Behaviour Research and Therapy 46 (2008) 1230–1237

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

Emotion-regulation skills as a treatment target in psychotherapyq

Matthias Berking a, *,1, Peggilee Wupperman b, Alexander Reichardt c, Tanja Pejic d,
Alexandra Dippel e, Hansjörg Znoj c
a
University of Washington, Department of Psychology, P.O. Box 351525, Seattle, WA 98195, USA
b
Department of Psychiatry, Yale University, USA
c
Department of Psychology, University of Bern, Switzerland
d
Department of Psychology, University of Giessen, Germany
e
Vogelsberg Clinic, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: Deficits in emotion-regulation skills have been shown to be integral to the development
Received 27 March 2008
and maintenance of a wide range of mental disorders.
Received in revised form 15 August 2008
Accepted 21 August 2008 Aim: To evaluate the importance of these skills as a treatment target in psychotherapeutic interventions.
Method: Nine specific emotion-regulation skills were assessed in a sample of 289 inpatients before and
Keywords: after cognitive-behavioural treatment. Self-reports of success in pretreatment skills application were first
Emotion regulation compared to those of 246 non-clinical controls. Pretreatment skills application and change in skills
Emotion-regulation skills application during therapy were then related to a variety of outcome measures. Finally, the effects of
Skills training integrating a brief training of general emotion-regulation skills into the CBT-based treatment were
Mental health evaluated in a controlled trial.
Psychotherapy
Results: Uni- and multivariate analyses identified the skills of acceptance, tolerance, and active modifi-
cation of negative emotions as particularly important for current mental health and treatment outcome.
Replacing parts of the standard CBT treatment with the emotion-regulation training enhanced the effects
of the CBT treatment on skills application and on other measures of mental health.
Conclusion: Incorporating interventions that directly target general emotion-regulation skills may
improve the effectiveness of psychotherapeutic interventions.
Ó 2008 Elsevier Ltd. All rights reserved.

Introduction
Throughout the past two decades, the development and evalu-
ation of disorder-specific treatments has been one of the most
prosperous fields in psychotherapy research. But despite the
notable progress, these treatments are not yet as effective as we
would like (e.g., Barlow, 2002; Westen & Morrison, 2001). Given
that difficulties in emotion regulation are common among a broad
range of mental disorders (Gross & Muñoz, 1995; Thoits, 1985), we
propose that the effectiveness of current psychological interven-
tions for mental disorders can be improved by: (a) identifying
general emotion-regulation skills that are integral to the develop-
ment, maintenance, and treatment of a broad range of mental
disorders; (b) developing non-disorder-specific interventions that
can enhance these skills; and (c) incorporating these interventions
into treatment packages that also contain disorder-specific
components (for similar ideas, see Moses & Barlow, 2006).
According to Thompson (1994), emotion regulation has been
defined as ‘‘the extrinsic and intrinsic processes responsible for
monitoring, evaluating, and modifying emotional reactions, espe-
cially their intensive and temporal features, to accomplish one’s
goals’’ (pp. 27–28). Building on this definition and synthesizing
established emotion-regulation theories (e.g., Gratz & Roemer,
2004; Gross, 1998; Larsen, 2000; Saarni, 1999), Berking (2007) has
proposed a model that conceptualizes adaptive emotion regulation
as the interaction of nine specific emotion-regulation skills. Based
on the available literature, the following skills are considered
important: The ability to (a) consciously process emotions/be

q Preparation of this paper was supported by Grant PA001-113040 from the Swiss National Science Foundation to Matthias Berking.
* Corresponding author. Tel.: þ1 206 616 0487; fax: þ1 206 616 1513.
E-mail address: matthias.berking@psy.unibe.ch (M. Berking).
1
Present address: Department of Clinical Psychology and Psychotherapy, University of Bern, Gesellschaftsstrasse 49, CH-3012 Bern, Switzerland. Tel.: þ41 31 631 54 17;
fax: þ41 631 41 55. E-mail: matthias.berking@psy.unibe.ch.

