Emotion regulation therapy

1. Introduction

Version followed: the manualised 16-session individual ERT for generalised anxiety disorder with or without co-occurring depression ("distress disorders") as described by Renna, Quintero, Fresco & Mennin (2017). Concrete client-facing material is filled in from the University of Michigan ERT-V patient website (a 10-session adaptation), and short-format detail comes from the 8-session AR-ERT trial protocol (Jacoby, MGH). The earlier 20-session version (Mennin et al. 2015, 2018) and the Mennin & Fresco handbook chapter are not drawn on [uncertain].

Emotion regulation therapy (ERT) was developed by Douglas Mennin and David Fresco. It is a mechanism-targeted, integrative CBT that combines skills training and exposure with ideas from acceptance, mindfulness, emotion-focused therapy and basic affective science [source: Renna et al. 2017]. It was built for people with chronic, high distress, which it understands like this:

They are temperamentally very sensitive to two motivational systems: threat and safety ("security") and reward and loss.
They respond to the resulting emotions with self-referential, reactive responses: worry, rumination and self-criticism, plus behavioural reactions such as avoidance, reassurance-seeking and emotional eating or drinking.
These responses bring short-term relief, keep distress going and narrow learning about what the context actually offers [source: Renna et al. 2017; ERT-V "Emotional Responding"].

ERT holds that change comes through three regulatory capacities: attention regulation (orienting, allowing), metacognitive regulation (decentering or distancing, reframing) and a rebalanced motivation. Together these move the client from reactive to counteractive to proactive responding. In Phase II, experiential exposure to actions that are rewarding but anxiety-provoking builds new meanings and broader responses. Fear reduction alone is not the goal [source: Renna et al. 2017].

2. Framework

Format. ERT is delivered individually, in weekly sessions. The current manual has 16 sessions; an earlier version had 20 [source: Renna et al. 2017]. Session length is not stated in the Frontiers paper; the 8-session AR-ERT protocol uses 60-minute sessions [source: Jacoby AR-ERT protocol]. Other versions exist:

an 8-session ERT that was being tested for dosing and access [source: Renna et al. 2017; Jacoby protocol];
ERT-V, a 10-session programme with a client app, run alongside low-vision rehabilitation (Phase I = sessions 1–6, Phase II = sessions 7–10) [source: ERT-V site];
AR-ERT, 8 sessions limited to the attention module [source: Jacoby protocol].

The source trials used doctoral-level clinicians trained and supervised by the developers, with adherence and skilfulness ratings [source: Renna et al. 2017].

Assessment and ongoing monitoring. There is no single assessment instrument. The therapist keeps a running clinical impression of four things: emotional intensity, a narrowed focus on security, reactive responding, and reduced pursuit of reward. Before every session the client completes a short self-report battery covering worry, rumination, anxiety, depression, attention regulation, decentering and reappraisal [source: Renna et al. 2017]. The specific measures used are not listed here; choose validated measures you are licensed to use [synthesis].

Phase I: mindful emotion regulation skills (the first half; in the 16-session manual roughly sessions 1–8) [uncertain: the Frontiers paper does not give the session split; the "first half" split is inferred from the 20-session RCT descriptions, which are not drawn on].

Goals: (a) psychoeducation on emotions, security and reward motivations, and reactive responding; (b) cue detection using Catch Yourself Reacting monitoring; (c) four regulatory skills taught in order: Orienting, Allowing, Decentering/Distancing, Reframing (with self-compassion built in); (d) taking counteraction. Phase I ends with the ERT Toolbox [source: Renna et al. 2017].
Typical order, from the ERT-V version: model → motivations → orienting → allowing → distancing → reframing and Toolbox [source: ERT-V site]. In AR-ERT, orienting runs in sessions 1–4 and allowing in sessions 5–8 [source: Jacoby protocol].

Phase II: experiential exposure and proactive engagement (the second half, ending with termination in sessions 14–16).

