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The Affect Regulation Training (ART): a transdiagnostic approach
to the prevention and treatment of mental disorders
Matthias Berking and Christian A Lukas
Deficits in emotion regulation skills likely contribute to the
development and maintenance of various mental health
problems. Thus, we developed the Affect Regulation Training
(ART) as a transdiagnostic intervention that can be used to
enhance such skills whenever a focus on emotion-regulation
appears promising in preventing or treating mental health
problems. In the present article we introduce the readers to the
theoretical background, the aim and scope, and the procedure
constituting ART. We will also present some research on the
treatment’s efficacy as well as perspectives for future treatment
development and research.
Address
University of Erlangen-Nuremberg, Germany
Corresponding author: Berking, Matthias (matthias.berking@fau.de)
Current Opinion in Psychology 2015, 3:64–69
This review comes from a themed issue on Emotion regulation
Edited by Amelia Aldao and Matthew T Tull
For a complete overview see the Issue and the Editorial
Available online 16th February 2015
http://dx.doi.org/10.1016/j.copsyc.2015.02.002
2352-250X/# 2015 Elsevier Ltd. All rights reserved.
Introduction
Arguably, almost all mental disorders involve at least
some kind of undesired affective state — either as inte-
gral parts of the diagnostic criteria or as likely cues of
cognitive or behavioral symptoms. For example, binge
eating, restrictive eating, alcohol or drug consumption,
self-harming behavior, worrying or even psychotic symp-
toms have been discussed as means to avoid or reduce
aversive affective states or restore a sense of control over
one’s feelings (e.g., [1,2,3]). Consistent with these
theories, numerous empirical findings suggest that defi-
cits in affect regulation are an important risk and main-
taining factor in various mental disorders (e.g., [4,5]).
Therefore, enhancing adaptive affect regulation skills
might qualify as a promising target in transdiagnostic
interventions aiming to prevent or restore mental health
in the context of a broad range of disorders [1,5,6,7].
Transdiagnostic interventions have recently been dis-
cussed as a promising alternative or addendum to disor-
der-specific interventions [5,8,9]. Preliminary evidence
Current Opinion in Psychology 2015, 3:64–69
for the usefulness of these interventions includes findings
from etiological research indicating that various factors
likely increase the risk to develop mental disorders in
general (e.g., experiential avoidance; [2]) and findings
from epidemiological studies indicating that many
patients meet criteria for several disorders at a given time
[10] or move from one disorder to another over the course
of their lifespan [11]. Providing these patients with the
skills that are necessary to cope with the factors responsi-
ble for the development of various disorders might be a
more efficient approach to the treatment of highly comor-
bid patients than simply compiling a number of disorder-
specific interventions [12]. Finally, it is of note that
transdiagnostic interventions are easier to disseminate
as they, ceteris paribus, require less training and can be
delivered more easily in a group format [8].
Because of these arguments for transdiagnostic treat-
ments and evidence for the transdiagnostic importance
of adaptive emotion regulation skills, we have developed
the Affect Regulation Training. The purpose of ART is to
enhance adaptive affect regulation whenever such a focus
is considered helpful for maintaining or restoring mental
health. Accordingly, ART can be used, first, as a preven-
tive intervention in healthy and at-risk groups, second, as
a stand-alone intervention for individuals suffering from
minor mental disorders, or third, as an adjunctive inter-
vention that complements disorder-specific treatments of
severe mental disorders. Based on theories and data
indicating that various affective states contribute to the
development and maintenance of mental disorders if they
are not adaptively responded to [13], ART focuses on
enhancing general affect regulation skills, that is, skills
that are relevant for coping with a broad range of usually
undesired feelings (including stress/tension, anxiety, an-
ger, sadness, shame, guilt, depressed mood [14]).
Theoretical underpinnings of ART
To develop effective skill-building interventions, re-
search needs to identify adaptive skills and clarify how
such skills interact [15]. For this purpose, we synthesized
and expanded upon previous theories (e.g. [16–19]) and
proposed a skill-based model of emotion regulation.
According to the Adaptive Coping with Emotions (ACE)
model [20] (Figure 1), effective emotion regulation can be
conceptualized as the situation-adapted interplay of the
abilities to, first, be aware of emotions (e.g., [21,22]),
second, identify and label emotions (e.g., [23,24]), third,
correctly interpret emotion-related body sensations (e.g.,
[25,26]), fourth, understand the prompts of emotions
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 The Affect Regulation Training Berking and Lukas 65

