The Importance of Emotional Regulation in Mental Health

Abstract

Mental health is a critical component of overall well-being and exists on a continuum much like physical health. Although many ways to assess mental health exist outside of either having a disorder or not, practitioners often rely on the presence or absence of symptomatology. The assessment and promotion of emotional regulation in patients is one way to encourage individuals to engage in mental health-promoting behaviors. Specific techniques are discussed that address emotional regulation. Overall, providing patients with the tools to regulate emotional responding will likely have a direct impact on well-being as well as reduce MH symptomology.

“Instead of intervening when a diagnosis is given, practitioners can help individuals to have improved MH and to decrease the likelihood of disorders.”

Introduction

The field of lifestyle medicine posits that well-being rests on 6 behavioral pillars representing diet, exercise, sleep, substance use, stress, and relational skills. ¹ Mental health (MH) status influences the extent to which individuals are able to adopt health-promoting behaviors within each pillar, and conversely, practicing health-promoting behaviors will influence MH status. ² This bidirectionality highlights the role of MH as a fundamental change agent in meeting lifestyle goals. Further, given that 27% of patients from a variety of medical outpatient clinics have clinical or subthreshold diagnoses of depression ³ and 6% of primary care patients have anxiety or subthreshold anxiety disorders, ⁴ strategies to promote MH may enhance the ability of lifestyle medicine practitioners to facilitate positive behavior change among many of their patients.

Thus far, the field of lifestyle medicine has not sufficiently addressed the relationship between health-promoting behaviors and MH. Merlo and Vela (2021, this issue) have issued a call to action for lifestyle medicine researchers and practitioners to integrate existing MH conceptual models with the lifestyle medicine framework in service of delivering innovative integrated lifestyle medicine interventions. In this paper, we propose a transdiagnostic, self-regulatory concept (i.e., emotion regulation) and accompanying evidence-based change strategies that may facilitate the lifestyle medicine approach to promote mental and physical health.

Self-regulatory processes include executive functions (e.g., goal setting and monitoring), cognitions (e.g., self-appraisals and self-efficacy), and emotional responding to internal and external stressors (e.g., inhibition, control, and expression). ⁵ Behavior and emotion are linked. ⁶ Emotion regulation requires metacognitive awareness of one’s current emotional state and involves implementation of effective problem solving or acceptance/coping strategies. Emotional dysregulation exists along a continuum from extreme emotional control to the complete inability to regulate responses. Emotional dysregulation is a transdiagnostic symptom of several MH problems, including anxiety, substance use, eating pathology, and depression, and may derail attempts to adopt health-promoting behaviors. Consequently, learning to regulate emotional responding to internal and external stressors will likely have a direct impact on quality of life and well-being as well as reduce MH symptomology. In this commentary, we will review 2 behavioral, psychotherapy models as well as introduce cross-cutting interventions for use with patients.

Notable Practices for Skill Development in Emotion Regulation

Acceptance and Commitment Therapy (ACT).^7,8 The ACT approach focuses on creating a quality of life that embraces the inevitable pain that goes with living a meaningful life. ⁹ ACT encourages patients to (1) accept internal events (e.g., effectively managing painful thoughts and difficult emotions without avoidance) and (2) clarify and define personally held values, which form the foundation for goal setting and behavior change. Behavior change is possible through psychological flexibility, or the ability to be present in the moment, accept lived experiences with openness, and take value-guided actions to do what matters. When working with patients, providers may notice psychological inflexibility in those who have limited self-awareness or who spend too much of their energies on the past (depression) or future (anxiety). ¹⁰ ACT encourages providers and patients to non-judgmentally examine “unworkable actions” and the lack of congruency between values and actions with curiosity and mindfulness to overcome resistance and to clarify motivation for change. Evidence supports the use of ACT with pain, anxiety, chronic pain, patients facing disability, and similar medical conditions. ¹¹

