How Does Emotion Regulation Change During Psychotherapy?

A Daily Diary Study of Adults in a Transdiagnostic Partial Hospitalization Program

Emotion dysregulation is implicated in the development and maintenance of many psychiatric disorders.

Emotion regulation skills are often incorporated into evidence-based therapies to reduce dysfunctional regulatory patterns like avoidance and rumination while increasing more constructive regulation through reappraisal and acceptance.

However, most treatment research examines one disorder at a time, focuses on a limited number of strategies, and only compares pre-post treatment differences. This overlooks potentially informative day-to-day regulatory changes throughout therapy that might influence outcomes.

Goodman, F. R., Peckham, A. D., Kneeland, E. T., Choate, A. M., Daniel, K. E., Beard, C., & Björgvinsson, T. (2023). How does emotion regulation change during psychotherapy? A daily diary study of adults in a transdiagnostic partial hospitalization program. Journal of Consulting and Clinical Psychology, 91(12), 731–743. https://doi.org/10.1037/ccp0000838

Key Points

1. The study found that during transdiagnostic psychiatric treatment in a partial hospitalization program:
   • Patients increased use of engagement emotion regulation strategies like acceptance and cognitive reappraisal.
   • Patients decreased use of disengagement strategies like distraction and expressive suppression.
   • Patients decreased use of perseverative strategies like experiential avoidance and rumination.
   • These changes occurred within the first 7 days of treatment and were sustained at discharge for all strategies except distraction.
2. Decreased use of experiential avoidance predicted next-day changes in disengagement strategy use like distraction and suppression.
3. Faster decreases in suppression use uniquely predicted reduced symptoms of anxiety, depression, and general psychopathology at discharge.
4. The intensive transdiagnostic treatment provides evidence that targeting emotion regulation can lead to broad symptomatic improvements.

Rationale

Transdiagnostic refers to similar psychological processes, symptoms, or interventions across mental health diagnoses.

Emotion dysregulation is a transdiagnostic process implicated in mood disorders, anxiety disorders, substance use disorders, trauma disorders, eating disorders, and personality disorders (Fowler et al., 2021; Sloan et al., 2017).

Difficulties with emotion regulation are associated with increased psychopathology and functional impairment across diagnoses (Fowler et al., 2021). As such, many evidence-based therapies, including cognitive behavioral therapy, acceptance and commitment therapy, and dialectical behavior therapy, directly target emotion regulation skills in treatment (Gross & Jazaieri, 2014).

These therapies utilize techniques to reduce maladaptive regulatory patterns like rumination, suppression, and avoidance while increasing more adaptive strategies like cognitive reappraisal and acceptance (Diedrich et al., 2016).

However, most clinical research examines treatment response within single diagnoses without considering transdiagnostic mechanisms (Sloan et al., 2017).

Additionally, studies tend only to assess emotion regulation abilities at pre and post-treatment, which overlooks meaningful within-treatment regulatory fluctuations that likely shape outcomes (Kramer et al., 2016).

For example, how quickly patients acquire more helpful regulation strategies versus drop maladaptive ones during therapy could influence long-term gains, but daily regulatory patterns remain understudied (Blalock et al., 2016).

This study helps address these gaps by modeling day-to-day emotion regulation changes throughout transdiagnostic psychiatric treatment using intensive repeated assessments.

Method

This study utilized daily diary methods to assess changes in six emotion regulation strategies – acceptance, distraction, suppression, reappraisal, experiential avoidance, and rumination – throughout treatment in a partial psychiatric hospitalization program.

The program treated 364 adults with heterogeneous disorders using cognitive-behavioral and dialectical behavior therapy skills targeting emotion regulation.

Patients completed validated measures of emotion regulation daily during the first seven treatment days. They also completed measures of anxiety, depression, overall psychiatric symptoms, and quality of life at intake and discharge.

Sample

• N = 364 adults aged 34.6 years on average; 60% female; 85% Non-Hispanic White
• Primary diagnoses: 52% major depression, 37% generalized anxiety disorder

Statistical Analysis

Latent curve modeling with structured residuals to model within-person (daily) and between-person (average) changes in strategy use over seven days of treatment. Associations tested between individual trajectories and symptom/functioning outcomes.

Results

How Does Emotion Regulation Strategy Use Change Throughout Treatment?

• Patients increased use of the engagement strategies, acceptance and cognitive reappraisal, over the first 7 treatment days.
• Patients decreased use of the disengagement strategies, expressive suppression and distraction, over the first 7 days, although the change in distraction use was nonsignificant.
• Patients decreased use of the perseverative strategies, experiential avoidance and rumination, over the first 7 days.
• Rates of change over time were relatively uniform across patients for acceptance, experiential avoidance, and suppression.
• Rates of change varied significantly between patients for distraction, reappraisal, and rumination.

How Does Strategy Use on One Treatment Day Predict Use on the Next Treatment Day?

• On days with above-average experiential avoidance use, patients reported above-average distraction and suppression use the next day.
• No other strategy predicted next-day changes in use of other strategies.

How Do Changes in Emotion Regulation Strategies Predict Treatment Outcomes?

• Faster decreases in suppression use uniquely predicted reduced symptoms of anxiety, depression, and general psychopathology at discharge.
• Faster decreases in experiential avoidance use predicted reduced general psychopathology symptoms and improved quality of life at discharge.
• Faster decreases in rumination predicted reduced depression symptoms and improved quality of life at discharge.
• Faster increases in reappraisal use predicted reduced general psychopathology symptoms and improved quality of life at discharge.

