REVIEW CURRENTOPINION Emotion regulation and mental health: recentfindings, current challenges, and future directionswww.co-psychiatry.coma b,cMatthias Berking and Peggilee WuppermanPurpose of reviewIn recent years, deficits in emotion regulation have been studied as a putative maintaining factor andpromising treatment target in a broad range of mental disorders. This article aims to provide an integrativereview of the latest theoretical and empirical developments in this rapidly growing field of research.

Recent findingsDeficits in emotion regulation appear to be relevant to the development, maintenance, and treatment ofvarious forms of psychopathology. Increasing evidence demonstrates that deficits in the ability to adaptivelycope with challenging emotions are related to depression, borderline personality disorder, substance-usedisorders, eating disorders, somatoform disorders, and a variety of other psychopathological symptoms.Unfortunately, studies differ with regard to the conceptualization and assessment of emotion regulation,thus limiting the ability to compare findings across studies. Future research should systematically work touse comparable methods in order to clarify the following: which individuals have; what kinds of emotionregulation difficulties with; which types of emotions; and what interventions are most effective in alleviatingthese difficulties.

SummaryDespite some yet to be resolved challenges, the concept of emotion regulation has a broad and significantheuristic value for research in mental health.

Keywordsemotion regulation, mental disorders, psychopathology, review, skillsaDepartment of Clinical Psychology and Psychotherapy, Philipps-Univer-sity, Marburg, Germany, bJohn Jay College, City University of New York,New York and cYale School of Medicine, New Haven, Connecticut, USA

Correspondence to Matthias Berking, Department of Clinical Psychologyand Psychotherapy, Philipps-University, Gutenbergstrasse 18, D-35032Marburg, Germany. Tel: +49 6421 282 4050; fax: +49 6421 282 4065;e-mail: berking@staff.uni-marburg.de

Curr Opin Psychiatry 2012, 25:128134

DOI:10.1097/YCO.0b013e3283503669INTRODUCTION

Emotion regulation refers to extrinsic and intrinsicprocesses responsible for monitoring, evaluating,and modifying emotional reactions, especially theirintensive and temporal features, to accomplishones goals [1]. After years as a major research topicin developmental psychology and borderlinepersonality disorder (BPD), the concept of emotionregulation has recently become popular in generalmental-health and psychotherapy research. At thispoint, not a month passes without at least one peer-reviewed publication on emotion regulation in thecontext of depression, anxiety, substance-relateddisorders, eating disorders, and so on. However,despite its popularity, the concept struggles to attainviability as a scientific construct due to variousunmet challenges involving definition, assessment,and clinical implications. Such problems have beendiscussed (although not solved) in the context ofdevelopmental psychology [1,2], but not yet inrelation to the specific needs of research with aclinical focus. Therefore, the aim of this article isto, briefly, first, review relevant findings regardingemotion regulation and psychopathology and,second, address the above challenges as they pertainto research focused on clinical psychology, psychia-try, and psychotherapy.BRIEF OVERVIEW OF RELEVANT FINDINGS

A significant focus on emotion regulation can beobserved in the following areas of clinical research.Volume 25 Number 2 March 2012

mailto:berking@staff.uni-marburg.de

KEY POINTS

Deficits in emotion regulation are relevant in the contextof various mental-health problems.

An overly broad conceptualization of emotionregulation threatens its value as a heuristic paradigm.

Validity of assessment of emotion regulation needs tobe improved.

A stronger clinical focus is needed in research onemotion regulation.

Research needs to identify mechanisms by whichemotion regulation skills affect psychopathology.