0005-7967/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2008.08.005
 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237
aware of emotions (e.g., Lischetzke & Eid, 2003), (b) identify and
label emotions (e.g., Bagby, Parker, & Taylor, 1994; Feldman-Barrett,
Gross, Christensen, & Benvenuto, 2001), (c) interpret emotion-
related body sensations correctly (e.g., Damasio, 1994; Marchesi,
Fontò, Balista, Cimmino, & Maggini, 2005), (d) understand the
prompts of emotions (e.g., Southam-Gerow & Kendall, 2002), (e)
support oneself in emotionally distressing situations (e.g., Gilbert,
Baldwin, Irons, Baccus, & Clark, 2006; Leahy, 2002), (f) actively
modify negative emotions in order to feel better (e.g., Catanzaro
& Greenwood, 1994; Salovey, Mayer, Goldman, Turvey, & Palfai,
1995), (g) accept emotions (e.g., Greenberg, 2002; Hayes, Strohsal,
& Wilson, 1999; Leahy, 2002), (h) be resilient to /tolerate negative
emotions (e.g., Kabat-Zinn, 2003; Kobasa, Maddi, & Kahn, 1982),
and (i) confront emotionally distressing situations in order to attain
important goals (e.g., Hayes, Wilson, Gifford, Follette, & Strohsal,
1996; Margraf & Berking, 2005). An important assumption of the
model is that the abilities to modify emotions in a desired direction
and/or accept and tolerate undesired emotions are integral for
mental health. In contrast, the other skills are only assumed to be
relevant to the extent that they facilitate the application of the
pivotal skills of modification and/or acceptance/tolerance (for
further details see Berking, 2007).
General emotion-regulation skills (i.e., skills that can be applied
to successfully regulate a wide range of emotions) are important for
several reasons: First, negative emotions that are not necessarily
mentioned in the diagnostic criteria of a particular disorder often
cue behaviour patterns associated with the disorder (e.g., anger
cues binge eating; sadness cues substance abuse). Second, negative
emotions not necessarily mentioned in diagnostic criteria often
severely interfere with effective coping and implementation of
strategies learned in treatment (e.g., anxiety impedes depressed
patients from active problem solving; depressed mood and feelings
of hopelessness impede anxious patients from engaging in feared
situations). Finally, many patients suffer from more than one
disorder (Krueger & Markon, 2006), which could be explained at
least partly by general emotion-regulation deficits (e.g., inability to
accept one’s feelings likely will lead to a variety of responses, such
as avoidance or rumination, that eventually lead to multiple
disorders, such as anxiety and depression). Thus, the enhancement
of skills that are applicable to more than one emotion can target the
essence of a patient’s problems. Especially with patients high in
comorbidity, a focus on general emotion-regulation skills as
adjunctive to disorder-specific interventions may enhance efficacy
and efficiency of these interventions.
There is ample empirical evidence that emotion-regulation skills
are involved in the development, maintenance, and treatment of
mental disorders. For example, cross-sectional studies have shown
psychopathology to be associated with deficits in various emotion-
regulation skills (Levine, Marziali, & Hood, 1997; Novick-Kline, Turk,
Mennin, Hoyt, & Gallagher, 2005). Longitudinal studies have also
demonstrated that emotion-regulation skills predict status of
mental health at later points in time (Kraaij, Pruymboom, & Gar-
nefski, 2002; Seiffge-Krenke, 2000). In addition, neuroimaging
studies indicate that successful emotion regulation involves brain
areas that have been found to be functionally impaired in subjects
suffering from mental-health problems (for reviews see Grawe,
2006, or Ochsner & Gross, 2008). Finally, mediational and experi-
mental studies have demonstrated that emotion-regulation skills
mediate the effects of a stressor on the development of psycho-
pathological symptoms (Sim & Zeman, 2005) and influence
emotional responses toward experimentally induced emotions and/
or components of emotions (Campbell-Sills, Barlow, Brown,
& Hofmann, 2006; Feldner, Zvolensky, Stickle, Bonn-Miller, & Leen-
Feldner, 2006; Rusting & Nolen-Hoeksema, 1998).
Additionally, the effectiveness of treatments that focus on
enhancing emotion-regulation skills suggests that these skills
1231
might be important mechanisms of change in psychological inter-
ventions. For example, emotion regulation is a core skill taught in
dialectical behaviour therapy (DBT; Linehan, 1993), which has dis-
played effectiveness in the treatment of borderline personality
disorder (BPD; for review see Lynch, Trost, Salsman, & Linehan,
2007) and has amassed at least preliminary evidence indicating
effectiveness in the treatment of substance abuse (Linehan et al.,
2002), eating disorders (Safer, Telch, & Agras, 2001; Telch, Agras,
& Linehan, 2001), and depression in older adults (Lynch, Morse,
Mendelson, & Robins, 2003). Further examples of promising
treatments that focus on emotion-regulation skills include treat-
ments for binge eating (Clyne & Blampied, 2004), PTSD related to
childhood abuse (Cloitre, Koenen, Cohen, & Han, 2002), and
generalized anxiety disorder (Mennin, Heimberg, Turk, & Fresco,
2002), as well as an acceptance-based emotion-regulation training
for BPD (Gratz & Gunderson, 2006).
However, although extensive data suggest that deficits in
general emotion-regulation skills are involved in the development,
maintenance, and treatment of a variety of mental disorders,
several limitations in current research make it difficult to use this
knowledge to improve psychological interventions. First, most
studies have focused exclusively on one or two specific skills. Since
these studies usually differ in methodology, it is difficult to
compare results and clarify which skills are most strongly associ-
ated with mental health. Second, at this point we have little
information about which (of the above) emotion-regulation skills
must be enhanced in order to improve outcome of psychological
interventions. Third, we do not know whether certain emotion-
regulation skills are more likely to be improved by specific types of
treatment. Fourth, there is a striking lack of studies that system-
atically vary the amount of training in emotion-regulation skills
during treatment. Finally, there is not yet one empirical study that
investigates the effectiveness of an emotion-regulation interven-
tion that can be added to a variety of empirically based treatments
and can target emotion-regulation deficits in a broad range of
mental disorders. This final limitation is particularly problematic, as
such an intervention could be applied more economically and
disseminated more easily than a series of disorder-specific
emotion-regulation trainings. Therefore, the aim of this pilot study
is to clarify the importance of general emotion-regulation skills as
a treatment target by addressing the following questions:
1 Which emotion-regulation skills are particularly associated
with sound mental health?
2 For which emotion-regulation skills is skill-enhancement
during treatment particularly associated with treatment
outcome?
3 Can the effects of a CBT-based treatment be improved by
incorporating a non-disorder-specific intervention that
specifically targets general emotion-regulation skills?
Method
Study participants
The primary sample of this study consisted of 289 inpatients
treated for a variety of mental disorders in a mental-health hospital
in Germany. Recruitment occurred between January and April
2006. Patients were eligible for the study if they were at least 18
years of age, met criteria for a mental disorder according to ICD-10
(Dilling, Mombour, & Schmidt, 1991), were German-speaking, and
