Psychotherapy Research

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Enhancing emotion regulation

Shigeru Iwakabe, Kaori Nakamura & Nathan C. Thoma

To cite this article: Shigeru Iwakabe, Kaori Nakamura & Nathan C. Thoma (2023): Enhancing
emotion regulation, Psychotherapy Research, DOI: 10.1080/10503307.2023.2183155
To link to this article: https://doi.org/10.1080/10503307.2023.2183155

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Psychotherapy Research, 2023
https://doi.org/10.1080/10503307.2023.2183155

EMPIRICAL PAPER

Enhancing emotion regulation∗

SHIGERU IWAKABE , KAORI NAKAMURA , & NATHAN C. THOMA

Department of Psychology, Ritumeikan University, Ibaraki-Shi, Japan

(Received 12 January 2023; revised 15 February 2023; accepted 15 February 2023)

ABSTRACT
Background: Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives:
This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential
methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER.
Method: A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A
total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation. Results: In eight
studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused
therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods
from pre- to post-treatment was large (g = 0.82). Conclusions: Both affect-focused and structured skill training are
associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must
consider how patients’ cultural backgrounds inform display rules, as well as what might be considered adaptive or
maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

Keywords: psychotherapy methods; emotion regulation; affect-focused therapies; emotional awareness; experiential
avoidance; psychotherapy; psychotherapy outcome; meta-analysis

Clinical Impact Statement

. Enhancing patient emotional regulation capacity
is therapeutic for a variety of behavioral
disorders.
. Therapists may use either affect-oriented
methods or structured psychoeducational and
skill training methods to work with emotion
regulation.
. Therapist in-session methods aimed at undoing
experiential avoidance, enhancing emotional
awareness, promoting a full emotional experi-
ence, and teaching strategies to cope with dis-
tress may be effective in facilitating in-session
emotion regulation.
Emotion dysregulation is considered one of the
common core mechanisms of psychopathology
(Gratz et al., 2015) and is an emerging transdiagnos-
tic focus of psychotherapy for a wide range of behav-
ioral disorders. Frequent methods of enhancing
patient emotion regulation across a variety of treat-
ment packages include: (a) undoing avoidance of
negative emotions, (b) enhancing emotional aware-
ness, (c) allowing the full experience of feared or
avoided emotion, (d) learning effective cognitive
reappraisal, and (e) learning behavioral and action
strategies to modulate unpleasant emotions
(Berking et al., 2008; McMain et al., 2010).

∗
This article is adapted, by special permission of Oxford University Press, by the same authors in C. E. Hill & J. C. Norcross (Eds.) (2023),
Psychotherapy skills and methods that work. New York: Oxford University Press. The interorganizational Task Force on Psychotherapy
Methods and Skills was cosponsored by the APA Division of Psychotherapy/Society for the Advancement of Psychotherapy.
Correspondence concerning this article should be addressed to Shigeru Iwakabe Department of Psychology, Ritumeikan University,
Iwakuracho2-150, Ibaraki-Shi, Osaka, 567-8570, Japan. Email:siwakabe@fc.ritsumei.ac.jp

© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium,
provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The terms on which this article has
been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2 S. Iwakabe et al.
Psychotherapies that address emotion regulation
can be roughly divided into two groups. The first
group consists of structured psychoeducation and
emotion regulation skills training rooted in the cogni-
tive behavioral tradition. These include the unified
protocol (UP; Barlow et al., 2017), acceptance-and
commitment therapy (ACT; Hayes, 2004), dialecti-
cal-behavior therapy (DBT; Linehan, 1993), and
mindfulness-based cognitive therapy (MBCT; Segal
et al., 2002). The methods developed specifically to
address emotion regulation skills include skills train-
ing in affect and interpersonal regulation (STAIR;
Cloitre et al., 2002), acceptance-based behavioral
therapy (ABBT; Roemer et al., 2008), emotion regu-
lation therapy (ERT; Mennin et al., 2015; Renna
et al., 2017), and affect regulation training (ATR:
Berking & Lukas, 2015).
The second group of psychotherapies is affect-
focused, experiential treatments that aim to facilitate
immediate patient ER, most often used in affect-
focused therapies. These include emotion-focused
therapy (EFT; Greenberg, 2021), accelerated experi-
ential dynamic psychotherapy (AEDP; Fosha, 2021),
affect phobia therapy (McCullough et al., 2003), and
intensive short-term dynamic psychotherapy (ISTDP:
Abbass, 2015; Frederickson et al., 2018). The thera-
pist helps patients tolerate and regulate maladaptive
emotions and transform them by facilitating the
experience of adaptive emotions (Greenberg, 2021),
ultimately resulting in decreased emotional arousal
and greater calmness and wellbeing (Fosha, 2021).
Although these approaches have somewhat differ-
ent therapeutic foci reflecting respective underlying
theories of emotion regulation, they nonetheless
address patient emotion regulation as one of the
central targets of psychotherapy. In the structured
methods, modules address each of the above
emotion regulation components and progressively
build emotion regulation capacities. In affect-
focused methods, therapists try to be responsive to
the patient’s immediate emotional experiencing in
selecting an optimally facilitative method.
Definitions and Clinical Description
Emotion regulation (ER) refers to the process of mod-
ulating one or more aspects of an emotional experi-
ence or response (Gross, 1998). Regulated emotion
keeps the individual within a window of tolerance
in which optimal emotional functioning is possible
(Greenberg, 2021; Siegel, 1999). Emotion regu-
lation is considered to be intrinsic to mental health
and adaptive psychological functioning.
ER involves both internal and external actions to
initiate, increase, maintain, decrease, or transform
both positive and negative emotions in response to
changing demands of emotion-evoking situations.
Although often used to refer to a person’s behaviors
undertaken once distressing emotions have occurred,
ER also includes emotion generation, which is how
emotion occurs (e.g., Campos et al., 2004). Thus,
therapeutic work is not only about teaching strategies
to cope with emotions that have already occurred but
about transforming those aversive emotions so that
more adaptive emotions are experienced in their
place (Greenberg, 2021).
There is no singular therapist method directly
associated with enhancing patient ER. Therefore,
enhancing ER can be defined as a group of therapist
methods and responses designed to build and
strengthen patient emotion regulation capacity. That
can be accomplished through a variety of means: pro-
viding relational and dyadic responses, facilitating
emotional processing and transformation, and teach-
ing skills for tolerating distressing emotions.
Given that most people seeking psychotherapy
have difficulties regulating emotions, facilitating
effective ER is a common goal across psychothera-
pies (Leahy et al., 2011). Reviewing the clinical lit-
erature on emotion processing and regulation,
McMain and associates (2010) detailed eight
common principles: (a) engage in an ongoing assess-
ment of patient’s capacity to modulate emotions; (b)
develop a compassionate, accepting, and genuine
therapeutic relationship; (c) educate patients about
emotions and their function; (d) promote awareness
and acceptance; (e) help patients reduce problematic
avoidance and inhibition of emotions; (f) increase the
capacity to adaptively express emotion; (g) increase
positive emotional experiences; and (h) facilitate
changes in emotional processes by providing oppor-
tunities for new experiences.
Structured Approaches
Structured methods frequently address ER skills by
means of psychoeducation, skills training, and home-
work exercises. The outline of each session typically
includes specific tasks to be completed with accom-
panying workbooks that patients use for homework.
The Unified Protocol (UP; Barlow et al., 2017;
Farchione et al., 2021) teaches ER skills in 10–20 ses-
sions of individual treatment. Four modules specifi-
cally target ER: (a) psychoeducation about the
nature and function of emotions, including a detailed
discussion of how the patient’s avoidance of emotion
is problematic as it reduces the emotion in the short
term but reinforces the cycle of emotions in the long
term; (b) teaching patients to observe, name, and let
go of their emotions without evaluation; (c) learning