Goals: identify values; run imaginal proaction exposures ("Do It"); hold conflict dialogues (chairwork); plan and carry out between-session proactions logged on See Yourself Acting forms. In sessions 14–16 the focus is termination: independence, goal-setting, Toolbox review, naming personal change, planning for intense emotions, rumination and mood swings, and exposure to hypothetical future stressors [source: Renna et al. 2017].

Criteria for moving between phases. The sources describe a fixed manualised sequence, not formal mastery criteria [source: Renna et al. 2017]. Use the following practical readiness checks [synthesis]:

the client completes CYR forms most weeks and can name the trigger, emotion, security and reward pulls, and reactive response;
they practise recorded skills on most days and can use at least one on-the-spot version;
they can state a counteraction for a recent episode.

If these are absent, use one or two extra Phase I sessions, or carry skill practice into Phase II. Do not delay exposure indefinitely [synthesis].

3. Guiding principles

[source: Renna et al. 2017 unless marked; one-line meanings are synthesis]

Emotions are motivational information. Treat each emotion as a signal of a pull toward security or toward reward, not as a symptom to remove. Ask what the emotion is pulling toward.
Both systems are always present. A strong security pull does not mean the reward pull is absent. Always look for the reward side.
Target reactive self-referential processing. Worry, rumination and self-criticism are the problem. Name them as attempts to manage emotion, not as facts about the world.
Guilt and shame often sit on top of anxiety and sadness. When the client reports guilt or shame, look for the underlying fear or loss.
Mechanism-targeted. Each skill is aimed at a specific deficit (attention, metacognition, motivation). Choose and coach skills by the deficit you see.
Reactive → counteractive → proactive. The arc of therapy is moving from noticing reactions, to choosing opposite actions, to living by values in advance. Frame every intervention within this arc.
Coach, don't direct. The therapist helps the client notice their own pulls with an open stance. Ask more than you tell; let the client find the counteraction.
Engage reward, not just fear, in exposure. During imagery, actively amplify the anticipated reward and meaning, not only habituation.
New meaning over fear reduction (inhibitory learning). Exposure aims to broaden responses and build new meanings. Measure success by approach and flexibility, not by low anxiety.
Off-line plus on-the-spot practice. Every skill has a daily recorded meditation and a brief in-the-moment version. Assign both and check both.
Start each session from lived material. Open with a poignant CYR; skills are taught on the client's real episodes.
Compassion is built into change. Reframes must validate pain and offer self-compassion, not argue it away.
Values steer exposure. Phase II targets domains with the largest gap between importance and lived consistency.
Graded, collaborative steps. If an imagined proaction is too intense, pick a smaller step [source: Renna et al. 2017].
Integrative but formulation-led. CBT, functional analysis and emotion-focused methods are used inside an ERT case formulation, not as a menu.
Toward independence. Termination builds "knowing ERT by heart" [source: ERT-V site]: the client should be able to run the Toolbox without the therapist.

4. Intervention inventory

The source of each item is given after its heading. Example language is illustrative (my wording) unless it is quoted and cited. The developers' recorded meditation scripts, forms and handouts were not available; the steps below paraphrase what the sources describe, and procedural detail beyond that is marked [synthesis].

4.1 Psychoeducation: normal versus disordered emotional responding

[source: Renna et al. 2017; ERT-V "Emotional Responding" article]

Purpose and when to use: Session 1 (and revisited as needed). It builds a shared model and gives a rationale for the skills.
Steps:
1. Ask for two recent episodes: one where an emotion helped and one where it got stuck.
2. Contrast healthy functioning with chronic anxiety and recurring depression, using the client's own examples. In healthy functioning, an emotion arises, you look for its cause, you respond, and it passes. In the chronic pattern, emotion becomes prolonged anxiety or low mood.
3. Describe the functions: anxiety signals that something important is at stake in the future and prompts action; sadness marks a loss or an unreachable goal and helps you disengage.
4. Introduce reactive responding: worry, rumination, self-criticism, reassurance-seeking, avoidance and withdrawal, and compulsive or self-destructive behaviour (for example over- or under-eating, drinking, smoking, drugs).
5. Draw the cycle: trigger and motivational pulls → reactive responding → consequences → more reactivity. The ERT-V material uses a snowball that picks up dirt and ice as it rolls; it calls this "a dirty and icy snowball" [source: ERT-V].
6. Map the client's episodes onto the cycle and name the four target areas: motivation, attention, metacognition and behavioural consequences [source: ERT-V].
Example language (illustrative): "Worry feels like it's protecting you. Let's look at what it actually did last Tuesday: what it gave you in the first ten minutes, and what it cost you by evening."
Watch for: Clients hearing this as "your emotions are the problem". Stress that emotions are useful and that the reactions layered on top are the target. It is working when the client spontaneously labels a response as "reacting".