Figure 1

Adaptive Coping with Emotions Model

Awareness 1

Identifying
& 2
Labeling

Understanding 3
3a 3b
Identifying Adaptive
Targets for Hopelessness
Change
Effective
7
Self-Support

Acceptance
Modification 4 & 5
Tolerance
Readiness
6a 6 6b
to Confront
In Vivo Skills Practice Development of Resilience
Current Opinion in Psychology

Adaptive Coping with Emotions model (ACE model) 1.

(e.g., [27]), fifth, actively modify negative emotions (e.g.,
[28,29]), sixth, accept negative emotions when necessary
(e.g., [2,19,30,31]), seventh, tolerate negative emotions
when they cannot be changed (e.g., [32,33]), eighth,
confront (vs. avoid) distressing situations in order to attain
important goals (e.g., [34,35]), and ninth, compassionately
support (encourage, self-soothe, guide) oneself when
facing undesired emotions [31,36]. The ACE model also
includes the assumption that the skills of accepting and
tolerating negative emotions and modifying negative
emotions are the most critical for mental health. The
other skills included in the model are hypothesized to
foster mental health only by facilitating the successful
application of the acceptance/tolerance and modification
skills.
To validate the model, we developed the emotion regu-
lation skills questionnaire (ERSQ). Empirical studies
using this measure have added to previous research by
demonstrating that self-reports of the successful applica-
tion of all skills included in the ACE model are signifi-
cantly associated with various indicators of mental health
in clinical and at-risk populations [12,37–39]. Moreover,
ERSQ scores were associated with subsequent indicators
of mental health and well-being in healthy [38], at-risk
[40,41], and clinical samples [42,43,44]. Further stud-
ies confirmed the hypothesis that modification as well as
acceptance and tolerance might be crucial for maintaining
and restoring mental health, whereas the other skills
might only be relevant to the extent that they facilitate
the successful application of the ultimately important
skills [12,45].
To overcome the limitations associated with self-report
measures, we developed an experimental paradigm
designed to evaluate the efficacy of the skills included
in the model. Studies using this paradigm provide pre-
liminary evidence that the ability to compassionately
support oneself in distressing situations might be more
effective than established strategies (such as reappraisal)
in more severely depressed patients [46]. Moreover,
these studies provide preliminary evidence that self-
compassion might facilitate the subsequent utilization
of strategies that have been shown to be effective but
that patients often find difficult to apply (such as reap-
praisal [47]).
Development of ART
Inspired by the lack of transdiagnostic interventions
targeting a broad range of affect regulation capabilities,
we began to develop the Affect Regulation Training
(ART) by integrating techniques from various approaches
into a comprehensive training program. As such, ART
synthesizes elements of cognitive behavioral therapy
(e.g., [48]), mindfulness [49], compassion-based treat-
ments [50–52], emotion focused therapy [19], acceptance
and commitment therapy [2], dialectical behavior therapy
[53], neuro-psychotherapeutic translational approaches