cognitive emotion regulation strategies to change mis-
appraisals related to negative emotions; and (d) mod-
ifying emotionally driven behaviors, which are a
specific set of reactive behaviors associated with
emotion to drive a person to withdraw, avoid, and
escape with exposure to feared emotions.
In dialectical behavior therapy (DBT; Linehan,
2015), the enhancement of ER is guided by three
basic principles (McMain et al., 2001): (a) enhancing
the ability to be aware of and accept emotional experi-
ence, (b) cultivating the ability to regulate emotions
and tolerate distress, and (c) changing negative
emotions through new learning experiences with
exposure. DBT differentiates distress tolerance skills
from ER skills. The goal of distress skills is to accept
overwhelming emotions and survive through the
crises by distracting themselves with pleasurable and
self-soothing activities, but not to effect and change
their environment as is the aim of ER skills. Mindful-
ness skills play a central role in both ER and distress
tolerance skill learning. Patients learn to nonjudgmen-
tally observe and describe the present moment
through contemplative practice and develop wise
mind, which is finding a middle path integrating
their reason and emotion (Linehan, 2015).
In the first phase of emotion regulation therapy
(ERT; Mennin et al., 2015; Renna et al., 2017),
the therapist helps the patient cultivate mindful ER
skills to increase awareness of emotional experiences,
and act flexibly to the intense emotional experiences.
They then teach meta-cognitive regulation skills,
such as decentering, reframing, and distancing to
create a healthy distance and emotional clarity
rather than being reactive and consumed by
emotions. The therapist also uses a series of
imagery exercises to have the patient vividly remem-
ber and experience triggers of their emotional
response and facilitate “Do-Overs” in which the
patient elaborates and enacts a sequence of more
adaptive responses in the session. Patients are also
taught breathing and other relaxation techniques.
In the second phase, therapists teach patients to
adopt a proactive orientation, consciously choosing
to exposing themselves to anxiety-provoking, yet
rewarding experiences to replace dysregulating pat-
terns. The therapist also uses imaginal exposure
and chair dialogue to rehearse taking actions
toward their personal values rather than responding
reactively through worry and rumination.
Affect-Focused Therapies
ER is enhanced in affect-focused therapies by acces-
sing and facilitating the experience of adaptive
emotion whose experience has been previously
Psychotherapy Research 3
inaccessible, blocked, or avoided (Greenberg,
2021). The therapist’s consistent empathy, warmth,
and validation, even in the face of patient’s feeling
upset or overwhelmed, is important because it is
internalized by the patient and becomes a part of
the way the patient subsequently responds to upset-
ting events. In addition, the moment-to-moment
empathic attunement to the patient’s emotional
state creates a clear focus on the patient’s here-and-
now experiences as well as ongoing assessment of
emotional processing. Therapists also help patients
pay attention to physical signs of emotions from
changes in breathing, muscular tension, and other
nonverbal signs, staying with and absorbing/taking
in such experiences, and symbolizing or finding
words to describe them.
In addition, therapists facilitate the experience of
adaptive emotions through various expressive and
evocative techniques (Medley, 2021). The therapist
encourages the patient to stay with the emerging
emotional experience, sometimes exaggerating and
repeating certain actions or phrases so that these
are vividly experienced. Dysregulated emotions are
transformed by a new experience of adaptive
emotions, which Greenberg (2021) called “changing
emotion with emotion.” The experience of adaptive
emotions is followed by a reflective process of creat-
ing its new meaning. Therapists may also help
patients reflect the relational experience of being
accompanied by the therapist who bears witness to
the transformation (Fosha, 2001).
Assessment
Assessing ER Methods
We know of no specific measures of ER methods.
Early psychotherapy process researchers identified
affect-focused therapist responses using categories
of therapist verbal responses (Elliott et al., 1987),
such as the revised Hill Counselor Verbal Response
Modes Category System (Hill, 1985, 1986). These
studies differentiate therapist responses that were
facilitative of patient affect such as reflection and
minimum encourager from those that were not
directly related to facilitation of affect such as pro-
vision of information, direct guidance, and advice-
giving.
Three rating scales used by trained judges include
items that evaluate the extent of affect focus and
some aspects of therapist methods for ER. For
example, the Psychotherapy Process Q-set (Jones
et al., 1988) has items such as, “Therapist draws
attention to patient’s non-verbal behavior.” The
Comparative Psychotherapy Process Scale (Hilsen-
roth et al., 2005) includes items such as, “Therapist
4 S. Iwakabe et al.
encourages patient to experience and express feelings
in the session.” The Multitheoretical List of Interven-
tions-30 (Solomonov et al., 2019) includes items that
identify and label emotions, defenses, conflict splits,
moment-to-moment experience, exploring personal
meaning, and showing interest in patient’s experience.
Fosha et al. (2018) developed the AEDP 9 + 1
Change Process Scale, a therapist-rated measure of
therapeutic methods used in AEDP. Five of the
nine items (facilitating access to the bodily-rooted
experience and to the felt sense of experience,
defense work, experientially processing core affective
experience, metatherapeutic processing of transfor-
mational experience, promoting integration and pro-
cessing core state experience) relate to facilitating
patient emotional process. One item relates to
responding to in-session emotion dysregulation
(working with overwhelming and highly distressing
emotions and alleviating these emotions within the
window of tolerance).
Assessing Outcomes of ER Work
Several observer-rated scales measure in-session be-
havioral indications of ER. Adequate interrater
agreement or reliability have been demonstrated for
all of them. The Observer-Measure of Affect Regu-
lation (Watson et al., 2011) defines emotion regu-
lation as consisting of level of awareness/labeling,
modulation and arousal, modulation of expression,
acceptance of affective experience, and reflection
on experience. The Client Emotional Productivity
Scale-Revised (Auszra et al., 2013) measures the
degree to which a patient experiencing a primary
emotion in an effective and useful manner (attend-
ing, symbolization, congruence, acceptance, regu-
lation, agency, and differentiation). The
Classification of Affective-Meaning State (Pascual-
Leone & Greenberg, 2005) classifies patient
emotional state into specific types of primary or sec-
ondary emotions based on vocal tone, involvement,
and meaning. The Achievement of Therapeutic
Objectives Scale (Berggraf et al., 2012) includes a
subscale of Activating Affects, and the Client
Expressed Emotional Arousal Scale-III-R
(Machado et al., 1999) measures expressed emotions
in terms of its intensity and type (anger, fear, joy,
love, sadness, and surprise) based on the vocal
quality and nonverbal behaviors.
In addition, there are a number of self-report
measures of ER that would typically be completed
by patients’ post-session; adequate reliabilities and
validities have been reported for all. These include:
Emotion Regulation Questionnaire (Gross & John,
2003), Difficulties in Emotion Regulation Scale
(Gratz & Roemer, 2004), Emotion Dysregulation
Questionnaire (Gill et al., 2021), Action and Accep-
tance Questionnaire-II (Bond et al., 2011), Affective
Style Questionnaire (Hofmann & Kashdan, 2010),
Emotion Regulation Skills Questionnaire (Berking
& Znoj, 2008), Cognitive Emotion Regulation Ques-
tionnaire (Garnefski et al., 2001), Affect Integration
Inventory (Solbakken et al., 2011), Distress Toler-
ance Scale (Simons & Gaher, 2005), Meta-emotion
Scale (Mitmansgruber et al., 2008), Emotional Pro-
cessing Difficulties Scale-Revised (Faustino et al.,
2022), Emotion Regulation Goals Scale (Brandão
et al., 2022), and Dimensions of Openness to
Emotions (Reicherts, 2007). Several scales tapping
common positive and negative emotions are also
sometimes used as client self-report measures of
emotion regulation: The Positive and Negative
Affect Schedule (Watson et al., 1988) and Profiles
of Mood State Questionnaires (Mcnair et al.,
1971). In addition, the Self-Compassion Scale
(Neff, 2003) measures how individuals respond to
emotionally distressing events.
Zelkowitz and Cole (2016) examined convergent
and discriminant validity of eight self-report
emotion regulation scales with a large university
student sample. Exploratory factor analysis revealed
three factors: out-of-control negative emotions repre-
senting the degree to which a person experiences
strong negative emotions that are beyond one’s
ability to regulate; emotional awareness and expression
representing the degree to which individuals are
aware of, admit to, and express strong pro-social
emotions ranging from joy to guilt; and cognitive strat-
egies for emotion regulation, reflecting concrete cogni-
tive strategies for regulating negative emotion such
as positive reappraisal, refocusing on planning, and
putting into perspective.
Clinical Examples
In the following, we present three examples of
working with emotional regulation. All three are
within the context of psychotherapy practice from
the United States with experienced therapists of
each orientation.
AEDP Methods for Working with
Dysregulated Emotions
The first example is taken from Lamagna (2021) who
illustrates the work with emotion dysregulation in
AEDP. A married white female patient in a late
middle age (P) on the verge of leaving her husband
was flooded with distressing emotions.1 The thera-
pist is an experienced AEDP white male therapist.