4.2 Motivational psychoeducation: security and reward pulls

[source: Renna et al. 2017; ERT-V "Emotions Signal Motivations" article and "Your Motivational Anchors" exercise]

Purpose and when to use: Sessions 1–2. It turns emotions into readable motivational messages and sets up later counteraction and values work.
Steps:
1. Explain the two systems:
  - Security is the survival system. It protects against real danger and pulls toward escape, avoidance or inaction.
  - Reward is about thriving rather than surviving. It pulls toward approach, novelty, accomplishment and connection.
2. Stress that pulls are strong but not deterministic. Both can be active at once (a tug-of-war), and each has trade-offs. Reward risks failure or rejection; security offers protection but costs opportunity and enjoyment.
3. Use the orchestra image from ERT-V: each emotion is an instrument, intense emotions drown out the others, and the aim is to hear the whole piece [source: ERT-V].
4. Take a recent distressing moment and list every possible pull. Then ask how different combinations would lead to different thoughts and actions. This is the purpose of the Motivational Anchors exercise; its 10 items are not drawn on [uncertain].
5. Ask the client to write down security and reward pulls during difficult moments between sessions.
Example language (illustrative): "Part of you wanted to cancel. That's the security pull. Was there any part, even quiet, that wanted to go?"
Watch for: Clients who can only find security pulls, often in depression. Keep asking about what has been lost, because loss signals a reward that matters. It is working when the client names both pulls unprompted.

4.3 Catch Yourself Reacting (CYR) self-monitoring

[source: Renna et al. 2017; ERT-V CYR form]

Purpose and when to use: From session 1 throughout. It trains cue detection and gives material for every session. Later it tracks skill use and counteraction.
Steps:
1. Assign CYR several times a week, completed when an intense emotion arises (ERT-V asks for 2–3 times a week).
2. Fields, as described in the sources (paraphrased):
  - trigger: external or internal, including bodily sensations and behaviours;
  - time since the trigger;
  - emotions felt;
  - motivational pulls;
  - reactive thoughts (worry, rumination, self-criticism, distraction, numbing);
  - reactive behaviours and consequences (avoidance, reassurance-seeking, compulsions, emotional eating or drinking, substance use).
3. As skills are taught, add two columns: the skill used, and the counteractive response that could have been used [source: Renna et al. 2017].
4. Open each session by reviewing one poignant CYR.
Example language (illustrative): "Pick the one form from this week that still has some heat in it. Walk me through it from the trigger."
Watch for: Forms filled in from memory at the end of the week. Encourage logging close to the event. The ERT-V form records time since trigger, which you can use to see whether that is happening. It is working when triggers are caught earlier and the reactive columns thin out.

4.4 Session-opening CYR review

[source: Renna et al. 2017; procedure synthesis]

Purpose and when to use: At the start of every session. It links the week's events to the model and to the current skill.
Steps [synthesis]:
1. Choose one CYR with the client.
2. Slow down the moment of the trigger.
3. Identify emotions, then pulls, then reactive responses, then consequences.
4. Ask where the current skill could have entered.
5. Generate one counteraction.
6. Link to today's agenda.
Example language (illustrative): "Where in this sequence was the earliest moment you could have noticed you were starting to react?"
Watch for: The review sliding into problem-solving the content. Keep it at the level of process.

