Emotion regulation group skills training for adolescents and parents: A pilot study of an add-on treatment in a clinical setting

Emotional abilities in preadolescents and adolescents with long-term cochlear implant use

OBJECTIVES

Emotional abilities (EAs) are particularly important during preadolescence/adolescence, two challenging periods characterized by significant biological, physical, and cognitive changes. The present study attempted to a holistic EA approach in preadolescents/adolescents with cochlear implants (CI) and typical hearing (TH), considering various aspects such as perception, cognitive facilitation, comprehension, and management of emotions. A secondary aim was to identify significant demographic and audiological factors of EA development.

METHODS

CI/TH groups were matched for chronological age, nonverbal IQ, gender, economic income, and maternal level of education. Each group consisted of 43 participants (age range 10-18 years). EAs were evaluated by using the multi-trait/method IE-ACCME test. Auditory-linguistic assessments included participants' lexical skills and Matrix performance as well.

RESULTS

EA performance for perception and cognitive facilitation did not show any statistically significant CI/TH group differences (p > 0.05). Significant CI/TH differences emerged for emotion comprehension and management: CI group performed significantly worse in understanding emotional blends (t = 2.56, p = 0.014) but better in personal emotion management (t = -2.01, p = 0.048). For the CI group, gender showed statistically significant effects on cognitive facilitation in sensations, with males performing better than females (U = 129, p = 0.018). TH preadolescents showed significantly lower scores in understanding emotional changes in comparison to TH adolescents (U = 125.5, p = 0.01). Emotional blends understanding showed a weak negative correlation with Matrix performance (r = - 0.38, p = 0.013) and a moderate positive correlation with lexical skills (r = 0.40, p = 0.008). Relationships management showed various significant correlations: weak negative correlations with age at CI (r = - 0.38, p = 0.011) and Matrix performance (r = - 0.36, p = 0.016) as well as weak positive correlations with nonverbal-IQ (r = 0.38, p = 0.013) and positive moderate correlations with lexical skills (r = 0.49, p < 0.001).

CONCLUSION

Cochlear implantation seems to show significant positive effects on emotional development in children, allowing them to achieve age appropriate EAs as they grow up and become preadolescents/adolescents. EA assessment in CI users may not only support monitorization of EA trajectory, but also early identification of any EA disorders, so that subjects with low EA profiles could be timely and properly intervened.

Early evaluation of a DBT-informed online intervention for people with eating disorders

OBJECTIVES

Eating disorders (EDs) have a worldwide prevalence of 7.8%, with towering mortality rates and high healthcare costs. The current recommended treatment for EDs principally works by directly targeting ED thoughts and behaviours, but recovery rates are low. A multifaceted link between difficulties with emotions and EDs is now widely established, and newer third-wave therapies that aim to address these underlying emotion difficulties are promising. The current study piloted an online emotion self-help intervention which was co-developed with clinicians and people with lived experienced of EDs. The intervention aimed to specifically address difficulties with emotion identification and regulation, as well as unhelpful beliefs about emotions, which are believed to give rise to and maintain ED thoughts and behaviours.

METHOD

We recruited 39 people with self-reported EDs to test this intervention over a one-week period. Our participants were asked to complete a series of questionnaires measuring emotion processes and psychopathology on Day 1 (T1) before being given access to the intervention. Participants were then asked to practice the newly acquired skills for seven days, before taking the same questionnaires on Day 9 (T2). We also asked participants to qualitatively report on their experience of the intervention.

RESULTS

We found significant improvements in ED psychopathology (ED-15), depression (PHQ-9), and anxiety (GAD-7) pre- to post-intervention, with medium to large effect sizes. All our emotion variables namely alexithymia (TAS-20), difficulties regulating emotions (DERS-SF), and unhelpful beliefs about emotions (EBQ) also showed significant changes post-intervention with medium to large effect sizes. Most importantly, changes in emotion regulation processes were linked to improved eating psychopathology. The qualitative analysis corroborated this finding, highlighting how the intervention helped them form new beliefs about emotions, which helped them reduce ED behaviours.

