emotion regulation group therapy manual
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emotion regulation group therapy manualThese science-based exercises will not only enhance your ability to understand and regulate your emotions but will also give you the tools to foster the emotional intelligence of your clients, students or employees. These four modules include: Clients are encouraged to accept that they will undoubtedly experience negative emotions in their life, no matter how happy or well-balanced they may be. Image by Malgorzata Tomczak on Pixaby. The three most popular and most evidence-backed scales are included below. It was developed in 2003 by James Gross and John Oliver, based on five studies spanning the question development, validity and reliability, and structure of the questionnaire. The scale covers two facets, the Cognitive Reappraisal facet and the Expressive Suppression facet, and produces a separate score for each facet. This scale was developed very recently (2016) by researchers Hofmann, Carpenter, and Curtiss. Each subscale has a minimum score of 5 and a maximum score of 25. It differs from other emotional regulation questionnaires in its focus on the individual’s thoughts and exclusion of the behavior; it aims to find out what cognitive strategies the individual uses, rather than how they behave. It includes nine separate cognitive coping strategies, with four items comprising each strategy. In this form of therapy, you won’t have to worry about vague ideas surrounding healing and moving forward; your therapist will have a detailed list of skills, strategies, and techniques you can use to start feeling and doing better. Free Image Courtesy of Pixaby. Secondary emotions: the reaction to your primary emotions or thoughts (Bray, 2013). However, secondary emotions are more dangerous and more within our control; we generally have more of a choice about how to respond to the fact that we are sad when someone dies. Our emotions are unique, organic experiences that cannot be molded to fit ideas of what is “normal,” and to try can be harmful.http://fcimoveis.com/imgs/devil-may-cry-4-automatic-or-manual.xml
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Practicing mindfulness helps us become more aware of our thought patterns, our emotions, and how our thoughts and feelings affect our reactions to events. Instead of simply letting them go, we often hold ever tighter to them, obsessing over every little bit of our emotional experience and wondering why it’s happening to us. Image by Pexels from Pixaby. When we accept that we are suffering, we stop running from the difficult emotions and turn to face them—and when we do, we might see that it wasn’t the big bad monster we thought it was, but a smaller and more manageable beast. Acknowledge that it exists, stand back from it, and get yourself unstuck from it; You may find it helpful to concentrate on some part of the emotion, like how your body is feeling or some image about it. For example, you could use this imagery: Don’t try to push the emotion away. This makes it bigger and increases our suffering. Don’t reject the emotion. Don’t judge your emotion. It is not good or bad. It is just there. There are no bad emotions, just emotions. Anger, fear, sadness are all painful emotions, but they are not bad. Everyone has them, and they are just as valid as the happy emotions. At the same time, do not hang on to your emotion. Don’t rehearse it over and over to yourself. Don’t escalate it or make it bigger. Sometimes when we feel a very painful emotion, like anger or a deep grief, we hold on to it, or we intensify it, making it stronger and stronger, in our efforts to deal with it or to give it our full attention. Try not to do this. Just let it be however it is. This can result in a lessening of the pain.” Your emotion is part of you, but it is not all of you. You are more than your emotion; You may just need to sit with the emotion. Often, acting can intensify and prolong the emotion; This can be a difficult concept. Why would we want to love painful emotions?http://www.eventing.hu/userfiles/devil-may-cry-4-manual-automatic.xml You don’t have to like your freckles, but they are there and you can’t change that, so if you just accept or love them, you will feel a lot better than if you keep fighting the idea that they are there (Dietz, 2012). These get-togethers can be great opportunities to reconnect with loved ones, but they can also be stressful and emotionally charged. Take care of yourself by eating healthy meals, exercising regularly, getting enough sleep, avoiding toxic or mood-altering substances, and treating any illnesses or issues that require treatment. You shouldn’t ignore your negative emotions, but make sure to leave room for the positive as well. Leave yourself open to the possibility of renewing old friendships, as well as to forging new friendships. Even if bad things happen, there’s bound to be at least one or two positive things to savor. Crowd out the negative in your head with all the positive that you can find. Remind yourself that you deserve to have fun, to enjoy your time with friends, and to bask in the warmth of a loving family. Make room in your mind for the positive, and the negative will have less space to fill (Dietz, 2012). It incorporates aspects of Cognitive Behavioral Therapy (CBT), DBT, and mindfulness meditation to help you more effectively address and manage your emotional response to a challenging, difficult, or rage-inducing incident. How important will it be in 6 months’ time. For me? For others? For the situation? o What can I do that fits with my values.Learning how to pause in between an intense emotional reaction and your ensuing actions