Emotion regulation and mental health Berking and WuppermanClinical child and adolescent psychology

Evidence suggests that emotion regulation ininfants is initiated largely by caregivers and gradu-ally becomes more self-initiated over time [2]. Strat-egies evolve under the influence of variousinteracting factors, including the quality of care-givers support as the child learns to cope withdistressing situations [3]. Emotion regulation skillsin children and adolescents have been demon-strated to (negatively) predict (subsequent) external-izing and internalizing problems in numerousstudies [4,5

&

].Borderline personality disorder

Substantial evidence supports emotion dysregula-tion as a core construct underlying BPD. BPD isassociated with less emotional awareness and clarity[6,7], less ability to tolerate distress when pursuinggoals [8], the reported tendency to use harmfulemotion regulation strategies (e.g., self-injury) inresponse to distressing situations [9], and deficitsin the ability to use cognitive reappraisal to regulateemotions [10

&

]. Persons with BPD tend to displaylower parasympathetic activity in response toemotional stressors than do controls [11]; andemotion dysregulation predicts subsequent BPD fea-tures, even when controlling for impulsivity [12].Finally, individuals with BPD endorse deficits in allfacets of emotion regulation self-report measures[13]; also, self-reported emotion regulation deficitsare associated with amygdala activation [14

&

].Depression

Depression is widely conceptualized as a con-sequence of dysfunctional emotion regulation[1517]. Consistently, depressed individuals reportdifficulties, first, identifying emotions [18,19];0951-7367 2012 Wolters Kluwer Health | Lippincott Williams & Wilksecond, supporting themselves when experiencingnegative emotions [20

&&

,21]; third, accepting andtolerating negative emotions [2226]; and, fourth,adaptively modifying emotions [2729]. Longitudi-nal research shows that positive expectations aboutthe ability to modify negative affect predictreductions in depression [29], and dysfunctionalemotion-regulation strategies predict depressionlevels 2 years after initial assessment [30]. Further-more, experimental studies show that depressedindividuals display difficulties utilizing adaptiveemotion regulation strategies (e.g., accepting nega-tive emotions [31]) and respond to negative moodinduction with less effective emotion regulationstrategies (e.g., suppression) than do nondepressedindividuals [32

&

].Anxiety disorders

Emotion regulation deficits are involved in a varietyof anxiety disorders [33

&

]. Such deficits can result inineffective coping with conditioned fear responses,leading the fear reaction to seem (even more) aver-sive and uncontrollable thus reconditioning thereaction and increasing the likelihood of avoidancebehaviors that may become chronic. Consistently,when compared with nonanxious controls, individ-uals with generalized anxiety disorder report poorerunderstanding of emotions, greater negative reac-tivity to emotions, and less ability to self-sootheafter experiencing negative emotions [34,35] (seereference [36] for conflicting findings on the abilityto identify and describe emotions). In individualswith posttraumatic stress disorder (PTSD), symptomseverity and impairment are both associated withlack of emotional clarity, lack of emotional accept-ance, difficulty engaging in goal-directed behaviorwhen upset, and an overall limited ability to engagein emotion regulation strategies [37,38]. Emotionregulation difficulties also mediate the associationbetween PTSD symptom severity and substance ab-use in patients with histories of chronic abuse [39],and enhancement of emotion regulation skills inthe first phase of PTSD treatment increases theeffectiveness of the second (exposure-based) phase[40].Substance-related disorder

One of the most prominent clinical factors in alco-hol and drug use is difficulty coping with negativeaffect [41], to the extent that substance misuse iswidely conceptualized as an effort to regulate oravoid negative emotions [20

&&

,41,42,43&

]. Forexample, epidemiological and treatmentoutcomestudies show that negative affect predictsins www.co-psychiatry.com 129

Behavioural medicinesubsequent desire to drink and drinking levelin individuals treated for alcohol dependence[4448]; the induction of negative affect predictsincreased urges to drink [4951]; interventionsaimed at alleviating depressed mood or anxietysymptoms have been shown to decrease relapseand severity of use [52,53]; and deficits in emotionregulation skills predict relapse during and aftercognitivebehavioral therapy for dependence[20

&&

]. Additionally, cocaine-dependent individualsreport more emotion regulation difficulties than docontrols, particularly during early abstinence [54].Eating disorders