4.5 Do-Over

[source: Renna et al. 2017; AR-ERT imaginal rehearsal of past situations, Jacoby protocol]

Purpose and when to use: When a CYR wasn't done, or when an episode "didn't go as planned". It recreates the emotional moment in session so it can be monitored and the skills applied live.
Steps:
1. Pick a recent episode.
2. Have the client close their eyes or lower their gaze and vividly re-imagine it in the present tense, including the setting, the body and what the other people say.
3. Pause at the peak and complete a CYR in the room.
4. Re-run the scene, this time catching the cue earlier and applying the current skill (orienting, allowing, distancing or reframing).
5. Debrief what changed. The AR-ERT protocol describes the same sequence: re-imagining past situations, then exploring earlier cue detection and skill use [source: Jacoby protocol].
Example language (illustrative): "Let's go back to Thursday night. You're at the kitchen table, the phone has just buzzed. What do you notice in your body right now?"
Watch for: The client narrating rather than re-experiencing. Use present tense and sensory prompts. Temporary distress is expected; monitor tolerability [source: Jacoby protocol].

4.6 Orienting (attention regulation skill 1)

[source: Renna et al. 2017; ERT-V session 3; Jacoby protocol]

Purpose and when to use: Taught in early Phase I. It builds flexible shifting of attention and reliable tracking of visceral and emotional experience, and it counters the narrowing of attention under distress.
Steps:
1. In session, lead a guided meditation that attends to the breath and the body and notices tension versus relaxation. In AR-ERT it is "mindfulness of the breath" for flexibly shifting attention [source: Jacoby]. ERT-V describes orienting as focusing and broadening attention [source: ERT-V].
2. Record the meditation for the client. In the source trials therapists recorded the meditations themselves.
3. Assign daily practice at a set time ("off-line" practice). ERT-V asks for the skill exercise 2–3 times per week [source: ERT-V].
4. Teach a brief on-the-spot version for stressful moments. The paper says each skill has one but does not detail orienting's, so the following is [synthesis]: three slow breaths, noticing where tension sits, then widening attention to the room.
5. Debrief: what pulled attention away, and how the client returned.
Example language (illustrative): "Let your attention rest on the breath. When it wanders — and it will — notice where it went, and bring it back. The returning is the exercise."
Watch for: Using the skill to relax away emotion. Orienting is for awareness, not suppression. It is working when the client notices body cues of emotion earlier on CYR forms.

4.7 Allowing (attention regulation skill 2)

[source: Renna et al. 2017; ERT-V session 4; Jacoby protocol]

Purpose and when to use: Taught after orienting. It sustains attention on all of one's experience, including the upsetting parts, and welcomes intense emotion rather than suppressing it.
Steps:
1. In a guided meditation, move from an anchor to open attention without an anchor such as breath or sound, letting thoughts and emotions come and go. AR-ERT calls this "mindfulness of thoughts and emotions" [source: Jacoby].
2. Invite the client to turn toward a mildly difficult emotion and stay with its sensations.
3. Record the meditation and assign daily practice.
4. Teach the on-the-spot version: telling oneself to pause or allow when an emotion surges [source: Renna et al. 2017].
Example language (illustrative): "See if you can make a little room for this feeling, as if you're saying to it: you can be here for now."
Watch for: White-knuckling, where the client endures instead of opening. Ask about the quality of attention as well as how long they managed. It is working when emotions are reported as rising and passing, with less worry or rumination recruited.

4.8 Decentering / Distancing (metacognitive regulation skill 3)

[source: Renna et al. 2017; ERT-V session 5]

Purpose and when to use: Taught after the attention skills. It creates perspective so the client can see clearly instead of reacting, and it directly targets worry and rumination.
Steps:
1. Teach two forms of distance:
  - temporal: viewing the current state as temporary and passing;
  - spatial: viewing thoughts, feelings and sensations as objects separate from oneself.
2. Lead a recorded meditation that practises observing thoughts as passing events; daily practice (ERT-V: at least 3 times a week).
3. Teach an on-the-spot version [synthesis for exact form]: "This is a worry-state; it will shift", or picturing the thought from across the room.
4. Apply it to the session's CYR episode.
Example language (illustrative): "Imagine stepping back a few feet and watching this worry as it happens to you. How big is it from there? Will it be this size next week?"
Watch for: Distancing used as avoidance or dismissal ("it doesn't matter"). The aim is clarity, not detachment from caring. It is working when the client describes a state as "a state".

