Extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology.

Gratz, Kim L.; Tull, Matthew T.

doi:10.1037/a0022144

Cited by 115Personality Disorders and PsychopathologySuicide and Self-Harm StudiesPsychotherapy Techniques and Applications

Extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology.

Gratz, Kim L., Tull, Matthew T.·2011·Personality Disorders: Theory, Research, and Treatment

DOI 10.1037/a0022144

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Abstract

Deliberate self-harm (DSH) is a clinically important behavior commonly associated with borderline personality disorder (BPD). Despite the clinical relevance and associated negative consequences of this behavior, however, there are few empirically supported treatments for DSH among individuals with BPD, and those that exist are difficult to implement in many clinical settings (due to their duration and intensity). To address this limitation, Gratz and Gunderson (2006) examined the efficacy of a 14-week, adjunctive emotion regulation group therapy (ERGT) for DSH among women with BPD. Although the results of this initial trial were promising (indicating positive effects of this treatment on DSH, emotion dysregulation, experiential avoidance, and psychiatric symptoms), they require replication and extension. Thus, the purpose of this study was to further develop this ERGT by examining its utility across other settings, a more diverse group of patients, a wider range of outcomes, and group leaders other than the principal investigator. Twenty-three women received this ERGT in addition to their ongoing treatment in the community. Self-report and interview-based measures of DSH and other self-destructive behaviors, psychiatric symptoms, adaptive functioning (including social and vocational impairment and quality of life), and the proposed mechanisms of change (emotion dysregulation and experiential avoidance) were administered pre- and posttreatment. Results indicate significant changes over time (accompanied by large effect sizes) on all outcome measures except quality of life and self-destructive behaviors (although the latter was a large-sized effect). Further, 55% of participants reported abstinence from DSH during the last two months of the group.

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Trials of treatments provided in routine clinical settings can evaluate how a treatment works under real-world conditions and contribute information about the utility and feasibility of a treatment in traditional clinical settings.
“Trials of treatments provided in routine clinical settings, on the other hand, can evaluate how a treatment works under more real-world conditions and, as such, contribute important information about the utility and feasibility of a treatment in traditional clinical settings.”
From Emotion regulation group therapy for deliberate self-harm: A multi-site evaluation in routine care using an uncontrolled open trial design (2017) · cites this paper as [20]
Mean ratings of treatment credibility and expectancy completed after the second session were 5.7 (SD=1.8) and 47.0% (SD=25.5), respectively.
“Mean ratings of treatment credibility and expectancy completed after the second session were 5.7 (SD=1.8) and 47.0% (SD=25.5), respectively (for comparison, mean ratings reported by Gratz and Tull were 6.91% and 57%, respectively).20”
From Emotion regulation group therapy for deliberate self-harm: A multi-site evaluation in routine care using an uncontrolled open trial design (2017) · cites this paper as [20]

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Treating Nonsuicidal Self-Injury: A Systematic Review of Psychological and Pharmacological Interventions
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“…utility of this ERGT within a more diverse and underserved setting, found significant improvements from pre- to post-treatment in DSH, emotion dysregulation, experiential avoidance, BPD symptoms, depression, anxiety, and stress symptoms, and social and vocational impairment (Gratz & Tull, 2011).”
BackgroundSelf-citation
Is Distraction an Adaptive or Maladaptive Strategy for Emotion Regulation? A Person-Oriented Approach
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MethodInfluential
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Self-citation
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Self-citation
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“Further, treatments that decrease emotional avoidance also decrease engagement in self-harm (e.g., Gratz & Gunderson, 2006; Gratz & Tull, 2011).”
BackgroundInfluential
Posttraumatic stress disorder symptoms and risky behaviors among trauma-exposed inpatients with substance dependence: The influence of negative and positive urgency
Weiss, N. H., Tull, M. T., Sullivan, T. P., Dixon–Gordon, K. L., & Gratz, K. L. (2015) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2015.07.679 · Cited by 110 · see citing works
Self-citation
Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder
Gratz, K. L., Bardeen, J. R., Levy, R., Dixon–Gordon, K. L., & Tull, M. T. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.12.005 · Cited by 102 · see citing works
“To address this need, Gratz and colleagues (Gratz & Gunderson, 2006; Gratz & Tull, 2011) developed an adjunctive emotion regulation group therapy (ERGT) forDSHamongwomenwithBPD,designed to augment the usual treatments provided in the community by * Corresponding author.”
Self-citation
Psychotherapeutic approaches to non-suicidal self-injury in adolescents
Washburn, J. J., Richardt, S. L., Styer, D. M., Gebhardt, M., Juzwin, K. R., Yourek, A., & Aldridge, D. (2012) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/1753-2000-6-14 · Cited by 80 · see citing works
“This group treatment has been shown to reduce NSSI in adult women with subthreshold or threshold BPD [53,54], although more studies are needed to confirm the findings.”