P: (Getting more distressed) It just hurts so much. (tears
up) It’s still so close — that feeling . . . (pause) and I
feel afraid of it.
T: Yes. Let me help you with that feeling.
P: I don’t know what I’m feeling. It’s too hard for me
(increasingly agitated, gasping with tears in her eyes).
T: Linda . . . can you just check in with me for a second?
Can you feel me here with you?
P: [Not registering the therapist’s statement] It all hurts too
much. I miss my mother. (breaks into sobs).
T: (Softly) Yes.
P: (Sobbing) I missed so much.
T: (Slowly and with softness) Yeah, you did. Keep
breathing.
P: I keep telling myself I’m doing well. I have this won-
derful world around me . . . (sobs)
T: Can you check in and see that I’m here with you? See
if we can ask this distressed part of you if she would be
willing to separate out —- just a little bit. And if she
won’t, it’s okay. We’ll figure out other ways of
helping.
P: I’m just surprised it’s so deep.
T: Okay. Do you have a sense whether there is a willing-
ness for the distress to step back? Did you feel any
shifting in your body?
P: I’m just able to breathe. (Seems slightly calmer)
Th: Just notice that you can breathe now. (long pause)
What are you noticing now?
The therapist first responded with calling attention
to his empathic presence, using a gentle tone and
slowed-down speech, to dyadically regulate the
patient’s dysregulation that exacerbated her sense
of aloneness. Then he used physical regulation
(breathing) to help the patient attend to and accept
the somatic experience of her emotion, to which the
patient responded partially. The therapist also used
intra-relational method which asked the patient to
separate from the distressed part of herself. The
patient finally made a meaningful contact with the
therapist and partially regulated her distressing
emotion.
Affect-oriented Methods for Enhancing
Emotional Awareness
In the following vignette (from Paivio & Pascual-
Leone, 2010), a young adult male patient, who had
complex PTSD, felt he could never rely on others
for support.2 Acknowledging his emerging sense of
insecurity and neediness was uncomfortable and
made him uneasy. The experienced middle-age
white therapist oriented the patient’s attention to
emergent feelings and aimed to help him allow the
emotional experience and increase his emotional
awareness.
Psychotherapy Research 5
T: So, it’s about feeling alone, that’s the main concern,
like you can’t handle it?
P: It’s not, “can’t handle it,” exactly, but … lonely. I hate it.
T: OK, stay with that lonely feeling. It’s uncomfortable, I
know, but let’s explore it a bit.
P: Like, I hate coming home from work, the apartment is
so empty, we used to talk about stuff. She always
seemed to understand, well, at least listen (laughs)
… Like now I‘m just floundering around …
T: Floundering, directionless. So, she was like your
anchor, it’s like you were so very attached to her.
P: Yes, I guess I was.
T: And now she’s gone, you’ve become unattached, not
only lonely but kind of insecure?
P: Yes, I do feel insecure, less confident, it’s weird. I
never realized how much I depend on her.
T: Say more, depended on her for what?In the above
vignette, the therapist uses empathic responding to
help the patient explore the nuance of the patient’s
subjective emotional experience; as a result, the
patient learns to differentiate his lonely feeling to
enhance a sense of emotional clarity.
UP Methods for Addressing Emotional
Avoidance
The third example, taken from the UP for emotional
disorders by Barlow et al. (2018), addresses patient’s
emotional avoidance and concerns about being more
in the present with her emotional experiences in the
module of mindful emotional awareness. The thera-
pist is a middle age experienced white male, while the
patient is a young adult white female.
P: I don’t like to sit still— it makes me more anxious.
T: Tell me more— what happens when you sit still?
P: I don’t know— I just feel like I should be doing some-
thing. I feel like if I stop thinking about everything I
need to do, my whole day will fall apart. I’m also
afraid I’ll start thinking about things I’d really rather
not think about.
T: So by sitting still and focusing on the present, you’re
afraid you will be losing control of things that are sup-
posed to happen today and that you might start think-
ing about things that have happened in the past?
P: Yeah, and that just makes me even more anxious.
T: So, you are not late for anything at the moment, but
you are focusing on the possibility that
you might be late later on. How does focusing on the
possibility you might be late later on make you feel?
P: Anxious!
T: And what about the information that right now, in
this moment, you are not running late?
P: Well, much less anxious. But I still could run late
later!
T: The thing is, you have no way of knowing exactly what
may happen later. You may hit traffic or your doctor’s
appointment might run over. Or, alternatively, you
6 S. Iwakabe et al.
might find the roads are clear and your appointment
only lasts 15 minutes instead of the scheduled 30
minutes. In other words, you just don’t know. The
only thing you do know for sure is that you are in
this office right now, and at the moment you are not
late for anything. This means that the only thing
that is different about worrying about the future as
opposed to paying attention to the present moment
is that one makes you really anxious and the other
makes you less anxious.
In this excerpt, the therapist uses a psychoeduca-
tional approach to help the patient focus on the
present rather than worrying about the future. He
thus tried to help her modulate her anxiety by differen-
tiating the anxious thoughts from the external reality.
Previous Reviews
Sloan and associates (2017) identified 67 studies that
measured changes in both emotion regulation and
psychopathology following a psychological treat-
ment, both individual and group. The treatments
examined included affect-focused therapies such as
EFT and STDP, as well as structured therapies
such as ACT, CBT, DBT, EMT, and MBCT.
Both maladaptive emotion regulation strategies and
overall emotion dysregulation significantly decreased
at post-treatment in all but two studies regardless of
(a) specific treatment, (b) the measure of emotion
regulation, and (c) the patient’s disorder.
Moltrecht and colleagues (2021) examined 21
RCTs of psychological treatments for improving
ER in youth (from ages 6–24). These treatments
improved patients’ ER, which in turn was associated
with the improvements in psychopathology, but
effect sizes were small.
A meta-analysis by Daros et al. (2021) included 90
RCTS on treating depression and anxiety among
patients aged from 14 to 24. Treatments included a
variety of cognitive-behavioral therapies, such as ACT,
CBT, and DBT, as well as ERT. Patients’ ER skills sig-
nificantly improved, which was positively related to
improvements in their depression and anxiety.
In sum, these meta-analyses generally showed the
positive effect of structured treatment packages on
ER. They did not, however, review the specific com-
ponents of treatments associated with the changes in
ER.
Research Review
Search Strategy and Inclusion Criteria
We searched PUBMED, PsycINFO, and Web of
Science between August 2021 and May 2022 using
the following terms: counseling or therapy, therapist
response, therapist interventions, therapist strategies,
emotion regulation, emotional experience, outcome,
and emotional expression. We also asked colleagues
for articles that might have been missed in the search.
The following inclusion criteria were set: (a) actual
individual psychotherapy studies (no analogues), (b)
published in English, (c) included actual adult
patients (age 18 or over) with psychological pro-
blems, (d) included at least one validated self-
report or observational measure of ER, (e) included
a measure of immediate, intermediate, or distal
outcome. Studies were excluded if (a) the treatment
was predominantly given in a group format or in an e-
learning format; (b) they consisted of analog sessions
with those within a normative population; and (c) the
studies did not report sufficient data on above
inclusion criteria (e.g., pre- and post-treatment
means, SDs, sample sizes) or obvious errors in
these values were found (e.g., unusually large effect
sizes).
Identified publications were downloaded from the
databases. If relevant literature was identified during
the abstract screening, we manually screened their
reference lists for further eligible publications. The
selected studies were appraised independently by
the first two authors for methodological aspects,
such as sampling and sample characteristics accord-
ing to our inclusion and exclusion criteria. The two
authors discussed and came to agreement when the
eligibility of a study was unclear. The final list was
examined by the third author.
The flow chart provides an overview of the extrac-
tion procedure (Figure 1). The initial web search
identified 743 articles. We added 64 additional
records identified from previous meta-analyses.
From a total of 807 studies, 763 articles were
excluded based on the abstract and method screen-
ing. An effectiveness study on AEDP (Iwakabe
et al., 2022) was added because it included an ER
measure. In total, 44 studies entered the full text
screening. Of these, 13 papers had to be excluded
due to insufficient data reported. Thirty-one studies
matched the selection criteria and provided sufficient
data. During the data extraction, three studies were
excluded because some values were clearly wrong
(e.g., effect size d > 3.0).
ER and Immediate and Intermediate
Outcomes
We first reviewed the literature on immediate and
intermediate in-session treatment outcomes.
Immediate outcomes were typically assessed in the
subsequent speaking turn or the same segment of a