Increasing evidence suggests that eating disordersymptoms (binging, purging, and/or restricting)serve as dysfunctional attempts to regulate or sup-press negative emotions [5558]. For example, nega-tive mood predicts binging and purging in bulimianervosa [57,59,60], as well as binge episodes inbinge eating disorder (BED) [6163]. Compared withcontrols, women with bulimia nervosa, BED, andanorexia nervosa report greater difficulties withemotional awareness [64,65,66

&

], greater tendencyto avoid emotions, and less ability to accept andmanage emotions [67]. In a sample of adolescentgirls, low awareness of emotions and dysfunctionalstyles of coping with emotions partially mediated therelationship between body dissatisfaction and buli-mia nervosa symptoms [68]. In college students withBED, the frequency of binge episodes was predictedby total score of the Difficulties in Emotion Regula-tion Scale (DERS) [69], as well as every one of thesubscales [70]. Finally, women with anorexia nervosareport significantly more difficulties in all subscalesof the DERS than do nonpsychiatric controls [71].Somatoform disorders

Emotion regulation has long been thought to play acentral role in the development of somatoformsymptoms. In the 1970s, Nemiah and Sifneos [72]introduced the concept of alexithymia (difficultyidentifying and describing emotions): individualsunable to detect, name, and express emotions wouldlikely have difficulties using cognitive resources toregulate emotions and, thus, have an increasedlikelihood of misrepresenting bodily sensationsaccompanying emotions [73]. In the ensuing deca-des, numerous empirical studies have provided sub-stantial evidence that somatoform disorders areassociated with deficits in the abilities to con-sciously experience and tolerate emotions, correctlyidentify emotions, and accurately link emotions tobody sensations [74,75,76

&

,7780].130 www.co-psychiatry.comRELEVANT CHALLENGESIn order to enhance the viability of emotion regu-lation as a scientific construct, the following chal-lenges must be addressed in clinically focusedresearch.Definition-related challenges

Perhaps the primary concern regarding emotionregulation as a scientific construct is that everythingseems to be emotion regulation these days. Whetherit is worry, catastrophizing, rumination, suppres-sion of emotional expression, and so on variousconcepts formerly investigated as relevant phenom-ena on their own are currently being subsumedunder the concept of emotion regulation[81

&

,82,83]. However, such a loosely defined con-ceptualization runs the risk of losing meaning and,thus, heuristic value. Therefore, a critical assessmentis needed to specify what actually constitutesemotion regulation. Of note is that emotion regu-lation is traditionally defined in terms of function,not content. Every process can be described asemotion regulation if driven by (explicit or implicit)intentions, goals, and/or efforts to redirect andmodify the flow of emotions [84]. In contrast, con-cepts such as worry, catastrophizing, and rumina-tion are largely components of affective states suchas anxiety and dysphoric mood [2]. Their function isnot to regulate these states, but instead to assess theseriousness of perceived threat or find a way out ofaversive and uncontrollable situations. Therefore,these processes are often more consistent witha self-regulation perspective, as opposed to anemotion regulation perspective.

With regard to the suppression of the emotionalexpression, it is of note that at least in clinicalpopulations such attempts are usually driven bythe intention to avoid negative evaluation by others(and/or by oneself for feeling out of control and/ordisplaying emotions in front of others). Given thatemotions can exist without being expressed andthat one does not necessarily strive to regulateemotional experience when suppressing emotionalexpression, we propose that this process should notbe considered an emotion regulation strategy per se.Future research should work to distinguish moreclearly between the suppression of emotion (poten-tially an emotion regulation strategy) and the sup-pression of the expression of emotion (unlikely anemotion regulation strategy).Assessment-related challenges

One of the most relevant challenges remains thedevelopment of instruments and procedures thatvalidly and reliably assess emotion regulation.Volume 25 Number 2 March 2012

