Article

Emotion Regulation Therapy for Generalized Anxiety Disorder

G.V. (Sonny) Montgomery VA Medical Center
Cognitive and Behavioral Practice (Impact Factor: 1.33). 02/2013; 20(282):300. DOI: 10.1016/j.cbpra.2013.02.00

ABSTRACT

Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.

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Questions & Answers about this publication

  • David M Fresco added an answer in Mindfulness:
    Is Mindfulness an effective treatment?
    Mindfulness is used for cognitive therapy, stress reduction, mind-fitness training for the military (pre- and post-deployment), cancer treatment, education, sports performance, etc. What are your experiences with Mindfulness? Is Mindfulness an effective therapy? What environments would Mindfulness not be effective in?
    David M Fresco
    I think it's important to be clear on the definition of several terms in the original question. First, what do you mean by mindfulness? This term gets bandied about quite a bit and probably co-opted in ways that distort, denude, and denature the meaning. For instance in the world of psychotherapy, a broader array of approaches get lumped under the mindfulness umbrella. In the narrowest sense, mindfulness interventions involve minimally some form of formal sitting practice (e.g., breath awareness, gentle yoga, body scan, etc.) and possibly some mindfulness in daily life. In systems such as DBT, ACT, etc., daily sitting practice may or may not be part of the approach. Conversely, MBSR, MBCT and emotion regulation therapy (ERT; https://www.researchgate.net/publication/235510892_Emotion_Regulation_Therapy_for_Generalized_Anxiety_Disorder; https://www.researchgate.net/publication/256419569_Emotion_Regulation_Therapy?ev=prf_pub) do incorporate sitting practice as an important part of their approach. At the risk of being called an elitist or creating an in-group/out-group scenario, I tend to use the more restrictive definition of mindfulness to approaches that require formal daily practice at a set-aside time each day. This definition is closer to canonical Buddhism and sets what I believe to be a reasonable lower limit to what is in and what is out.

    Next, it's important to operationally define therapy. Jon Kabat-Zinn has been careful NOT to call MBSR therapy. When I received MBSR training from Jon and Saki Santorelli, they were both very careful to call MBSR a training, and that each meeting was a class led by a teacher, not a therapist. In fact, MBSR teachers come from all walks of life and there is no hard and fast requirements for what formal education beyond their training in MBSR. In the world of psychotherapy, the only mindfulness enriched treatments that use the more restrictive definition of mindfulness that I have suggested, that are meant for the acute care of a psychiatric condition are ERT, Acceptance Based Behavior Therapy (ABBT), and mindfulness based relapse prevention (MBRP). There are some trials with MBSR and MBCT with acutely ill individuals, but Segal and colleagues still are cautious to say MBCT is for relapse prevention.

    Finally, here are two good meta-analyses on mindfulness enriched treatments:

    http://www.ncbi.nlm.nih.gov/pubmed/17764203

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848393/
    • Source
      [Show abstract] [Hide abstract]
      ABSTRACT: Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.
      Full-text · Article · Feb 2013 · Cognitive and Behavioral Practice

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  • David M Fresco added an answer in Psychiatry:
    Which type of treatment is more effective for a generalized anxiety disorder, pharmacotherapy or psychotherapy?
    Which type of treatment is more effective for a generalized anxiety disorder, pharmacotherapy or psychotherapy?
    David M Fresco
    As much as I am a fan of mindfulness enriched treatments, and the one that I have worked on, emotion regulation therapy, contains a heavy dose of mindfulness, and has shown impressive efficacy for GAD and anxious depression, I hesitate to make blanket statements about mindfulness interventions without explaining some rationale for how and why they are likely to positively impact a condition such as GAD. The Evans et al implementation of MBCT for GAD, for instance was efficacious, but not more so than most CBTs. The Roemer and Orsillo ABBT treatment is quite promising and has some mindfulness elements, but not so much sitting practice, more mindfulness of every day life. Our ERT has formal sitting practice, which to the best of my knowledge is the first acute treatment to have that. Our trial papers need to find their way through the peer review process before I feel comfortable making claims, but we have published a couple of preliminary papers on ERT. https://www.researchgate.net/publication/235510892_Emotion_Regulation_Therapy_for_Generalized_Anxiety_Disorder?ev=prf_pub As for mechanisms, my rationale for mindfulness enriched treatments for GAD is that they may an especially well suited intervention to help overcome negative self-referential processing, which is quite common in GAD https://www.researchgate.net/publication/248391117_What_me_worry_and_ruminate_about_DSM-5_and_RDoC_The_importance_of_targeting_negative_self-referential_processing?ev=prf_pub
    • Source
      [Show abstract] [Hide abstract]
      ABSTRACT: Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.
      Full-text · Article · Feb 2013 · Cognitive and Behavioral Practice