Figure 1. Flow diagram of the study selection process.
session in which a therapist method was used. Inter-
mediate outcomes were assessed with self-report ER
questionnaires administered at post session after a
particular intervention module such as emotional
awareness skills module was used.
Table I summarizes a total of eight studies (84
clients and 33 therapists) of ER in association with
immediate in-session outcomes and two studies (14
clients and 2 therapists) of intermediate outcomes.
Most studies were multiple case studies, and one
was a qualitative study. Given the small number of
studies, we could not conduct a meta-analysis.
Instead, we used box scores (our judgment based
on the evidence of the outcomes) to aggregate the
effects of ER methods across studies.
Table II contains the coded results of the 10
studies. For all outcomes, the three authors read
each study and consensually arrived at box score
Psychotherapy Research 7
for each outcome: “+” denotes a positive effect, “
= ” denotes a neutral/no effect, and “−“ denotes a
negative effect. We assigned +1 to a positive box
score, 0 to a neutral box score, and −1 to a negative
box score in order to determine an overall box score
for each outcome across samples. Furthermore, in
order to account for sample size differences, we
then multiplied the box score by the sample size for
the finding, summed across the samples, and then
divided into the total sample size to get a weighted
box score for each immediate and intermediate
outcome. We considered scores between −1 to -.5
negative, between -.49 to + .49 neutral, and
between .5 to +1 positive.
For immediate outcomes, we first looked at five
studies of client experiencing. In two studies of
short-term psychodynamic therapy, plan-compatible
interpretations were associated with the higher level
 8
S. Iwakabe et al.
Table I. Studies of immediate and intermediate outcomes of emotion regulation methods.

Study Sample Measures of ASR, Outcomes, Moderators Results

Stalikas and 3 archival single sessions with 3 clients all from the
Fitzpatrick U.S., and 1 RET, 1 client-centered, 1 gestalt
(1996) therapist who is from South Africa.
Gazzola and 6 single Sessions conducted by Carl Rogers 2 male
Stalikas and 4 female clients, all apparently from the U.S.
(1997)
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: 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)
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)
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)
Intermediate Outcomes
. No relation was significant between degrees of
structure of therapist responses and experiencing
(= box score).
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.
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)

(Continued )
Table I. Continued.
Study Sample Measures of ASR, Outcomes, Moderators
Silberschatz Three adult patients with good, moderate, and poor Measure of Therapist Method: Transference interpretations
et al. (1986) outcome in a 16-session individual psychotherapy were classified using the Malan intervention typology
from the Mount Zion Brief Therapy Research defined as any interpretation directed toward the patient’s
Project. Therapists were experienced feelings about the therapist or the therapy. Plan
psychodynamic therapists. compatibility of intervention scale was used to measure the
A multiple case study 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)
Silberschatz and Two adult patients with dysthymic disorder in a 16- Measure of therapist method: Patient test scale was used to
Curtis (1993) session individual psychotherapy from the Mount identify segments of patient’s testing the therapist. Patient
Zion Brief Therapy Research Project. Therapists test scale was used to identify segments which had included
were experienced psychodynamic therapists. Both testing of a central pathogenic beliefs in the therapeutic
had an excellent outcome. relationship. Therapist Scale was then used to rate the
A multiple case study 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
Town et al. 24 10-minute segments from 6 adult patients with Measure of therapist ER method: The PICS Psychotherapy
(2012) cluster C personality disorder receiving Short-term Interactional Coding System as coded by trained judges
psychodynamic psychotherapy for 36- to 60 from videotapes and transcripts has 8 categories: question,
sessions (mean 47 sessions). information, self-disclosure, clarification, directive,
(4 female therapists, 2 male therapists; all White). support, interpretation, and confrontation. The four
The therapist, who was the originator of the STDP, content categories are: defenses, anxieties, impulse/feeling,
treated all patients. 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.
Results
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)
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)
Immediate In-Session Outcomes
The highest predicted levels of patient immediate
Psychotherapy Research
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)
9
(Continued )
Table I. Continued.
Study Sample
Ulvenes et al. Fifty Norwegian patients with cluster C personality
(2014) 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.
Nakamura and Six episodes of corrective emotional experiences
Iwakabe (CEE) taken from individual affect-focused therapy
(2018) with adult patients (female = 4; male = 2) all
Japanese. All patients achieved reliable change
index on ER. One experienced therapist.
A qualitative study
Measures of ASR, Outcomes, Moderators
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).
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.
10 S. Iwakabe et al.
Results
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.
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.
(Continued )
Table I. Continued.

Study Sample Measures of ASR, Outcomes, Moderators Results

Bentley et al. Ten adults with NSSI (non-suicidal Self-Injuries)
(2017) 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.
Abasi et al. Four patients with SAD with comorbidity of
(2021) depression. All Iranian (female = 1; Male = 3)
Multiple case experiments. Therapist was a doctoral
candidate under supervision.
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.
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
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).
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).

Psychotherapy Research 11
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.

Note. HCVRCS = Hill Counselor Verbal Response Mode Category System (Hill, 1985, 1986). HCVRCS-R = Hill Counselor Verbal Response Mode Category System-Revised (Friedlander,
1982).
 12 S. Iwakabe et al.
Table II. Studies included in meta-analysis of treatment distal effects on patient emotion regulation.