4.9 Reframing (metacognitive regulation skill 4)

[source: Renna et al. 2017; ERT-V session 6 "Courageous & Compassionate Reframing"]

Purpose and when to use: The last Phase I skill. Reframing is cognitive reappraisal that validates emotional pain and offers compassion, and it builds self-compassion directly.
Steps:
1. Take a difficult situation from the CYR.
2. Name the initial negative conclusion.
3. Validate the pain and the motivation behind it.
4. Generate "courageous and compassionate self-statements" [source: Renna et al. 2017]. A common route is to imagine compassion from someone who cares and then turn it inward.
5. Refine the statement until it feels both true and kind.
6. Have the client carry it as a cue. In the case example the reframe went on a business card.
7. Practise via a recorded exercise (ERT-V: at least 3 times a week).
Example language (illustrative): "If your closest friend were in your shoes right now, what would you want them to hear from you? Can you say that to yourself?"
Watch for: Reframes that dispute or minimise the feeling, or upbeat statements the client doesn't believe. They must hold both the pain and the courage. It is working when self-criticism after an emotional episode decreases.

4.10 Taking counteraction

[source: Renna et al. 2017; ERT-V "Being Counteractive"]

Purpose and when to use: Late Phase I. It shifts from noticing to choosing differently when security pulls are strong, reward pulls weak, loss is present or both pulls are distressing. The authors relate it to opposite action and to outside-in behavioural activation.
Steps:
1. Identify the current dominant pull and the reactive action it urges.
2. Imagine acting in the opposite direction.
3. Sense what that configuration feels like in the body, including the rise in the security pull and any glimmer of reward.
4. Use orienting, allowing, distancing and reframing to tolerate the imagined action.
5. Pick a small real counteraction for the week and log it in the CYR counteraction column.
Example language (illustrative): "The pull is to stay home and rehearse the conversation. What would the opposite look like, just as an image? Notice what your body does as you picture it."
Watch for: Counteractions chosen to please the therapist. Check that the action is meaningful to the client. It is working when the CYR counteraction column starts to be filled with actions the client has actually taken.

4.11 Recorded meditations and the off-line / on-the-spot practice structure

[source: Renna et al. 2017; ERT-V skills-practice pages]

Purpose and when to use: Throughout. It carries each skill from the session into daily life.
Steps:
1. Record each guided meditation in session or soon after.
2. Agree a fixed daily time for formal practice.
3. Pair it with the skill's brief on-the-spot version.
4. As skills accumulate, keep the earlier ones as optional practice (as ERT-V does).
5. Review practice at each session alongside the CYR.
Watch for: Practice at times of acute distress only. Formal practice should happen at calm times so the skill is available under stress [synthesis].

4.12 ERT Toolbox

[source: Renna et al. 2017; ERT-V "ERT Skills Toolbox"]

Purpose and when to use: The end of Phase I and again in termination. It consolidates the four skills into one portable plan.
Steps:
1. Create a one-page summary with the client [synthesis on layout]: their typical triggers and pulls; their main reactive responses; the four skills, each with its off-line and on-the-spot form; their best reframe; one or two go-to counteractions.
2. Rehearse choosing a tool for a recent CYR.
Example language (illustrative): "When you notice the snowball starting, which tool do you reach for first?"

4.13 Values identification

[source: Renna et al. 2017; ERT-V session 7 "Identifying What You Value"]

Purpose and when to use: At the start of Phase II. It selects the life domains where proactive exposure will be done.
Steps:
1. List life domains, such as family, intimate relationships, friendships, work or career, community, and self-care.
2. The client rates each domain twice on 0–10 scales: how important it is, and how consistently they are currently living by it.
3. Identify the domains with the largest gap between importance and consistency.
4. Choose one or two of those domains for Phase II work.
5. In each chosen domain, describe what the client wants to be like, not only what they want to achieve.
Example language (illustrative): "Career is a 9 for importance and a 3 for how you're living it. That gap is where we'll spend our exposure time."
Watch for: Values that are really security goals in disguise (for example "never upset anyone"). Probe for what the reward is. It is working when the client can name a concrete action in the chosen domain.