    + 1 more attachment

    David M Fresco
    If you want an answer from the world of RCTs, the answer appears to be that ADM and psychotherapy are efficacious, but as compared to other disorders (e.g., MDD, social phobia, etc.), the effect sizes are relatively smaller. Also, when more stringent criteria for treatment response are applied (e.g., high endstate functioning), patients with GAD fare less well. There are also the findings from STAR*D where anxious depression were most refractory to ADM even when medication algorithms were applied. We are working up the trial papers from our ERT trials where we have found impressive improvements for GAD patients as well as GAD+MDD patients. This paper, https://www.researchgate.net/publication/235510892_Emotion_Regulation_Therapy_for_Generalized_Anxiety_Disorder?ev=prf_pub, and our chapter that is coming out in James Gross' Handbook of Emotion https://www.researchgate.net/publication/256419569_Emotion_Regulation_Therapy?ev=prf_pub provides an overview of our findings.
    • Source
      [Show abstract] [Hide abstract]
      ABSTRACT: Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.
      Full-text · Article · Feb 2013 · Cognitive and Behavioral Practice

    + 1 more attachment

  • David M Fresco added an answer in Resilience:
    Is anyone aware of recent research on Dollard and Millers Aggression-Frustration hypothesis for understanding Depression?
    Before behavioural science's ascendancy and the dominance of CBT as a dominant treatment choice for depression, Dollard and Miller were working on a more existential framework for understanding the roots of aggression, called the Frustration-Aggression hypothesis. Dollard and Miller's Aggression-Frustration Hypothesis as a way of understanding depression has been neglected in recent years. I am interested in exploring the current relevance of the Aggression-Frustration Hypothesis in understanding depression - if depression can be construed as internalised rage/aggression how is that linked to externalised aggression/irritability? Are there any links between aggression/irritability and anxiety? any links with one's ability to self-sooth? tolerance of vulnerable feelings? resilience?
    David M Fresco
    Not exactly an answer to your question, but we have been examining themes consistent with Dollard an Miller in terms of risk/reward conflicts that have some relevance to depression.
    https://www.researchgate.net/publication/256419569_Emotion_Regulation_Therapy?ev=prf_pub

    and

    https://www.researchgate.net/publication/235510892_Emotion_Regulation_Therapy_for_Generalized_Anxiety_Disorder?ev=prf_pub
    • Source
      [Show abstract] [Hide abstract]
      ABSTRACT: Generalized anxiety disorder and major depression (often termed “distress disorders”; see Watson, 2005) are commonly comorbid and appear to be characterized by temperamental features that reflect heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss. Further, individuals with these disorders tend to perseverate (i.e., worry, ruminate) as a way to manage this motivationally relevant distress and often utilize these self-conscious processes to the detriment of engaging new contextual learning. Emotion Regulation Therapy integrates principles from traditional and contemporary cognitive behavioral treatments (e.g., skills training & exposure) with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding regulatory characteristics of individuals with distress disorders. This emphasis on affect science permits identification of candidate mechanisms of treatment in terms of core disruptions of normative cognitive, emotional, and motivational systems, which in turn, helps generate more targeted solutions for clients to utilize adaptive ways to cope or compensate for these core deficits. In essence, contrasting a client’s difficulties with what we understand as normative functioning allows us to generate theory-driven hypotheses that form that basis of our case conceptualization and treatment planning. Outcome and mechanism data provide preliminary support for the use of ERT to treat distress disorders.
      Full-text · Chapter · Dec 2013

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