is one of the most valuable and life-changing skills that a person can have. Practice STOPPing, and you will be in a great position to manage your most difficult emotions. There are also many techniques that on the surface seem like they will help you keep your emotional balance but upon further consideration reveal themselves to be unhealthy. Image by David Schwarzenberg on Pixaby.http://ninethreefox.com/?q=node/14765 Try an activity that will result in you learning something new or developing a new skill, and allow yourself the space to build on it every day. The worksheet encourages you to try the following: Use acceptance techniques such as visualization, awareness exercises, or affirmations. Concentrate on a mantra of acceptance, such as “That’s just how it is,” or “All is the way it should be.’” Briefly, you will: One example might be a disagreement with a loved one; Where were they? Who were they with? They will ideally be able to label it. What do they feel like doing now. Note that this is not about how they reacted at the time, but what want to do in the moment as they revisit this experience. What did they notice about each? Among other things, it can be particularly useful for clients who would like to target their impulsive tendencies or urges. However, we often assume the relationship is from the emotion to behavior, rather than the other way around. If you’re angry, try talking quietly instead of yelling. If you are sad, try chatting with friends instead of withdrawing from them. Or does it just match my assumptions of the situation? You will likely find it much easier to manage your emotions if you also manage your health and your body. It’s natural, but it’s not helpful! You can practice by doing one small, positive activity every day, focusing on the good parts of the activity as you do it. Ignore minor issues and notice the enjoyment, pleasure, and fun! Image by Maggie Morrill from Pixaby. The easy-to-identify symbols make understanding the zones simple for children, and intuitive for anyone who has paid attention to the world outside of their car! If the reader is not sure how they are feeling, it can guide the reader in identifying his or her emotion. This can be a fun activity for young children, and it encourages them to think about their emotions.https://oknagoda.com/images/99-kodiak-400-manual.pdf However, it is best for them if they figure out how to keep their emotions within Green and sometimes Yellow while limiting the time they spend in Red. This can be an excellent lead-in for mindfulness practice or any other emotion regulation skill development! What techniques did you use. Would you use any of these techniques. Let us know in the comments section below. Don’t forget to download our 3 Emotional Intelligence Exercises for free. Good Therapy. Retrieved from. Journal of Personality and Social Psychology, 85, 348-362. Cornell Research Program on Self-Injury and Recovery. Retrieved from Psych Central. Retrieved from She is currently working as a researcher for the State of California and her professional interests include survey research, well-being in the workplace, and compassion. Thank you so much! May I have some questions to you about you doing research??? I am working in Atlanta, GA As a budding coach this is very helpful for me. It is an amazing curriculum and helps kiddos develop self regulation strategies and perspective taking skills. This isn’t an option at this time. I want to conduct research to regulation emotions or check the emotion at the door so that students can learn better with better results. Do you know what research has been done in this area? Will be using this as part of staff training. I wonder where my head was when I wrote that sentence. Now, a year and a half later, one can only begin to imagine. Thank you for the correction! Updated accordingly. Keep up the amazing work! Its a very good job. Iam Portuguese and iam therapist and Mindfulness Instructor. Its importante to know and grow all the time. Thank you! Another way to look at this is to ask the person the intention behind the action.Great insights for use with toddlers as well as adults at all stages of life. The worksheets are very insightful. You guys at positivepsychologyprogram are doing awesome. I’m very glad I found this post because I’m struggling with the loss of a relationship I really wanted, and I can’t seem to get myself out of the cycle of sadness and hopelessness. I will work on these skills to improve my emotions and responses. Thank you very much! Something specific, things to do, to try and regulate my emotions which have always been a bit here and there but more so after the death of my husband 6 years ago. It may not work, it may be difficult AND it is something positive I can do and keep doing. Thank you for sharing this. I will try some out. Thank you so much I will apply what I had learned here. I’m so glad you found it useful. Thanks for letting us know! Now I’m gonna replicate my study and will be modeling it based on this article ?? Best of luck in your new research ?? I always knew I had some emotional dysregulation difficulties and they’ve been intensified ever since our daughter was born. It’s gotten to the point where my wife is afraid to leave our daughter alone with me for fear that I might seriously injure our daughter. After reading through all of the content you posted, I’m eager to try some of them out in the hopes of earning my wife’s trust back and being allowed to properly love and care for our child together. I’m still very scared of relapses in my behavior but will reread your post for how to deal with that. I’m so sorry to hear of the difficulties you are facing. As exciting and joyous as a new