were scheduled for 6 weeks of inpatient treatment. In order to
maximize the clinical realism and ensure that the sample was
representative of patients treated in routine clinical practice, there
were no further exclusion criteria. The most common primary
1232 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237
disorders, as diagnosed during the standard intake interview by
senior clinicians (all with masters degrees or greater in medicine or
psychology) according to ICD-10 criteria, were major depressive
episode (25%), recurrent depressive disorder (23%), adjustment
disorders (22%), panic disorder (5%), posttraumatic stress disorder
(3%), somatoform pain disorder (3%), and dysthymia (2%).
A significant proportion of patients met ICD-10 criteria for more
than one F-diagnosis (41%). Average age of participants was 47
years (SD ¼ 9.0; 20–78); the majority were women (77%); and all
were Caucasian. Five patients (three patients invited to participate
in emotion-regulation training and two patients not invited)
dropped out of treatment due to private or work-related reasons
and were consequently excluded from the study.
In order to compare emotion-regulation skills in patients versus
non-clinical controls, a community-based sample of 246 controls
was recruited by research assistants and students at the Universi-
ties of Bern, Freiburg (Switzerland), and Bochum (Germany)
through people approached during street fairs. Subjects were
excluded from the sample if they reported current involvement in
psychotherapeutic treatment. Subjects were not matched to the
clinical sample in a systematic way. Average age in the community-
based sample was 29.9 years (SD ¼ 11.6; 18–76). The majority of
participants were female (63%); all were Caucasian. Regarding
maximum years of education completed; 6% reported 10 years, 72%
reported 12 years, and 22% reported master degrees.
Measures
General emotion-regulation skills were assessed with the Fra-
gebogen zur Selbsteinschätzung Emotionaler Kompetenzen (SEK;
Emotion Regulations Skills Questionnaire, ERSQ; Berking & Znoj,
2008). The ERSQ is a 27-item self-report measure that assesses
application of emotion-regulation skills during the previous week
on a five-point Likert-type scale (‘‘not at all’’ to ‘‘almost always’’). It
contains nine scales that correspond to the nine emotion-regula-
tion skills previously discussed. Items are preceded by the stem,
‘‘Last week.’’ and include ‘‘I paid attention to my feelings’’; ‘‘my
physical sensations were a good indication of how I was feeling’’; ‘‘I
was clear about what emotions I was experiencing’’; ‘‘I was aware of
why I felt the way I felt’’; ‘‘I was able to accept my negative feel-
ings’’; ‘‘I felt strong enough to tolerate even negative emotions’’; ‘‘I
supported myself in emotional distressing situations’’; ‘‘I could do
what I intended to do despite of my negative feelings’’; and ‘‘I was
able to influence my negative feelings.’’
Results from validation studies (Berking & Znoj, 2008) indicate
that both the total score and the subscales of the ERSQ have good
internal consistencies (Cronbach’s a ¼ 0.90, and 0.68–0.81, respec-
tively) and adequate retest-reliability (rtt ¼ 0.75 and 0.48–0.74,
respectively). All scales have demonstrated convergent and
discriminate validity, including strong positive correlations with
constructs related to emotion regulation (Berking & Znoj, 2008).
Sensitivity to change has been demonstrated in several samples of
patients undergoing psychotherapeutic treatment (Berking & Znoj,
2008). Moreover, in two recent studies with 1081 total participants,
the ERSQ was shown to predict subsequent indicators of emotional
adjustment over and above previous adjustment, whereas indica-
tors of emotional adjustment did not predict subsequent ERSQ
scores (Berking, Orth, Wupperman, Meier, & Caspar, in press). These
findings suggest that the skills assessed with the ERSQ do not
merely represent a symptom of mental-health problems.
Mental-health problems were operationalized as the severity of
psychopathological symptoms, the intensity of negative affect (NA),
and the absence of positive affect (PA). Psychopathological symp-
toms were assessed using the German versions of the Symptom
Checklist-90-Revised (SCL-90-R; German: Franke, 2002) and the
Beck Depression Inventory (BDI; German: Hautzinger, Bailer,
Worall, & Keller, 1995). Positive and negative affect was assessed
with the German version of the Positive and Negative Affect
Schedule (PANAS; German: Krohne, Egloff, Kohlmann, & Tausch,
1996), referring to the last week before assessment in order to cover
the same time period as the ERSQ. All above measures are widely
used in clinical research and have been shown to be reliable and
valid (Franke, 2002; Hautzinger, Bailer, Worall, & Keller, 1995;
Krohne, Egloff, Kohlmann, & Tausch, 1996).
Treatments
CBT-based treatment as usual (TAU)
All patients in the clinical sample received psychotherapeutic
inpatient treatment. The inpatient treatment lasted 6 weeks and
consisted mainly of cognitive-behavioural therapy (CBT), which
included techniques such as behaviour analyses, contingency
management, cognitive restructuring, role play, relaxation train-
ings, etc. (see Dobson, 2001). Therapists were free to use techniques
from other evidence-based approaches (e.g., interpersonal and
experiential) if deemed necessary and if integrated into the CBT-
concept according to Grawe’s (2006) rationale of common-factor-
based treatment. Patients received one session of individual
therapy and an average of six sessions of group therapy per week.
Interventions were supplemented with sports therapy and phys-
iotherapy, as well as medical treatment when necessary. Treatment
was delivered by 13 experienced therapists and 6 therapists in
training. Adherence was ensured via weekly supervision of all
therapists by licensed senior therapists.
Training of emotion-regulation skills
A randomly selected subgroup of patients was offered the
option to replace 1.5 h per day of the CBT-based treatment as usual
(TAU) with an abbreviated version of the Training Emotionaler
Kompetenzen (Integrative Training of Emotional Competencies
[ITEC]2; Berking, 2007) during the last week of treatment. The core
of this group-based intervention consists of a set of general
emotion-regulation skills that are practiced as often and intensely
as possible. The training utilizes techniques from cognitive-
behavioural therapy (Dobson, 2001), dialectical behavioural
therapy (Linehan, 1993), mindfulness-based interventions (Kabat-
Zinn, 2003), empathy trainings (Gilbert et al., 2006), emotion
focused therapy (Greenberg, 2002), and problem-solving therapies
(e.g., Nezu, D’Zurilla, Zwick, & Nezu, 2004). As shown in Table 1, the
training begins with a thorough outline of the origins, functions,
mechanisms, and possible risks and benefits of emotional reactions.
Integrating findings and pictures from the affective neurosciences,
seven neural ‘‘vicious circles’’ are presented that are deemed
important for long-term maintenance of negative emotions (e.g.,
activation of the amygdala can increase muscle tension and vice
versa). For each vicious circle, a technique is presented that is
designed to interrupt the circle (see Table 1). Each of these skills is
first practiced in a long version (approximately 20 min per skill).
Subsequently, patients are trained to apply each skill in a shorter
period of time (5 s to 5 min). These abbreviated methods of skills
application are then combined into what is called the ITEC
Sequence, and patients are trained to apply the entire sequence of
skills to emotions they have difficulty regulating. To facilitate skills
application in distressing situations, ITEC strongly emphasizes the
