REVIEW

URRENT
C
OPINION

Emotion regulation and mental health: recent

findings, current challenges, and future directions
Matthias Berking a and Peggilee Wupperman b,c

Purpose of review
In recent years, deficits in emotion regulation have been studied as a putative maintaining factor and
promising treatment target in a broad range of mental disorders. This article aims to provide an integrative
review of the latest theoretical and empirical developments in this rapidly growing field of research.
Recent findings
Deficits in emotion regulation appear to be relevant to the development, maintenance, and treatment of
various forms of psychopathology. Increasing evidence demonstrates that deficits in the ability to adaptively
cope with challenging emotions are related to depression, borderline personality disorder, substance-use
disorders, 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 to
use comparable methods in order to clarify the following: which individuals have; what kinds of emotion
regulation difficulties with; which types of emotions; and what interventions are most effective in alleviating
these difficulties.
Summary
Despite some yet to be resolved challenges, the concept of emotion regulation has a broad and significant
heuristic value for research in mental health.
Keywords
emotion regulation, mental disorders, psychopathology, review, skills

INTRODUCTION
Emotion regulation refers to extrinsic and intrinsic
processes responsible for monitoring, evaluating,
and modifying emotional reactions, especially their
intensive and temporal features, to accomplish
ones goals [1]. After years as a major research topic
in developmental psychology and borderline
personality disorder (BPD), the concept of emotion
regulation has recently become popular in general
mental-health and psychotherapy research. At this
point, not a month passes without at least one peerreviewed publication on emotion regulation in the
context of depression, anxiety, substance-related
disorders, eating disorders, and so on. However,
despite its popularity, the concept struggles to attain
viability as a scientific construct due to various
unmet challenges involving definition, assessment,
and clinical implications. Such problems have been
discussed (although not solved) in the context of
developmental psychology [1,2], but not yet in
relation to the specific needs of research with a
clinical focus. Therefore, the aim of this article is
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to, briefly, first, review relevant findings regarding

emotion regulation and psychopathology and,
second, address the above challenges as they pertain
to research focused on clinical psychology, psychiatry, and psychotherapy.

BRIEF OVERVIEW OF RELEVANT FINDINGS

A significant focus on emotion regulation can be
observed in the following areas of clinical research.

a
Department of Clinical Psychology and Psychotherapy, Philipps-University, 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 Psychology

and Psychotherapy, Philipps-University, Gutenbergstrasse 18, D-35032
Marburg, 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.0b013e3283503669
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Emotion regulation and mental health Berking and Wupperman

KEY POINTS

second, supporting themselves when experiencing

negative emotions [20 ,21]; third, accepting and
tolerating negative emotions [2226]; and, fourth,
adaptively modifying emotions [2729]. Longitudinal research shows that positive expectations about
the ability to modify negative affect predict
reductions in depression [29], and dysfunctional
emotion-regulation strategies predict depression
levels 2 years after initial assessment [30]. Furthermore, experimental studies show that depressed
individuals display difficulties utilizing adaptive
emotion regulation strategies (e.g., accepting negative emotions [31]) and respond to negative mood
induction with less effective emotion regulation
strategies (e.g., suppression) than do nondepressed
individuals [32 ].
&&

 Deficits in emotion regulation are relevant in the context

of various mental-health problems.
 An overly broad conceptualization of emotion
regulation threatens its value as a heuristic paradigm.
 Validity of assessment of emotion regulation needs to
be improved.
 A stronger clinical focus is needed in research on
emotion regulation.
 Research needs to identify mechanisms by which
emotion regulation skills affect psychopathology.

&

Clinical child and adolescent psychology

Evidence suggests that emotion regulation in
infants is initiated largely by caregivers and gradually becomes more self-initiated over time [2]. Strategies evolve under the influence of various
interacting factors, including the quality of caregivers support as the child learns to cope with
distressing situations [3]. Emotion regulation skills
in children and adolescents have been demonstrated to (negatively) predict (subsequent) externalizing and internalizing problems in numerous
studies [4,5 ].
&

Borderline personality disorder

Substantial evidence supports emotion dysregulation as a core construct underlying BPD. BPD is
associated with less emotional awareness and clarity
[6,7], less ability to tolerate distress when pursuing
goals [8], the reported tendency to use harmful
emotion regulation strategies (e.g., self-injury) in
response to distressing situations [9], and deficits
in the ability to use cognitive reappraisal to regulate
emotions [10 ]. Persons with BPD tend to display
lower parasympathetic activity in response to
emotional stressors than do controls [11]; and
emotion dysregulation predicts subsequent BPD features, even when controlling for impulsivity [12].
Finally, individuals with BPD endorse deficits in all
facets of emotion regulation self-report measures
[13]; also, self-reported emotion regulation deficits
are associated with amygdala activation [14 ].
&