Result
Extending research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with nonsuicidal self-injury disorder: open pilot trial and mediation analysis of a novel online version
Bjureberg, J., Sahlin, H., Hedman-Lagerlöf, E., Gratz, K. L., Tull, M. T., Jokinen, J., Hellner, C., & Ljótsson, B. (2018) · BMC Psychiatry · doi:10.1186/s12888-018-1885-6 · Cited by 96 · see citing works
Self-citation
Emotion Regulation Difficulties and Maladaptive Behaviors: Examination of Deliberate Self-harm, Disordered Eating, and Substance Misuse in Two Samples
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“…regulation (e.g., dialectical behavior therapy and emotion regulation group therapy; see Linehan 1993; Gratz et al. 2014) may be particularly beneficial for individuals with multiple maladaptive behaviors (see Courbasson et al. 2012; Gratz and Tull 2011; Gratz et al. 2014; Linehan et al. 2006).”
BackgroundSelf-citation
Clinical Utility of the F ive‐ F actor M odel of Personality Disorder
Mullins‐Sweatt, S. N., & Lengel, G. J. (2012) · Journal of Personality · doi:10.1111/j.1467-6494.2012.00774.x · Cited by 85 · see citing works
“…of personality characteristics in treatment empirically, though some research has examined a specific personality process, emotion dysregulation, in treating borderline personality disorder and other emotional disorders (Allen, McHugh, & Barlow, 2008; Gratz & Gunderson, 2006; Gratz & Tull, 2011).”
Background
Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study
Bjureberg, J., Sahlin, H., Hellner, C., Hedman-Lagerlöf, E., Gratz, K. L., Bjärehed, J., Jokinen, J., Tull, M. T., & Ljótsson, B. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1527-4 · Cited by 84 · see citing works
“The utility of ERGT for NSSI has been supported in multiple studies [14, 19, 20].”
MethodSelf-citation
A Functional Analysis of Two Transdiagnostic, Emotion-Focused Interventions on Nonsuicidal Self-Injury
Bentley, K. H., Nock, M., Sauer-Zavala, S., Gorman, B., & Barlow, D. (2017) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000205 · Cited by 65 · see citing works
“…(ERGT; Gratz & Gunderson, 2006), which includes a multitude of emotion regulation and acceptance-based skills, are encouraging for NSSI (e.g., Gratz & Tull, 2011; Gratz, Tull, & Levy, 2014); however, ERGT has primarily been tested in female samples with at least subthreshold BPD who also…”
Background
Body Regard in Nonsuicidal Self-Injury: Theoretical Explanations and Treatment Directions
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“Instead, treatments for NSSI tend to emphasize emotion regulation, cognitive restructuring, interpersonal skills and relationships along with problem-solving/coping skill development (Gratz & Tull, 2011; Kerr, Muehlenkamp, & Turner, 2010; Klonsky & Muehlenkamp, 2007; Klonsky et al., 2011).”
Background
Emotion Regulation as a Mechanism of Change in an Acceptance-Based Emotion Regulation Group Therapy for Deliberate Self-Harm Among Women With Borderline Personality Pathology
Gratz, K. L., Levy, R., & Tull, M. T. (2012) · Journal of Cognitive Psychotherapy · doi:10.1891/0889-8391.26.4.365 · Cited by 69 · see citing works
“A complete description of the samples and procedures of the two trials can be found in the original articles (see Gratz & Gunderson, 2006; Gratz & Tull, 2011).”
MethodSelf-citation
The role of emotion dysregulation in the presence, associated difficulties, and treatment of borderline personality disorder.
Gratz, K. L., Moore, K. E., & Tull, M. T. (2016) · Personality Disorders Theory Research and Treatment · doi:10.1037/per0000198 · Cited by 62 · see citing works
Self-citation
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Cobos-Sánchez, L., Flujas-Contreras, J. M., & Becerra, I. G. (2022) · Current Psychology · doi:10.1007/s12144-020-01067-7 · Cited by 59 · see citing works
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“Researchers have reported decreased NSSI among women with BPD and subclinical BPD assigned to receive ERGT and TAU when compared with those receiving TAU alone at posttreatment (Gratz & Gunderson, 2006; Gratz & Tull, 2011) and at 9-month follow-up (Gratz, Tull, & Levy, 2014).”
Body Regard as a Moderator of the Relation between Emotion Dysregulation and Nonsuicidal Self‐Injury
Muehlenkamp, J. J., Bagge, C. L., Tull, M. T., & Gratz, K. L. (2013) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12032 · Cited by 54 · see citing works
Self-citation
Emotion regulation group therapy for deliberate self-harm: A multi-site evaluation in routine care using an uncontrolled open trial design
Sahlin, H., Bjureberg, J., Gratz, K. L., Tull, M. T., Hedman, E., Bjärehed, J., Jokinen, J., Lundh, L.-G., Ljótsson, B., & Hellner, C. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-016220 · Cited by 50 · see citing works
“These trials also play an important role in increasing the availability of evidence-based treatments.(20) Thus, further research examining the utility of empirically supported treatments for DSH within BPD in realworld clinical settings is needed.”
BackgroundSelf-citation
Predictors of treatment response to an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder.
