = 0.54). Participants reported making sub-
stantial progress toward their goals, beyond the end of
treatment.
Transition ratings
Similarly, on a self-assessment measure of change with
respect to capacity for ER, 48.6% of the participants
reported large improvement, 40.6% reported moderate
improvement, and only 10.8% reported no or minimal
improvement.
Satisfaction with treatment
Satisfaction with Therapy and Therapist Scale
On the Satisfaction with Therapy factor of the STTS,
the mean score at the end of treatment was 5.2/6.0,
whereas on the Client Evaluation of Therapist factor, the
mean score was 5.6/6.0, suggesting an overall satisfaction
with the online delivery of the intervention.
Exit interview
The majority of participants stated that they found
Online EmReg to be helpful and convenient. When
asked what they liked about it, they mentioned that it
was a good learning experience (45%), they enjoyed the
connection with others (25%), and thought it was con-
venient to connect from home (13%). When asked what
they did not like about the intervention, 12% mentioned
technical difficulties, 10% alluded to group dynamics
(eg, people monopolizing conversations), and 9% re-
ferred to organizational issues (eg, the group time felt
too short). About 50% of responses to this question ex-
plicitly stated that there was nothing they disliked about
Online EmReg. The majority of participants (98.5%)
stated that they found the material relevant to them and
their goals.
DISCUSSION
This study built upon previous findings that demon-
strated feasibility of delivering a complex inter-
vention, such as EmReg, online using Web-based
videoconference.29 The reasonable next step was to de-
sign a study to explore the effectiveness of Online Em-
Reg. Limited access to post–acute rehabilitative care after
TBI necessitates innovation in the delivery of empiri-
cally supported interventions in ways that preserve their
active ingredients, minimize barriers to access, and have
the potential to improve the lives of many people.
The results of the study provide preliminary evidence
that Online EmReg is an effective intervention for im-
proving a broad range of ER skills. Difficulties in ER
were significantly reduced following the intervention
and continued to diminish by follow-up, which suggests
www.headtraumarehab.com
362 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2017
that participants continued to use and apply the strate-
gies they learned beyond their time in treatment. Trans-
ferring the skills learned outside the treatment context,
and applying them to daily life, is a necessary compo-
nent of effective neuropsychological rehabilitation inter-
ventions. Skill transfer is embedded in EmReg and re-
inforced through repeated homework assignments. The
fact that scores on the DERS continued to improve
through the follow-up period suggests that maintenance
of treatment effects was achieved.
Improvements were noted on other measures of well-
being and executive functions as well. There is a hy-
pothesized relationship between ER and difficulties in
problem solving following TBI6,24 such that emotional
dysregulation interferes with effective problem solving.
Gaining the ability to manage their emotions more effec-
tively would be expected to have a positive impact on the
participants’ ability to engage in problem solving, by ex-
ercising better impulse control and making more cogni-
tive resources available for choosing, planning, and ini-
tiating executive behaviors. In addition, acquiring strate-
gies to enhance emotional awareness and regulation
could potentially strengthen the participants’ sense of
self-efficacy over their behavioral control, which could
result in a more positive self-evaluation across measures.
Incidentally, participants obtained higher scores on the
PSI but showed only marginal improvement on the
SPSI-R:S. However, significant improvement was noted
on the Negative Problem Orientation subscale. The Neg-
ative Problem Orientation scale assesses how much of
a threat to well-being, how much frustration, and how
much doubt are experienced when confronted with a
problem. Learning ER strategies may have enabled par-
ticipants to deal with the emotional consequences of be-
ing faced with a challenge more successfully. In contrast,
the Positive Problem Orientation subscale assesses atti-
tudes and skills related to constructive problem-solving,
something which is not the target of EmReg. There-
fore, the lack of improvement on this subscale is not
surprising, given the focus on the intervention on mit-
igating emotional and behavioral responses and not on
problem-solving strategy training.
Another promising result of this study was that we
were able to deliver a complex and interactive interven-
tion to a group of people remotely. In previous interven-
tion trials, we limited delivery to in-person participation
and designated our catchment area to a 90-mile radius.
This selection criterion not only affected the rate of
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