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Dialectical behaviour therapy and emotion regulation:
How does DBT help in managing and regulating emotions?

Overview

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DBT in action ...
Figure 1. Female client working with a therapist

Sarah struggled with regulating her emotions, [grammar?] she often felt overwhelmed and experienced frequent outbursts. She reported these difficulties to her doctor, who referred her to a psychologist for dialectical behaviour therapy (DBT). After commencing DBT, Sarah learnt skills to manage her emotions more effectively (see Figure 1). Within six months, she reported fewer outbursts and a greater sense of control, highlighting DBT’s potential to improve emotion regulation and enhance daily functioning.

DBT, developed by Linehan (1993), is an evidence based intervention originally designed for borderline personality disorder (BPD) and suicidal behaviours. Derived from cognitive behaviour therapy (CBT), DBT integrates acceptance and change strategies to equip individuals with practical skills for managing distress, regulating emotions, and improving their relationships (Linehan, 1993). Over the years, DBT’s use has expanded to a wide range of conditions, including anxiety, mood disorders, substance use, and eating disorders (Menefee et al., 2022).

A core aim of DBT is to strengthen emotion regulation (ER), defined as the ability to monitor, evaluate, and modify emotional responses to promote wellbeing and adaptive functioning (Gross, 1999). ER is a crucial process for fostering both mental and physical health. Conversely, individuals who experience challenges with regulation may develop emotional dysregulation, often gravitating towards maladaptive strategies that worsen psychological distress (D’Agostino et al., 2017). In such circumstances, DBT plays a vital role by teaching structured skills that facilitate healthier ER outcomes.

This chapter outlines theoretical models of ER and DBT, examine how DBT targets dysregulation and review empirical evidence for its effectiveness. Overall, this chapter highlights how DBT functions as a key intervention for improving ER.


Focus questions
  • What is emotion regulation?
  • How does DBT help people regulate their emotions?
  • What evidence is there that shows DBT improves emotion regulation?

Theoretical framework of emotion regulation

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ER is a core psychological process that shapes how individuals experience, manage, and respond to their emotions, playing a vital role in both wellbeing and adaptive functioning (Gross, 1998). Given that emotions are multifaceted, ER can occur across a wide range of contexts, whether an individual is experiencing intense negative or positive emotions. These internal processes of ER can occur either consciously or automatically, as they can involve both the up-regulation and down-regulation of emotional intensity depending on situational demands (Thompson, 1994).

Emotional regulation process model

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Figure 2. Emotional Process Model, adapted from Gross (1998)

One of the most prominent frameworks surrounding ER is the process model (PM) introduced by Gross (1998). According to Gross (1998) the PM views ER as five key process that encompass regulation through a generative process (see Figure 2), these include:

  1. Situation selection: occurs before an emotional event by choosing whether to enter, avoid, or approach certain contexts to influence which emotions are likely to arise.
  2. Situation modification: occurs before or during the event, involving actively changing aspects of the situation to alter its potential emotional impact.
  3. Attentional deployment: occurs during the event, by directing one’s focus toward or away from features of the situation.
  4. Cognitive change: occurs once the situation is underway but before the full emotional response, involving reinterpreting or reframing the meaning of the situation to shift its emotional significance.
  5. Response modulation: occurs after the emotional response has been generated, including attempts to influence experiential, behavioural, or physiological reactions.

The PM highlights how individuals are able to move through theses stages when experiencing an emotional episode and use a combination of strategies rather than one alone (Gross & Jazaieri, 2014). Additionally, these five steps within the process model are further categorised into two factors antecedent- and response-focused. Antecedent-focused process occurs prior or during the emotion, whereas response focus occurs after the emotional response (Webb et al., 2012). This distinction highlights how individuals can intervene at multiple points in the ER process, either proactively or reactively, to shape their emotional experiences.