Gratz, K. L., Dixon-Gordon, K. L., & Tull, M. T. (2014) · Personality Disorders: Theory, Research, and Treatment · doi:10.1037/per0000062 · Cited by 51 · see citing works
“Created by Gratz and colleagues (Gratz & Gunderson, 2006; Gratz & Tull, 2011) to augment the usual treatments provided by clinicians in the community by directly targeting both DSH and its proposed underlying mechanism of emotion dysregulation (Chapman, Gratz, & Brown, 2006; Gratz, 2007; Gratz &…”
BackgroundInfluentialSelf-citation
Characterizing emotional dysfunction in borderline personality, major depression, and their co-occurrence
Dixon–Gordon, K. L., Weiss, N. H., Tull, M. T., DiLillo, D., Messman‐Moore, T. L., & Gratz, K. L. (2015) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2015.07.014 · Cited by 47 · see citing works
“Moreover, research using this cutoff within other community adult samples has provided support for its construct validity, finding higher rates of self-injury (one of the most common behaviors in BPD) among individuals classified as High versus Low BPD on this measure [68,69].”
Self-citation
Emotion regulation group skills training for adolescents and parents: A pilot study of an add-on treatment in a clinical setting
Holmqvist Larsson, K., Andersson, G., Stern, H., & Zetterqvist, M. (2020) · Clinical Child Psychology and Psychiatry · doi:10.1177/1359104519869782 · Cited by 43 · see citing works
“…shown to successfully reduce addiction, nonsuicidal self-injury, symptoms of posttraumatic stress disorder (PTSD), symptoms of borderline personality disorder (BPD) and depression and anxiety, to mention some examples (Barlow et al., 2011; Gratz & Tull, 2011; Linehan, 1993; Rathus & Miller, 2015).”
Background
A Longitudinal Examination of Posttraumatic Stress Disorder Symptoms and Risky Sexual Behavior: Evaluating Emotion Dysregulation Dimensions as Mediators
Weiss, N. H., Walsh, K., DiLillo, D., Messman‐Moore, T. L., & Gratz, K. L. (2019) · Archives of Sexual Behavior · doi:10.1007/s10508-019-1392-y · Cited by 44 · see citing works
Self-citation
The Impact of Group Emotion Regulation Interventions on Emotion Regulation Ability: A Systematic Review
Moore, R., Gillanders, D. T., & Stuart, S. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11092519 · Cited by 44 · see citing works
“Finally, in two studies, the other interventions which participants were receiving were better described, but as they had no control group, it is unknown to what extent non‐ study interventions may have impacted outcome data [34,68].”
BackgroundMethodResultInfluential
A Preliminary Pilot Study Comparing Dialectical Behavior Therapy Emotion Regulation Skills with Interpersonal Effectiveness Skills and a Control Group Treatment
Dixon–Gordon, K. L., Chapman, A. L., & Turner, B. J. (2015) · Journal of Experimental Psychopathology · doi:10.5127/jep.041714 · Cited by 41 · see citing works
“People with BPD pathology who received adjunctive skills-based group treatment targeting emotion regulation evidenced improvements in emotion regulation, BPD symptom severity and frequency of non-suicidal selfinjury (NSSI) (Gratz & Gunderson, 2006; Gratz & Tull, 2011).”
BackgroundResult
Treatment of Borderline Personality Disorder.
Levy, K. N., McMain, S. F., Bateman, A., & Clouthier, T. L. (2018) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2018.07.011 · Cited by 26 · see citing works
Development of an Intervention for Nonsuicidal Self-Injury in Young Adults: An Open Pilot Trial
Andover, M. S., Schatten, H. T., Morris, B. W., & Miller, I. W. (2014) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2014.05.003 · Cited by 38 · see citing works
“Gratz and colleagues (Gratz & Gunderson, 2006; Gratz & Tull, 2011) developed an adjunctive emotion regulation group therapy (ERGT) for women with borderline personality disorder (BPD) to reduce the frequency of NSSI.”
Background
A Preliminary Experimental Investigation of Emotion Dysregulation and Impulsivity in Risky Behaviours
Weiss, N. H., Tull, M. T., Davis, L. T., Searcy, J., Williams, I., & Gratz, K. L. (2015) · Behaviour Change · doi:10.1017/bec.2015.5 · Cited by 38 · see citing works
“ERGT has been shown to significantly reduce deliberate self-harm and other impulsive behaviours among women with borderline personality pathology (Gratz & Tull, 2011).”
BackgroundMethodSelf-citation
A Preliminary Experimental Examination of the Effect of Emotion Dysregulation and Impulsivity on Risky Behaviors Among Women With Sexual Assault–Related Posttraumatic Stress Disorder
Weiss, N. H., Tull, M. T., & Gratz, K. L. (2014) · Behavior Modification · doi:10.1177/0145445514547957 · Cited by 34 · see citing works
“…disorder; Roemer, Orsillo, & Salters-Pedneault, 2008), and approach and distraction (vs. emotionally avoidant) strategies to modulate the intensity and/or duration of emotions (ERGT; Gratz & Gunderson, 2006; Gratz & Tull, 2011; Gratz et al., 2013), may result in a reduction in risky behaviors.”
BackgroundMethodSelf-citation
Emotion dysregulation as a cross-cutting target for inpatient psychiatric intervention
Fowler, J. C., Clapp, J. D., Madan, A., Allen, J. G., Oldham, J. M., & Frueh, B. C. (2016) · Journal of Affective Disorders · doi:10.1016/j.jad.2016.07.043 · Cited by 29 · see citing works
Emotion Regulation and Self-Harm Among Forensic Psychiatric Patients
Laporte, N., Tuente, S. K., Ozolins, A., Westrin, Å., Westling, S., & Wallinius, M. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.710751 · Cited by 28 · see citing works
Does drinking to cope explain links between emotion-driven impulse control difficulties and hazardous drinking? A longitudinal test.
