Emotion Regulation Therapy

Definition

Emotion Regulation Therapy is a psychotherapy approach aimed at helping clients achieve durable change by changing how they understand, tolerate, and work with emotions.

Founder(s) and history

Douglas Mennin and David Fresco developed ERT in the 2000s, initially from research on generalized anxiety disorder and depression. Their observation was that people with GAD and depression do not merely "worry" or "feel sad"; they have disrupted MECHANISMS for relating to emotions.

Mennin's work on GAD identified four regulation deficits: 1. Heightened emotional intensity 2. Poor understanding of emotions 3. Negative reactivity to emotions 4. Maladaptive management through rumination, worry, and avoidance

ERT combined three streams:

Cognitive-behavioral tradition - analysis, skills, assignments
Experiential tradition - working with emotion in the moment
Mindfulness tradition - decentering and awareness

Key publications:

Mennin & Fresco (2009): first description of ERT
Mennin & Fresco (2014): expanded protocol
Mennin et al. (2018): manual, Emotion Regulation Therapy: A Mechanism-Targeted Treatment

Key concepts

Core concepts

The MARS model: four components of emotional dysregulation:

M - Motivational awareness: poor understanding of the motivational meaning of emotions
A - Attentional flexibility: attentional stuckness, especially rumination and worry
R - Regulatory flexibility: inflexible regulation strategies
S - Sensory awareness: weak awareness of bodily sensations

Repetitive negative thinking (RNT) is an umbrella term for rumination and worry. Mennin treats both as expressions of one mechanism: an attempt to control emotion through thinking, which then increases distress.

Motivational awareness: emotions are not enemies; they are SIGNALS. Anxiety signals threat, sadness signals loss, anger signals boundary violation.

Decentering: a metacognitive position - observing one's thoughts and emotions from the side, without merging with them. "I am having anxiety" rather than "I am anxious."

Contrasting: holding the current state (distress) and a desired state (a value-oriented goal) at the same time. The gap between them creates motivation for action.

Regulatory flexibility: the ability to choose a regulation strategy according to context. There is no single "right" strategy; there is a strategy adequate to the situation.

ERT vs other approaches

Parameter	CBT	DBT	UP	ERT
Target	Cognitions	Distress tolerance	Emotional avoidance	Regulation mechanisms
Worry	Cognitive restructuring	Skills module	Modules 4-5	Central focus
Rumination	Limited focus	Limited focus	Limited focus	Central focus
Decentering	No	Partly (Observe)	Module 3	Core
Contrasting	No	No	No	Distinctive technique
Positive emotions	Limited	Limited	Limited	Motivational component

Practice

Who it fits:

Generalized anxiety disorder (the main development target)
Comorbid GAD + depression
Conditions with marked rumination or worry
Emotional dysregulation across different disorders

Format: individual therapy, usually 16 weekly sessions of 50-60 minutes.

Therapist role: active, but with a strong experiential component. Psychoeducation + in-session practice + between-session assignments.

Limitations:

A relatively young approach; more RCTs are needed
Requires training; it is not "just another CBT"
May be difficult for clients with severe alexithymia
Contrasting requires the ability to hold two states at once

Therapy format

ERT is a manualized protocol, usually 16 sessions:

Module	Sessions	Focus
1. Motivational awareness	1-4	Emotions as signals; understanding needs
2. Regulation skills	5-8	Decentering, attention, bodily awareness
3. Experiential exposure	9-12	Contrasting, emotional experiencing, action
4. Integration and prevention	13-16	Consolidation and maintenance plan

Key sequence: UNDERSTAND the signal -> ALLOW it to be present -> ENGAGE in values-based action.

Evidence base

Mennin et al. (2015): open trial of ERT for GAD - significant reductions in anxiety and depression and improved regulation
Renna et al. (2018): RCT, ERT vs CBT for comorbid GAD + depression - ERT was not inferior to CBT and performed better on decentering
Mennin et al. (2018): RCT of ERT for GAD with depression - significant effects maintained at 9 months
O'Toole et al. (2019): meta-analysis of emotion-focused interventions - support for components relevant to ERT
Fresco et al. (2013): decentering as a mediator of change - a key mechanism

Limitations

Limited evidence base - fewer RCTs than cognitive-behavioral therapy
Acute states - psychosis, active suicidality, or severe substance dependence require stabilization before ERT
Therapist training requirements - quality depends on training and supervision
Cultural adaptation - the approach needs adaptation to the client's cultural context

Assessment: regulation patterns

ERT begins by assessing HOW the client handles emotions. Not only "which emotions?", but "what do you do when they arise?"