Emotion regulation and mental health Berking and WuppermanCommon problems with current practices includesimply assessing intensity of negative emotions(e.g., sadness in depression) and concluding thatdeficits in emotion regulation must be present ifindividuals are unable to reduce the intensity ofunwanted emotions. However, depression is definedthrough the existence of such unwanted emotions;thus, the heuristic value of such a conclusion isclearly limited unless the emotion regulationdeficits are specified and assessed separately.Additionally, it is of note that often emotions areassessed with problematic instruments. Forexample, the trait version of the widely usedState-Trait Anxiety Inventory by Spielberger et al.[85] includes the item I feel like crying. As crying iscommonly acknowledged as an indicator of sadness(not anxiety), the face validity of this scale isseverely compromised.

Another challenge is the use of self-reportmeasures, which have been criticized on thegrounds that assessing emotional awareness anddifferentiation with self-reports is paradoxical[86]. However, as it is possible that at least on atrait level individuals may be able to reportsuch skills with the help of social comparisonsand feedback received from others, these instru-ments might be useful in spite of this argument.Nevertheless, the validity of self-report definitelyrequires further research. Another challenge is thatnumerous emotion regulation measures inquireabout methods of coping with emotions or feel-ings without specifying to what emotion thequestion is referring. However, depressed personsare likely to refer to feelings of sadness, despair, andhopelessness, whereas anxious persons would bemore likely to refer to feelings of fear and anxiety.If studies using these instruments find that depres-sed persons are less able to engage in a certainemotion regulation skill, such a finding might bedue to specific skills deficits of depressed persons but it might also be due to specific characteristics ofthe emotion to which the person refers whenanswering the question. Thus, the validity of suchinstruments should be investigated carefully, andemotion-specific self-reports should be developed[87,88].

Experimental assessment of emotion regulationalso has problems and limitations. With regard toecological validity, every aspect of an experimentshould be examined carefully to determine whetherparticipant performance is affected by the stimuliused to elicit the emotion, the instructions on howto regulate the emotion, and/or the surroundings inwhich the experiment occurs. Moreover, of noteis that experimental paradigms only investigateshort-term effects of emotion regulation strategies0951-7367 2012 Wolters Kluwer Health | Lippincott Williams & Wilkin certain situations. Thus, in order to provide themost valid assessment of emotion regulation, itsantecedents, and its consequences, future researchshould combine self-reports (questionnaire or,preferably, ecological momentary assessment pro-cedures) with experimental assessments and applymultitraitmultimethod procedures to longitudinaldesigns.Challenges regarding valid and clinicallyrelevant conclusions

The surge in popularity of emotion regulationresearch has increased the risk of premature con-clusions regarding clinical relevance. For example,the vast majority of studies on emotion regulationand psychopathology employ cross-section designsand argue that cross-sectional associations provideevidence that emotion regulation deficits contrib-ute to the development and maintenance of psy-chopathology. However, as deficits in emotionregulation may also develop as a result of a mentaldisorder, additional prospective research addressingboth putative causal pathways is dearly needed [89].

In experimental research, generalizability isoften an issue. For example, findings that reapprais-ing the situation is a more effective strategy thansuppressing the expression of emotions [83] haveoften been used to argue that strategies with a focuson antecedents of emotions (e.g., the situation cue-ing the emotion, the perception of the situation, orthe appraisal of the situation) are more effectivethan strategies with a focus on the emotionalresponses themselves (e.g., the expression of theemotion). However, for a valid test of this hypo-thesis, a representative sample of each categorymust first be drawn and evaluated. This need isparticularly relevant in that other response-focusedstrategies such as expressing an emotion throughappropriate actions, utilizing self-soothing strat-egies, and the dialectical behavior therapy skill ofopposite action have been utilized successfully intherapeutic treatments for several years.