Treatment Characteristics ER Outcomes

Post/Follow-Up
N Pre Mean (SD) Mean (SD)
First author, ER treatment
Year Design Disorder Intervention components Session Treatment Control ER Measure Treatment Control Treatment Control Effect Size a Association

Dalrymple Open trial SAD ACT Mindfulness 12 × 60-min 19 AAQ-9 41.21 33.46 Pre-Post Earlier changes in the
(2007) weekly sessions (7.74) (8.86) d = 0.93 AAQ predicted later
3-month Pre-3-month changes in symptom
34.92 d = 0.75 severity (β = -.48, p
(8.91) < .05).
Petersen and Random AUD ACT vs TAU; Common Mindfulness Mean 5.2 × 30- 12 12 AAQ-9 44.8 45.5 34.4 44.1 ACT Reductions in AAQ
Zettle assignment therapeutic interventions min bi- (5.1) (6.3) (10.6) (5.7) d = 1.32 scores were
(2009) (e.g., group therapy) weekly significantly
sessions correlated with
improvement on
the HRS (r = .57, p
= .05), but not the
BDI-II (r = .32, p
= . 31).
Twohig et al. RCT OCD ACT vs PRT contact with the 8 × 60-min 41 38 AAQ-16 59.76 57.16 73.69 63.81 Pre-Post
(2010) present moment or weekly sessions (11.36) (11.67) (13.22) (7.69) ACT
mindfulness d = 1.06
exercises PRT
d = 0.47
3-month 67.13 Pre-3-month
73.37 (10.74) ACT
(14.44) d = .86
PRT
d = .64
Arch et al. RCT Anxiety ACT vs CBT acceptance, 12 × 60-min 57 71 AAQ-16 59.01 58.49 70.82 69.43 Pre-Post
(2012) disorder mindfulness weekly sessions (12.35) (11.84) (13.14) (14.75) ACT
d = 1.16
CBT
d = 0.90
6-month 6- Post-6-
72.14 month month
(10.86) 68.38 ACT
(13.76) d = 0.63
CBT
d = 0.45
12-month 12- 6-month-12-
71.71 month month
(11.42) 68.43 ACT
(11.65) d = 0.10
CBT
d = 0.00
Dehlin et al. Case reports OCD ACT acceptance, 8 × 60–90-min 5 AAQ-II 36.2 21.6 [Pre-Post When graphed,
(2013) mindfulness weekly sessions (5.2) (4.8) g = 2.32] declining AAQ-II
3-month [Pre-3- slopes appear to
20.6 month generally co-occur
(8.4) g = 1.49] with declines in both
compulsions and
avoided valued
activities.
Walser et al. Open trial Depression ACT acceptance, 12–16 sessions 926 AAQ-II 30.93 38.92 [g = 0.71] Interaction of time
(2015) mindfulness (10.246) (11.742) with experiential
acceptance to
predict depression
severity was not
significant (b =
0.05, p = .362).
Khoramnia RCT SAD ACT vs WL acceptance, 12 × 90-min 12 12 AAQ-II 79.72 82.27 94.45 83.00 MANCOVA
et al. (2020) mindfulness sessions (9.55) (13.10) (7.28) (12.73) ES = 0.43
[Pre-Post
g = 1.96]
2-month 2- ES = 0.627
83.02 month [Pre-2-
(16.46) 75.18 month
(15.89) g = 1.02]
SCS 78.18 84.27 94.81 81.27 ES = 0.38
(12.70) (14.93) (6.21) (10.09) [Pre-Post
g = 2.71]
2-month 2- ES = 0.435
96.77 month [Pre-2-
(16.98) 83.54 month
(16.57) g = 2.85]
DERS 115.5 117.36 101.36 117.00 ES = 0.311
(13.71) (9.78) (9.26) (10.86) [Pre-Post
g = 1.80]
2-month 2- ES = 0.301
98.54 month [Pre-2-
(15.77) 120.18 month
(10.60) g = 2.40]
Roemer and Open trial GAD ABBT a variety of 16 × 60- to 90- 16 AAQ-9 44.56 29.81 univariate
Orsillo mindfulness min weekly to (5.99) (7.41) ANOVA
(2007) practices, bi-weekly η2p = 0.76
diaphragmatic sessions [Pre-Post
breathing and g = 2.04]
progressive 3-month η2p = 0.58
muscle relaxation 34.17 [Pre-3-
(7.76) month
g = 1.38]
Kumar et al. Open trial Depression EBCT mindfulness 20–24 sessions 29 AAQ-16 75.33 67.37 d = .61
(2008) (13.30) (12.94)

Psychotherapy Research 13
Price et al. RCT SUD MABT + TAU vs WHE developing the 8–10 × 90-min 74 WHE DERS 87.3 WHE 77.4 WHE [MABT vs
(2019) + TAU vs TAU only capacity to sustain sessions 46 (25.1) 88.2 (24.2) 85.7 TAU
(including group interoceptive (27.0) (28.0) g = 0.76]
sessions) awareness as a TAU TAU TAU
mindful process to 67 83.8 83.6
facilitate appraisal of (27.3) (27.5)
interoceptive
experiences

(Continued )
Table II. Continued.

14 S. Iwakabe et al.
Treatment Characteristics ER Outcomes

Post/Follow-Up
N Pre Mean (SD) Mean (SD)
First author, ER treatment
Year Design Disorder Intervention components Session Treatment Control ER Measure Treatment Control Treatment Control Effect Size a Association

Axelrod Open trial BPD & DBT 60-min weekly 24 DERS 118.00 94.80 [g = 1.23] Significant
et al. substance individual (18.47) (17.89) interactions were
(2011) dependence sessions and observed with
90-min frequency of
weekly group substance use and
sessions for emotion
20 weeks 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 Open trial BPD DBT vs healthy controls 50–60-min 11 11 DERS 120.5 56.6 101.5 54.8 MANOVA Reduction in
et al. weekly (24.2) (14.9) (25.7) (14.4) ⍰2 = 0.21 amygdala activity
(2014) individual [g = 1.64] to repeated
sessions and unpleasant pictures
90-min following DBT was
weekly group associated with
sessions for improved emotion
12 months regulation as
measured by the
change in total
DERS score (r =
0.70, p < 0.02).
Bianchini RCT (a pilot BPD DBT vs TAU core mindfulness 60-min weekly 10 11 DERS 56.6 52.9 65.6 65.1 [g = 0.39]
et al. study) skills, distress individual (11.77) (19.52) (9.40) (15.57)
(2019) tolerance, sessions and
emotional 120-min
regulation weekly group
sessions for
12 months
Ito et al. Open trial Depressive and UP Mean 18.13 × 17 ERQ: 16.2 23.8 Pre-Post
(2016) anxiety disorders 50- to 90-min Reappraisal (6.9) (7.7) g = −0.92
weekly sessions 3-month Pre-3-month
25.4 (4.9) g = −1.37
ERQ: 13.9 13.8 (3.5) Pre-Post
Suppression (6.0) g = 0.09
3-month Pre-3-month
13.4 (3.4) g = 0.15
Sauer- Case reports BPD and UP mindfulness 16–20 weekly 5 DERS 112.00 84.40 ESsg = 1.29
Zavala comorbid (present-focused sessions (16.26) (24.85) [g = 0.83]
et al. anxiety and and non-
(2016) mood disorders judgmental
attention)
Beaumont Random Trauma-related CBT + CMT vs CBT developing empathy 12 sessions 16 16 SCS-SF 2.13 1.94 3.72 3.21 [g = 0.66]
et al. assignment symptoms for themselves (0.75) (0.51) (0.57) (0.57)
(2012) and acceptance of
their distress
Wonderlich RCT BN ICAT vs CBT-E 21 × 50-min 40 40 DERS 100.6 98.4 88.9 90.5 [Pre-Post
et al. (2014) sessions for 19 (18.4) (17.6) (13.2) (13.7) g = 0.42]
weeks 4-moth 4- [Pre-4-
90.0 month month
(13.8) 93.0 g = 0.58]
(13.3)
MacDonald RCT ED CBT-RR vs MI; day distress tolerance; 4 × 60-min 23 21 DERS: 20.87 20.10 14.56 15.41 univariate
et al. (2017) hospital including CBT emotion regulation weekly sessions Nonacceptance (6.50) (7.17) (4.93) (6.34) time by
group therapy condition
interactions
[g = 0.32]
DERS: 20.52 19.33 15.90 19.15 [g = 1.19]
Goals (5.00) (4.76) (4.30) (4.31)
DERS: 27.57 27.48 20.55 24.01 [g = 0.53]
Impulse (6.21) (7.80) (5.43) (8.74)
DERS: 16.52 15.24 13.02 15.23 partial
Awareness (4.57) (4.23) (3.99) (4.39) η2 = .16
[g = 0.99]
DERS: 19.74 20.04 15.11 18.62 [g = 1.00]
Strategies (6.05) (7.68) (4.77) (6.98)
DERS: 20.65 20.71 15.74 18.88 partial
Clarity (3.93) (3.66) (3.89) (5.10) η2 = .19
[g = 1.09]
Zalaznik Open trial PDA CBT therapist encourages 12 sessions 31 ERQ: 3.78 2.87 [g = 0.69]
et al. exploration of Suppression (1.29) (1.28)
(2019) experiences of
bodily sensations
without
suppression or
avoidance
Monell et al. Open trial ED CBT or 12-month 307 DERS 101.80 87.60 d = −0.59 Change in emotion
(2022) Other therapies 44% (25.45) (29.58) dysregulation
Treatment primarily had an
terminated indirect effect
56% (through change in

Psychotherapy Research 15
Treatment self-image), while
ongoing change in self-
image had a direct
effect, on change in
ED
psychopathology
improvement.