When you feel a strong emotion, what happens next? What do you do with it?

Regulation deficit	Manifestation
Intensity	Emotions are too strong; they flood the person
Poor understanding	"I do not know what I feel" - alexithymia
Reactivity	A negative reaction to a negative emotion
Rumination	Getting stuck in thoughts about the past
Worry	Getting stuck in thoughts about the future
Avoidance	Suppression, distraction, withdrawal

⚠️ ERT focuses not on separate disorders, but on MECHANISMS: rumination, worry, and avoidance maintain suffering.

Motivational awareness

The first component of ERT: understanding that emotions carry information. They are not enemies, but signals about needs and values.

If your anxiety could speak, what would it say? What is it trying to protect?

Core principles:

Emotions are adaptive signals, not system errors
Behind anxiety is a need for safety
Behind sadness is a need for connection
Behind anger is a need for justice or respect
Behind shame is a need for acceptance and belonging

Emotion	Motivational signal	Need
Anxiety	"Something threatens me"	Safety
Sadness	"Something has been lost"	Connection, closeness
Anger	"A boundary has been crossed"	Justice, respect
Shame	"I do not measure up"	Acceptance, belonging
Joy	"This matters"	Continuation, repetition

✅ When the client sees emotion as a SIGNAL, they stop fighting it and begin to listen.

Decentering

Decentering is the capacity to observe thoughts and emotions from the side without merging with them. It is close to mindfulness, but with a stronger focus on metacognitive position.

Instead of "I am anxious", try: "I notice that anxiety is present." Do you feel the difference?

Decentering practices:

Naming: "I am having the thought that."
Observing: "I notice anxiety. It is here, and I am here"
Widening the field: "Anxiety is ONE of the things I am feeling right now"
Impermanence: "This emotion is like a cloud. It came, and it will pass"

⚠️ Decentering is not detachment or suppression. It is a step back for a wider view.

Regulatory flexibility

The central ERT skill: choosing a regulation strategy flexibly according to context. There is no single "right" strategy. There is a strategy that fits NOW.

Context	Helpful strategy	Harmful strategy
The situation can be changed	Active problem solving	Acceptance without action
The situation cannot be changed	Acceptance, reappraisal	Rumination, struggle
The emotion is informative	Listen to the signal and act	Suppression
The emotion is excessive	Shift attention, create distance	Immerse in it
Support is available	Ask for help	Isolation

Which strategy do you usually use? The same one every time, or different ones? In which situations does your strategy NOT work?

Contrasting

A distinctive ERT technique: holding two opposite states at the same time - current distress and the desired state. Not "remove the bad", but "see both poles."

Right now you feel anxiety. Can you also imagine what it would be like to feel calm? Not instead of the anxiety, but next to it?

Steps of contrasting: 1. Acknowledge the current state: "Yes, I am anxious" 2. Evoke the desired state: "I want to feel calm" 3. Hold both: "Anxiety is here. Calm is possible" 4. Notice motivation: "The gap between them is energy for change"

⚠️ Contrasting is not positive thinking. It creates a TENSION between what is real and what is desired, and that tension motivates action.

Working with rumination and worry

Rumination (getting stuck in the past) and worry (getting stuck in the future) are the two main "absorbers" in ERT. Both are forms of repetitive negative thinking (RNT).

When you think about this situation again and again, does it help you find a solution? Or are you going in circles?

Strategies for RNT:

Recognition: "I am ruminating / worrying right now"
Decentering: "This is the process of rumination, not useful reflection"
Functional analysis: "What do I gain? What does it cost?"
Shift to action: "What CAN I do right now?"
Contrasting: hold the current state and the desired state

Closing the session

Review: which skills did we use? What did you notice?
Assignment: practice one skill, such as decentering or contrasting
Small step: one concrete action
Feedback: "What was useful? What was not?"

Which skill from today do you want to try this week?

Motivational AwarenessMotivational Awareness

Teaching the client to see emotions as informative signals about needs and values, rather than as problems that must be eliminated.

Ask which emotion was present and what it seemed to be saying
Decode the signal: anxiety as threat, sadness as loss, anger as boundary violation
Ask which need stands behind the emotion
Discuss how one can respond if the emotion is a signal
Translate the need into one possible action

When to use:

Module 1, with every important emotion
When the client treats emotions as enemies

Key phrases:

What is this emotion trying to tell you?

Follow-up questions:

What need could stand behind it?