4.14 "Stranded on a desert island" values exercise (optional)

[source: ERT-V session 7 listing only; content not drawn on — uncertain]

Purpose and when to use: An optional ERT-V exercise to help a client who finds values ratings abstract. It explores what matters most and imagines living in line with it.
Steps: The exact procedure was not seen [uncertain]. A cautious version [synthesis]: ask the client to imagine being cut off from ordinary demands, then notice whom and what they would miss, and what they would want to be doing. Translate the answers into the values domains used in 4.13.
Watch for: Do not present this as part of the core 16-session manual. The Frontiers paper does not mention it.

4.15 Imaginal proaction exposure ("Do It")

[source: Renna et al. 2017; Jacoby protocol (proactive imaginal rehearsal)]

Purpose and when to use: Phase II, most sessions. It is experiential exposure to a valued action that is rewarding but anxiety-provoking. The aim is to tolerate the security pull, strengthen the reward pull and build new meaning.
Steps:
1. Choose a proaction from a values domain.
2. Obtain consent and rate expected intensity. If it is too intense, choose a smaller step.
3. Begin with the client imagining a safe space where there is little need for security.
4. Guide step-by-step imagery of the proaction, moment by moment. In the case example, the steps were logging on, finding deadlines and registering for an exam.
5. At each step, ask the client to notice the security pull and to apply allowing, distancing or reframing.
6. Actively boost the reward side: what it would mean, what it would open up, how it would feel to have done it.
7. Include imagined difficulties and feared outcomes as well as success [source: Jacoby protocol].
8. Debrief: which pulls were present, what changed, and what new meaning emerged.
Example language (illustrative): "You're clicking 'register'. Notice the tightening — there's the security pull. Stay with it… and now notice what else is here. What does it mean to you to be the person who clicked that button?"
Safety and contraindications [synthesis plus source]: Temporary distress is expected [source: Jacoby]. Do not begin before Phase I skills are available. Screen first for active suicidality, psychosis or mania, and for trauma memories that the scene might trigger; trauma memories may need a trauma-focused protocol instead. The AR-ERT trial excluded active suicidal ideation, psychotic and bipolar disorder, and interfering substance use [source: Jacoby]. Agree a stop signal in advance.
Watch for: A focus on fear alone, which loses ERT's distinctive emphasis on reward. Watch also for imagery that skips the hard moments. It is working when the client is willing to schedule the real action and reports meaning, not just reduced anxiety.

4.16 Conflict dialogue (two-chair work)

[source: Renna et al. 2017]

Purpose and when to use: Phase II, when a proaction stalls because of internal conflict. Two themes are described:
- motivational conflict, where the security side blocks the reward side;
- self-critical reactions to one's own emotions. The dialogue builds tolerance for conflict and generates new meaning about obstacles.
Steps:
1. Set up two chairs: one for the security (or critical) side and one for the proactive (or experiencing) side.
2. The client voices the security side in its chair, giving its concerns and what it protects.
3. The client switches chairs and answers from the proactive side, speaking from the value and the reward.
4. Alternate, with the therapist coaching each side to be specific and felt rather than abstract.
5. Work toward a compromise the two sides can accept that allows the action.
6. Debrief and turn the compromise into a proaction. The detailed coaching moves are adapted from emotion-focused two-chair practice and are not fully specified in the ERT sources [uncertain].
Example language (illustrative): "From this chair, tell the other side what you're afraid will happen if it registers." Then: "Switch. What do you want it to know about why this matters?"
Watch for: Intellectualised exchanges (prompt for feeling and the body), and one side collapsing too fast (slow down and ask the security side whether it is really satisfied). It is working when the sides soften and a specific compromise action appears.