Emotional regulation extended process model

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While the PM provided a foundational framework for understanding when and how regulation occurs within the emotion generative process, it faced limitations in explaining how regulation is actually enacted in practice. To address this, Gross (2015) introduced the Extended Process Model (EPM). The EPM retains the five original processes but adds three further stages:

  1. Identification: which involves recognising that an emotional response is occurring and determining whether it requires regulation.
  2. Selection: which refers to choosing the most appropriate regulation strategy from the available options.
  3. Implementation: focuses on effectively putting the chosen strategy into practice.

Gross (2015) further emphasises that successful ER depends not only on having strategies available, but also on the capacity to identify when regulation is needed, select the most suitable approach, and implement it effectively within the context.


Test your knowledge

1

According to the Extended Process Model, which stage involves deciding whether an emotion requires regulation?

Selection
Identification
Implementation

2

Attentional deployment, cognitive change, and situation modification are all examples of antecedent-focused strategies.

True
False

Adaptive vs maladaptive strategies

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ER strategies are crucial for maintaining emotional balance however, [grammar?] not all strategies lead to the same outcomes. Adaptive strategies are defined as those that reduce distress and link to better outcomes, while maladaptive strategies are those that maintain or worsen symptoms (Aldao et al., 2014). Conklin et al. (2015) found that adaptive strategies such as acceptance, reappraisal, and problem-solving were associated with reduced psychopathology, particularly when individuals also relied heavily on maladaptive strategies. Similarly, Menefee et al. (2022) demonstrated that reappraisal mitigated the harmful effects of rumination and experiential avoidance, further supporting the notion that adaptive ER strategies promote resilience even when maladaptive tendencies are present. Together, these findings highlight the importance of fostering flexible, adaptive ER skills in order to improve psychological functioning. Given the disproportionate impact of maladaptive strategies on ER and the benefits of adaptive strategies, DBT is designed to directly reduce these maladaptive patterns. DBT actively strengthens adaptive skills such as mindfulness, reappraisal, and problem-solving thus, assisting individuals work towards a better well-being.


The use of maladaptive vs adaptive strategies

Emily feels anxious before an exam, [grammar?] she sometimes uses rumination, replaying past mistakes, and imagining failure. This maladaptive strategy increases her stress and disrupts her sleep. At other times, she applies cognitive reappraisal, reminding herself she has prepared and that one exam does not define her future. Combined with acceptance and problem-solving, these adaptive strategies reduce her anxiety and help her perform better.

Theoretical framework of DBT

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DBT has proven to be an influential therapeutic modality within psychology, incorporating core skills such as mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness as its four core modules (Linehan & Wilks, 2015). This integration creates a comprehensive approach that balances acceptance with change, allowing individuals to both validate their current experiences and work toward healthier coping strategies (Linehan, 1993).

Biosocial theory of BPD

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Figure 3. Biosocial model of BPD

One of the core frameworks underpinning DBT is the biosocial theory of BPD, proposed by Marsha Linehan (Rizvi et al., 2013). According to Linehan (1993) the theory posits that emotional dysregulation arises from the interaction of two primary factors (see Figure 3):

  1. Biological vulnerability: individuals experience heightened emotional sensitivity, intense reactivity, and a slower return to baseline.
  2. Invalidating environments: social contexts in which emotional experiences are dismissed, trivialised, or punished

According to this model, the dysfunctional behaviours often observed in individuals with BPD represent maladaptive attempts at self-regulation (McMain et al., 2001).The interplay of heightened vulnerability and invalidating environments creates a transactional cycle in which emotions are experienced with greater intensity, while the individual lacks the skills or validation necessary to regulate effectively. Over time, this cycle contributes to maladaptive coping behaviours such as avoidance, self-injury, or impulsivity (Linehan, 1993). By conceptualising BPD through the biosocial model, DBT directly targets both sides of the equation: it reduces emotional vulnerability through skills such as mindfulness and emotion regulation, while simultaneously addressing invalidation through validation and therapeutic support.