Insight

This study demonstrates that targeting emotion regulation skills in intensive transdiagnostic treatment can lead to broad improvements in heterogeneous patient groups.

Patients successfully increased the use of engagement strategies and decreased the use of problematic disengagement/perseveration strategies after just seven days. Suppression reduction appeared to be a particularly potent change mechanism. Decreased experiential avoidance also facilitated next-day changes in other maladaptive regulation attempts.

Notably, regulatory changes occurred despite most patients entering treatment with moderate-severe symptoms and reporting high initial use of problematic strategies like rumination. This indicates that regulatory patterns are mutable early in treatment regardless of patients’ baseline tendencies. It also highlights the value of intensive interventions for catalyzing meaningful therapeutic change across presenting problems.

By modeling day-to-day regulatory shifts, this study captures clinically useful processes overlooked in pre-post assessments. The ability to pinpoint quick within-treatment changes in emotion regulation that facilitate broader symptom reduction could inform treatment refinement.

For instance, directly targeting experiential avoidance early in treatment may potentiate positive cascading effects on strategy use and outcomes.

Strengths

• Large clinical sample with heterogeneous disorders
• Daily diary methods sensitive to regulatory changes
• Innovative statistical modeling of within-person processes
• Assessed multiple emotion regulation strategies simultaneously
• Intensive transdiagnostic intervention well-suited to capturing early change

Limitations

• Partial hospitalization limits generalizability to other settings
• Brief single-item measures of regulation may overlook strategy complexity
• Cannot determine causality due to lack of control group
• Sample lacked diversity in terms of demographic variables

Clinical Implications

These findings support the promise of targeting emotion regulation to address transdiagnostic mechanisms underlying varied disorders.

Suppression reduction, in particular, may be valuable to prioritize early when possible, given its consistent associations with treatment gains. Intensive interventions could kickstart this process by challenging rigid regulatory habits.

Community accessibility is essential since treatment-seeking samples have limited diversity. Lowering structural barriers around cost, transportation, work schedules etc. could make intensive treatment feasible for more people.

Future research should clarify optimal timing and methods for enhancing engagement and reducing disengagement/perseveration strategies.

References

Primary reference

Goodman, F. R., Peckham, A. D., Kneeland, E. T., Choate, A. M., Daniel, K. E., Beard, C., & Björgvinsson, T. (2023). How does emotion regulation change during psychotherapy? A daily diary study of adults in a transdiagnostic partial hospitalization program. Journal of Consulting and Clinical Psychology, 91(12), 731–743. https://doi.org/10.1037/ccp0000838

Other references

Blalock, D. V., Kashdan, T. B., & Farmer, A. S. (2016). Trait and daily emotion regulation in social anxiety disorder. Cognitive Therapy and Research, 40(3), 416–425. https://doi.org/10.1007/s10608-015-9739-8

Bullis, J. R., Boettcher, H., Sauer-Zavala, S., Farchione, T. J., & Barlow, D. H. (2019). What is an emotional disorder? A transdiagnostic mechanistic definition with implications for assessment, treatment, and prevention. Clinical Psychology: Science and Practice, 26(2). https://doi.org/10.1111/cpsp.12278

Daros, A. R., Haefner, S. A., Asadi, S., Kazi, S., Rodak, T., & Quilty, L. C. (2021). A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety. Nature Human Behaviour, 5(10), 1443–1457. https://doi.org/10.1038/s41562-021-01191-9

Diedrich, A., Grant, M., Hofmann, S. G., Hiller, W., & Berking, M. (2016). Self-compassion as an emotion regulation strategy in major depressive disorder. Behaviour Research and Therapy, 58, 43–51. https://doi.org/10.1016/j.brat.2014.05.006

Fowler, J. C., Charak, R., Elhai, J. D., Allen, J. G., Frueh, B. C., & Oldham, J. M. (2021). Construct validity and factor structure of the difficulties in emotion regulation scale among treatment-seeking adults. Psychiatry Research, 296, Article 113681. https://doi.org/10.1016/j.psychres.2020.113681

Gross, J. J., & Jazaieri, H. (2014). Emotion, emotion regulation, and psychopathology: An affective science perspective. Clinical Psychological Science, 2(4), 387–401. https://doi.org/10.1177/2167702614536164

Kramer, U., Pascual-Leone, A., Despland, J.-N., & de Roten, Y. (2015). One minute of grief: Emotional processing in short-term dynamic psychotherapy for adjustment disorder. Journal of Consulting and Clinical Psychology, 83(1), 187–198. https://doi.org/10.1037/a0037979

Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017). Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: A systematic review. Clinical Psychology Review, 57, 141–163. https://doi.org/10.1016/j.cpr.2017.09.002

Keep Learning

1. How might the role of emotion regulation in psychopathology and treatment response differ across cultural contexts? What mediators should future research explore?
2. This study found quicker changes in emotion regulation than some previous treatment research. What factors could explain these rapid effects in this sample and setting? What are the pros and cons of intensive interventions?
3. What ethical considerations should guide attempts to modify emotion regulation abilities, especially disengagement strategies that may have situational benefits? When might reducing use of certain strategies be harmful?