&

Depression
Depression is widely conceptualized as a consequence of dysfunctional emotion regulation
[1517]. Consistently, depressed individuals report
difficulties, first, identifying emotions [18,19];

Anxiety disorders
Emotion regulation deficits are involved in a variety
of anxiety disorders [33 ]. Such deficits can result in
ineffective coping with conditioned fear responses,
leading the fear reaction to seem (even more) aversive and uncontrollable thus reconditioning the
reaction and increasing the likelihood of avoidance
behaviors that may become chronic. Consistently,
when compared with nonanxious controls, individuals with generalized anxiety disorder report poorer
understanding of emotions, greater negative reactivity to emotions, and less ability to self-soothe
after experiencing negative emotions [34,35] (see
reference [36] for conflicting findings on the ability
to identify and describe emotions). In individuals
with posttraumatic stress disorder (PTSD), symptom
severity and impairment are both associated with
lack of emotional clarity, lack of emotional acceptance, difficulty engaging in goal-directed behavior
when upset, and an overall limited ability to engage
in emotion regulation strategies [37,38]. Emotion
regulation difficulties also mediate the association
between PTSD symptom severity and substance abuse in patients with histories of chronic abuse [39],
and enhancement of emotion regulation skills in
the first phase of PTSD treatment increases the
effectiveness of the second (exposure-based) phase
[40].
&

Substance-related disorder
One of the most prominent clinical factors in alcohol and drug use is difficulty coping with negative
affect [41], to the extent that substance misuse is
widely conceptualized as an effort to regulate or
avoid negative emotions [20 ,41,42,43 ]. For
example, epidemiological and treatmentoutcome
studies show that negative affect predicts

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subsequent desire to drink and drinking level

in individuals treated for alcohol dependence
[4448]; the induction of negative affect predicts
increased urges to drink [4951]; interventions
aimed at alleviating depressed mood or anxiety
symptoms have been shown to decrease relapse
and severity of use [52,53]; and deficits in emotion
regulation skills predict relapse during and after
cognitivebehavioral therapy for dependence
[20 ]. Additionally, cocaine-dependent individuals
report more emotion regulation difficulties than do
controls, particularly during early abstinence [54].
&&

Eating disorders
Increasing evidence suggests that eating disorder
symptoms (binging, purging, and/or restricting)
serve as dysfunctional attempts to regulate or suppress negative emotions [5558]. For example, negative mood predicts binging and purging in bulimia
nervosa [57,59,60], as well as binge episodes in
binge eating disorder (BED) [6163]. Compared with
controls, women with bulimia nervosa, BED, and
anorexia nervosa report greater difficulties with
emotional awareness [64,65,66 ], greater tendency
to avoid emotions, and less ability to accept and
manage emotions [67]. In a sample of adolescent
girls, low awareness of emotions and dysfunctional
styles of coping with emotions partially mediated the
relationship between body dissatisfaction and bulimia nervosa symptoms [68]. In college students with
BED, the frequency of binge episodes was predicted
by total score of the Difficulties in Emotion Regulation Scale (DERS) [69], as well as every one of the
subscales [70]. Finally, women with anorexia nervosa
report significantly more difficulties in all subscales
of the DERS than do nonpsychiatric controls [71].
&

Somatoform disorders
Emotion regulation has long been thought to play a
central role in the development of somatoform
symptoms. In the 1970s, Nemiah and Sifneos [72]
introduced the concept of alexithymia (difficulty
identifying and describing emotions): individuals
unable to detect, name, and express emotions would
likely have difficulties using cognitive resources to
regulate emotions and, thus, have an increased
likelihood of misrepresenting bodily sensations
accompanying emotions [73]. In the ensuing decades, numerous empirical studies have provided substantial evidence that somatoform disorders are
associated with deficits in the abilities to consciously experience and tolerate emotions, correctly
identify emotions, and accurately link emotions to
body sensations [74,75,76 ,7780].
&

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RELEVANT CHALLENGES
In order to enhance the viability of emotion regulation as a scientific construct, the following challenges must be addressed in clinically focused
research.