DISCUSSION

Significant improvements in emotion processing and regulations, as well as psychopathology, along with positive qualitative feedback, suggest that the intervention effectively met its aims of increasing awareness of the link between emotions and eating psychopathology, providing help to identify and regulate emotions, and normalising emotional experiences. While our results are promising, further research is required to assess its effectiveness longer term and in clinical settings.

"It's ok that I feel like this": a qualitative study of adolescents' and parents' experiences of facilitators, mechanisms of change and outcomes in a joint emotion regulation group skills training

BACKGROUND

Emotion regulation difficulties underlie several psychiatric conditions, and treatments that focus on improving emotion regulation can have an effect on a broad range of symptoms. However, participants' in-depth experiences of participating in emotion regulation treatments have not been much studied. In this qualitative study, we investigated participants' experiences of a joint emotion regulation group skills training in a child and adolescent psychiatric outpatient setting.

METHODS

Twenty-one participants (10 adolescents and 11 parents) were interviewed about their experiences after they had participated in a seven-session transdiagnostic emotion regulation skills training for adolescents and parents. The aim of the skills training was to decrease emotion regulation difficulties, increase emotional awareness, reduce psychiatric symptoms, and enhance quality of life. The skills training consisted of psychoeducation about emotions and skills for regulating emotions. The interviews were transcribed and analysed using reflexive thematic analysis.

RESULTS

The analysis resulted in three overarching themes: Parent - Child processes, Individual processes, and Group processes. The result showed that participants considered an improved parent-child relationship to be the main outcome. Increased knowledge, emotion regulation skills and behavioural change were conceptualised as both mechanisms of change and outcomes. The group format, and the fact that parents and adolescents participated together, were seen as facilitators. Furthermore, the participants experienced targeting emotions in skills training as meaningful and helpful.

CONCLUSION

The results highlight the potential benefits of providing emotion regulation skills training for adolescents and parents together in a group format to improve the parent-child relationship and enable the opportunity to learn skills.

Effects of DBT-based interventions on alexithymia: a systematic review

While dialectical behavior therapy (DBT) appears effective for some psychiatric conditions commonly associated with alexithymia, it is unclear whether DBT improves difficulties experienced by alexithymic individuals. This review investigated the current evidence on the effectiveness of DBT-based interventions in improving alexithymia. A qualitative synthesis of studies that investigated the efficacy of DBT on self-reported alexithymia was performed, identifying eligible studies using EBSCO/Essentials, Google Scholar, PubMed, Web of Science, and PsychINFO databases. Eight studies were identified. Overall, the results were inconclusive due to the heterogeneity of the studies but suggest that DBT-based interventions may be associated with self-reported decreases in alexithymia and increases in the ability to identify emotional states. The literature is limited by significant methodological problems, such as the low number of controlled trials, small samples, and high variability between DBT programs, which increases the risk of bias across study outcomes. More research is needed to reach conclusions regarding the effectiveness of DBT in improving alexithymia. Future studies should conduct randomized controlled trial designs (primarily with active treatment control conditions), greater standardization of DBT-based interventions, and a more in-depth examination of the level of participant involvement in long-term DBT-based interventions may help to understand whether DBT improves alexithymia difficulties.

Effectiveness of an add-on guided internet-based emotion regulation training (E-TRAIN) in adolescents with depressive and/or anxiety disorders: study protocol for a multicenter randomized controlled trial

BACKGROUND

During adolescence, depressive and anxiety disorders are among the most common mental health disorders. Both disorders tend to persist, are predictive for other mental disorders, and are associated with severe impairment in diverse areas. Although Cognitive Behavioral Therapy (CBT) has proven to be an effective treatment, a considerable number of adolescents do not respond to CBT and residual symptoms often remain. Therefore, it is of great importance to improve treatment outcomes for depressed and/or anxious adolescents. Dysfunctional emotion regulation appears to be a transdiagnostic factor in the development and maintenance of aforementioned disorders. Enhancing emotion regulation skills may therefore reduce symptom severity. In light of this, we developed a guided internet-based emotion regulation training (E-TRAIN) that will be added to CBT. This study aims to evaluate the effectiveness of E-TRAIN + CBT compared to CBT alone on depressive and anxiety outcomes among adolescents with depressive and/or anxiety disorder.