need for a regular practice. Patients are taught a specific set of skill-
building exercises; they develop their own training regiment to
practice the skills; they are provided audio-CDs that guide them
through skill-building exercises; and they can choose to receive
2
A preliminary English version of the ITEC manual can be obtained from the first
author.
 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237
Table 1
Overview of ITEC
Sessiona Topic/Skill Content
1&2 Psycho-education (1) Illustration of biological and psychological
origins, functions, mechanisms, and possible risks
and benefits of emotional reactions;
(2) deduction of basic skills from
neuropsychological ‘‘vicious circles’’; and
(3) explanation of importance
of regular practice.
3 PMR þ breathing Introduction to progressive muscle relaxation
relaxation (Jacobson, 1938) and slow exhalation in order to
reduce psychophysiological arousal.
4&5 Non-judgmental Learning to be aware of emotions and the
awareness antecedents of emotions (sensations, cognitions,
motivational impulses), as well as labeling
emotions without judgment and without giving
into emotion-induced action tendencies
(e.g., Kabat-Zinn, 2003).
6 Acceptance and (1) Setting acceptance as a goal;
tolerance (2) providing a justification for this goal;
(3) viewing emotions as allies that can deliver
important messages and suggest potentially
helpful actions;
(4) becoming aware of one’s capacity to
tolerate negative emotions; and
(5) realizing that emotions are not permanent.
7&8 Effective self-support (1) Visualizing oneself in the distressing situation;
(2) activating an empathetic mind set; and
(3) approaching, encouraging, and soothing
oneself in the imagined scene.
9 Analysis Understanding the cues of the present emotion
by applying a schema that addresses:
the objective situation; present needs, wishes,
goals, and expectations; cognitive appraisals;
old schemata affecting appraisals;
primary emotions; secondary emotions;
action tendencies; and actions taken.
10 Modification Modification of quality and/or quantity of an
emotional reaction with the help of a five-step
emotion modification plan, which is based on the
general problem-solving model and includes:
(1) setting a specific and realistic goal of how one
wants to feel;
(2) brainstorming possible ways of
changing the antecedents of the emotion;
(3) choosing a strategy;
(4) making a specific plan; and
(5) evaluating progress, including reinforcement
of successful efforts or change of plan/goal
if necessary.
a
Note. 45 min per session. PMR ¼ Progressive Muscle relaxation. For further
details see Berking (2007).
text messages or emails that suggest a variety of short exercises.
ITEC is designed as a stand-alone or adjunctive intervention that
can be added to any form of empirically validated treatment in
order to enhance general emotion-regulation skills in clinical or at-
risk populations. The standard training consists of 12 modules, each
lasting for 1.5 h, scheduled on three separate days with 2 weeks of
autonomous practice between each training day.
In this study, the standard ITEC had to be modified to match the
therapeutic resources of the setting. The adapted version differed
from the standard in that the training was offered during the last
week of treatment for 1.5 h per day, resulting in 7.5 h of group-
based training in five days, as opposed to 18 h of group-based
training in 6 weeks. Moreover, the text-message coaching was
offered to patients only after they had left the clinic; thus, assess-
ment of possible effects took place before this part of the training
was delivered. ITEC groups consisted of 8–10 participants and were
conducted by three ITEC-trained therapists. These therapists were
supervised by a senior therapist to ensure adherence to the ITEC
manual. They were also involved in delivering the CBT-based
1233
treatment as usual. There was no evidence suggesting that the
three ITEC therapists had superior skills and/or more experience
compared with the other therapists who exclusively delivered the
CBT-based treatment.
Procedures
Subjects of the community-based sample anonymously
completed the ERSQ, as well as additional measures which are not
a focus of the current study. Subjects of the clinical sample
completed paper-and-pencil measures of emotion-regulation skills
and mental health on the first and last days of inpatient treatment.
Questionnaires were administered and entered by administrative
staff that was blind to treatment condition. One day after admis-
sion, a randomly selected sub-sample of new arrivals (alternating
upper versus lower two-thirds of new arrivals per week, according
to ranked dates of applications for treatment) was introduced to the
goals and content of ITEC. These patients were offered the option of
participating in the training during the last week of treatment or
continuing with treatment as usual. In the final analyses, we
compared treatment effects for patients who had not been invited
to participate in the training (TAU; N ¼ 114) and patients who had
been invited and had chosen to participate in the training
(TAU0 þ ITEC; N ¼ 90). All potential participants were informed that
participation in the study was voluntary and that information
would be kept confidential.
Statistical analyses
Analysis of Covariance (ANCOVA) models were used to assess
differences in successful skills application in non-clinical controls
versus patients. As emotion-regulation skills have been shown to
be significantly correlated (Berking & Znoj, 2008), stepwise logistic
regression was used to identify skills that best discriminated
between the two groups when the influence of other skills was
controlled. For these multivariate analyses, significance levels of
p ¼ 0.05 were required to include a variable in the equation, and
levels of p ¼ 0.10 for that variable to be retained. To address the
inherent unreliability in standard stepwise approaches, we repli-
cated the analyses more than 1000 times by sampling with
replacements from the original sample, and we retained only those
predictors that were significant more than half of the time (boot-
strap re-sampling; Mick & Ratain, 1994; Sauerbrei, 1999). A final
stepwise model was implemented with candidate predictors
determined from the boot-strap process. Spearman correlations
were used to assess univariate associations between pretreatment
successful skills application and outcome measures, and between
change in successful skills application and change in outcome
measures. Additionally, we used stepwise multiple regression in
order to determine which skills best predicted outcome measures
for both pretreatment and gain scores while controlling for asso-
ciations between skills. For these analyses, we used the same alpha-
levels as in the logistic regression and the boot-strapping procedure
described above to enhance reliability of the analyses.
To evaluate the impact of CBT-based treatment and the addi-
tional impact of the emotion-regulation training, repeated
measurement analyses of covariance (ANCOVA) were used. These
analyses were performed with time and time  treatment as inde-
pendent variables, and with the ERSQ total score, the ERSQ
subscales, and measures of mental health as dependent variables.
A power analysis estimated that 102 participants were required in
each group for a power of 80% with a small-to-medium effect size
and a set at 0.05, one-tailed. As sex and age have been found to be
associated with methods of dealing with emotions (e.g., Blanchard-
Fields, Stein, & Watson, 2004; Nolen-Hoeksema, & Morrow, 1991),
these variables were included as covariates in the correlation and
1234 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237

