Young adulthood is a critical life stage marked by social and emotional challenges and by emotional vulnerability as the young person navigates the demands and transitions of this complex developmental phase. For adolescents exposed to childhood trauma and developmental stress, this vulnerability is particularly evident, as these early life experiences can reduce opportunities to develop skills and techniques for managing emotions. Adverse life experiences such as abuse, neglect, family conflict, and homelessness radically impact the development of emotion regulation capabilities. Most mental health disorders emerge between late adolescence and young adulthood, and this further adds to the significant vulnerability of this cohort of young people, many of whom access primary mental health services for assistance with mental health and substance use difficulties.
Dr Kate Hall and Dr Elise Sloan at Deakin University, Australia, say that although young people who present for treatment at youth services commonly have multiple mental health needs across diagnostic categories, there currently are few evidence-informed approaches that target the needs of this vulnerable cohort. Reasons for presenting to services may include problematic substance use or deliberate self-harm as well as various other mental health disorders, such as depression, anxiety, disordered eating, and traits of borderline personality disorder. Existing psychological treatment approaches rarely target more than one disorder and are not commonly developed with young people, for young people. These approaches often apply strategies to target symptoms of a specific mental health disorder, without focusing on the interactive complexity of processes that may underlie the presentation of mental health distress. Dr Hall and Dr Sloan argue that new transdiagnostic approaches are required to address the complexity and transdiagnostic treatment needs of young people who are navigating the social and emotional challenges necessary for a healthy transition from adolescence to young adulthood.
A transdiagnostic model considers the common psychological processes that underpin mental health disorders across diagnostic categories. These models offer a practical approach for managing the complexity with which young people present for treatment by simultaneously targeting psychological processes that maintain distress across multiple disorders. Transdiagnostic approaches have significant empirical support, gathered over decades of treatment studies.
Emotion regulation and impulse control (ERIC)
Dr Hall and Dr Sloan have collaborated on a six-year body of work, in partnership with youth services and their research team, to examine emotion dysregulation as a transdiagnostic target for the treatment of mental health and substance use conditions in vulnerable young people. Emotion regulation is a multidimensional concept which incorporates the processes and micro-skills involved in modulating and managing the experience and expression of emotions. It includes an awareness, understanding and acceptance of emotions, the ability to apply appropriate strategies or skills to manage emotions, and control the impulse to respond to emotions in unhealthy ways when experiencing negative emotions. The research team explains that difficulties with emotion regulation are a common underlying process evident in young people who have histories of trauma and experience complex mental health difficulties.
Emotion regulation is an important treatment target in transdiagnostic models that aim to address the complex patterns of mental health, substance use and psychosocial difficulties in young people.
Dr Hall and Dr Sloan examined profiles of emotion regulation in treatment-seeking young people to highlight the impact that engagement in maladaptive emotion regulation strategies (i.e. rumination, avoidance, and suppression) had on the severity of their mental health symptoms. They also undertook a large systematic review of studies that measure changes in both emotion regulation and symptoms of psychopathology and found that the ability to effectively regulate emotions is something that can be taught through cognitive behavioural-based interventions. Consequently, the research team have determined that emotion regulation is an important treatment target in transdiagnostic models that aim to address the complex patterns of mental health, substance use, and psychosocial difficulties that are often present in this group of young people. Taken together, this research informed the development of an Emotion Regulation and Impulse Control (ERIC) intervention. ERIC is a transdiagnostic treatment model that builds on various theoretical models of emotion regulation and applies evidence-based strategies to promote healthy social and emotional development outcomes in young adults by helping them to build emotion regulation and impulse control skills.
The intervention was developed as part of a three-year action research programme in Australia, involving youth services and vulnerable young people who were accessing services for assistance with multiple complex mental health needs. ERIC delivers emotion regulation micro-skills in a modular format, which means that it can be integrated and complement already existing interventions delivered in the youth sector, including case management, youth outreach support, life skills training and anger management, amongst others.
ERIC integrates and draws on existing theories of emotion regulation to deliver in eight domains of emotion regulation and impulse control. Each of these domains has outcomes that represent healthy development. The skills and processes in each of these domains are delivered in a modular format and comprise practical exercises that include psychoeducation delivered through analogy or mind mapping, behavioural exercises, reflection, and practice schedules. The micro-skills cultivated across all eight domains ultimately teach young people to flexibly use appropriate emotion regulation strategies to modulate their emotional responses in order to meet situational demands, i.e., to develop healthy repertoires of emotion regulation skills.