(Continued )
 16 S. Iwakabe et al.
Table II. Continued.

Treatment Characteristics ER Outcomes

Post/Follow-Up
N Pre Mean (SD) Mean (SD)
First author, ER treatment
Year Design Disorder Intervention components Session Treatment Control ER Measure Treatment Control Treatment Control Effect Size a Association

Jain et al. RCT PTSD or STAIR vs TAU emotion regulation 5 × 60-min 13 13 DERS 103.9 110.5 79.3 104.1 Pre-Post
(2020) Depression skills, Self- sessions (21.1) (25.4) (17.2) (21.4) STAIR
compassion g = 1.38
TAU
g = 0.30
3-month 3- Pre-3-month
85.3 month STAIR
(19.0) 102.7 g = 0.90
(20.2) TAU
g = 0.44
Doorn et al. Open trial Moderate to EDT the therapist helps one 2- to 3-hour 31 SCS-SF 24.88 27.16 d = 0.38
(2014) severe emotional the patient to initial session (8.10) (7.85)
problems gradually
experience more
underlying feeling
while regulating
anxiety and
reducing
defensive
behaviors
Chavooshi RCT MUP ISTDP online vs in- emotional 16 × 60-min Online In- ERQ: 16.2 17.91 16.2 24.12 Pre-Post
et al. (2017) person b awareness, tolerate weekly sessions 39 person Reappraisal (6.5) (6.5) (5.7) (4.8) Online
and experience 42 d = 0.48
emotions In-persion
d = 0.77
12-month 12- Pre-12-
15.4 month month
(5.6) 24.1 Online
(6.3) d = 0.49
In-persion
d = 0.74
ERQ: 12.3 11.15 11.9 5.52 Pre-Post
Suppression (8.5) (7.9) (7.5) (3.4) Online
d = 0.48
In-persion
d = 0.94
12-month 12- Pre-12-
11.3 month month
(7.2) 7.51 Online
(3.5) d = 0.42
In-persion
d = 0.73
 Iwakabe Open trial Transdiagnostic AEDP dyadic affect 16 × 60-min 63 DERS 94.62 76.97 Pre-Post
et al. (2022) regulation sessions (22.93) (21.25) d = −0.77
6-month Pre-6-month
74.13 d = −1.03
(22.48)
12-month Pre-12-
71.02 month
(21.16) d = −0.92
SCS 15.53 19.44 Pre-Post
(3.93) (4.73) d = 0.99
6-month Pre-6-month
19.98 d = 1.32
(5.00)
12-month Pre-12-
19.71 month
(4.69) d = 0.94
AAQ-II 30.57 21.82 Pre-Post
(6.61) (8.24) d = −1.25
6-month Pre-6-month
19.90 d = −1.77
(7.74)
12-month Pre-12-
19.75 month
(8.63) d = −1.46
Glisenti et al. Case reports BED EFT Phase 1: promoting 12 × 60-min 6 DERS 101.23 53.67 [g = 1.66]
(2018) awareness of weekly (18.75) (8.69)
emotions, sessions
welcoming and
accepting
emotions, putting
emotions into
words, identifying
primary emotions
Phase 2:
evaluating
whether the
primary emotion
was adaptive or
maladaptive,
identifying

Psychotherapy Research 17
destructive
emotion schemes,
accessing other
adaptive
emotions and
needs, and
transforming
maladaptive
emotion schemes

(Continued )
 18 S. Iwakabe et al.
Table II. Continued.

Treatment Characteristics ER Outcomes

Post/Follow-Up
N Pre Mean (SD) Mean (SD)
First author, ER treatment
Year Design Disorder Intervention components Session Treatment Control ER Measure Treatment Control Treatment Control Effect Size a Association

Normann- Open trial BPD or APD Step-down treatment or Step-down 52 ACI: 3.58 3-year d = 0.84 The AC change
Eide et al. outpatient treatment treatment c: Global AC (0.50) 4.00 explained 7.7% of
(2015) Median 45 (0.58) the variance in CIP
individual (p = .033), 8.6% of
session the variance in
Outpatient Identity
treatment: Integration (p
Median 46 = .026), and 8.7%
individual of the variance in
session Relational
Capacities (p
= .005) at 3-year.
Mennin RCT GAD ERT vs MAC patients were 20 × 60- to 90- 28 25 ERQ: 22.6 21.6 Mid Mid g = 0.54 All proposed
et al. (2018) encouraged to min weekly Reappraisal (6.2) (9.2) 26.4 21.6 mediators showed an
deploy regulation sessions (5.2) (9.7) indirect effect of
skills during in- Post Post group on the primary
session and out-of- 29.7 24.0 outcomes. For
session exposures (4.4) (9.9) example, GAD CSR
DERS 98.2 104.8 Mid Mid g = 0.80 was mediated by ERQ
(23.1) (22.4) 82.3 102.2 Reappraisal (B = -.27,
(20.3) (23.2) p < .05) and DERS
Post Post (B = -.39, p < .05).
74.6 96.0
(19.0) (22.0)
O’Toole Open trial GAD ERT the cultivation of 16 × 60- to 90- 31 ERQ: 20.8 29.2 d = 0.9 Changes in cognitive
et al. emotion min weekly Reappraisal (7.8) (7.3) reappraisal
(2019) regulation skills sessions 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.