regression analyses, as in the group comparisons if groups differed resilience showed the highest correlations (Mdn ¼ 0.52 and 0.51).
on these variables. Group differences with regard to sex, age, and When negative affect was controlled, the effect sizes for the total
baseline outcome scores were tested with simple t- and c2-tests. As score continued to range between 0.36 and 0.47 (Mdn ¼ 0.41). As
the intensity of negative affect is likely to be both a cause and an before, awareness of emotions and awareness of emotion-related
effect of success in skills application, we repeated primary analyses sensations showed the lowest correlations (Mdn ¼ 0.19 and 0.20),
while controlling for negative affect as assessed by the PANAS. SPSS while resilience and modification showed the highest (Mdn ¼ 0.40
(version 14.0) was used for all analyses. and 0.38).
The overall pattern of results for the stepwise multiple regres-
sion of pretreatment scores was largely consistent with the results
Results from the univariate analyses. In the boot-strapping procedure, only
modification and resilience were reliably identified as significant
Pretreatment emotion regulation and mental health predictors of pretreatment measures of mental health (over and
above the effects of sex and age). In the final regression analyses,
The clinical and community-based samples differed with regard modification was identified as the strongest predictor of all
to age and sex (t[446] ¼ 18.96, p < 0.001; c2[1, N ¼ 535] ¼ 93.96, measures over and above sex and age (GSI: b ¼ 0.53, DR2 ¼ 0.28,
p < 0.001); thus these variables were included as covariates. As F ¼ 107.42, p < 0.001; BDI: b ¼ 0.32, DR2 ¼ 0.28, F ¼ 104.09,
shown in Table 2, internal consistency of the ERSQ subscales was p < 0.001; PAPANAS: b ¼ 0.44, DR2 ¼ 0.34, F ¼ 140.08, p < 0.001;
adequate-to-good in both samples. Correlations between ERSQ NAPANAS: b ¼ 0.27, DR2 ¼ 0.18, F ¼ 58.89, p < 0.001). Resilience
subscales ranged from r ¼ 0.24–0.61 (Mdn ¼ 0.44) in the clinical significantly predicted all measures of mental health except the GSI
sample and r ¼ 0.05–0.63 (Mdn ¼ 0.36) in the control sample. over and above (sex, age and) modification (BDI: b ¼ 0.31,
Also shown in Table 2, ERSQ total scores were significantly lower DR2 ¼ 0.05, F ¼ 20.08, p < 0.001; PAPANAS: b ¼ 0.22, DR2 ¼ 0.03,
in the clinical sample than in the control sample, indicating that F ¼ 11.09, p < 0.001; NAPANAS: b ¼ 0.23, DR2 ¼ 0.03, F ¼ 9.33,
individuals in the clinical sample reported less mastery of emotion- p < 0.01). When NAPANAS was used as a covariate the overall pattern
regulation skills. For the subscales, the greatest differences occurred of results did not change, except for resilience (BDI: b ¼ 0.21,
for acceptance, resilience and understanding. This finding did not DR2 ¼ 0.10, F ¼ 41.01, p < 0.001; PAPANAS: b ¼ 0.19, DR2 ¼ 0.02,
change when the negative affect scale of the PANAS was included as F ¼ 7.74, p < 0.01) being identified as the strongest and modification
an additional covariate (acceptance: F[1,507] ¼ 41.88, h2 ¼ 0.08, (GSI: b ¼ 0.31, DR2 ¼ 0.08, F ¼ 43.15, p < 0.001; BDI: b ¼ 0.21,
p < 0.001; resilience: F[1,507] ¼ 29.97, h2 ¼ 0.06, p < 0.001; under- DR2 ¼ 0.02, F ¼ 11.19, p < 0.01; PAPANAS b ¼ 0.39, DR2 ¼ 0.21,
standing: F[1,508] ¼ 54.79, h2 ¼ 0.10, p < 0.001). The same skills F ¼ 89.62, p < 0.001) as the second strongest predictor for the BDI in
were also identified in the stepwise logistic regression with boot- the final regression analyses.
strap re-sampling as significant predictors of group status
(ORs ¼ 0.46, 0.51, and 0.44; CIs ¼ 0.29–0.74, 0.34–0.77, and 0.30–0.65; Change in emotion regulation during treatment and treatment
p < 0.001 in all cases; Chi-square goodness-of-fit tests for the whole outcome
model: c2[6, N ¼ 535] ¼ 371.82, p < 0.001). Unexpectedly, self-support
was associated with a higher likelihood of belonging to the group of As also shown in Table 3, change in the ERSQ total score during
patients (OR ¼ 1.84; CI ¼ 1.21–2.81; p < 0.01). Additional analyses treatment was significantly related to change in all other outcome
indicated that these results did not change notably when measures, with correlations ranging from 0.40 to 0.49
NAPANAS was included as a covariate (ORs ¼ 0.55, 0.62, 0.40 and (Mdn ¼ 0.45). The subscales awareness of emotion-related sensa-
1.86; CIs ¼ 0.33–0.91, 0.40–0.94, 0.27–0.60, and 1.20–2.87; tions, awareness of emotions, and clarity showed the lowest corre-
p < 0.01 in all cases; c2[7, N ¼ 535] ¼ 392.83, p < 0.001). lations with other outcome measures (Mdn ¼ 0.16, 0.20, and 0.23),
The following analyses refer to the clinical sample only. As dis- whereas modification, acceptance, and resilience, showed the high-
played in Table 3, the pretreatment ERSQ total score was signifi- est correlations (Mdn ¼ 0.47, 0.46, and 0.42). When negative affect
cantly associated with measures of psychopathologic symptoms, was controlled, correlations decreased and ranged between 0.27
depression, positive affect and negative affect. Correlations ranged and 0.38 for the ERSQ total score (Mdn ¼ 0.35). Awareness of
from 0.37 to 0.55 (Mdn ¼ 0.51). Subscales of the ERSQ differed in emotion-related sensations, self-support, and readiness to confront
their strength of associations with the other measures. Awareness of situations that trigger negative emotions demonstrated the lowest
emotions and awareness of emotion-related sensations showed the correlations (Mdn ¼ 0.13, 0.15, and 0.16), whereas acceptance,
lowest correlations (Mdn ¼ 0.20), whereas modification and resilience, and modification demonstrated the highest (Mdn ¼ 0.31,
0.30, and 0.30).
The boot-strapping multiple regression process identified the
Table 2
Group comparisons on ERSQ scales following skills as reliable predictors (over and above sex and age):
modification for all outcome measures, resilience for all outcome
Scale Patients Controls F(1,511) h2
measures except PAPANAS, acceptance for the BDI and PAPANAS, and
a M SD a M SD awareness for NAPANAS. In the final regression analyses, change in
Awareness 0.81 2.03 0.94 0.83 2.69 0.90 34.67* 0.06 modification was the strongest predictor of change in the GSI
Sensations 0.74 2.42 0.92 0.74 2.79 0.80 16.54* 0.03 (b ¼ 0.29, DR2 ¼ 0.20, F ¼ 63.28, p < 0.001), PAPANAS (b ¼ 0.36,
Clarity 0.79 2.35 0.94 0.78 2.91 0.83 45.95* 0.08
Understanding 0.77 2.10 0.95 0.66 2.92 0.69 85.51* 0.14
DR2 ¼ 0.27, F ¼ 92.79, p < 0.001) and NAPANAS (b ¼ 0.39, DR2 ¼ 0.17,
Acceptance 0.72 1.91 0.88 0.64 2.83 0.72 95.73* 0.16 F ¼ 53.21, p < 0.001), the change in modification predicted change in
Resilience 0.84 1.63 0.99 0.76 2.62 0.81 80.67* 0.14 the BDI over and above the effects of resilience and acceptance
Self-support 0.81 2.11 0.96 0.71 2.64 0.77 18.58* 0.04 (b ¼ 0.17, DR2 ¼ 0.02, F ¼ 5.21, p < 0.05). Change in resilience was
R. to confront 0.85 2.12 1.03 0.79 2.60 0.93 21.81* 0.04
the strongest predictor of change in the BDI (b ¼ 0.24, DR2 ¼ 0.22,
Modification 0.76 1.57 0.83 0.72 2.25 0.81 55.28* 0.10
ERSQtotal 0.94 2.03 0.71 0.90 2.70 0.52 90.58* 0.15 F ¼ 71.73, p < 0.001). Change in resilience also predicted change in
the GSI over and above modification (b ¼ 0.26, DR2 ¼ 0.04,
Note. All comparisons with sex and age as covariates; a ¼ Cronbach’s Alpha;.
ERSQ ¼ Emotion Regulation Skills Questionnaire; R. to confront ¼ readiness to
F ¼ 14.29, p < 0.001) and change in NAPANAS over and above modi-
confront situations that cue negative emotions. fication and awareness (b ¼ 0.21, DR2 ¼ 0.03, F ¼ 8.86, p < 0.01).
*p < 0.001. Change in acceptance predicted change in the BDI over and above
 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237 1235