Dialectical philosophy

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Dialectical philosophy represents another crucial foundation of DBT. Dialectics refers to the interconnectedness of opposing viewpoints, which within DBT is reflected in the balance between acceptance and change (Rizvi et al., 2013). In therapeutic practice, this means that a client’s emotions are validated as real and meaningful (acceptance), while the client is simultaneously encouraged to develop and implement new coping behaviours (change) (Linehan & Wilks, 2015).

This balance is essential in dialectics, as an overemphasis on change risks invalidating the client’s emotional experiences, whereas an overemphasis on acceptance risks leaving the client entrenched in maladaptive patterns (Chapman, 2006). The dialectical stance therefore provides the philosophical framework through which DBT addresses emotion dysregulation. By simultaneously holding acceptance and change, clients are supported to acknowledge their present emotional states while also progressing toward adaptive regulation strategies.[factual?]


Applying biosocial theory and dialectical philosophy

Mia grew up in an household where her emotions were often dismissed as “overreactions.” She developed heightened emotional sensitivity, reacting strongly to stress and struggling to calm down [grammar?] consistent with the biosocial theory of BPD. In DBT, Mia’s therapist first validated her feelings of shame and anger (acceptance) but also encouraged her to practise opposite action and mindfulness (change). This balance reflects dialectical philosophy, helping Mia both acknowledge her experience and build healthier coping strategies.

Structure and modules of DBT

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DBT is delivered through a multimodal structure that ensures clients not only learn new skills but also have multiple opportunities to practice and generalise them into everyday life, as seen in Table 1 (Linehan, 1993, 2015).

Table 1

Modes of treatment in DBT

Therapy structure Description Purpose
Individual therapy Weekly one-on-one sessions between client and therapist. Focuses on behavioural analysis, applying DBT skills to daily life, and maintaining motivation. Targets personal problems directly while balancing acceptance and change.
Group skills training Conducted in a class-like format, covering the four DBT modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Teaches and rehearses core DBT skills in a supportive group setting.
Phone coaching Clients can call their therapist between sessions for brief support during crises. Promotes generalisation of DBT skills to real-life contexts.
Therapist consultation team Regular meetings of DBT clinicians to review cases, maintain adherence to DBT principles, and support therapist wellbeing. Ensures motivation between therapists and reduces burnout.

Note. Adapted from Rizvi et al. (2013)

DBT modules

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DBT delivers skills through four structured modules mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness[factual?] as illustrated in Figure 4.

Mindfulness

The mindfulness module is one of the core components of DBT. It is taught through the “What” skills (observe, describe, and participate) and the “How” skills (non-judgmentally, one-mindfully, and effectively) (Linehan, 2015). These practices enable clients to increase emotional awareness and respond intentionally rather than impulsively, with research further supporting mindfulness as a central mechanism of change in DBT (Eeles & Walker, 2022).

Distress tolerance

Distress tolerance skills (DTS) are designed to help individuals endure periods of intense emotional arousal without resorting to maladaptive behaviours (Neacsiu et al., 2014). DTS are grouped into two main categories: crisis survival skills and reality acceptance skills. Crisis survival skills provide short-term strategies such as distraction or self-soothing to manage distress, whereas reality acceptance skills (e.g., radical acceptance) enable clients to acknowledge painful situations without judgment (Linehan, 2015). Together, these skills equip individuals to withstand crises, reduce reactivity, and prevent escalation until longer-term coping strategies can be applied.