Watkins, L. E., Franz, M. R., DiLillo, D., Gratz, K. L., & Messman‐Moore, T. L. (2015) · Psychology of Addictive Behaviors · doi:10.1037/adb0000127 · Cited by 26 · see citing works
“These interventions may increase adaptive responses to emotional distress and decrease problematic substance use (e.g., Axelrod, Perepletchikova, Holtzman, & Sinha, 2011; Gratz & Tull, 2011).”
BackgroundSelf-citation
Feeling better or worse? The lived experience of non-suicidal self-injury among Malaysian University students
Tan, S.-C., Tam, C., & Bonn, G. (2018) · Asia Pacific Journal of Counselling and Psychotherapy · doi:10.1080/21507686.2018.1541912 · Cited by 26 · see citing works
“Emotion Regulation Group Therapy or ERGT (Gratz & Tull, 2011) is one such approach to treatment that has shown promise in reducing both emotion dysregulation and self-injury among women with bipolar disorder (Gratz, Tull, & Levy, 2014; Sahlin et al., 2017).”
Background
Evidence for a curvilinear dose-response relationship between avoidance coping and drug use problems among women who experience intimate partner violence
Weiss, N. H., Duke, A. A., & Sullivan, T. P. (2014) · Anxiety, Stress, & Coping · doi:10.1080/10615806.2014.899586 · Cited by 24 · see citing works
“Notably, although treatments that teach effective use of distraction have been found to reduce substance use (Axelrod, Perepletchikova, Holtzman, & Sinha, 2011; Gratz & Tull, 2011), few studies have examined the effects of these treatments outside the context of borderline personality pathology.”
Background
A Preliminary Investigation of the Relationship Between Emotion Dysregulation and Partner Violence Perpetration Among Individuals with PTSD and Alcohol Dependence
Watkins, L. E., Schumacher, J. A., & Coffey, S. F. (2016) · Journal of Aggression, Maltreatment & Trauma · doi:10.1080/10926771.2015.1129657 · Cited by 23 · see citing works
“Researchers have demonstrated that the DERS and its subscales have good test–retest reliability as well as construct and predictive validity (see Gratz & Roemer, 2004; Gratz & Tull, 2011).”
Background
Emotional dysregulation as a target in the treatment of co-existing substance use and borderline personality disorders: a pilot study
Hall, K., Simpson, A., O'donnell, R., Sloan, E., Staiger, P. K., Morton, J., Ryan, D., Nunn, B., Best, D., & Lubman, D. I. (2018) · Clinical Psychologist · doi:10.1111/cp.12162 · Cited by 22 · see citing works
“…with intervention studies for BPD examining acceptance-based interventions with an emotion regulation focus, which have successfully reduced self-harm, emotion dysregulation, experiential avoidance, and BPD symptomatology among women with BPD (Gratz & Gunderson, 2006; Gratz & Tull, 2011).”
Background
Taking what we have and making what we need: Utilizing Natural Helping Support Networks to decrease self directed violence among Adolescents of Color.
Ingram, L., & Drew, V. (2017) · Journal of Family Strengths · doi:10.58464/2168-670x.1336 · Cited by 20 · see citing works
Eating disorder behaviors as a form of non-suicidal self-injury
Washburn, J. J., Soto, D., Osorio, C. A., & Slesinger, N. C. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.115002 · Cited by 19 · see citing works
Personality profiles as potential targets for intervention: Identification and replication
Clark, L. A., Nuzum, H., Shapiro, J. L., Vanderbleek, E. N., Daly, E. J., Simons, A. D., & Ro, E. (2019) · Personality and Mental Health · doi:10.1002/pmh.1455 · Cited by 19 · see citing works
Shame and Psychotherapy: Theory, Method and Practice
Sinha, M. (2017) · Springer eBooks · doi:10.1007/978-3-319-53100-7_11 · Cited by 17 · see citing works
A Preliminary Examination of Negative Affect, Emotion Dysregulation, and Risky Behaviors Among Military Veterans in Residential Substance Abuse Treatment
Weiss, N. H., Williams, D. C., & Connolly, K. M. (2015) · Military Behavioral Health · doi:10.1080/21635781.2015.1038405 · Cited by 16 · see citing works
“Indeed, treatments that directly target emotion dysregulation, such as dialectical behavior therapy and emotion regulation group therapy, have been found to result in significant reductions in risky behaviors (Axelrod et al., 2011; Gratz & Tull, 2011).”
Background
The Unique Contributions of Distinct Experiential Avoidance Domains to Severity and Functionality of Non-Suicidal Self-Injury
Bentley, K. H., Sauer-Zavala, S. E., & Wilner, J. G. (2015) · Journal of Experimental Psychopathology · doi:10.5127/jep.040613 · Cited by 16 · see citing works
“EA is implicated across well-established conceptualizations and treatments of NSSI (e.g., Chapman, Gratz, & Brown, 2006; Klonsky, 2007; Gratz & Gunderson, 2006; Gratz & Tull, 2011; Linehan, 1993; Nock, 2009, 2010).”