baby can be, it’s still an extremely stressful time that can trigger some very intense emotions and regulation problems. I’m happy to hear you found this piece helpful, and I wish you the BEST of luck in applying these exercises. You can do it! If interested, please email me. I am diagnosed bipolar but as of recently, including after reading this article, I truly feel I have BPD. The love of my life just ended things because of my inability to handle emotions. I have seen and used DBT strategies before but I have never seen a lot of what is included here. Now that I have these tools I am confident that I can better myself. Thank you so much. We’re happy to share, and so glad you found it useful. Thank you so much! Thanks for letting us know! Thanks for your comment. Thankyou Courtney Ackerman via Stroh Fontlan Penn and possitive psychologists programs resource. Let us observe the success. Thank you Hopefully you observe the same great results that so many others have found with these techniques. It’s great to hear you will share this with your clients. I hope they find it just as useful! Thanks for your comment, Rajinder! Thank you for letting us know you enjoyed it. I like your helpful article, thank you very much for posting, for me it is easier to read and understand english, than to express exactly what I feel in taht language I could probably figure out the gist of the comment, at least.Thank you very much for this extensive piece of work. I can use aspects of this in my work with children and parents. I’m happy to hear you can apply some of this in your work. Best of luck! I plan on sharing in bits with my school staff to help with self-care and understanding student behaviors. Thanks!! Thanks for letting us know you found this piece so useful. I work with people with a lived experience of mental illness. Most having difficulty with emotional regulation particularly when faced with stressful life events. Before I recommend a strategy to a client I give it a go myself. Thanks for sharing. Regards Andy Emotion regulation issues are so tough to address because our emotions demand so much energy and attention. That’s wonderful that you’re working with people dealing with such issues. Positive Emotions What is the Positive and Negative Affect Schedule? (PANAS). The goals of ERT are for individuals to become better able to: Identify, differentiate, and describe their emotions, even in their most intense form; Increase acceptance of affective experience and ability to adaptively manage emotions when necessary; Decrease use of emotional avoidance strategies (such as worry, rumination and self criticism); and Increase ability to utilize emotional information in identifying needs, making decisions, guiding thinking, motivating behavior, and managing interpersonal relationships and other contextual demands. This mechanism-targeted behavioral intervention focuses on the training of three major emotion regulation skill groups: attention, allowance (targeted towards increasing implicit regulatory ability), distancing (decentering)(targeted towards more flexible responsivity to emotional stimuli; i.e., reactivity), and reframing (targeted towards greater utilization of explicit regulation). To date, the efficacy of ERT has been demonstrated in recently concluded NIMH-funded trials (NIMH R34 in collaboration with Dr. Richard Heimberg at Temple University) including an open trial and a randomized clinical trial. Patients in both trials evidenced reductions in measures of GAD severity, worry, trait anxious, and depression symptoms and corresponding improvements quality of life. These gains were maintained for nine months following the end of treatment. Evaluation of efficacy and investigation of treatment mechanisms is on-going in clinics at Kent State University and Hunter College. Drs. Mennin and Fresco have been asked to speak about ERT or provide trainings in numerous academic, medical, and private settings nationally and internationally, and are currently writing a book on ERT for Guilford Press. Additionally, ERT is included in Dr. James Gross', Stanford University, Handbook of Emotion Regulation (Second Edition). Other writing and talks can be found in the publications and presentations pages of this website. This mechanism-targeted behavioral intervention is based in an affect-science perspective, and focuses on the training of a number of regulatory skills including attentional flexibility, acceptance, cognitive distancing, and cognitive reframing as well as experiential exposure to contexts of perceived reward and risk. To date, the efficacy of ERT has been demonstrated in recently concluded NIMH-funded trials including an open trial and a randomized clinical trial. Evaluation of efficacy and investigation of treatment mechanisms is on-going in clinics at CUNY Hunter College and Kent State University. No commercial use is permitted unless otherwise expressly granted. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: This article has been corrected. See BMJ Open. 2017; 7(11): e016220corr1. This article has been cited by other articles in PMC. However, it has not been evaluated outside a research setting. In order to increase the availability of empirically supported treatments for individuals with borderline personality disorder and deliberate self-harm, an evaluation of ERGT in routine clinical care was conducted with therapists of different professional backgrounds who had received brief intensive training in ERGT prior to trial onset. Design Multi-site evaluation, using an uncontrolled open trial design with assessments at pretreatment, post-treatment and 6-month follow-up. Setting 14 adult outpatient psychiatric clinics across Sweden. Ninety-three per cent of participants completed the post-treatment assessment and 88 completed the follow-up assessment. Primary and secondary outcome measures Primary outcome was self-harm frequency as measured with the Deliberate Self-Harm Inventory. Secondary outcomes included self-harm versatility, emotion dysregulation, other self-destructive behaviours, depression, anxiety, stress symptoms and interpersonal and vocational difficulties. Intervention ERGT is an adjunctive, 14-week, acceptance-based behavioural group treatment that directly targets both self-harm and its proposed underlying mechanism of emotion dysregulation. Keywords: borderline personality disorder, group therapy, emotion regulation, implementation Strengths and limitations of this study This multi-site evaluation in routine clinical care suggests that emotion regulation group therapy may be an easily disseminated and useful treatment for deliberate self-harm. Participants reported continued reductions in deliberate self-harm after treatment conclusion. This study lacked a control group, limiting our ability to draw conclusions about the effectiveness of emotion regulation group therapy specifically. As only adult women were included in the study, generalisability to other patient populations is unclear. DSH has been implicated in the high levels of healthcare utilisation among individuals with BPD 7 and is one of the strongest predictors of future suicide attempts. 8 9. These trials also play an important role in increasing the availability of evidence-based treatments. 20 Thus, further research examining the utility of empirically supported treatments for DSH within BPD in real-world clinical settings is needed. This study sought to examine the utility of one such treatment in a nationwide open trial. Specifically, in an effort to increase the availability of clinically feasible treatments for DSH in BPD within the community, we conducted an evaluation of ERGT (a 14-week adjunctive group treatment with established efficacy in the treatment of DSH within BPD 12 ) in routine clinical care, as delivered by community clinicians at 14 psychiatric outpatient clinics throughout Sweden. Consistent with past research on ERGT, we expected to find significant improvements from pretreatment to post-treatment in DSH and other self-destructive behaviours, emotion dysregulation, psychiatric symptoms and adaptive functioning, as well as stability of these improvements during the 6-month follow-up period. Materials and methods Design and participants The present trial was conducted at 14 psychiatric outpatient clinics located throughout Sweden. We used an uncontrolled open trial design with a 6-month follow-up. Participants were recruited and assessed by community-based healthcare professionals at the psychiatric outpatient clinics. Exclusion criteria were minimal and included only: (a) a DSM-IV 22 diagnosis of psychotic or bipolar I disorder or ongoing (past month) substance dependence as assessed with the MINI International Neuropsychiatric Interview (MINI 6 23 ), (b) the presence of co-occurring psychiatric disorders that required immediate treatment (eg, anorexia nervosa), (c) insufficient understanding of the Swedish language and (d) current life circumstances that would interfere with treatment (ie, being homeless). Due to an administrative error, the study was not released on the Clinical Trials platform by the principal investigator, until November 4, 4 weeks after the first patient was included. At that date, one group had had one ERGT session and another group had had two ERGT sessions, but there were no changes in the study protocol at any time between the start of inclusion of patients and the release of the protocol. Between October 2013 and March 2014, 108 female participants with threshold or subthreshold BPD were considered for participation in the study. All participants provided written informed consent. Eight participants did not meet inclusion criteria, four dropped out before completing the pretreatment assessment and one completed the pretreatment assessment but died from suicide before beginning ERGT. Thus, the final sample size was 95 participants. Diagnostic and demographic data for the final sample are presented in table 1. Notably, this sample was comparable to those of both past ERGT trials and other BPD treatment outcome studies with regard to both demographic characteristics and co-occurring psychiatric disorders. 12 15 20 24 25 Participant flow through the trial is described in figure 1. Open in a separate window Figure 1 Participant flow through the study. BPD, borderline personality disorder; DSH, deliberate self-harm; ERGT, emotion regulation group therapy. Selection of participating clinics and study therapists An invitation to participate in the study was distributed through a national network of psychiatric caregivers (with representatives from all county councils). Thirty-two clinics responded to the invitation, from which 15 clinics were selected. Consideration was also given to the clinics’ geographical location, aiming for as broad a national geographical representation as possible. One included clinic did not participate in the study due to local administrative difficulties, leaving 14 clinics and 28 therapists in the study. Across these clinics, a total of 17 groups were conducted. Assessments Clinician-administered assessments at baseline included the BPD module of SCID-II, 21 an interview version of DSHI, 1 MINI 6 23 and the Columbia-Suicide Severity Rating Scale. 27 Treatment outcome measures were administered in self-report format at baseline, pretreatment, post-treatment and 6-month follow-up. All self-report measures used in the study were completed online (a method with demonstrated validity 28 ). DSHI was also used to assess DSH versatility (ie, number of different types of DSH behaviours in the past 4 months)—an index of DSH severity. 