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66 Emotion regulation
[54], problem-solving therapies [55], and strength-fo-
cused interventions [56,57].
Out of the large variety of skills that are focused upon in
these treatments, we picked a set of seven skills that first,
have been shown to be effective in basic and clinical
research, second, can be used to cope with a broad range
of challenging affective states, and third, can easily be
integrated into a comprehensive system of adaptive affect
regulation.
In the so-called ART-sequence (Figure 2) patients are
taught to respond to challenging affective states by:
 relaxing their muscles and their breathing
 switching into the mode of non-judgemental awareness
 activating an accepting attitude toward one’s emotions
and the belief in one’s capacity to tolerate this emotion
for some length of time
 providing oneself with effective self-support (by
engaging in self-compassion, practicing self-soothing
and self-encouragement, and actively coaching oneself
through the process of affect regulation)
 constructively analyzing the causes of one’s emotions
 working to modify undesired affective states with the
help of an emotion-focused problem-solving schema.
In ART, each of these skills is first introduced with the
help of a (‘neuro-psychotherapeutic’) translational model.
Then the skill is taught in a long version which is
shortened after each additional skill that is presented
to participants. Finally, participants should be able to
apply the skill in a very short period of time (3–30 s). The
combined sequence of ART-skills can then be applied
Figure 2
ART Skills and ART Sequence
1. Muscle
Relaxation
7. Modifying 2. Breathing
Emotions Relaxation
To change
6. Analyzing 3.
Emotions how I feel Nonjudgemental
Awareness
5.
Compassionate 4. Acceptance
Self-Support & Tolerance
Current Opinion in Psychology
ART skills and ART sequence 1.
Current Opinion in Psychology 2015, 3:64–69
whenever there is a need to cope with undesired affective
states.
To master the ART-skills and finally the entire ART-
sequence, ART aims to engage participants in an intense
training. For this purpose, a standardized set of progres-
sive exercises has been developed that includes seven
guided contemplations (that are about 20 min long and
can be delivered with the help of the ART audio train-
ing), and a set of about 140 short messages that can be sent
to participants through an automatic email/text message
delivery system. To foster the motivation to engage in
such an intense training, ART therapists work to identify
participants’ approach goals that can be obtained with the
help of better affect regulation skills and to promote the
insight that engaging in the ART practice is an effective
means to the end of attaining personally relevant goals.
Additionally, ART trainers systematically focus on the
participants’ resources and help participants to become
aware of their own strengths and capabilities. These
measures aim to increase emotion-related self-efficacy
and activate an approach motivation toward challenging
feelings and affect-related skills practice.
To help maintain the effects of the training after com-
pletion, ART aims to transform the ART exercises into
self-reinforcing rituals that ART completers are invited to
practice on a daily basis for as long as possible, even if they
have recovered from their initial mental-health problems.
ART therapists explain that the motivation to practice
relevant skills diminishes over time, particularly in the
absence of acute emotional suffering. However, continu-
ing the ART training greatly increases the chance to stay
well over a long time span. Therefore, ART participants
are advised to continue with the skills practice with a
reduced level of intensity and to increase its intensity as
soon as their emotional problems start reappearing.
Overview of research on ART
The experimental studies described in the ‘Theoretical
underpinnings of ART’ section provide preliminary evi-
dence for the efficacy of ART. They show that sequences
from the ART audio training significantly facilitate suc-
cessful coping with experimentally induced depressed
affect in individuals meeting criteria for major depressive
disorder (MDD). However, they fall short in clarifying
whether the ability to utilize these skills can be enhanced
by ART. To answer this question, the efficacy of ART was
evaluated in studies with both clinical and non-clinical
samples. In the first study targeting an at-risk population,
we evaluated ART in a sample of police officers. This
profession is known for being associated with many emo-
tional challenges such as stress, anger, guilt, worry, and
shame, subsequently leading to feelings of frustration,
helplessness, depressive symptoms, and anxiety [37].
Moreover, some authors argue that police officers tend
to rely on action-oriented and problem-focused coping
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strategies when dealing with occupational stress [58]. It can
be hypothesized that such a focus may lead to a lack of
emotion-focused coping strategies and can be regarded as
both cause and consequence of difficulties with regard to
acknowledging, sensing, understanding, accepting, toler-
ating and modulating challenging feelings [37]. Consistent
with this assumption, the ERSQ scores of a sample of
police officers were significantly lower than those of a
matched control condition. Police officers who subse-
quently participated in ART displayed a significantly
greater increase in their ERSQ scores than did a waiting
control condition. Moreover, after the training their
reported emotion regulation skills had increased to the
point where they no longer differed from the matched
control sample [37].
In a more recent study, ART was evaluated in a sample of
caregivers for the elderly [59]. Similar to police officers,
this profession is known to be associated with many