Emotion regulation

The ER module in DBT focuses on helping individuals understand and influence their emotions through psychoeducation and behavioural strategies. Clients are taught to recognise the functions of emotions, identify triggers, and apply skills such as problem-solving, checking the facts, and opposite action (Fassbinder et al., 2016). These strategies strengthen adaptive responses and reduce reliance on maladaptive ones, making ER skills central to DBT’s effectiveness in addressing emotion dysregulation (Linehan, 2015)

Interpersonal effectiveness

The interpersonal effectiveness (IE) module provides strategies to build and maintain healthy relationships while preserving self-respect and achieving personal goals (Neacsiu et al., 2014). Clients learn structured techniques that enable them to balance interpersonal demands with self-care. These skills provide individuals with practical tools to communicate effectively, reduce conflict, and strengthen social support factors that are essential for emotion regulation and overall wellbeing (Linehan, 2015).

Figure 4. DBT modules


How does DBT target emotional dysregulation?

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Emotional dysregulation is a central focus within the DBT framework. Linehan (1993) conceptualised dysregulation as characterised by heightened emotional sensitivity, intense reactions to triggers, and a slow return to baseline once emotions have been activated. If left unmanaged and continually addressed through maladaptive strategies, emotional dysregulation can be severely damaging to an individual’s psychological and social functioning. Linehan (1993) emphasised that such maladaptive behaviours often bring clients into therapy, including suicidal ideation, anger outbursts, and interpersonal conflict, highlighting the severity of the problem.

DBT aims to address these difficulties directly through its structured approach, which incorporates key strategies of acceptance and change (McMain et al., 2001). The therapy equips individuals with a broad set of adaptive skills across the four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (Linehan, 2015). Through these targeted interventions, individuals learn to replace maladaptive behaviours with adaptive strategies, leading to improvements in emotional stability, interpersonal functioning, and overall wellbeing.

Importantly, emotional dysregulation is not unique to BPD but is a transdiagnostic feature observed across a range of psychological disorders. Although DBT was originally developed for individuals with BPD and suicidal behaviours, dysregulation is also a central component of mood, anxiety, substance use, and eating disorders (Menefee et al., 2022). This broader relevance strengthens the case for DBT as an intervention with utility beyond BPD, underscoring its adaptability across diverse clinical populations.

Core emotion regulation skills

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As shown in Table 2, DBT addresses dysregulation directly by teaching practical skills that replace maladaptive strategies with adaptive ones.

Table 2

Core emotion regulation skills in DBT

Skill Purpose Example
Check the Facts Challenge distorted appraisals by testing thoughts against evidence. Realising a friend’s silence is due to being busy, not rejection.
Opposite Action Reduce maladaptive urges by acting opposite to the emotion-driven impulse. Attending an event despite feeling anxious.
Problem Solving Modify triggering situations by defining the problem and generating solutions. Practising for a presentation to reduce anxiety.
PLEASE Skills Maintain biological health to reduce emotional vulnerability. Getting adequate sleep to prevent irritability.
Accumulate Positives / Build Mastery Strengthen resilience by adding enjoyable activities and building competence. Scheduling hobbies or completing meaningful tasks.
Mindfulness of Emotions Observe and accept emotions as experiences without judgment. Noticing feelings of sadness without withdrawing from activities.

Note. Adapted from Linehan (2015); Neacsiu et al. (2014).


Quiz

1

Which DBT skill focuses on testing your thoughts against real evidence?

Opposite Action
Check the Facts
Mindfulness of Emotions
Accumulate Positives

2

A client chooses to attend a social event despite feeling anxious. Which DBT skill are they using?

Opposite Action
Problem Solving
PLEASE Skills
Mindfulness of Emotions

Integration into DBT

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DBT skills map directly onto Gross’s Process and Extended Process Models of emotion regulation (Gross, 1998, 2015).

For example:

  • Mindfulness → Identification & Attentional Deployment:Helps clients notice emotions early and shift attention with greater awareness.
  • Check the Facts → Cognitive Change: Encourages reappraisal of situations by testing thoughts against evidence.
  • Opposite Action → Cognitive Change & Response Modulation: Counters maladaptive urges by promoting intentional behavioural alternatives.
  • PLEASE Skills → Antecedent-Focused Vulnerability Reduction:. Strengthens biological and lifestyle foundations to reduce susceptibility to dysregulation.
  • Skills Menus & Wise Mind → Selection: Guide clients in choosing the most appropriate strategy from available options.
  • Phone Coaching & Therapist Support → Implementation: Provide real-time guidance to ensure skills are applied effectively in daily contexts.