29. Moreover, the following themes are emphasised throughout the treatment: (a) the potentially paradoxical effects of emotional avoidance; (b) the emotion regulating consequences of emotional acceptance and willingness; and (c) the importance of controlling behaviour when emotions are present, rather than controlling emotions themselves. A detailed description of the content and development of ERGT is available elsewhere. 11 Sudden deterioration or suicidal crises are monitored weekly through self-report measures assessing DSH frequency and emotion dysregulation and addressed by the group therapists in collaboration with the ongoing treatment provider if needed. The ERGT treatment manual was translated into Swedish through a collaborative and iterative process involving the treatment developer (KLG) and co-author of the ERGT manual (MTT) and the primary ERGT supervisors for this trial (HS and JB, in collaboration with LGL). The workshop consisted of didactic lectures, demonstrations, role playing and practice exercises. Of the 28 therapists, 22 were licensed psychologists, 2 were social workers, 2 were nurses, 1 was a psychiatric aid and 1 was an occupational therapist. All analyses were performed in R using random effects modelling. 40 The count variables, DSH frequency and BSL, are reported with medians and IQR and were analysed using negative binomial generalised mixed models, and the remaining continuous outcomes are reported as means and SD and were analysed using linear models. The models included all available data at the three assessment points (pretreatment, post-treatment and 6-month follow-up) for each outcome, thus making them intent-to-treat analyses. We estimated separate slopes for the change between the pretreatment and post-treatment assessments (S1) and the change between the post-treatment and 6-month follow-up assessments (S2). Random intercepts and random slopes as well as autoregressive correlation structures were included in the models if they significantly improved model fit according to log-likelihood ratio tests. Effect sizes were calculated for changes between pretreatment, post-treatment and 6-month follow-up. For the count variables (ie, DSHI frequency and BSL), the percentage change from baseline to any subsequent time point with 95 CI was used as an effect size. This was calculated by exponentiating the estimate for the slopes derived from the negative binomial models and interpreting the range below or above 1 as the percentage decrease or increase in the outcome for a 1-unit increase in the predictor. We also performed separate analyses where linear mixed models were applied to log-transformed DSH frequency and BSL scores and corresponding effect sizes were extracted. These effect sizes are reported together with observed means and SD of DSH frequency and BSL scores to permit comparison with previous studies of ERGT. 11 12 20 However, inferences of the statistical significance of changes on these measures were based on the more appropriate negative binomial regression models. CIs with a 95 margin for the effect sizes were calculated using 5000 bootstrap replications. 41 The bootstrap replications were clustered on participants. 42 First, the treating clinics were entered as random factors to test the possibility of clustering effects in the data. Second, we added concurrent medication status (coded as 0 for no concurrent medication and 1 for concurrent medication) and type of treatment as usual (coded as a factor with the following levels: cognitive behavioural therapy, psychodynamic therapy, supportive therapy or other) as covariates in the model. These covariates were added both as simple effects and as interaction effects with the S1 variable to investigate the possible influence of the covariates on DSH frequency and treatment effect. Third, we entered the number of treatment sessions attended as a predictor of improvement in DSH frequency during the treatment period. Finally, we examined the number of participants who reported no (zero) DSH episodes at each assessment point and used McNemar’s exact tests to analyse the changes between the assessment points. Post-treatment assessments were completed by 88 (93) participants, and 6-month follow-up assessments were completed by 76 (82) participants.There was a significant 52 reduction in DSH frequency from pretreatment to post-treatment and a 76 reduction from pretreatment to 6-month follow-up. CIs for effect sizes are based on 5000 bootstrap replications. At the 6-month follow-up, all of these improvements were either maintained or further improved on, with the change on DERS from pretreatment to 6-month follow-up reaching a large-sized effect. Median reduction in self-destructive behaviours over each time period is reported in table 2. Sensitivity analyses First, we included the treating clinics as random factors in the DSH frequency model. This did not improve model fit, suggesting that there was not a significant clustering effect of treating clinic in the data. Second, we included concurrent medication status and type of treatment as usual as simple effects and interaction effects with S1 (ie, the change between the pretreatment and post-treatment assessments) in the DSH frequency model. Third, we included the number of attended sessions as a predictor of improvement in DSH frequency. Results revealed significant improvements in DSH frequency and versatility, emotion dysregulation, self-destructive behaviours and depression and stress symptoms from pretreatment to post-treatment.