Developing a Mobile App for Young Adults with Nonsuicidal Self-Injury: A Prototype Feedback Study
Kruzan, K. P., Reddy, M. C., Washburn, J. J., & Mohr, D. C. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192316163 · Cited by 14 · see citing works
“In the Emotion Regulation Individual Therapy for Adolescents (ERITA) program, based on a manualized treatment (Emotion Regulation Group Therapy, [31]), there was a 69% reduction in NSSI after 6 months.”
Method
The relation of protective factors to deliberate self-harm among African-American adults: moderating roles of gender and sexual orientation identity
Davis, L. T., Weiss, N. H., Tull, M. T., & Gratz, K. L. (2017) · Journal of Mental Health · doi:10.1080/09638237.2017.1340610 · Cited by 15 · see citing works
Self-citation
Associations between parental incarceration and youth mental health conditions: The mitigating effects of adolescent resilience and positive coping strategies
Bomysoad, R. N., & Francis, L. A. (2021) · Current Psychology · doi:10.1007/s12144-021-01351-0 · Cited by 16 · see citing works
Non‐suicidal Self‐injury
Brackman, E. H., & Andover, M. S. (2017) · doi:10.1002/9781118877142.ch22 · Cited by 15 · see citing works
Exposure to Violence, Posttraumatic Stress Symptoms, and Borderline Personality Pathology Among Adolescents in Residential Psychiatric Treatment: The Influence of Emotion Dysregulation
Buckholdt, K. E., Weiss, N. H., Young, J., & Gratz, K. L. (2015) · Child Psychiatry & Human Development · doi:10.1007/s10578-014-0528-5 · Cited by 14 · see citing works
Self-citation
The Interactive Effects of PTSD, Emotion Regulation, and Anger Management Strategies on Female-Perpetrated IPV
Kendra, R., Bell, K. M., & Lilly, M. M. (2014) · Violence and Victims · doi:10.1891/0886-6708.vv-d-12-00123 · Cited by 12 · see citing works
“…with PTSD, IPV perpetration, self-harm tendencies, and borderline personality disorder (Frewen, Dozois, Neufeld, & Lanius, 2012; Gratz & Gunderson, 2006; Gratz & Roemer, 2004; Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006, 2009; Gratz & Tull, 2011; Tull, Barrett, McMillan, & Roemer, 2007).”
Understanding predictors of change in a day treatment setting for non‐suicidal self‐injury
Slesinger, N. C., Hayes, N. A., & Washburn, J. J. (2020) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12295 · Cited by 12 · see citing works
Predictors of improvement in an open-trial multisite evaluation of emotion regulation group therapy
Sahlin, H., Bjureberg, J., Gratz, K. L., Tull, M. T., Hedman‐Lagerlöf, E., Bjärehed, J., Jokinen, J., Lundh, L., Hellner, C., & Ljótsson, B. (2018) · Cognitive Behaviour Therapy · doi:10.1080/16506073.2018.1509119 · Cited by 11 · see citing works
“Emotion regulation group therapy (ERGT; Gratz & Gunderson, 2006; Gratz & Tull, 2011; Gratz, Tull, & Levy, 2014b) is a brief, acceptance-based behavioural group therapy and one of several e ﬃ cacious treatments for BPD and related pathology that has been developed during the past decades (e.g.…”
BackgroundSelf-citation
Willingness and Action Measure for Adolescents: Psychometric validation in Spanish adolescents
Cobos-Sánchez, L., Flujas-Contreras, J. M., & Becerra, I. G. (2019) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2019.11.006 · Cited by 11 · see citing works
Extending Findings of a Relation between Posttraumatic Stress Disorder and Emotion Dysregulation among African American Individuals: A Preliminary Examination of the Moderating Role of Gender
Weiss, N. H. (2013) · Journal of Traumatic Stress Disorders & Treatment · doi:10.4172/2324-8947.1000116 · Cited by 11 · see citing works
“Similarly, learning emotional approach and distraction strategies (to replace emotional avoidance strategies) may help African American women with PTSD effectively modulate the intensity and/or duration of their emotions [48].”
Background
Social and Occupational Functioning in Individuals With BPD: A Systematic Review
Dhar, A., Hay, P., & Meade, T. (2023) · Journal of Personality Disorders · doi:10.1521/pedi.2023.37.6.691 · Cited by 11 · see citing works
Factor structure, measurement invariance, and psychometric properties of the brief version of difficulties in emotion regulation scale (DERS-16) across four Chinese samples
Xiong, X., Zhan, N., Zou, J., Xu, F., & Geng, F. (2025) · Personality and Individual Differences · doi:10.1016/j.paid.2025.113343 · Cited by 10 · see citing works
The role of affect regulation in the treatment of people who have committed sexual offenses
Gunst, E., Watson, J. C., Willemsen, J., & Desmet, M. (2018) · Aggression and Violent Behavior · doi:10.1016/j.avb.2018.10.008 · Cited by 10 · see citing works
“Gratz et al. (2015) conclude their review article on AR in psychological interventions with the recommendation of a more systematic and regular examination of mechanisms of change in treatments, both those that focus on emotional experience and that influence AR (e.g. EFT), and those developed specifically to target A…”
Background
It's ok that I feel like this": a qualitative study of adolescents' and parents' experiences of facilitators, mechanisms of change and outcomes in a joint emotion regulation group skills training
Holmqvist Larsson, K., Thunberg, M., Münger, A.-C., Andersson, G., Falkenström, F., & Zetterqvist, M. (2023) · BMC Psychiatry · doi:10.1186/s12888-023-05080-5 · Cited by 9 · see citing works
Hoarding Behaviors and Alcohol Use: The Mediating Role of Emotion Dysregulation
Raines, A. M., Chavarria, J., Allan, N. P., Short, N. A., & Schmidt, N. B. (2017) · Substance Use & Misuse · doi:10.1080/10826084.2017.1305414 · Cited by 9 · see citing works
“A series of studies has provided support for the utility of this intervention on both primary (e.g., emotion dysregulation) and secondary outcomes (e.g., depression and anxiety) both immediately and over time (Gratz, Tull, & Levy, 2014; Gratz & Tull, 2011).”