Table 3
Spearman correlations of ERSQ scores and indicators of mental health (clinical sample)

Scale Pretreatment scores Gain scores

GSI BDI PAPANAS NAPANAS GSI BDI PAPANAS NAPANAS

Awareness 0.19** 0.21*** 0.30*** 0.10(*) 0.16** 0.24*** 0.30*** 0.09(*)
Sensations 0.17** 0.23*** 0.26*** 0.12** 0.15* 0.16** 0.23*** 0.10*
Clarity 0.33*** 0.36*** 0.34*** 0.20*** 0.20** 0.26*** 0.27*** 0.17**
Understanding 0.32*** 0.33*** 0.33*** 0.19** 0.25*** 0.31*** 0.30*** 0.23***
Acceptance 0.45*** 0.45*** 0.45*** 0.40*** 0.46*** 0.47*** 0.46*** 0.38***
Resilience 0.50*** 0.53*** 0.52*** 0.40*** 0.44*** 0.45*** 0.39*** 0.36***
Self-support 0.43*** 0.44*** 0.44*** 0.36*** 0.29*** 0.27*** 0.28*** 0.31***
R. to confront 0.41*** 0.43*** 0.46*** 0.33*** 0.24*** 0.26*** 0.32*** 0.27***
Modification 0.53*** 0.51*** 0.58*** 0.41*** 0.48*** 0.46*** 0.49*** 0.46***
ERSQtotal 0.50*** 0.52*** 0.55*** 0.37*** 0.44*** 0.47*** 0.49*** 0.40***