By explicitly linking theory to practice, DBT ensures that clients not only learn which skills to use but also when and how to apply them. Skills are introduced in group sessions, rehearsed with peers, personalised in individual therapy, and reinforced through real-time coaching. With repeated practice, these skills become more automatic, supporting long-term resilience and adaptive functioning (Linehan, 2015).


DBT mindfulness in action

Emma often withdrew from friends whenever she felt sad, which reinforced her loneliness and made her emotions more overwhelming. During DBT, she learned mindfulness of emotions, a skill that encouraged her to notice sadness without judgment and recognise it as a temporary state. By applying this skill in daily life, Emma was able to stay connected with her friends instead of avoiding social contact, which reduced her distress and strengthened her support network.

Research and effectiveness of DBT for emotion regulation

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DBT has extensive evidence supporting its effectiveness in improving emotion regulation (ER) across diverse populations and contexts. A review by MacPherson et al. (2013) examined the use of DBT with adolescents and reported consistent improvements in ER, alongside reductions in suicidal ideation, non-suicidal self-injury (NSSI), depression, anger, hopelessness, and borderline personality disorder (BPD) symptoms. These findings demonstrate the adaptability of DBT for younger populations, particularly when emotional dysregulation underlies high-risk behaviours.

Further evidence from Goodman et al. (2014) employed neuroimaging methods to investigate DBT’s effects on adults with BPD. The study identified significant improvements in self-reported ER (measured by the Difficulties in Emotion Regulation Scale; DERS), as well as reduced amygdala hyperactivity during emotional processing tasks. These results suggest that DBT strengthens both psychological and neural mechanisms of ER, indicating that the therapy not only improves how individuals regulate emotions but also modifies the underlying biological processes associated with dysregulation.

Evidence also extends to parenting contexts. Martin et al. (2017) conducted a case study of mothers with severe emotional dysregulation who participated in a 22-week DBT skills group. Findings revealed increased use of DBT skills, reductions in self-reported emotional dysregulation, and modest but meaningful improvements in parenting outcomes, such as reduced stress and less permissive discipline. This study highlights the potential of DBT skills training to enhance ER in non-clinical roles, underscoring its applicability beyond traditional psychiatric settings.

However, despite these promising findings, several limitations are evident. MacPherson et al. (2013) noted that adolescent trials were often small in scale, varied in their adaptations of DBT, and lacked long-term follow-up, raising questions about the durability of treatment effects. Similarly, Goodman et al. (2014) relied on a small sample and a pre–post design without robust control conditions, which limits the strength of causal inferences that can be drawn from the neuroimaging results. Likewise, Martin et al. (2017) conducted a case study with a very limited sample and relied on self-reported measures, raising concerns about generalisability and potential reporting bias.

Taken together, these studies illustrate DBT’s broad impact on ER. Improvements have been documented at psychological, behavioural, and neurological levels, across adolescents, adults with BPD, and parents experiencing high levels of stress and dysregulation. While methodological limitations exist, such as small sample sizes and the need for more rigorous randomised controlled trials (RCTs), the evidence base nonetheless provides strong support for DBT as an intervention that promotes adaptive ER in both clinical and non-clinical populations.


What the research says

Adolescents: DBT improves ER and reduces suicidal ideation, NSSI, depression, anger, hopelessness, and BPD symptoms (MacPherson et al., 2013).

Adults with BPD: DBT enhances self-reported ER and reduces amygdala hyperactivity during emotional processing tasks (Goodman et al., 2014).