Background
Are Emotion Regulation Strategies Associated With Visual Attentional Breadth for Emotional Information in Youth?
Boelens, E., Beveren, M. V., Raedt, R. D., Verbeken, S., & Braet, C. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.637436 · Cited by 9 · see citing works
Avoidant Coping as a Moderator of the Association Between Childhood Abuse Types and HIV/Sexual Risk Behaviors
Weiss, N. H., Bonner, C. P., & Sullivan, T. P. (2018) · Child Maltreatment · doi:10.1177/1077559518793228 · Cited by 8 · see citing works
Self-Compassion and Emotion Dysregulation Mediate the Effect of Stress Appraisals on Elder Abuse and Neglect Behaviors in Dementia Family Caregiving
Pickering, C. E. Z., Weiss, N. H., Yıldız, M., & Sullivan, T. P. (2024) · The Journals of Gerontology Series B · doi:10.1093/geronb/gbae138 · Cited by 7 · see citing works
“These findings highlight the transdiagnostic utility of treatments aimed at ameliorating emotion dysregulation, including those for maladaptive behavior (Gratz & Tull, 2011).”
Background
Nonsuicidal Self-Injury in Children and Adolescents
Westers, N. J. (2023) · Autism and child psychopathology series · doi:10.1007/978-3-031-24926-6_50 · Cited by 7 · see citing works
Personality traits and self-harm behaviors among Chinese children and adolescents: The mediating effect of psychological resilience
Jiao, X.-Y., Xu, C., Chen, Y., Peng, Q.-L., Ran, H., Che, Y., Fang, D., Peng, J., Chen, L., Wang, S., et al. (2022) · World Journal of Psychiatry · doi:10.5498/wjp.v12.i3.494 · Cited by 7 · see citing works
The Emotional Resources Group: Provisional outcome data for a pilot six‐session emotion regulation programme for secondary care
Bacon, T., Doughty, C., Summers, A. R., Wiffen, B. D. R., Stanley, Z., & McAlpine, S. (2018) · British Journal of Clinical Psychology · doi:10.1111/bjc.12171 · Cited by 7 · see citing works
PAI-A Predictors of Treatment Response in a DBT-A-Informed Intervention for Adolescent Boys
Charles, N. E., Floyd, P. N., Bulla, B. A., Barry, C. T., & Anestis, J. C. (2021) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-021-09886-z · Cited by 6 · see citing works
Intimate Partner Violence and HIV-Risk Behaviors: Evaluating Avoidant Coping as a Moderator
Weiss, N. H., Bonner, C. P., & Sullivan, T. P. (2016) · AIDS and Behavior · doi:10.1007/s10461-016-1588-2 · Cited by 6 · see citing works
“Likewise, emotion regulation group therapy, which teaches approach and distraction strategies to replace emotionally-avoidant strategies, as well as other emotion regulation skills, is associated with reductions in deliberate self-harm and other self-destructive behaviors [64], and improvements in emotion regulation s…”
Borderline Personality Disorder
Chapman, A. L., Hope, N. H., & Turner, B. J. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108333931.041 · Cited by 6 · see citing works
Self‐Injurious Thoughts and Behaviors From Pregnancy to Postpartum: Risk Factors and Clinical Implications
Molina, N. C., Kaliush, P. R., Mendes, S. O., Pappal, A. E., Wright, K. R., Zhou, A. M., King, K. M., Conradt, E. D., & Crowell, S. E. (2025) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.70030 · Cited by 4 · see citing works
“The BSL's 11-item behavior supplement (Gratz and Tull 2011) was also included to assess aggressive and self-destructive behaviors ( α = 0.74).”