If this were a signal, how could you respond to it?

Does the signal fit the actual situation?

Warnings:

⚠️ Not every emotion accurately reflects reality
⚠️ Motivational awareness is the first step; the signal still needs to be checked against the situation

Mennin & Fresco, 2014; Mennin et al. 2018

Details →

Decentering PracticeDecentering Practice

Developing a metacognitive position: observing thoughts and emotions from the side without merging with them. The client learns to say, 'I am having the thought that.' rather than 'This is true.'

Explain that thoughts are not facts and can be observed
Ask the client to name the thought currently present
Rephrase it as: 'I am having the thought that.'
Widen the field: this is one thought among many experiences
Add impermanence: the thought appeared and will pass
Assign five minutes of daily decentering practice

When to use:

Module 2
When rumination, worry, or fusion with thoughts is present
As a daily practice

Key phrases:

Can you notice this as a thought, not as the whole truth?

Follow-up questions:

What changes if you say, 'I am having the thought that.'?

Where is the emotion in the body while you observe the thought?

What else is present besides this thought?

Warnings:

⚠️ Decentering is not emotional coldness or detachment
⚠️ The client observes with interest, not with avoidance

Mennin & Fresco, 2014; Fresco et al. 2013

Details →

Regulatory Flexibility TrainingRegulatory Flexibility Training

Training the client to choose an emotion-regulation strategy according to context: when to solve the problem, when to accept, when to reappraise, and when to seek support.

Identify the client's usual emotion-regulation strategy
Show that a strategy may work in some situations and fail in others
Introduce the controllable vs uncontrollable situation distinction
For the current situation, ask what can actually be changed
If change is not possible, select acceptance, reappraisal, or support
Practice noticing strategy choice during the week

When to use:

Modules 2-3
When the client is stuck in one strategy, such as avoidance or rumination

Key phrases:

Which strategy fits this situation, not just your habit?

Follow-up questions:

Can the situation be changed?

If it cannot be changed, what kind of response is useful?

What happens when you use the same strategy everywhere?

Warnings:

⚠️ Do not impose one 'correct' strategy
⚠️ Avoidance can sometimes be adaptive; evaluate context

Mennin et al. 2018

Details →

Somatic Awareness of EmotionsSomatic Awareness of Emotions

Developing the ability to notice emotions through bodily sensations: where the emotion lives in the body, how it changes, and what it communicates.

Invite attention to the body with eyes closed if appropriate
Scan head, face, throat, chest, abdomen, back, arms, and legs
Describe any sensation: location, size, temperature, pressure, movement
Link the sensation to an emotion or motivational signal
Observe what changes when the client simply notices
Reinforce the idea that the body often knows before the mind

When to use:

Module 2
When alexithymia or emotional numbness is present
As a complement to decentering

Key phrases:

Where do you notice this emotion in the body?

Follow-up questions:

If this sensation could speak, what would it say?

Does it move, change, or stay the same?

Can you describe it without interpreting it yet?

Warnings:

⚠️ Some clients with trauma or dissociation may not feel the body
⚠️ Do not push; begin with neutral sensations if needed

Mennin & Fresco, 2014

Details →

Experiential Exposure (ERT)Experiential Exposure (ERT)

Experiencing avoided emotions in session while using ERT skills: motivational awareness, decentering, sensory awareness, regulatory flexibility, and contrasting.

Select an avoided emotional theme
Prepare the client with decentering and bodily awareness
Evoke the emotion through imagery, memory, or current material
Track body, thoughts, and motivational signal
Allow the emotion without escape or suppression
Contrast current distress with the desired value-oriented state
Identify one values-based action

When to use:

Modules 9-12
After the client has practiced basic regulation skills
When avoidance maintains anxiety or depression

Key phrases:

Can we stay with this emotion and listen to what it is asking for?

Follow-up questions:

What happens in the body as you allow it?

What does this emotion want to protect or restore?

What valued action becomes visible from here?

Warnings:

⚠️ Do not begin exposure before basic stabilization and skills are in place
⚠️ Monitor dissociation, panic, or shutdown
⚠️ Exposure must be collaborative and paced

Mennin et al. 2018

Details →

Relapse Prevention (ERT)Relapse Prevention (ERT)

Consolidating ERT skills and building a personal plan for recognizing early warning signs: rumination, worry, avoidance, emotional flooding, and loss of regulatory flexibility.