Psychotherapy Research 19
20 S. Iwakabe et al.
of client experiencing (Silberschatz et al., 1986; Sil-
berschatz & Curtis, 1993). Similarly, in client-cen-
tered therapy, interpretations referring to feelings
given with particular nonverbal qualities were associ-
ated with a higher level of experiencing (Gazzola &
Stalikas, 1997). In Hill et al. (1988), however,
interpretations did not have a higher experiencing
level compared to other response modes such as
self-disclosure, open question, and approval. Simi-
larly, Stalikas and Fitzpatrick (1996) did not find a
significant relationship between therapist response
modes and the client experiencing. There were thus
three positive and two neutral box scores. The
weighted box score across these five studies was .50
for interpretations on ER as measured with the
client experiencing scale.
We also examined three short-term dynamic psy-
chotherapy studies of therapist affect-oriented skills
including confrontation on affect, defenses, and facil-
itative/supportive methods (Town et al., 2012) and
focusing on affects (Ulvenes et al., 2014) in associ-
ation with adaptive affect. Therapist focus on affect
was associated with a higher level of adaptive affect
experiences, which is a part of ER via emotional
transformation. In a qualitative study, Nakamura
and Iwakabe (2018) found that the immediate
outcome of experiential methods was arriving at an
emotional resolution. For these three studies, there
were three positive box scores; the average weighted
box score was 1.
In terms of intermediate outcomes, Bentley and col-
leagues (2017) tested the introduction of mindful
emotional awareness skills and emotion modulation
skills related to improvements in specific areas of ER
(The Southanmpton Mindfulness Questionnaire for
mindful emotional awareness and The Emotion
Regulation Questionnaire-Reappraisal Subscale for
emotion modulation) in the Unified Protocol. The
result showed no module-specific effects. Abasi et al.
(2021) studied four cases of Emotion Regulation
Therapy for social anxiety disorder in which the intro-
duction of ER modulation skills component had an
additive effect to the mindful emotional awareness
component that was initially given. They used the
acceptance subscale of Difficulties in Emotion Regu-
lation Scale for emotional awareness, the Affect Inten-
sity Measure for emotional modulation, and
Reappraisal subscale of the Emotion Regulation
Questionnaire for adaptive emotion regulation strat-
egy for every session. Neither study found module-
specific effects, though most patients achieved reliable
change by the end of the course of treatment on these
emotion regulation scales as well as their symptoms
for social anxiety. Box scores for module-specific
outcome are neutral for three emotion regulation
scales.
In sum, immediate outcomes (client experiencing
and activating affect) were positive, indicating that
interpretations focusing on immediate feelings with
gentle and tentative manner of delivery and focusing
on the patient immediate emotional experience
resulted in a higher level of experiencing and adaptive
affect. The experiencing level, however, does not
specifically tell us about what aspects of emotion
regulation is at work. On the other hand, Nakamura
and Iwakabe (2018) showed that the process of
emotional change leading to a regulated emotional
state may involve qualitative shifts from secondary
emotions which are symptomatic emotional distress
such as helplessness, anxiety, and feeling hurt, via
more painful emotions to grief and self-compassion,
followed by positive emotional experience with the
therapist. This finding suggests that ER involves
overcoming avoidance and defenses to allow distres-
sing emotions, facing more difficult and painful
emotions, allowing of underlying adaptive emotions
and reflecting on emotional experience in the thera-
peutic relationship.
In contrast, no module specific effects of mindful
emotional awareness or emotion modulation skills
were found in studies on intermediate outcomes,
though they were effective in improving ER.
Bentley et al. (2017) suspected that different thera-
pist methods may address the extinction of distress
in response to intense emotions. They also suggested
that individuals respond differently to different treat-
ment modules.
ER and Distal Treatment Outcomes
From the search strategy detailed above, 28 indepen-
dent studies encompassing a total of 1034 patients
and 201 therapists (the number of therapists was not
cited in 10 studies) were included in the meta-analysis
of distal outcomes. The main characteristics of the 28
included studies are summarized in Table II. The data
on which our analysis is based span over 15 years
(2007–2022) and consist of published studies using
independent samples collected in naturalistic settings
(k = 18) and RCTs (k = 10). The number of eligible
studies (k = 28) included in this meta-analysis is
smaller than the size of previous meta-analyses
because we included only individual treatments with
clinical samples. ACT (k = 7), DBT (k = 3), and UP
(k = 2), were the most commonly employed treatment
packages. These therapies had some group com-
ponents (k = 7) in addition to individual therapy.
Although one study compared online intervention
with in-person intervention, we included only the in-
person data in this meta-analysis. A variety of psycho-
logical disorders and problems were treated, including

anxiety disorders, eating disorder, borderline person-
ality disorder, and substance use disorder.
The most frequently used outcome scales were
DERS (k = 13), AAQ (k = 10), and ERQ (k = 5).
Although they measure somewhat different aspects
of ER, we combined them in one analysis given
that moderate to high correlations have been
reported among them. We report both overall mean
scores and subscale means when they were available
(Table II). For the meta-analysis, we used effect sizes
for the full scale unless specified.
We conducted a series of random effects models.
This model is based on the assumption that the
studies in this meta-analysis were randomly
sampled from a population of studies. All analyses
were conducted using Comprehensive Meta-Analy-
sis (Borenstein et al., 2013). First, we tested an
overall pre-and post-treatment difference in ER.
Second, we examined potential moderators –
whether effect sizes systematically varied due to (a)
measures, (b) types of treatments, (c) types of
control group, and (d) type of disorder. In addition,
comparisons between the treatment group and differ-
ent control groups were tested when available. Treat-
ment effect was estimated using the weighted mean
effect size Hedges’ g.
The random effects model with all 28 independent
studies resulted in a large treatment effect (g = 0.82,
95% CI [0.71, −0.93], p < .001) compared to no
treatment/wait list. That is, multiple therapies evi-
denced large improvements in patient ER compared
to no treatment or pre to post treatment. At the
same time, there was a large heterogeneity
Figure 2. Funnel plot of treatment effects on emotion regulation outcomes.
Psychotherapy Research 21
in the effect sizes, I2 = 82.66% (Q = 155.68, df =
27, p < .001).
We also calculated the effect size of pre-treatment
to 2-to 6-month follow-up for the 10 studies that
reported those data (g = 0.86, 95% CI [0.59,
−1.14], p < .001; I2 = 74.06; Q = 34.69, df = 9, p
< .001) and pre-treatment to 12-month follow-up
for 3 studies (g = 0.71, 95% CI [0.26, −1.15], p
= .002; I2 = 89.37; Q = 18.81, df = 2, p < .001). The
results indicate that treatment gains in ER were
largely maintained; there was no significant
deterioration from post-treatment to 2- to 6- and
12-month follow-up (for 2- to 6-month, k = 10; g =
−0.07, 95% CI [−0.26, - 0.12], p = .456; I2 =
58.02; Q = 21.44, df = 9, p = .011; for 12-month, k
= 3; g = 0.03, 95% CI [−0.29, - 0.35], p = .871; I2
= 83.12; Q = 11.85, df = 2, p = .003). Although the
number of studies with the follow-up data was
small, the treatment effect on ER was maintained
after termination.
The fail-safe N indicated that approximately 6811
studies with an effect size of zero would be need to be
published in order to bring the weighted mean effect
below .10, or practical significance. We also calcu-
lated Duval and Tweedie’s trim and fill. The
adjusted effect size for a random effects model was
g = 0.71 (observed value g = 0.82, 95% CI [0.60, -
0.83]). All our data are based on a search of elec-
tronic databases and included only published
articles, which may have resulted in bias toward
larger N studies and positive effect sizes. Figure 2
presents a funnel plot, which is a diagram of standard
error on the Y axis and the ES on the X axis.
22 S. Iwakabe et al.

Given the large heterogeneity in effect sizes, we
conducted a series of moderator analyses. The mod-
erator analyses related to the ER measure, therapy
type, comparison group, and patient type were all
statistically significant. The effect sizes for each ER
measure are presented in Table II. The effect sizes
for the DERS, AAQ, and SCS as outcome measures
were similar (from 0.86 to 0.97), whereas effect sizes
for the suppression subscale in ERQ were signifi-
cantly smaller in comparison (g = 0.49). Table III
also shows the average effect sizes for the psychologi-
cal treatments on the ER outcome. ACT (k = 7; g =
0.95) and DBT (k = 3; g = 1.11) had slightly larger
effect sizes than CBT and UP, but all were moderate
to large effect sizes. The effect size comparing the ER
treatment against active control (k = 9) was g =
0.67 (95% CI [0.39, −0.94], p < .001). Compared
to waiting list group, the effect size was significantly
larger (k = 3; g = 1.51, 95% CI [0.85, −2.18], p
< .001). For the 16 studies with no control group,
the effect size was also large (g = 0.83, 95% CI
[0.70, −0.96], p < .001).
The psychological treatments were more effective
for depression and anxiety (k = 10; g = 0.82, 95%
CI [0.60, −1.05], p < .001), personality disorder (k
= 5; g = 0.93, 95% CI [0.61, −1.26], p < .001;
mostly of borderline personality disorder), and sub-
stance use disorder (k = 2; g = 0.85, 95% CI [0.47,
−1.23], p < .001) than eating disorder (k = 4; g =
0.81, 95% CI [0.34, −1.27], p = .001). The