Note. N ¼ 247–280. All correlations control for sex and age. ERSQ ¼ Emotion Regulation Skills Questionnaire; GSI ¼ SCL 90-R Global Severity Index; BDI ¼ Beck Depression
Inventory; R. to confront ¼ readiness to confront situations that cue negative emotions; PAPANAS ¼ Positive Affect Subscale from PANAS; NAPANAS ¼ Negative Affect Subscale
from PANAS.
(*)p < 0.10; *p < 0.05; **p < 0.01; ***p < 0.001.

resilience (b ¼ 0.20, DR2 ¼ 0.05, F ¼ 15.86, p < 0.001) and change in
PAPANAS over and above modification (b ¼ 0.25, DR2 ¼ 0.04,
F ¼ 12.88, p < 0.001). Finally, change in awareness predicted change
in NAPANAS over and above modification (b ¼ 0.20, DR2 ¼ 0.03,
F ¼ 8.08, p < 0.01). When negative affect was included as a covariate
resilience and modification were identified as reliable predictors for
the GSI (b ¼ 0.16, DR2 ¼ 0.05, F ¼ 21.24, p < 0.001; b ¼ 0.15,
DR2 ¼ 0.01, F ¼ 5.86, p < 0.05), acceptance and resilience for the BDI
(b ¼ 0.20, DR2 ¼ 0.09, F ¼ 35.90, p < 0.001; b ¼ 0.20, DR2 ¼ 0.02,
F ¼ 9.35, p < 0.01), and modification and acceptance for the PAPANAS
(b ¼ 0.25, DR2 ¼ 0.11, F ¼ 43.33, p < 0.001; b ¼ 0.20, DR2 ¼ 0.02,
F ¼ 9.43, p < 0.01).
Treatment effects
There were no significant differences between the TAU condi-
tion and the TAU0 þ ITEC condition with regard to age (t[202] ¼ 1.12,
p ¼ 0.90), sex (c2[1, N ¼ 204] ¼ 2.8, p ¼ 0.09) and prescores of
emotion-regulation and mental-health measures (ERSQtotal:
t[190] ¼ 1.6, p ¼ 0.11; GSI: t[194] ¼ 0.1.09, p ¼ 0.28; BDI:
t[197] ¼ 0.11, p ¼ 0.92; PAPANAS: t[190] ¼ 0.63, p ¼ 0.53; NAPANAS:
t[190] ¼ 0.64, p ¼ 0.53). As can be seen in Table 4, all outcome
measures significantly improved in both treatment conditions.
Significant interaction terms and small-to-moderate effect sizes
indicated that, compared with the CBT condition, treatment gains
were slightly larger in the TAU0 þ ITEC condition for the ERSQ total
score, the BDI, and both scales of the PANAS. There were no group
differences with regard to the GSI. When changes in NAPANAS were
included as a covariate, the effects of condition on outcome were
reduced to a trend for the ERSQtotal score (F[1,176] ¼ 3.49, h2 ¼ 0.02;
p ¼ 0.063), were no longer significant for PAPANAS (F[1,176] ¼ 1.44,
h2 ¼ 0.01; p ¼ 0.23), and were still significant for the BDI
(F[1,176] ¼ 4.21, h2 ¼ 0.02; p ¼ 0.042).
Additional exploratory analyses demonstrated that within the
CBT condition the subscale modification demonstrated the greatest
gain (h2 ¼ 0.31). The subscales awareness of emotions, under-
standing, acceptance, and resilience also showed notable improve-
ments (h2 ¼ 0.26, 0.24, 0.22 and 0.21). This pattern changed slightly
when NAPANAS was controlled (h2 ¼ 0.12, 0.18, 0.15, 0.06 and 0.06).
Compared with the CBT condition, larger gains in the TAU0 þ ITEC
condition were found with regard to awareness of emotions,
acceptance, and resilience (h2 ¼ 0.06, 0.04 and 0.02). The latter were
notably decreased when negative affect was controlled (h2 ¼ 0.05,
0.02 and 0.00).
Discussion
The goal of this study was to evaluate the importance of tar-
geting general emotion-regulation skills in psychological inter-
ventions. To this end, we assessed self-reports of skills application
in a sample of 289 inpatients pre- and posttreatment, as well as in
a sample of 246 controls. Results show that psychotherapy patients
report fewer emotion-regulation skills than non-clinical controls.
Additionally, pretreatment emotion-regulation skills were

Table 4
Effects of CBT-based treatment on ERSQ scales (ANOVA)

Source Condition Pre Post Time Time  condition

M SD M SD F(1,78–101) h2 F(1,177–183) h2
ERSQtotal TAU 2.08 0.74 2.51 0.75 39.20*** 0.28 6.37* 0.04
TAU0 þ ITEC 1.91 0.62 2.59 0.63 108.58*** 0.58