Parents: DBT skills training increases skill use, reduces emotional dysregulation, and improves parenting outcomes such as lower stress and less permissive discipline (Martin et al., 2017).

Conclusion

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This chapter demonstrated that DBT offers an effective framework for managing and regulating emotions. By integrating strategies of acceptance and change, DBT equips individuals with practical skills across mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, each of which directly addresses common difficulties in emotional control. Drawing on Gross’s process and extended process models, DBT skills can be mapped onto key stages of emotional regulation, guiding clients from maladaptive responses toward more adaptive regulation. Empirical evidence further supports DBT’s effectiveness across diverse populations, highlighting improvements in self-reported emotional regulation, reductions in maladaptive behaviours, and even measurable changes in neural functioning. For personal growth and development, this evidence underscores that while emotions cannot be eliminated, they can be managed more effectively. With consistent practice, DBT provides individuals with tools to reduce emotional vulnerability, make healthier choices, and strengthen resilience in both clinical and everyday contexts.

See also

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References

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Conklin, L. R., Cassiello-Robbins, C., Brake, C. A., Sauer-Zavala, S., Farchione, T. J., Ciraulo, D. A., & Barlow, D. H. (2015). Relationships among adaptive and maladaptive emotion regulation strategies and psychopathology during the treatment of comorbid anxiety and alcohol use disorders. Behaviour Research and Therapy, 73, 124–130. https://doi.org/10.1016/j.brat.2015.08.001

D’Agostino, A., Covanti, S., Rossi Monti, M., & Starcevic, V. (2017). Reconsidering Emotion Dysregulation. Psychiatric Quarterly, 88(4), 807–825. https://doi.org/10.1007/s11126-017-9499-6

Eeles, J., & Walker, D. (2022). Mindfulness as taught in Dialectical Behaviour Therapy: A scoping review. Clinical Psychology & Psychotherapy, 29(6). https://doi.org/10.1002/cpp.2764

Fassbinder, E., Schweiger, U., Martius, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion Regulation in Schema Therapy and Dialectical Behavior Therapy. Frontiers in Psychology, 7(1373). https://doi.org/10.3389/fpsyg.2016.01373

Goodman, M., Carpenter, D., Tang, C. Y., Goldstein, K. E., Avedon, J., Fernandez, N., Mascitelli, K. A., Blair, N. J., New, A. S., Triebwasser, J., Siever, L. J., & Hazlett, E. A. (2014). Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. Journal of Psychiatric Research, 57(57), 108–116. https://doi.org/10.1016/j.jpsychires.2014.06.020

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Linehan, M. M., & Wilks, C. R. (2015). The Course and Evolution of Dialectical Behavior Therapy. American Journal of Psychotherapy, 69(2), 97–110. https://doi.org/10.1176/appi.psychotherapy.2015.69.2.97

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Martin, C. G., Roos, L. E., Zalewski, M., & Cummins, N. (2017). A Dialectical Behavior Therapy Skills Group Case Study on Mothers With Severe Emotion Dysregulation. Cognitive and Behavioral Practice, 24(4), 405–415. https://doi.org/10.1016/j.cbpra.2016.08.002

McMahon, T. P., & Naragon-Gainey, K. (2018). The Moderating Effect of Maladaptive Emotion Regulation Strategies on Reappraisal: A Daily Diary Study. Cognitive Therapy and Research, 42(5), 552–564. https://doi.org/10.1007/s10608-018-9913-x

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Menefee, D. S., Ledoux, T., & Johnston, C. A. (2022). The importance of emotional regulation in mental health. American Journal of Lifestyle Medicine, 16(1), 28–31. https://doi.org/10.1177/15598276211049771

Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59(59), 40–51. https://doi.org/10.1016/j.brat.2014.05.005

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Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59(2/3), 25–52. https://doi.org/10.2307/1166137

Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: A meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychological Bulletin, 138(4), 775–808. https://doi.org/10.1037/a0027600

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