METHODS

In this multicenter two-arm randomized controlled trial with parallel group design, we aim to include 138 adolescents, aged 13-19 years, referred for treatment and diagnosed with depressive and/or anxiety disorder. Participants will be allocated to either CBT or CBT + E-TRAIN. Assessments will take place at baseline, and at 3 (T1), 6 (T2) and 12 (T3) months after baseline. We will conduct multi-informant assessments: the adolescent, a parent/caregiver, and the CBT therapist will be asked to fill in questionnaires. The continuous primary outcome measure is self-reported depressive and anxiety symptoms at six months after baseline, measured with the RCADS25. Secondary outcome measures include anxiety or depression diagnosis based on a semi-structured clinical interview, emotion (dys) regulation, and parent-report measures of anxiety, depression and emotion (dys) regulation.

DISCUSSION

This study is the first randomized controlled trial to examine the additional value of a guided internet-based emotion regulation training to regular CBT in adolescents with depressive and/or anxiety disorders. If this intervention is effective, it can be implemented in mental health care and improve treatment for these young people.

TRIAL REGISTRATION

Registered on June 23, 2021 in The Netherlands Trial Register (NL9564). Retrospectively registered. Recruitment started in May 2021 and is ongoing.

Psychoeducation Reduces Alexithymia and Modulates Anger Expression in a School Setting

Bullying and violence are relevant issues in school settings and negatively impact students’ well-being and mental health. Psychoeducation and anti-bullying programs may prevent violence among students by addressing emotional expression and regulation, alexithymia, and anger. We describe the impact of a psychoeducational intervention delivered to 90 male and 101 female school youths (N = 191), aged 12–14 years old, and aimed to improve their emotional recognition and regulation, as well as to reduce alexithymia in order to prevent aggression and bullying episodes. A psychological assessment has been performed before (T0) and after (T1) the intervention including levels of alexithymia, measured with the Toronto Alexithymia Scale-20 (TAS-20), the State-Trait Anger Expression Inventory (STAXI), Empathy Quotient (EQ), and the Emotion Regulation Questionnaire (ERQ). Females have shown higher levels of alexithymia at baseline whereas other characteristics (anger, empathy quotient and emotional regulation) did not differ among sex groups. The psychoeducational program significantly increased the empathy quotient (+10.2%), the emotional regulation reappraisal (+20.3%), and the assertive anger expression (+10.9%); alexithymia significantly decreased after the intervention in all the samples (−14.4%), above all among students scoring ≥61 at TAS-20 (−48.2%). Limitations include a small sample from a single school setting, the lack of a control group without psychoeducation, and an assessment based on self-reported measures. We may conclude that psychoeducation has significantly reduced levels of alexithymia and improved empathy and emotional regulation among adolescents.

Structured group psychotherapies: Advantages, challenges, and possibilities

OBJECTIVE

Structured group therapies offer the delivery of theory-specific interventions combined with beneficial group processes. Usually time-limited, such treatments present several advantages for both clinicians and patients.

METHODS

Several different models of structured group therapy are highlighted, with a brief description of their intended populations and treatment mechanisms.

RESULTS

Possibilities and challenges in the advancement of structured group psychotherapy are discussed.

CONCLUSION

Further research and training efforts are needed to support the expansion of structured group treatments, which in turn may help to increase patient access to effective psychotherapy.

Assessing Clinical Features of Adolescents Suffering from Depression Who Engage in Non-Suicidal Self-Injury

Depressive disorders (DDs) and non-suicidal self-injury (NSSI) are important juvenile mental health issues, showing alarming increasing rates. They frequently co-occur, mainly among adolescents, increasing the suicide risk. We aimed to compare the clinical features of two groups of adolescents with DDs, differed by their engagement or not in NSSI (“DD + NSSI” and “DD”). We hypothesized that NSSI would characterize particularly severe forms of DDs suitable for becoming specific phenotypes of adolescent depression. We enrolled 56 adolescents (11–17 years) diagnosed with a DD according to the DSM-5 criteria. They were assessed for NSSI endorsement (Ottawa Self-Injury Inventory), depressive symptoms (Children’s Depression Inventory 2), emotional dysregulation (Difficulties in Emotional Regulation Scale), and anxiety symptoms (Screen for Child Anxiety-Related Emotional Disorders). The two groups accounted for 31 (“DD + NSSI”) and 25 (“DD”) individuals. The “DD + NSSI” group had significantly higher suicidal ideation (p 0.0039), emotional dysregulation (p 0.0092), depressive symptoms (p 0.0138), and anxiety symptoms (p 0.0153) than the “DD” group. NSSI seemed to characterize more severe phenotypes of adolescent depression, applying for a potential role as a “specifier” of DDs, describing relevant information for their management. Further studies are needed to support this hypothesis and its potential opportunities for prevention and treatment.