The theoretical models that inform the ERIC strategies include Gratz and Roemer’s 2004 Multidimensional Model of Emotion Dysregulation and Berking and Whitley’s 2014 Adaptive Coping with Emotions Model. These models focus on emotional awareness and understanding emotional experiences and triggers, as well as applying techniques to modify emotions. ERIC also incorporated Gross’s 1998 Process Model of Emotion Regulation, which focuses on applying strategies for managing emotions both before the onset of the response and in response to an event.Good Friend
The research team reviewed empirical evidence extensively and incorporated evidence from existing studies together with the theoretical constructs underpinning the model and the treatment literature. Empirical constructs informing the model included work on specific emotion regulation strategies such as rumination, suppression avoidance, reappraisal, mindfulness, acceptance, problem-solving, and self-compassion. The skills taught in ERIC include distress tolerance, increasing emotional clarity, everyday mindfulness, problem solving, values-based decision making, and goal-directed behaviour.
Optimising health outcomes
The eight domains the ERIC programme is organised into each pertain to important processes underpinning healthy Emotion Regulation and Impulse Control. Firstly, Reducing Vulnerability helps young people to reduce rumination and emotional suppression and to face up to avoidance by teaching strategies that interrupt ruminative thinking cycles, help promote optimal self-care, such as reaching out to others, eating, sleeping, and exercising well, and being kind to the self and others. The second module focuses on Emotional Literacy, and how to identify emotions and understand the way these impact thoughts, behaviours, and the body, as well as recognise their purpose. Emotional literacy also includes being able to recognise the difference between helpful and unhelpful responses to emotions. Thirdly, the development of Flexible Thinking is taught by helping young people learn to look at a situation from another person’s perspective, be aware of bias when interpreting situations and to learn to accept other people’s perspectives as valid. The fourth module, Allowing, incorporates acceptance of the self and others, including observing and accepting one’s thoughts and learning to be kind and compassionate to the self.
ERIC was designed to promote healthy social and emotional development outcomes for vulnerable young people.
The fifth domain is Micro Mindfulness which teaches everyday mindfulness practices in simplified form, such as leaning mindfully or focusing on the breath, to help the young person focus attention on their mind and body and remain focused on the present. The programme teaches skills for Tolerating Discomfort that equip participants with techniques, such as distraction and self-comfort to manage uncomfortable thoughts, feelings and body signals. Decision Making focuses on helping young people learn to make decisions in line with their goals, despite strong emotions. The eighth and final domain, Identity and Values, helps the young person be aware of their personal values, goals and strengths, motivational drivers and how they want to live their lives.
Improving youth mental health
To evaluate the effectiveness of ERIC within a real-world setting, with young people who would not ordinarily participate in research trials, Drs Hall and Sloan and the research team undertook a number of research trials. The results of these trials have been published in numerous scientific papers reporting on the effectiveness of ERIC in addressing the mental health needs of young people presenting with multiple complex health needs. One study, delivered as an adjunct to residential substance use treatment, found a 60% reduction of emotion dysregulation and reductions of 50-60% in depression and anxiety post-intervention. In another study with participants accessing youth mental health support services, research indicated clear associations between emotion regulation responses and symptoms of psychopathology when adaptive strategies were absent. Another twelve-week ERIC intervention programme for young people, alongside usual care, showed an improvement in emotion dysregulation and symptoms of depression, anxiety and stress.
Unlike the large majority of clinical trials in young people which are regularly criticised due to their lack of generalisability to treatment seeking populations, all of the ERIC research studies have been undertaken in partnership with clinical services and therefore have included samples of young people that are highly vulnerable and arguably more representative of actual service users.
Hope for a better tomorrow
Vulnerable young people may experience ongoing individual and psychosocial vulnerability throughout their life span, if not correctly supported. Drs Hall and Sloan say that ERIC was designed to promote healthy social and emotional development outcomes for vulnerable young people. The ability to effectively regulate emotions, manage urges and make good decisions in spite of emotional distress are essential in helping young people to navigate the immense social and emotional demands of this period. The researchers explain that a healthy development in these areas can help young people to navigate the different domains of their life, which include the physical, social, emotional, academic, moral, cultural, spiritual, sexual, and intellectual sphere. Learning how to manage and regulate emotions and behavioural impulses empowers young people to create a sense of emotional safety and protection for themselves and to know how to comfort themselves through challenging situations.
Would ERIC have applicability for all adolescents as part of a Life Skills curriculum in the high school environment?
ERIC has captured the interest of parents, teachers and adults and is being applied in a community-wide dissemination as part of a ‘whole of community’ approach in Melbourne, Australia. This three-year programme of work has meant family and youth practitioners have undergone ‘train the trainer’ learning in order to disseminate ERIC throughout the community. Teachers at high school and primary schools, practitioners at primary health services, youth drop-in centres and outreach services for families across an inner city catchment are being trained in ERIC to contribute to a healthy community that cares for and supports young people.