Influential
Functional Assessment of Non-suicidal Self-Injury and Eating Disorders
Andover, M. S., Holman, C. S., & Shashoua, M. Y. (2013) · Springer eBooks · doi:10.1007/978-3-642-40107-7_6 · Cited by 4 · see citing works
A preliminary trial of ACT skills training for aggressive behavior
Zarling, A. N. (2013) · doi:10.17077/etd.vevz0zh6 · Cited by 4 · see citing works
“Emotion dysregulation scores on the DERS at pre-treatment (mean = ~127) were higher than those previously reported in a sample of undergraduate students (Shorey, Cornelius, & Idema, 2011), but commensurate with those reported by Gratz and Tull (2011) in a sample of women”
A State-Wide Initiative to Improve Health System Responses to People With Borderline Personality Disorder Symptoms in Crisis: A Retrospective Audit
Bartsch, D. R., Everitt, C. M., Bednarz, J., Ludbrook, C., & Cammell, P. (2024) · Journal of Personality Disorders · doi:10.1521/pedi.2024.38.1.87 · Cited by 3 · see citing works
Experiences of change in Emotion Regulation Group Therapy. A mixed-methods study of six patients
Dahlberg, A., Wetterberg, E., Lundh, L., & Sahlin, H. (2018) · Journal for Person-Oriented Research · doi:10.17505/jpor.2018.02 · Cited by 3 · see citing works
“Treatment elements as described by Gratz and Tull (2011) are drawn from Dialectical Behaviour Therapy (DBT; Linehan, 1993) and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999).”
MethodResult
Recalling Tough Times: Exploring the Effect of Acceptance on Autobiographical Memory in Daily Life
Colombo, D., Wrzesien, M., & Baños, R. (2024) · Mindfulness · doi:10.1007/s12671-024-02301-0 · Cited by 4 · see citing works
Non-Suicidal Self-Injury
Andover, M. S., Wren, A., Schatten, H. T., Morris, B. W., Shashoua, M. Y., & Holman, C. S. (2014) · Springer eBooks · doi:10.1007/978-1-4899-7497-6_33 · Cited by 3 · see citing works
Understanding Perceptions of Nonsuicidal Self-Injury: Descriptive and Injunctive Norms
Min, J., Lopez, S. V., Dunn, D. S., Leffingwell, T. R., & Mullins‐Sweatt, S. N. (2021) · Psychiatric Quarterly · doi:10.1007/s11126-021-09933-8 · Cited by 3 · see citing works
Dialectical Behavior Therapy for Adolescents with Borderline Personality Disorder: Emotion Dysregulation, Abuse, and Treatment Outcomes
Shogren, N. P., Wilner, J. G., Porter, N., Kaplan, C., Ronzio, B., Au, J. S., & Fruzzetti, A. E. (2024) · Evidence-Based Practice in Child and Adolescent Mental Health · doi:10.1080/23794925.2024.2306625 · Cited by 3 · see citing works
“This result is encouraging, given that studies have high-lighted the positive impact that reductions in emotional dysregulation can have on impairment and distress (Chapman, 2019) and the severity of other BPD symptoms (e.g. Gratz & Tull, 2011) among adults with BPD.”
Feasibility and Efficacy of Brief DBT Intervention for Adults With Borderline Personality Disorder/Traits: A Systematic Review
Zhang, Y., Chen, S. X., Smit, M., & Chapman, A. L. (2025) · Personality and Mental Health · doi:10.1002/pmh.70034 · Cited by 2 · see citing works
“…forms of DBT treatment, such as stand-alone DBT skills training (Valentine et al. 2020), Internet-delivered DBT skills training (Vasiljevic et al. 2022; Wilks et al. 2018), and adjunctive DBT that augments standard therapy provided by community therapists (Gratz et al. 2014; Gratz and Tull 2011).”
Negative Affect and Nonsuicidal Self-Injury
Swerdlow, B. A., Pearlstein, J. G., Sandel, D. B., & Johnson, S. L. (2023) · Oxford University Press eBooks · doi:10.1093/oxfordhb/9780197611272.013.13 · Cited by 2 · see citing works
Experiences of Interpersonal Emotion Regulation for People with Heightened Emotions: An Examination in People with Bipolar Disorder and Those with High Aggression
Swerdlow, B. A., Berk, L., & Johnson, S. L. (2023) · Journal of Emotion and Psychopathology · doi:10.55913/joep.v1i1.30 · Cited by 2 · see citing works
“…and mental health (cf. Essau,LeBlanc, & Ollendick, 2017; Kring & Sloan, 2009; Rottenberg & Johnson, 2007; Gruber, 2019), and many psychological treatments focus on emotion or emotion regulation processes (e.g., Farchione et al., 2012; Gratz & Tull, 2011; Linehan, 1993; Mennin & Fresco, 2014).”