A new integrative model for the co-occurrence of non-suicidal self-injury behaviours and eating disorder symptoms

OBJECTIVE

The high co-occurrence of non-suicidal self-injury (NSSI) behaviours and eating disorder (ED) symptoms suggests these conditions share common aetiological processes. We assessed a new integrative model of shared factors for NSSI and ED symptoms, where affect dysregulation, impulsivity, self-esteem, and body dissatisfaction mediated the relationship between insecure attachment and maladaptive schemas and NSSI and ED symptoms. A further aim of the study was to assess whether the model behaved similarly across a clinical eating disorder (ED) and a community sample.

METHOD

123 females with a lifetime ED diagnosis and 531 female individuals from the community completed an online survey, which included measures assessing the variables of interest. A cross-sectional single time point analysis was used.

RESULTS

Invariance testing indicated that the model was structurally non-invariant (different across groups). The proposed integrative model was a good fit for the ED group, but for the community sample only a revised model reached an acceptable fit. Both attachment and maladaptive schemas, included early in the model, were implicated in the pathways leading to ED and NSSI symptoms in the ED and community groups. In the community group, impulsivity, a mediator, was a shared predictor for NSSI and bulimic symptoms. No other mediating variables were shared by NSSI and ED symptoms in the two groups. Overall, the proposed model explained slightly more variance for the ED group relative to the community group in drive for thinness (R² = .57 vs .51) and NSSI (R² = .29 vs .24) but less variance in bulimic symptoms (R² = .33 vs .39).

CONCLUSION

We conclude that the current model provides only limited support for explaining the comorbidity between NSSI and ED symptoms. It is vital to consider both common (e.g., attachment and maladaptive schemas) and specific factors (e.g., impulsivity) to better understand the pathways that lead to the co-occurrence of NSSI and ED symptoms. A new integrative model assessed whether emotion dysregulation, impulsivity, self-esteem, and body dissatisfaction were mediators in the relationship between insecure attachment and maladaptive beliefs about the world and the self and subsequent eating disorder and self-harm symptoms. A further aim was to assess whether the proposed model differed between a clinical eating disorder and a community sample. All participants were female and included 123 patients with a lifetime eating disorder and 531 individuals from the community. Participating individuals completed an online survey at one timepoint, which included measures assessing the variables of interest. The findings of the current study indicated that the proposed model was a good match for the clinical eating disorder sample, but for the community sample only a revised model yielded acceptable statistical fit. Both insecure attachment and maladaptive beliefs about the world and the self, included early in the model, were indirectly related to eating disorder and self-harm symptoms for both the eating disorder and the community groups. Impulsivity, a mediator, was the only shared predictor for self-harm, and bulimic symptoms in the community group. We conclude that the current model provides only limited support for explaining the comorbidity between self-harming behaviours and disordered eating symptoms.

Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study

Self-harm and suicidal behaviors are prevalent among autistic adults without intellectual disability (ID). Emotion dysregulation (ED), the difficulty in modulating emotions, has been identified as an important risk factor. Dialectical behavior therapy (DBT) has been proved effective to treat ED in disorders other than autism spectrum disorder. Our study aimed at assessing the feasibility, acceptability and preliminary efficacy of DBT in seven autistic adults without ID exhibiting self-harm and/or suicidal behaviors linked to severe ED. Our results suggest that DBT is feasible and highly acceptable to autistic adults without ID. Additionally, mean scores on the Difficulties in Emotion Regulation Scale decreased significantly post-treatment and at 4-month follow-up, suggesting that DBT might be efficacious in reducing ED in this population.

