Emotion Regulation Therapy for GAD: What to Expect

An Introduction to ERT

Emotional tug of war
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Emotion regulation therapy (ERT) is a type of psychotherapy that has been successfully tested in adults with generalized anxiety disorder (GAD) and those with co-occurring GAD and major depressive disorder (MDD).  Born out of cognitive behavioral therapy (CBT) tradition, ERT integrates components of cognitive, acceptance and mindfulness-based approaches.

Research has shown that ERT effectively and significantly reduces GAD and MDD symptoms by the end of a course of treatment.

The benefits remain at least three and six months after treatment has ended. Preliminary studies of the mechanism of the intervention (i.e., the possible ways in which it is impacting change) support the idea that this type of talk therapy helps people better attend to emotional conflict and become less reactive to it.

Though initially conceptualized as an intervention for those with chronic anxiety and recurrent mood problems, ERT is also undergoing evaluation as a treatment for people experiencing expectedly high, continuous distress such as caregivers to loved ones with cancer.

What Exactly Is ERT?

ERT is a present-focused, structured psychotherapy that emphasizes awareness of emotions, acknowledgment of the conflict between desires for safety and value-guided action, creation of a healthy distance from harsh, critical thoughts about the self, and adoption of a more compassionate view of the self.

Emotional awareness is developed through education about the purpose of feelings. The use of meditation exercises aimed to help reduce emotional avoidance—to improve tolerance of the presence of multiple, sometimes conflicting, emotions and sensations. Emotions are conceptualized as arising from within and reflecting competing motivations.

From the ERT perspective, people with chronic anxiety and low mood worry a lot, ruminate, and look to others for reassurance as ways to avoid unpleasant feelings and feel more secure about themselves or their circumstance. At the same time, these individuals really want to behave in line with their particular life values. The motivational pulls of safety and reward may be experienced as conflicting with one another.

Sometimes it is also hard to step far enough away from the worry or self-criticism to figure out the most rewarding course of action. In ERT,  imagery, exposure, and internal role-play is practiced during and between sessions to help individuals establish a healthy distance from their negative, perpetually critical voice. During ERT role plays, the therapist facilitates a dialogue between the patient’s conflicting internal voices. The goal of this exercise is to be able to cope better with an internal, distressed voice while continuing to act in accordance with one's values.

Overall, this type of therapy aims to help people who are stuck in their heads—ruminating, worry, and so on—to return to the moment with increased awareness and ability to act with clarity towards identified goals.

How Is It Different From Traditional CBT or Acceptance and Commitment Therapy (ACT)?

Unlike CBT, the cognitive work of ERT does not focus explicitly on labeling cognitive distortions. While there is a shared aim of enhancing awareness of one’s thought patterns and their impact on behavior, ERT stresses the development of compassionate self-talk over the overt weighing of evidence for and against a particular belief.

ACT and ERT overlap in their goal of reducing the struggle to control or eliminate distressing emotions and enhancing proactive involvement in activities consistent with personal values. However, unlike ACT, ERT utilizes exposure- and behavioral-activation-based techniques during and between sessions in the latter phase of treatment.

Who Provides ERT?

An ERT therapist will be an active guide during a session. Clinicians who provide this type of psychotherapy receive specific training in it. The therapist could be a psychiatrist, psychologist, social worker, or mental health counselor. Ask about your treatment provider’s training background to ensure that they are experienced with this technique.

What Happens During an ERT Session?

In the initial phase of ERT, the goals are to gain emotional awareness and tolerance and to begin to “catch yourself reacting” in the moment. Mindfulness of emotions is practiced routinely. Meditations are used, particularly in the service of helping people to gain perspective on difficult moments, feelings, and beliefs.

The latter phase of ERT integrates exposure and behavioral activation principles in and between sessions. Sessions, therefore, might include a worry exposure, guided imagery of a feared scenario with a desired coping response, or role play exercises in which an individual hears from and talks to his or her “worry voice.”

ERT therapists may start sessions with an imagery exercise. Written (and ultimately, behavioral) homework is commonly assigned and then reviewed in-session.

More information about the ERT approach can be found on the website maintained by the treatment’s developers, Douglas Mennin, Ph.D. and David Fresco, Ph.D.

How Can I Find an ERT Therapist?

For help finding an ERT therapist, try referral sources such as 

Sources:

Decker, M. L., Turk, C. L., Hess, B. & Murray, C. E. Emotion regulation among individuals classified with and without generalized anxiety disorder. J. Anxiety Disord. 22, 485–494 (2008).

Fresco, D. M., Mennin, D. S., Heimberg, R. G. & Ritter, M. Emotion Regulation Therapy for Generalized Anxiety Disorder. Cogn. Behav. Pract. 20, 282–300 (2013).

Mennin, D. S., Fresco, D. M., Ritter, M. & Heimberg, R. G. An open trial of emotion regulation therapy for generalized anxiety disorder and co-occurring depression. Depress. Anxiety 32, 614–623 (2015).

Mennin, D. S., & Fresco, D. M. What, me worry and ruminate about DSM-V and RDoC?: The importance of targeting negative self-referential processing. Clinical Psychology: Science and Practice, 20, 258-267 (2015).

Mennin, D. S., & Fresco, D. M. (2014). Emotion Regulation Therapy (pp. 469-490). In J.J. Gross (Ed.), Handbook of Emotion Regulation (Second Edition). New York: Guilford Press.

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