Background
Emotion regulation as a mechanism of change in psychotherapy
Dixon–Gordon, K. L., Waite, E. E., Gaines, A. N., & Constantino, M. J. (2024) · Elsevier eBooks · doi:10.1016/b978-0-323-95604-8.00008-3 · Cited by 2 · see citing works
Brief Therapeutic Approaches for Personality Disorders
Dixon–Gordon, K. L., Conkey, L. C., & Woods, S. E. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108333931.083 · Cited by 2 · see citing works
Emotion in non-suicidal self-injury: A contradiction between global self-reports and real-time responses
Robinson, K. (2021) · doi:10.26686/wgtn.16960195.v1 · Cited by 2 · see citing works
Group-based intervention for eating disorders with non-suicidal-self-injury: a case series
Vieira, A., Rodrigues, T. F., Brandão, I., Timóteo, S., Nunes, P., & Gonçalves, S. (2021) · Clinical Psychologist · doi:10.1080/13284207.2021.1892454 · Cited by 2 · see citing works
Eficacia de un programa de intervención basado en la terapia dialéctico-conductual en pacientes con trastorno límite de la personalidad
Saiz, A. D. C. G., & Bueno, A. C. (2021) · MLS Psychology Research · doi:10.33000/mlspr.v4i2.704 · Cited by 1 · see citing works
“…la predicción emocional y la resolución de problemas (Blum, Pfohl, John, Monahan & Black, 2002), la terapia de grupo de regulación de las emociones (Gratz & Tull, 2011; Gregory et al., 2008; Gross et al., 2002), la relación terapéutica orientada al motivo (Kramer, Guillory & Hancock, 2014), la…”
Background
Eine mehrdimensionale Untersuchung der Emotionsregulation im Kontext Nicht-Suizidaler Selbstverletzung im Jugendalter
Sigrist, C., Resch, F., Kaess, M., & Koenig, J. (2021) · Praxis der Kinderpsychologie und Kinderpsychiatrie · doi:10.13109/prkk.2021.70.8.699 · Cited by 1 · see citing works
The intermediate role of substance use indices in relation between trait impulsivity and emotional dysregulation with state impulsivity in chronic methamphetamine users
Jebraeili, H., Moradi, A., & Habibi, M. (2020) · Armaghane Danesh · doi:10.52547/armaghanj.25.2.240 · Cited by 1 · see citing works
Nonsuicidal self-injury and emotion regulation : clinical correlates and novel treatments
Bjureberg, J. (2018) · Figshare · Cited by 1 · see citing works
Non-suicidal self-Injury and mindfully coping with anxiety
Walker, G. (2013)
Untangling the Impact of Social Context on Non-suicidal Self-injury
Turner, B. J. (2014) · Summit (Simon Fraser University)
Reciprocal risk: The longitudinal relationship between emotion regulation and non-suicidal self-injury
Robinson, K. (2017) · doi:10.26686/wgtn.17065211

Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder
Gratz, K. L., Tull, M. T., & Levy, R. (2014) · Psychological Medicine · doi:10.1017/s0033291713002134 · Cited by 194 · see citing works
Self-citation
Emotion Regulation as a Mechanism of Change in an Acceptance-Based Emotion Regulation Group Therapy for Deliberate Self-Harm Among Women With Borderline Personality Pathology
Gratz, K. L., Levy, R., & Tull, M. T. (2012) · Journal of Cognitive Psychotherapy · doi:10.1891/0889-8391.26.4.365 · Cited by 69 · see citing works
Self-citation
Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder
Gratz, K. L., Bardeen, J. R., Levy, R., Dixon–Gordon, K. L., & Tull, M. T. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.12.005 · Cited by 102 · see citing works
Self-citation
Emotion regulation group therapy for deliberate self-harm: A multi-site evaluation in routine care using an uncontrolled open trial design
Sahlin, H., Bjureberg, J., Gratz, K. L., Tull, M. T., Hedman, E., Bjärehed, J., Jokinen, J., Lundh, L.-G., Ljótsson, B., & Hellner, C. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-016220 · Cited by 50 · see citing works
Self-citation
Preliminary Data on an Acceptance-Based Emotion Regulation Group Intervention for Deliberate Self-Harm Among Women With Borderline Personality Disorder
Gratz, K. L., & Gunderson, J. G. (2006) · Behavior Therapy · doi:10.1016/j.beth.2005.03.002 · Cited by 618 · see citing works
Self-citation

Authors: Gratz, K. L., & Tull, M. T.
Affiliations: University of Mississippi Medical Center (US)
ORCID: Gratz, Kim L.
Tull, Matthew T.
Venue: Personality Disorders: Theory, Research, and Treatment
Publisher: American Psychological Association (APA)
Published: 2011-10
Volume: 2
Issue: 4
Pages: 316-326
ISSN: 1949-2715 (ISSN-L)
1949-2723
DOI: 10.1037/a0022144
OpenAlex: W2139419707
Cited by: 115
References: 32
Citations by year: 2026: 3 · 2025: 4 · 2024: 5 · 2023: 6 · 2022: 4 · 2021: 11 · 2020: 5 · 2019: 7 · 2018: 13 · 2017: 14 · 2016: 5 · 2015: 11 · 2014: 13 · 2013: 8 · 2012: 6
FWCI: 9.30
Type: journal article
Language: en
Open access: closed
Locations: Personality Disorders Theory Research and Treatment (publishedVersion)
PubMed (publishedVersion)
Funders: National Institute of Mental Health (R34 MH079248)
Topics: Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords: self-harm, borderline personality disorder, adjunctive therapy, emotional dysregulation, experiential avoidance, women, self-destructive behavior, psychiatric symptoms, adaptive behavior, quality of life, mechanisms of change
MeSH terms: Adaptation, Psychological, Adolescent, Adult, Analysis of Variance, Borderline Personality Disorder, Emotions, Female, Humans, Interview, Psychological, Medically Underserved Area, Middle Aged, Mississippi, Pilot Projects, Poverty, Psychiatric Status Rating Scales, Psychotherapy, Group, Quality of Life, Randomized Controlled Trials as Topic, Self-Injurious Behavior, Treatment Outcome, Patient Satisfaction, Young Adult, Intention to Treat Analysis, Self Report

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Extending research on the utility of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality pathology.

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