4.17 Between-session proactions and the See Yourself Acting (SYA) form

[source: Renna et al. 2017; ERT-V session 7–8 SYA preparation and debrief pages]

Purpose and when to use: At the end of every Phase II session. It moves exposure into real life.
Steps:
1. Together, choose one action aligned with a value. If the imagined version was too intense, choose a smaller step. In the case example, buying a prep book was the smaller step alongside registering, and a self-care activity was added.
2. Part 1 of the SYA form, completed in session:
  - anticipated emotions;
  - likely reactive responses;
  - expected security and reward levels;
  - obstacles and how to troubleshoot them.
3. Part 2, completed after the action:
  - what happened;
  - the emotions and reactions that came up;
  - the security and reward levels actually experienced.
4. Review the form at the start of the next session. Compare what was predicted with what was experienced, then plan the next proaction.
Example language (illustrative): "Before you go, let's predict: how loud will the security pull be, 0–10? And the reward? We'll check those against what actually happens."
Watch for: Proactions that are really safety behaviours, for example going but over-preparing. Check that predicted and actual ratings are recorded, because the mismatch is where new learning happens [synthesis, consistent with the inhibitory learning rationale].

4.18 In vivo proactive exercises

[source: Jacoby AR-ERT protocol]

Purpose and when to use: In AR-ERT these are added in later sessions. The client approaches, in session or in real life, situations that usually trigger repetitive negative thinking.
Steps:
1. Choose a trigger situation that can be done in or near the session (for example sending a delayed email, or making a call).
2. Prepare using a proactive skill.
3. Do it.
4. Debrief pulls and skill use. Steps beyond the protocol's one-line description are [synthesis].
Watch for: The same consent and safety points as 4.15.

4.19 Pre-session self-report and running clinical impressions

[source: Renna et al. 2017]

Purpose and when to use: Every session. It tracks the targeted mechanisms as well as symptoms.
Steps:
1. Before each session the client completes brief measures of worry, rumination, anxiety, depression, attention regulation, decentering and reappraisal.
2. The therapist notes emotional intensity, narrowing toward security, reactivity and reward pursuit.
3. Use changes to choose emphasis. For example, high rumination with low decentering suggests revisiting distancing [synthesis].
Watch for: Rising scores during exposure phases. These can be expected, so interpret them alongside approach behaviour [synthesis].

4.20 Termination: knowing ERT by heart

[source: Renna et al. 2017; ERT-V sessions 9–10]

Purpose and when to use: Final sessions (14–16 in the 16-session manual). It consolidates independence.
Steps:
1. Review the Toolbox.
2. The client names in their own words the changes they have made.
3. Set goals for after therapy.
4. Make specific plans for intense emotions, rumination and mood swings.
5. Continue experiential exposure to hypothetical future stressors, imagining a likely future setback and rehearsing the skills and a proactive response.
6. Review recent proactions and plan new ones.
7. Process the ending and celebrate progress [source: ERT-V].
Example language (illustrative): "Imagine it's a hard week next spring and the old worry starts rolling. Walk me through what you do, step by step, without me there."
Watch for: Anxiety about ending showing up as new crises. Name it, and treat ending itself as a proaction.

5. Handling problems

The ERT sources say little about problem management. Responses from a source are tagged; everything else is [synthesis].