emotional challenges and an increased risk for the devel-
opment of mental health problems [60,61]. Caregivers
who participated in the ART program displayed a greater
increase in affect regulation skills than did a (non-ran-
domized) control condition. Moreover, participants in the
ART condition displayed a significantly greater improve-
ment of well-being and maintained these changes over a
6-months follow-up period [59]. Together these findings
provide preliminary evidence that ART can be effective-
ly used as a preventive intervention in at-risk populations.
With regard to the efficacy of ART as an intervention for
individuals meeting criteria for mental disorders, system-
atic research so far has focused on the effects of com-
plementing disorder-specific interventions with a
stronger focus on emotion regulation skills through repla-
cing parts of the original treatment with ART. In one
study, an abbreviated version of ART was integrated into
a six-week, CBT-based inpatient treatment program in
order to clarify whether CBT + ART would result in
better outcome than CBT alone [12]. Findings from a
sample of 289 patients meeting criteria for various mental
disorders indicated that those patients treated with
CBT + ART improved their emotion regulation skills
significantly more than the CBT-only group. Moreover,
the patients who participated in ART showed significant-
ly greater decreases in depression and negative affect and
a significantly greater increase in positive affect than
those receiving traditional CBT [12].
Although the results from this study appear promising,
they are preliminary as participants were not completely
randomized to treatment conditions. Therefore, we re-
cently conducted a completely randomized, controlled,
and prospective clinical trial with a sample of 432 inpa-
tients who met diagnostic criteria for MDD [62]. In this
study, participants received either traditional CBT-based
therapy or CBT complemented with a shortened version
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The Affect Regulation Training Berking and Lukas 67
of ART. Comparisons across the two groups indicated
that integrating ART into the CBT-based treatment was
associated with greater gains in the acquisition of impor-
tant emotion regulation skills. Moreover, participants in
the CBT + ART group reported a greater reduction in the
severity of depressive symptoms than participants receiv-
ing traditional CBT. More specifically, 65% of partici-
pants who received the CBT + ART treatment attained
remission status compared to 51% of participants who
received conventional CBT.
With regard to specific disorders other than depression,
ART has recently been used to increase the focus on
emotion regulation skills in CBT-based treatment of
medically unexplained symptoms [63]. Traditionally,
such symptoms have often been associated with deficits
in the ability to be aware of emotions, understand their
causes, and effectively modify their quality, intensity or
duration [64]. In an attempt to improve the unsatisfying
efficacy of available treatments for these symptoms,
Gottschalk and colleagues [63] have integrated ART into
conventional CBT. Findings from an uncontrolled study
provide preliminary evidence for the feasibility, accep-
tance, and efficacy of this approach [63].
Conclusions
There are various limitations to the research that has been
conducted to evaluate the ART program. First, at this
point efficacy research on ART exclusively used self-
report measures (such as the ERSQ, ‘Theoretical under-
pinnings of ART’ section). Therefore, future research
should complement self-report-based assessments with
observer-based, biological or experimental measures.
Moreover, the ERSQ inquires whether or not a person
has been able to apply various regulatory skills to his/her
‘feelings’ or ‘emotions’ in general although the ability to
cope adaptively with emotions may differ significantly
across specific affective states. To address this limitation,
we have recently developed and validated a modified
version of the ERSQ, which assesses affect regulation
skills separately in the context of various affective states
(Affect Regulation Skills Questionnaire,a ARSQ; [14]).
Other limitations include the focus on ART as an adjunc-
tive intervention, the lack of studies varying the point in
treatment when ART is used to complement disorder-
specific interventions and, most importantly, the lack of
studies with other carefully defined clinical groups.
To overcome these limitations we have recently complet-
ed a study in which ART is evaluated as a stand-alone
intervention in a sample of 150 clinically depressed out-
patients [65]. In this study, we have also tested the
hypothesis that participating in ART enhances the effects
of subsequent individual CBT for depression. In order to
a
An English version of the ARSQ can be obtained from the first
author.
Current Opinion in Psychology 2015, 3:64–69
68 Emotion regulation
further clarify whether enhancing affect regulation skills
is truly a promising transdiagnostic approach, we have also
initiated a study evaluating ART as a treatment for binge
eating disorder.
Future research needs to continue expanding this re-
search to a broad range of mental disorders. Ideally, such
research on the efficacy of entire skill enhancing programs
should be complemented with research that evaluates the
utility of specific regulation strategies and the efficacy of
various methods of training patients in particularly effec-
tive strategies. Such a fine grained approach to evaluating
self-help and therapeutic strategies would provide em-
pirically based guidelines for the decisions that patients
have to make when they have to respond to challenging
affective states and that therapists have to make when
having to respond to patients presenting affect-related
problems.
Conflict of interest
Nothing declared.
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