Schulbasiertes Training für Jugendliche zur Emotionsregulation

Zusammenfassung. Theoretischer Hintergrund: Trainingsprogramme zur Emotionsregulation für Jugendliche sind notwendig, da eine Dysregulation der Emotionen die Entwicklung von psychischen Störungen begünstigen kann. Fragestellung: Ziel dieser systematischen Literaturübersicht ist es, einen Überblick über aktuelle Publikationen zu Trainingsprogrammen von 2015 – 2020 zu geben. Methode: Im Rahmen der Literaturrecherche konnten sechs Publikationen eingeschlossen werden. Ergebnisse: Es zeigten sich positive Effekte bei der Programmdurchführung durch externe Personen, vor allem durch Fachpersonen und keine bis negative Effekte bei der Durchführung durch das Schulpersonal. Ein positiver Einfluss durch die Einbeziehung der Eltern konnte in einem Trainingsprogramm vermutet werden, wobei die Ergebnisse statistisch nicht signifikant waren. Schlussfolgerung: Es zeigt sich die Notwendigkeit weiterer Evaluation von Trainingsprogrammen, welche sich vor allem auch mit dem Einbezug der Bezugspersonen beschäftigen und untersuchen, inwiefern Trainer_inneneffekte auch bei Studien mit einer besseren Vergleichbarkeit vorliegen.

Emotion regulation training as a treatment element for externalizing problems in adolescence: A randomized controlled micro-trial

Improving interventions for externalizing problems in adolescence may require determining which treatment elements actually produce change. In this micro-trial, we tested a treatment element addressing one widely-hypothesized mechanism underlying externalizing problems: emotion regulation. We tested whether emotion regulation could be improved via training, whether adolescents who received such training would subsequently show reduced externalizing problems, and which training approach and sequence was most effective. We randomized 108 adolescents with elevated externalizing problems (71.3% boys, M_age = 13.66, SD = 1.10) to a control condition or an experimental condition teaching emotion regulation through either a cognitive or behavioral approach, in alternated sequences. Effects of the modules were assessed before and after the modules, and with weekly assessments. The results showed a positive effect of the experimental training on self-reported use of adaptive emotion regulation strategies. However, self-reported externalizing problems decreased more in the control condition than in the experimental condition. No mediation, approach (cognitive versus behavioral) or sequence (cognitive-behavioral versus behavioral-cognitive sequence) effects were found. These findings illustrate that change in a proposed mechanism may not be accompanied by change in targeted problems; this highlights the importance of testing the hypothesized impact of specific treatment elements on targeted mental health problems. TRIAL REGISTRATION: This trial was registered in the Dutch Trial Register (NTR7334, July 10th, 2018) and the study protocol was published (te Brinke, Schuiringa, Menting, Deković, & de Castro, 2018).

Emotion regulation group skills training: a pilot study of an add-on treatment for eating disorders in a clinical setting

BACKGROUND

Emotion regulation difficulties appear to play a role in the development and maintenance of several eating disorders. This pilot study aimed at examining whether a short add-on group skills training in emotion regulation for young adults with different eating disorders was feasible in a psychiatric clinical setting. We also investigated if the treatment increased knowledge of emotions, and decreased self-reported difficulties with emotion regulation, alexithymia, symptoms of eating disorder, anxiety and depression, as well as clinical impairment.

METHODS

Six skills training groups were piloted with a total of 29 participants (M = 21.41 years, SD = 1.92). The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired samples t-test was used to compare differences between before-and-after measures.

RESULTS

The primary outcomes measures difficulties in emotion regulation (p <  0.001) and alexithymia (p <  0.001) showed significant improvement after treatment. The total eating disorder score (p = 0.009) was also significantly reduced, as was clinical impairment (p <  0.001). Acceptance/valued direction, identifying primary emotions and learning about secondary emotions was rated as especially helpful.

CONCLUSIONS

This preliminary pilot study showed that group training targeting emotion regulation skills was feasible and appreciated by participants, as well as being potentially promising as an adjunctive treatment for different eating disorders. Further controlled studies are needed.

TRIAL REGISTRATION

The study was retrospectively registered NCT04148014 on October 30th 2019.