Dialectical Behavior Therapy (DBT). DBT is a biopsychosocial, cognitive-behavioral intervention originally designed for the treatment of borderline personality disorder, but recent evidence suggests effectiveness with anxiety, ¹² alcohol misuse, ¹³ and eating pathology.^14,15 DBT focuses on developing skills to cope with difficulties in emotion regulation, both over control and lack of control. DBT posits a theory of emotion dysregulation that includes an emotional vulnerability to internal and external stressors and an inability, even when giving a best effort, to self-soothe or regulate intense emotional arousal or nonverbal and verbal expressive emotional responses. In addition, some individuals struggle with a slow return to emotional baseline following intense responses. DBT incorporates skills for increased distress tolerance, interpersonal effectiveness, and impulse control. ¹⁶ Patients are introduced to a “WISE mind” concept, which refers to the balancing of both emotions and reason in reacting to situations that stimulate intense emotional arousal. Collaborating with patients to build coping skills without intense emotional arousal will increase their abilities to meet their lifestyle goals.

Cross-Cutting Skills for Emotion Regulation

Mindfulness practices. Mindfulness is a cross-cutting technique of DBT and ACT, among other interventions, and is best described as the practice of intense focus and concentration on one’s immediate situation with curiosity and acceptance rather than judgment and avoidance.^17,18 It involves present-centered awareness of sensory sensations (e.g., sight, smell, and touch) while experiencing the flow of one’s inner thoughts and emotions as an outside non-judgmental observer. Mindfulness increases awareness and tolerance of, and reduces reactivity to, emotional experiences. ¹⁹ A mindful approach to life may be cultivated with regular mindful meditation practice. Patients may experience emotion regulation benefits with as little as 5-10 minutes of daily mindful meditation practice per day. ²⁰ During mindful meditation, the patient may experience mindfulness by anchoring attention on their involuntary breathing while sitting or lying comfortably without distractions. During this practice, the patient may focus on the sensation of the breath moving in and out of their lungs, and when their mind wanders, they can gently return focus to their breath. With the continued practice of returning attention to the breath, the ability to be mindful strengthens, and overall MH improves.

Behavioral activation is another cross-cutting emotion regulation practice that can be easily introduced to patients for a variety of MH concerns. It is well established that healthy lifestyle behaviors like exercise, good sleep, hygiene, participation in pleasurable activities, mastering skills, and spending time with friends/family elevates mood.^21,22 Overcoming the lethargy and inertia of depressed mood and paralyzing anxiety to engage in one or more of these behaviors helps to reverse the downward cycle into depression and anxiety.^21,22 Behavioral activation is a systematic process of identifying mood-elevating behavioral goals and outlining a plan to overcome obstacles and achieve those goals.

Integrated MH and Primary Care

Over the past decade, research has shown there are numerous healthcare benefits to patients when MH care services are co-located within the primary care setting. The Primary Care Mental Health Integration (PCMHI) model utilizes MH professionals for intermittent or time-limited, brief interventions, typically lasting 1 to 6 sessions. ²³ The largest medical network in the US, the Veterans Health Administration, has adopted the PCMHI model across the US with positive satisfaction from Veterans, primary care providers, and MH professionals within those services.^24,25 Community practitioners without MH integration can encourage their patients to use internet-based programs and mobile phone apps. ²⁶ For new onset or mild depression or anxiety, practitioners can refer patients to self-guided, internet-based ACT or DBT programs as effective options.^27,28

Conclusions

In lifestyle medicine, physical health is often viewed in terms of a continuum. Instead of dichotomizing individuals into “healthy” and “sick” categories, professionals understand well that certain characteristics lead to improved health, whereas others increase the likelihood of disease. It is important that we have a similar view of MH. Instead of intervening when a diagnosis is given, practitioners can help individuals to have improved MH and to decrease the likelihood of disorders. For example, assessing and encouraging steps to improve emotional regulation and helping clients to increase awareness of and tolerance for emotional reactivity can be extremely beneficial to improving both quality of life and decreasing the risk of symptoms reaching clinical levels. Although barriers to addressing MH in an integrated way are evident, the routine engagement of patients around factors that promote improved MH is critical in providing care that addresses the holistic health of our patients.