Definition-related challenges
Perhaps the primary concern regarding emotion
regulation as a scientific construct is that everything
seems to be emotion regulation these days. Whether
it is worry, catastrophizing, rumination, suppression of emotional expression, and so on various
concepts formerly investigated as relevant phenomena on their own are currently being subsumed
under the concept of emotion regulation
[81 ,82,83]. However, such a loosely defined conceptualization runs the risk of losing meaning and,
thus, heuristic value. Therefore, a critical assessment
is needed to specify what actually constitutes
emotion regulation. Of note is that emotion regulation is traditionally defined in terms of function,
not content. Every process can be described as
emotion regulation if driven by (explicit or implicit)
intentions, goals, and/or efforts to redirect and
modify the flow of emotions [84]. In contrast, concepts such as worry, catastrophizing, and rumination are largely components of affective states such
as anxiety and dysphoric mood [2]. Their function is
not to regulate these states, but instead to assess the
seriousness of perceived threat or find a way out of
aversive and uncontrollable situations. Therefore,
these processes are often more consistent with
a self-regulation perspective, as opposed to an
emotion regulation perspective.
With regard to the suppression of the emotional
expression, it is of note that at least in clinical
populations such attempts are usually driven by
the intention to avoid negative evaluation by others
(and/or by oneself for feeling out of control and/or
displaying emotions in front of others). Given that
emotions can exist without being expressed and
that one does not necessarily strive to regulate
emotional experience when suppressing emotional
expression, we propose that this process should not
be considered an emotion regulation strategy per se.
Future research should work to distinguish more
clearly between the suppression of emotion (potentially an emotion regulation strategy) and the suppression of the expression of emotion (unlikely an
emotion regulation strategy).
&

Assessment-related challenges
One of the most relevant challenges remains the
development of instruments and procedures that
validly and reliably assess emotion regulation.
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Emotion regulation and mental health Berking and Wupperman

Common problems with current practices include

simply assessing intensity of negative emotions
(e.g., sadness in depression) and concluding that
deficits in emotion regulation must be present if
individuals are unable to reduce the intensity of
unwanted emotions. However, depression is defined
through the existence of such unwanted emotions;
thus, the heuristic value of such a conclusion is
clearly limited unless the emotion regulation
deficits are specified and assessed separately.
Additionally, it is of note that often emotions are
assessed with problematic instruments. For
example, the trait version of the widely used
State-Trait Anxiety Inventory by Spielberger et al.
[85] includes the item I feel like crying. As crying is
commonly acknowledged as an indicator of sadness
(not anxiety), the face validity of this scale is
severely compromised.
Another challenge is the use of self-report
measures, which have been criticized on the
grounds that assessing emotional awareness and
differentiation with self-reports is paradoxical
[86]. However, as it is possible that at least on a
trait level individuals may be able to report
such skills with the help of social comparisons
and feedback received from others, these instruments might be useful in spite of this argument.
Nevertheless, the validity of self-report definitely
requires further research. Another challenge is that
numerous emotion regulation measures inquire
about methods of coping with emotions or feelings without specifying to what emotion the
question is referring. However, depressed persons
are likely to refer to feelings of sadness, despair, and
hopelessness, whereas anxious persons would be
more likely to refer to feelings of fear and anxiety.
If studies using these instruments find that depressed persons are less able to engage in a certain
emotion regulation skill, such a finding might be
due to specific skills deficits of depressed persons
but it might also be due to specific characteristics of
the emotion to which the person refers when
answering the question. Thus, the validity of such
instruments should be investigated carefully, and
emotion-specific self-reports should be developed
[87,88].
Experimental assessment of emotion regulation
also has problems and limitations. With regard to
ecological validity, every aspect of an experiment
should be examined carefully to determine whether
participant performance is affected by the stimuli
used to elicit the emotion, the instructions on how
to regulate the emotion, and/or the surroundings in
which the experiment occurs. Moreover, of note
is that experimental paradigms only investigate
short-term effects of emotion regulation strategies

in certain situations. Thus, in order to provide the

most valid assessment of emotion regulation, its
antecedents, and its consequences, future research
should combine self-reports (questionnaire or,
preferably, ecological momentary assessment procedures) with experimental assessments and apply
multitraitmultimethod procedures to longitudinal
designs.