Review the client's main emotional mechanisms
Identify early warning signs of relapse
List skills that worked: decentering, contrasting, sensory awareness, flexible regulation
Plan what to do when rumination or worry returns
Create a written maintenance plan
Discuss how and when to seek additional support

When to use:

Final module, sessions 13-16
Before planned ending
After a relapse-like episode

Key phrases:

What are your early signs that the old cycle is returning?

Follow-up questions:

Which skill should come first?

How will you know you are ruminating rather than reflecting?

Who or what can support the new strategy?

Warnings:

⚠️ Do not present relapse prevention as a one-page form only
⚠️ The plan must be tied to the client's actual mechanisms and habits

Mennin et al. 2018

Details →

ContrastingContrasting

Holding the current distressing state and a desired value-based state simultaneously so that the tension between them becomes motivation for change.

Name the current state accurately
Name the desired emotional or value-based state
Invite the client to hold both states at once
Notice the gap between them without forcing change
Ask what this gap calls the client to do
Translate the motivation into one small action

When to use:

Middle and late ERT modules
When the client is stuck in distress but cannot access direction
When values-based action needs emotional energy

Key phrases:

Can both be true right now: anxiety is here, and calm is possible?

Follow-up questions:

What do you long for while feeling this?

What is the gap between now and the desired state?

What does that gap move you toward?

Warnings:

⚠️ Do not use contrasting as forced positive thinking
⚠️ The current distress must be validated before the desired state is evoked

Mennin & Fresco, 2014

Details →

Rumination InterruptionRumination Interruption

Helping the client recognize rumination as a repetitive negative thinking process and shift from circular analysis of the past to decentering and useful action.

Identify the rumination episode and its trigger
Differentiate rumination from problem solving
Ask what the rumination promises and what it actually costs
Use decentering: 'This is rumination'
Shift to the present body and current need
Choose one concrete action or boundary

When to use:

When the client is stuck in past-focused repetitive thinking
In depression, shame, guilt, and self-criticism
Whenever thinking becomes circular rather than useful

Key phrases:

Is this helping you solve something, or is it keeping you in the loop?

Follow-up questions:

What does rumination promise you?

What has it cost you in the last hour?

What is one useful action available now?

Warnings:

⚠️ Do not shame the client for ruminating
⚠️ Some reflection is useful; the target is repetitive, unproductive looping

Mennin et al. 2018

Details →

Worry DefusionWorry Defusion

Helping the client relate to worry as a mental process about the future, rather than as a demand for immediate control or certainty.

Identify the worry topic and the feared future
Name it as worry: a process, not a prediction
Ask what certainty the client is trying to obtain
Use decentering language: 'I am having worry about.'
Return to the current signal and current action
Choose a small step that does not require certainty

When to use:

With future-focused repetitive negative thinking
In GAD and anticipatory anxiety
When the client tries to think their way into certainty

Key phrases:

Can we treat this as worry, not as a forecast?

Follow-up questions:

What certainty are you trying to get?

What does the worry ask you to do?

What action fits your values even without certainty?

Warnings:

⚠️ Do not argue about whether the feared future is possible
⚠️ The target is the relationship to worry, not reassurance

Mennin & Fresco, 2014

Details →

Values Clarification (ERT)Values Clarification (ERT)

Clarifying what matters to the client so that emotions become signals for values-based engagement, not merely symptoms to reduce.

Ask what the emotion shows is important
Identify the value or need behind the emotion
Distinguish values from goals and rules
Explore how avoidance has moved the client away from values
Define one small values-based action
Use contrasting to connect current distress with the desired life direction

When to use:

Throughout ERT
When the client wants only symptom removal
When action needs a motivational anchor

Key phrases:

What does this emotion show you care about?

Follow-up questions:

If anxiety is protecting something, what is it?

What value has avoidance pushed you away from?

What is one small action toward that value?

Warnings:

⚠️ Do not turn values into moral demands
⚠️ Keep values connected to concrete behavior

Mennin et al. 2018

Details →

🔧 Adapted diary

This approach does not define a standardized client diary. We prepared an adapted version based on its key concepts. If you have suggestions, write to us.

Client diary — ERT

A diary helps notice changes between sessions and prepare topics to discuss with the therapist.

What did you notice?

What did you try?

How do I feel now?

12345678910

What do I want to discuss in session?

Materials are informational and educational and summarize publicly available scientific sources. They are not medical or psychological advice, are not intended for self-diagnosis or self-treatment, and do not replace consultation with a qualified professional.

Core concepts

ERT vs other approaches

Practice

ALLIANCE

FOCUS

INTERVENTIONS

PRESENCE

CLOSING