Moreover, basic research on emotion regulationoften focuses on stimuli, emotions, and emotionregulation strategies that, although relevant to thegeneral population, might be of limited relevancefor patients experiencing psychiatric disorders.Thus, more clinically focused research is neededto address this gap. Additionally, studies are neededto investigate the mechanisms by which specificemotion regulation skills interact to affect psycho-pathology in clinical populations [90

&

]. As such,future research should include mediation analysesin prospective randomized controlled trials toidentify changes in emotion regulation mostins www.co-psychiatry.com 131

Time

Sym

pto

m s

ever

ity

(a) Patient

Type of disorder

Severity of disorder

Chronicity of disorder

Level of comorbidity

Personality traits

Social support

Strengths/resources

etc.

(1) Riskfactor

(4) Treatmenttarget

(2) Maintaining factor

(b) ER skills deficits

Awareness/clarity

Understanding

Acceptance/toleranceSelf-compassion

Situation selection

Attention deployment

Situation improvement

Reappraisal

etc.

(c) Emotions(& other affective responses)

Stress

Anxiety

Anger

Sadness

etc.

Shame

Guilt

Fear

(3) Symptom/consequence

(d) Interventions

Focus on one/few vs.broad range of skills

Implicit vs. explicitskills training

Cognitive techniques

etc.

Focus on one/few vs.broad range of emotions

Experiential techniques

Mindfulness-basedtechniques

Behavioral techniques

(5) Mechanismof change

FIGURE 1. Areas for future research on emotion regulation in the mental-health field. ER, emotion regulation.

Behavioural medicinestrongly associated with subsequent treatment out-come. Then, implicit or explicit strategies topromote these changes need to be developed andevaluated in randomized clinical trials. If shown tobe effective, these strategies should then be detailedto the extent that they could be used alone orincorporated into existing evidence-based treat-ments [91]. Thereby, psychotherapy research wouldmove away from evaluating only broad categories ofpsychotherapeutic interventions (which often seemto overlap on specific levels [92]) and wouldinstead also include a focus on specific interventionsfor specific problems.CONCLUSION

Although emotion regulation has become a popularscientific concept, the quest for conceptual clarity,valid assessment, and accurate conclusions aboutimplications has only begun. Thus, without claim-ing to offer solutions for all the challenges associ-ated with this concept, we have provided a briefoverview of relevant findings and offered a fewcaveats for consideration in future research. At thispoint, available data indicate that emotion regula-tion is associated with various forms of psycho-pathology and might be considered a putativetransdiagnostic factor relevant for the development,maintenance, and treatment of several mental dis-orders. Future research should include more strin-gent methods of investigating causal relationshipsand work to clarify the following: which patients or132 www.co-psychiatry.comat-risk individuals have; what types of difficulties inthe regulation of; what emotions; and what inter-ventions are most effective in alleviating these diffi-culties (Fig. 1).

In this context, future research should aim todistinguish between deficits in emotion regulationskills as a risk factor; maintaining factor; symptom/consequence of the disorder; treatment target; and/or mechanism of change (Fig. 1). This task willobviously be complex and require substantialresources. If researchers could agree upon a commondefinition, methods to elicit emotions and assessemotion regulation strategies, and means throughwhich the causal effect of emotion regulationon psychopathology could be investigated, thenavailable resources could be pooled, findings fromvarious work groups could be compared, and coor-dinated research activities could be initiated. If theseactivities consider the specific characteristics ofemotion regulation in a clinical context, and if thisresearch is conducted with the necessary scientificvigor, the emotion regulation paradigm will have aneven greater heuristic value for research on mentalhealth, psychopathology, and psychotherapy.

Acknowledgements

The authors thank Elena Heber for assisting in theliterature review on which this article is based. Pre-paration of this article was supported by GrantsPA001-113040 and PZ00P1-121576/1 from the SwissNational Science Foundation to M.B. and by GrantDF08-028 from the Donaghue Foundation to P.W.Volume 25 Number 2 March 2012

Emotion regulation and mental health Berking and WuppermanConflicts of interest

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