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

Hedges’s g and 95% confidence interval Heterogeneity

Number Point Lower Upper P- Q- df P- I-

Comparison Studies estimate limit limit value value (Q) value 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 2 0.66 0.34 0.98 <.001 1.20 1 .273 16.95
DERS)
UP (ERQ-Reappraisal and 2 0.90 0.60 1.21 <.001 0.25 1 .619 0.00
DERS)
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, 4 0.87 0.47 1.26 <.001 25.29 3 <.001 88.14
AEDP, and EFT)
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.

number of sessions (g = −0.001), year of publication
(g = 0.006), the number of participants (g = −0.00)
bore no systematic relation to the ER effect sizes
(p > .33).
Possible Negative Effects and Harm
Therapists using affect-focused methods to activate
or evoke strong emotions need to be cautious when
working with patients with impulse control pro-
blems, active substance abuse, and those whose dys-
regulation is exacerbated due to organic factors,
including thought disorders (Greenberg, 2015).
Individuals suffering from these disorders may not
contain strong emotions and as a result act out on
them. Affect-focused methods may not lead to
patient’s productive emotional experience when
patients are feeling negative toward the self, such as
shame, guilt, and self-contempt (Ulvenes et al.,
2014).
There has been no evidence that suggests that ER
methods lead to higher risk for dropouts and negative
effects than psychotherapy methods that do not
directly focus on or evoke emotional experience.
Nonetheless, future studies need to identify patient
characteristics that are associated with non-improve-
ment and deterioration.
Limitations of the Research
Few studies have examined therapist moment-to-
moment methods and their immediate, in-session
and intermediate effects on patient ER. Virtually all
studies have examined the effects of multicompo-
nents treatment packages on distal ER outcomes.
The overall treatments prove effective in enhancing
ER, but we do not know which specific components
or methods account for the improvement. Affect-
focused methods and structured methods are quite
different. Common and different change processes
according to each method should be delineated.
Another important task is to define ER and its mul-
tiple facets. There are several similar concepts, such
as emotional processing and emotional experiencing,
and their differences as well as overlaps have not yet
been empirically delineated.
Future researchers can also examine the thera-
peutic relationship in ER work. Implicit ER is
hypothesized to develop through internalizing an
empathic therapist. One study showed that patients
with therapists who had higher ER ability had signifi-
cantly better improvements in emotion regulation
(Abargil & Tishby, 2021). Future researchers could
also examine common and unique factors associated
Psychotherapy Research 23
with ER methods of different orientations in the
context of particular therapeutic relationships.
The vast majority of studies in our meta-analysis
were conducted in the United States among
samples of predominantly White individuals. Ethno-
racial status, gender differences, socioeconomic
status, and other cultural identity factors have not
been adequately examined.
The measurement of ER as an outcome has mostly
been conducted using self-report scales; however,
they may not capture the variability in how individ-
uals spontaneously select and implement ER strat-
egies (Aldao, 2013). Self-report questionnaires tend
to overlook natural fluctuations of ER in response
to daily environmental demands and emotional
experiences. They are also subject to recall bias and
do not necessarily correspond to the concurrent
report of ER (Aldao et al., 2010; Solhan et al., 2009).
An alternative to the self-report scales is ecological
momentary assessment, a set of techniques that
utilize repeated sampling of individuals’ real-time
behaviors by the use of mobile and internet technol-
ogy (Shiffman et al., 2008). This might identify how
a particular therapist method can affect patient’s ER
in their daily life. In addition, the moment-to-
moment measure of ER can be used to test the
immediate effect of therapist methods and relation-
ship behaviors. Common autonomic and electro-
myographic measures may be used to track
physiological arousal (Zaehringer et al., 2020).
Motion energy analysis (Ramseyer, 2020) using an
automated computer program may be also an effec-
tive way to track emotion regulation in the
moment-to-moment manner. Nonverbal synchrony,
or the coordination of patient’s and therapist’s bodily
movement, has been shown to be associated with
psychotherapy outcome and also with emotion regu-
lation (Tschacher et al., 2014). Considering that ER
occurs dyadically (Fosha, 2001), a combination of
these measures may detect microprocess of therapist
method and relational behaviors.
Training Implications
Given the meta-analytic evidence that multiple
psychological treatments lead to improvement in
ER for a range of psychological problems, trainees
could benefit from learning about ER as well as its
therapeutic methods. Students may learn to use
observer rating scales to identify in-session markers
for ER. They also can learn methods to increase
emotional awareness, identify emotional avoidance,
modulate dysregulated emotions, and transform
maladaptive emotions with adaptive emotions as
these are frequent components of ER work.
24 S. Iwakabe et al.
We suspect that deliberate practice might prove
helpful in mastering affect-focused methods and
related skills (Goldman et al., 2021). The therapist’s
use of voice and nonverbal behavior is critical in com-
municating empathy (Abargil & Tishby, 2021) and
helping patients modulate their emotions (Paivio &
Laurent, 2001). Trainees can practice these
responses while focusing on their voice and nonver-
bals associated with ER, repeatedly watch their per-
formance, receive feedback from supervisors,
incorporate it, and practice the skill until it is mas-
tered. One of the components of deliberate practice
training is the acquisition of inner skills for trainees
to regulate themselves. Working with dysregulated
patients can arouse strong emotional reactions in
therapists. Trainees need to develop their emotional
capacity to be aware of their own emotional state,
stay empathically attuned to their patients, and
adjust their verbal and nonverbal responses. In
most affect-focused therapies, videotaped supervi-
sion is the norm in which both supervisor and super-
visee track the moment-to-moment emotional
process and formulate therapist responses that are
most facilitative of emotional change (e.g, Greenberg
& Tomescu, 2017; Prenn & Fosha, 2017).
Finally, trainees can benefit from receiving training
in treatments focusing on ER. ACT, AEDP, DBT,
and EFT demonstrated larger effect sizes on ER in
our meta-analysis. Specific instructions for struc-
tured exercises and homework will be helpful tools
for trainees working with patients with emotional
dysregulation.
Therapeutic Practices
The meta-analysis demonstrated large gains in
patient ER from psychological treatments, but
empirical evidence is lacking on the effectiveness of
specific components or therapist methods. Hence,
we offer recommendations based on the sparse
research evidence and our clinical practice:
. Enhance patient ER capacity for a variety of be-
havioral disorders.
. Use either affect-oriented methods or structured
psychoeducational and skill training methods to
work with ER.
. Employ steps associated with enhancing patient
ER: undoing experiential avoidance, enhancing
emotional awareness, promoting a full emotional
experience, understanding the meaning of
experience, and learning strategies to cope with
distress.
. Provide a therapeutic relationship characterized
by empathy, validation, and support to help
patients develop ER capacity. Such a
relationship is frequently internalized by the
patient and may function to change schemas
that are putatively at the root of emotional
dysregulation.
. Address patients’ fearful avoidance or suppres-
sion of emotional experience via
psychoeducation.
. Consider the patient’s sense of self in focusing on
ER in session: When patients are in their nega-
tive self-state, they frequently do not recognize
positive aspects of themselves and focusing on
emotion is not likely to bring adaptive affects.
. Consider the patient’s cultural identity and
worldview as well as the context in which the
patient’s emotional experience occurs in evaluat-
ing the appropriateness of ER.
Notes
1
The clinical material presented here was gathered in compliance
with the APA ethics code and a written consent from the patient
was obtained. The original material was modified for brevity.
2
The case material was fictitious clinical amalgams for the sake of
clinical illustration by the authors.
Disclosure Statement
No potential conflict of interest was reported by the
author(s).
Funding
This work was supported by JSPS [grant number
22K03119].
ORCID
Shigeru Iwakabe http://orcid.org/0000-0001-7005-
8978
Kaori Nakamura http://orcid.org/0000-0002-
3980-0107
Nathan C. Thoma http://orcid.org/0000-0003-
2833-2464
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