GSI TAU 1.10 0.67 0.70 0.64 59.82*** 0.37 0.79 0.00
TAU0 þ ITEC 1.03 0.51 0.57 0.50 142.07*** 0.63

BDI TAU 18.45 10.46 11.93 10.22 68.97*** 0.41 7.66** 0.04
TAU0 þ ITEC 18.96 8.36 9.33 8.72 150.41*** 0.65

PAPANAS TAU 1.49 0.77 2.21 0.93 51.63*** 0.34 4.33* 0.02
TAU0 þ ITEC 1.39 0.72 2.41 0.75 99.18*** 0.56

NAPANAS TAU 1.61 0.79 1.02 0.80 47.80*** 0.33 5.11* 0.03
TAU0 þ ITEC 1.69 0.73 0.83 0.62 105.44*** 0.58

Note. ERSQ ¼ Emotion Regulation Skills Questionnaire; TAU ¼ CBT-based treatment as usual; ITEC ¼ Integrative Training of Emotion-Regulation Competencies.
*p < 0.05; **p < 0.01; ***p < 0.001.
1236 M. Berking et al. / Behaviour Research and Therapy 46 (2008) 1230–1237
significantly associated with measures of mental health and well-
being in the clinical sample. Thus, results are consistent with the
assumption that deficits in emotion-regulation skills contribute to
the development and maintenance of psychopathology. For both
findings, the relationship is only partly moderated by the intensity
of negative affect. Thus, the findings do not simply reflect the
impact of negative affect on the ability to cope with negative
emotions. The ERSQ subscales most strongly and consistently
related to mental health are modification, resilience, and acceptance
of negative emotions. This finding supports theories that focus on
emotion-related self-efficacy and theories that focus on the
acceptance and tolerance of negative emotions as fundamental for
mental health (Catanzaro & Greenwood, 1994; Hayes et al., 1996;
Hayes et al., 2004; Kobasa et al., 1982; Salovey et al., 1995).
However, the strongest support is provided for theories that focus
on both acceptance/resilience and on active modification as equally
essential for mental health (Greenberg, 2002; Linehan, 1993).
In contrast, theories emphasizing the importance of awareness
of emotions, awareness of emotion-related sensations, and clarity
about emotions (Bagby et al., 1994; Feldman-Barrett et al., 2001;
Marchesi et al., 2005) are only supported in part. These skills do not
contribute significantly to the prediction of mental health in the
multivariate analyses. These findings, combined with the moderate
effect sizes in the univariate analyses, provide preliminary support
for the hypothesis that these skills are important, but possibly only
to the extent that they facilitate the application of the crucial skills
of modifying, accepting, and tolerating.
Finally, the subscale self-support in distressing situations was
a significant predictor of belonging to the patient group. One partial
explanation for this finding may be that, after controlling for
important beneficial aspects of emotion regulation (such as
acceptance), this scale assessed an increased self-focused attention
that is typically associated with mental-health problems (Mor &
Winquist, 2002).
The strong correlations of change in ERSQ total score with
changes in other outcome measures support the hypothesis that
enhanced emotion-regulation skills facilitates treatment gains in
other areas. In addition, many of the effects sizes remain moderate
and most remain significant even when negative affect was
controlled, thus providing further support for the assumption that
success in skill application is not merely a symptom of mental well-
being. The (limited) effects of negative affect as a covariate may be
explained by assuming that the enhancement of emotion-regula-
tion skills has two effects: (a) Automatic responses toward
emotionally relevant stimuli are modified in a way that impedes
the development of negative emotions and (b) emotion-regulation
skills enable individuals to deal with the negative emotions that do
develop in a more-adaptive method that is less likely to lead to
mental-health problems. However, additional research is necessary
to provide equivocal evidence of the proximal effects of emotion-
regulation on well-being.
With regard to differences between skills, results indicate that
improvements in the abilities to modify, accept, and tolerate
negative emotions are the strongest and most consistent predictors
of treatment gains. The multivariate analyses indicate that the
prediction of change in all outcome measures is improved by
including both an indicator of modification and an indicator of
either acceptance or resilience. The replication of this finding across
all outcome measures provides evidence for the reliability of the
stepwise regression approach. In total, the findings are consistent
with our previous results: First, they support treatment approaches
that work to increase emotional self-efficacy (e.g., Hoffart, 1995;
Williams & Zane, 1989) and approaches that focus on acceptance
and resilience (e.g., Hayes, Luoma, Bond, Masuda, & Lillis, 2006;
Hayes et al., 1999; Kabat-Zinn, 2003). Second, the strongest support
is again provided for treatments that combine these approaches
and focus on modification, acceptance, and resilience (e.g., Green-
berg, 2002; Linehan, 1993). Finally, the findings do not provide the
same support for treatment rationales that focus exclusively on
awareness of feelings (and emotion-related sensations) as an end in
itself.
After a 6-week CBT-based inpatient program, patients reported
increased successful skills application. The effect size is large for the
ERSQ total score. This supports the assumption that CBT treatments
enhance general emotion-regulation skills. Patients who partici-
pated in a modified CBT treatment which incorporated a specific
training of emotion-regulation skills (TAU0 þ ITEC) demonstrated
significantly greater gains in self-reports of successful skills appli-
cation. Moreover, patients in the TAU0 þ ITEC condition demon-
strated a greater reduction in depression and negative affect and
a greater increase of positive affect. These findings provide
preliminary support for the utility of incorporating an intensive
emotion-regulation training to enhance the effectiveness of CBT-
based treatments. For a correct interpretation of the small effect
sizes, it has to be considered that the abbreviated version of ITEC
consisted of only five 90-min sessions and allowed only 1 week of
autonomous skills training; thus, the effects of the training had to
compete with the ‘‘noise’’ created by (a) the CBT-based therapeutic
interventions, which were administered during the first 5 weeks of
treatment and (b) those times during the last week that partici-
pants did not spend in separate treatment conditions.
Strengths of this study include: the simultaneous assessment of
a broad range of potentially relevant emotion-regulation skills; the
use of a fairly large sample of patients treated in a naturalistic
setting; and the combination of cross-sectional analyses, gain-score
analyses, and a quasi-experimental design. Major limitations of this
study include the assessment of emotion-regulation skills and
mental-health outcomes solely by self-reports, the lack of matching
between the community-based and clinical samples, the lack of
structured adherence coding, and the lack of a long-term follow-up.
In addition, as patients were not randomized to conditions, we
cannot equivocally declare that the superior performance of the
TAU0 þ ITEC condition was not caused by selection effects. Many
patients who declined to participate in ITEC reported that they
were quite satisfied with the treatment they were getting and did
not want to make any change in the treatment plan. On the other
hand, patients who participated in ITEC often indicated that they
considered themselves in need of better emotion-regulation skills.
Thus, patients in the TAU0 þ ITEC condition may have had a stronger
motivation for change. Future studies need to replicate these
findings while utilizing a true experimental design, incorporating
additional and possibly more-objective measures of emotion
regulation and mental-health outcomes, and assessing possible
long-term effects of emotion-regulation skills. Moreover, future
studies should clarify whether a focus on emotion-regulation skills
provides greater benefits for some disorders than for others, as well
as whether some forms of treatment profit more strongly from
adding a specific emotion-regulation training than do others.
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