Challenges regarding valid and clinically

relevant conclusions
The surge in popularity of emotion regulation
research has increased the risk of premature conclusions regarding clinical relevance. For example,
the vast majority of studies on emotion regulation
and psychopathology employ cross-section designs
and argue that cross-sectional associations provide
evidence that emotion regulation deficits contribute to the development and maintenance of psychopathology. However, as deficits in emotion
regulation may also develop as a result of a mental
disorder, additional prospective research addressing
both putative causal pathways is dearly needed [89].
In experimental research, generalizability is
often an issue. For example, findings that reappraising the situation is a more effective strategy than
suppressing the expression of emotions [83] have
often been used to argue that strategies with a focus
on antecedents of emotions (e.g., the situation cueing the emotion, the perception of the situation, or
the appraisal of the situation) are more effective
than strategies with a focus on the emotional
responses themselves (e.g., the expression of the
emotion). However, for a valid test of this hypothesis, a representative sample of each category
must first be drawn and evaluated. This need is
particularly relevant in that other response-focused
strategies such as expressing an emotion through
appropriate actions, utilizing self-soothing strategies, and the dialectical behavior therapy skill of
opposite action have been utilized successfully in
therapeutic treatments for several years.
Moreover, basic research on emotion regulation
often focuses on stimuli, emotions, and emotion
regulation strategies that, although relevant to the
general population, might be of limited relevance
for patients experiencing psychiatric disorders.
Thus, more clinically focused research is needed
to address this gap. Additionally, studies are needed
to investigate the mechanisms by which specific
emotion regulation skills interact to affect psychopathology in clinical populations [90 ]. As such,
future research should include mediation analyses
in prospective randomized controlled trials to
identify changes in emotion regulation most

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(a) Patient

(b) ER skills deficits (c) Emotions

(& other affective responses)

Type of disorder

Awareness/clarity

Stress

Severity of disorder

Understanding

Anxiety

Chronicity of disorder

Acceptance/tolerance
Self-compassion

Fear

Level of comorbidity

Symptom severity

Social support

Situation selection
Situation improvement

Anger

(d) Interventions
Implicit vs. explicit
skills training
Focus on one/few vs.
broad range of skills
Focus on one/few vs.
broad range of emotions
Cognitive techniques

Sadness

Behavioral techniques

Attention deployment

Shame

Experiential techniques

Strengths/resources

Reappraisal

Guilt

Mindfulness-based
techniques

etc.

etc.

etc.

etc.

Personality traits

(1) Risk
factor

(2) Maintaining factor

(3) Symptom/consequence

(4) Treatment
target
(5) Mechanism
of change

Time

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

strongly associated with subsequent treatment outcome. Then, implicit or explicit strategies to
promote these changes need to be developed and
evaluated in randomized clinical trials. If shown to
be effective, these strategies should then be detailed
to the extent that they could be used alone or
incorporated into existing evidence-based treatments [91]. Thereby, psychotherapy research would
move away from evaluating only broad categories of
psychotherapeutic interventions (which often seem
to overlap on specific levels [92]) and would
instead also include a focus on specific interventions
for specific problems.

CONCLUSION
Although emotion regulation has become a popular
scientific concept, the quest for conceptual clarity,
valid assessment, and accurate conclusions about
implications has only begun. Thus, without claiming to offer solutions for all the challenges associated with this concept, we have provided a brief
overview of relevant findings and offered a few
caveats for consideration in future research. At this
point, available data indicate that emotion regulation is associated with various forms of psychopathology and might be considered a putative
transdiagnostic factor relevant for the development,
maintenance, and treatment of several mental disorders. Future research should include more stringent methods of investigating causal relationships
and work to clarify the following: which patients or
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at-risk individuals have; what types of difficulties in

the regulation of; what emotions; and what interventions are most effective in alleviating these difficulties (Fig. 1).
In this context, future research should aim to
distinguish between deficits in emotion regulation
skills as a risk factor; maintaining factor; symptom/
consequence of the disorder; treatment target; and/
or mechanism of change (Fig. 1). This task will
obviously be complex and require substantial
resources. If researchers could agree upon a common
definition, methods to elicit emotions and assess
emotion regulation strategies, and means through
which the causal effect of emotion regulation
on psychopathology could be investigated, then
available resources could be pooled, findings from
various work groups could be compared, and coordinated research activities could be initiated. If these
activities consider the specific characteristics of
emotion regulation in a clinical context, and if this
research is conducted with the necessary scientific
vigor, the emotion regulation paradigm will have an
even greater heuristic value for research on mental
health, psychopathology, and psychotherapy.
Acknowledgements
The authors thank Elena Heber for assisting in the
literature review on which this article is based. Preparation of this article was supported by Grants
PA001-113040 and PZ00P1-121576/1 from the Swiss
National Science Foundation to M.B. and by Grant
DF08-028 from the Donaghue Foundation to P.W.
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Emotion regulation and mental health Berking and Wupperman

Conflicts of interest
There are no conflicts of interest.

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Volume 25  Number 2  March 2012