CYR forms not completed. Run a Do-Over in session and complete the CYR there [source: Renna et al. 2017]. Then [synthesis]:
- shorten the form to trigger, emotion, pull and reaction;
- allow phone notes or the app-style version;
- link logging to an existing daily routine;
- ask what got in the way. Avoiding the form is often itself security-driven, so treat it as a CYR episode.
Daily meditation practice not done. [synthesis] Negotiate a shorter recording and a fixed time. Check whether the client is trying to practise only when distressed. Ask what the practice feels like: for some anxious clients, attention to the body raises anxiety at first. In that case start with orienting to sound or external anchors, and frame the anxiety as material for allowing.
Worry or rumination taking over the session. [synthesis] Name the process gently ("we may be in the snowball right now"). Pause for a one-minute on-the-spot orienting or distancing practice, then return to the specific CYR moment. Avoid arguing about the content of the worry.
Client can only see security pulls; reward feels absent (often in depression). [synthesis, grounded in Renna et al. 2017's principle that both systems are present] Ask about losses and what used to matter, since loss points to reward. Use small proactions (self-care was one of the case example's proactions). Amplify any reward cue during imagery.
Overwhelm during allowing or imaginal exposure. [synthesis plus source] Temporary distress is expected; monitor tolerability [source: Jacoby protocol]. Then:
- return to the safe-space image or to orienting with an external anchor;
- lower the step, since a smaller proaction is the manual's own response to excessive intensity [source: Renna et al. 2017];
- shorten the exposure, ground the client before they leave, and review in the next session. If dissociation, panic or trauma flashbacks appear, stop the exposure and reassess the formulation; trauma-focused treatment may be needed.
Proaction not done (non-adherence in Phase II). [synthesis] Review SYA Part 1 predictions, and use a Do-Over of the moment the client decided not to act. Run a conflict dialogue on the security part that won. Re-grade to a smaller step. Never shame: self-criticism about non-completion is itself a target for reframing.
Self-criticism hijacking the work ("I'm failing at therapy too"). [synthesis, consistent with Renna et al. 2017's self-critical conflict theme] Treat it as reactive responding. Do reframing with compassion, or a two-chair dialogue between the critical side and the experiencing side.
Distancing or allowing used as avoidance. [synthesis] If the client uses skills to "not feel" or to stay detached from what matters, return to the motivational framing: skills exist to make room for emotion so it can guide action.
Reassurance-seeking from the therapist. [synthesis; reassurance-seeking is named as a reactive response in ERT-V] Notice it collaboratively as a security pull in the room, and invite an allowing practice instead of giving the reassurance.
Ruptures (client feels pushed, or that the therapist is "too positive"). [synthesis] Return to the coaching stance from the sources. Acknowledge that you may have pushed the reward side too fast. Explicitly validate the security side as protective, and re-negotiate the pace. A conflict dialogue can include the therapy relationship if useful.
Guilt or shame dominating. Look for the underlying anxiety and sadness [source: Renna et al. 2017]. Ask what fear or loss sits beneath the guilt, and work at that level.
Values that conflict with obligations (for example caregiving). [synthesis] Map both as values, and pick a proaction that honours both. The Frontiers case client had caregiving strain, and a self-care proaction was added [source: Renna et al. 2017].
Risk, including suicidal ideation. [synthesis plus source] The AR-ERT trial asked about suicidality at every visit and excluded active ideation [source: Jacoby]. In practice:
- assess risk at intake and whenever hopelessness rises, using standard structured risk assessment;
- build a collaborative safety plan, with lethal-means counselling covering safe storage and removal;
- pause exposure work until the client is stable.
Comorbid substance misuse or compulsive behaviours. [synthesis] These appear on the CYR as reactive behaviours. Treat urges as motivational pulls to monitor. Where use is moderate to severe, coordinate specialist care; the AR-ERT trial excluded interfering substance use [source: Jacoby].
Session count running out. [synthesis] Keep the termination sessions. Shorten Phase I by assigning more skill practice as homework rather than cutting Phase II, because exposure is ERT's change engine. Short-format versions of 8 or 10 sessions exist (ERT-V; AR-ERT) and show how the content can be compressed.

Sources

Sources:

Further reading (not drawn on) [uncertain]:

Mennin, D. S., & Fresco, D. M. Emotion regulation therapy. In J. J. Gross (Ed.), Handbook of Emotion Regulation (2nd ed.), 2014. Guilford.
Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Ritter, M. (2013). Emotion regulation therapy for generalized anxiety disorder. Cognitive and Behavioral Practice, 20, 282–300.
Mennin, D. S., Fresco, D. M., Ritter, M., & Heimberg, R. G. (2015). An open trial of emotion regulation therapy for generalized anxiety disorder and co-occurring depression. Depression and Anxiety.
Mennin, D. S., Fresco, D. M., Heimberg, R. G., & O'Toole, M. S. (2018). A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression. Journal of Consulting and Clinical Psychology, 86, 268–281.
Job key source PMC5841545: not drawn on.

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