Acceptability and Suppression of Negative Emotion in Anxiety and Mood Disorders
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Emotion Copyright 2006 by the American Psychological Association 2006, Vol. 6, No. 4, 587–595 1528-3542/06/$12.00 DOI: 10.1037/1528-3542.6.4.587 Acceptability and Suppression of Negative Emotion in Anxiety and Mood Disorders Laura Campbell-Sills David H. Barlow, Timothy A. Brown, and University of California, San Diego Stefan G. Hofmann Boston University The present study investigated perceived acceptability and suppression of negative emotion in partici- pants with anxiety and mood disorders. Sixty participants with these disorders and 30 control participants watched an emotion-provoking film and completed self-report measures of their experience and regu- lation of emotions. The film elicited similar increases in negative emotion for clinical and nonclinical participants; however, clinical participants judged their resulting emotions as less acceptable and suppressed their emotions to a greater extent. The higher level of suppression in the clinical group was attributable to females in the clinical group suppressing their emotions more than females in the nonclinical group. For all participants, high levels of suppression were associated with increased negative emotion during the film and during a postfilm recovery period. Further analyses showed that appraising emotions as unacceptable mediated the relationship between negative emotion intensity and use of suppression in the clinical group. This study extends the literature on emotion regulation to a clinical sample and suggests that judging emotions as unacceptable and suppressing emotions may be important aspects of the phenomenology of emotional disorders. Keywords: emotion regulation, acceptance, suppression, anxiety disorders, mood disorders Emotion regulation refers to conscious and unconscious pro- problems that incorporate mindfulness (Roemer & Orsillo, 2002; cesses that influence the occurrence, intensity, duration, and ex- Segal, Williams, & Teasdale, 2002) also discourage certain emo- pression of emotion (Gross, 2002). Despite the growing literature tion control efforts. More empirical research is needed to test the on emotion regulation in nonclinical samples and its potential assumptions about emotion regulation in clinical populations that relevance to emotional disorders, this topic has not been examined underlie these treatments. systematically in individuals with a history of psychopathology. Many theories and experimental findings pertaining to emotion Anxiety and mood disorders are characterized precisely by nega- regulation can be applied to understanding anxiety and mood tive emotions that have become excessive and persistent; therefore, disorders (e.g., Gross, 2002; Mennin, 2004; Nolen-Hoeksema, extending empirical research on emotion regulation to this popu- 2000; Tamir, 2005) and an exhaustive review will not be possible lation is warranted. here. It is notable that different emotion regulation strategies have Emotion regulation also has come to the forefront in the newest been shown to impact the subjective, physiological, and behavioral wave of behavioral therapies for anxiety and depression. For components of negative emotion in distinct ways. For example, example, the developers of Acceptance and Commitment Therapy both cognitive reappraisal and suppression have been shown to (ACT) have proposed that much psychological distress persists decrease the behavioral expression of negative emotion, but only due to maladaptive efforts to control negative emotions and other reappraisal decreases subjective distress (Gross, 1998). Moreover, unwanted experiences (Hayes, Strosahl, & Wilson, 1999). Novel emotion regulation strategies have varying effects on the temporal versions of cognitive–behavioral therapy for anxiety and mood course of emotions. Rumination has been shown to prolong epi- disorders (Barlow, Allen, & Choate, 2005) and treatments for these sodes of sadness, whereas distraction appears to shorten them (Nolen-Hoeksema & Morrow, 1993). Finally, habitual use of cer- tain emotion regulation strategies is meaningfully associated with Laura Campbell-Sills, Department of Psychiatry, University of Califor- interpersonal functioning and well being (Gross & John, 2003), nia, San Diego; David H. Barlow, Timothy A. Brown, and Stefan G. suggesting that some emotion regulation strategies may be “health- Hofmann, Department of Psychology, Boston University. ier” than others (John & Gross, 2004). All of these empirical This study is based on the first author’s dissertation, which was sup- findings may be relevant to understanding why negative emotions ported in part by the Clara Mayo Fellowship at Boston University. The first are excessive and persistent in anxiety and mood disorders; how- author was supported by National Institute of Mental Health Grant T32 ever, with the exception of establishing links between rumination MH 18399-19 during preparation of this article. The authors wish to and depressive disorders (Nolen-Hoeksema, 2000), the relation- acknowledge Tibor P. A. Palfai and Lizabeth Roemer for their contribu- tions. ship between emotion regulation strategies and clinical disorders Correspondence concerning this article should be addressed to Laura has yet to be explored. Campbell-Sills, Department of Psychiatry, University of California, San One well-studied emotion regulation strategy that may have Diego, 8950 Villa La Jolla Drive, Suite B218, La Jolla, CA 92037. E-mail: particular relevance to anxiety and mood disorders is suppression. [email protected] Experimental studies have established that suppression reduces 587 588 CAMPBELL-SILLS, BARLOW, BROWN, AND HOFMANN behavioral expression of emotion compared to control conditions, this hypothesis, we presented a negative emotion-provoking film but does not decrease the subjective experience of negative emo- to a diagnostically heterogeneous sample of individuals seeking tion (Gross, 1998; Gross & Levenson, 1997). Moreover, suppres- treatment for anxiety and mood disorders (“clinical participants”). sion appears to increase the sympathetic arousal associated with We compared their self-reported negative emotions and emotion negative emotion (Gross, 1998; Gross & Levenson, 1997). In- regulation strategies to a control sample of individuals who had no creased sympathetic arousal is counterproductive to the goal of current or lifetime anxiety or mood disorders (“nonclinical partic- reducing the intensity of negative emotions like anxiety and anger ipants”). We predicted that the clinical participants would rate and may be especially problematic for individuals with anxiety themselves as engaging in higher degrees of suppression (but not disorders, who often fear the physical sensations associated with other regulation strategies) compared to nonclinical participants. sympathetic arousal (Reiss, Peterson, Gursky, & McNally, 1986). Although some investigations have focused solely on suppression Literature on thought and pain suppression further suggests that of the behavioral expression of emotion (e.g., Gross, 1998), we suppression may cause a paradoxical persistence of the unwanted assessed participants’ suppression of “emotional reactions,” which experience. In their classic study, Wegner, Schneider, Carter, and included the subjective experience of emotion. Recent conceptu- White (1987) demonstrated that attempts to suppress thoughts alizations of anxiety and mood disorders have emphasized the about a white bear were associated with an increase in such potential role of suppression of internal states (Barlow et al., 2004; thoughts during a postsuppression period in which participants Hayes et al., 1999); therefore we measured “emotion suppression” were free to think about any topic. Individuals instructed to use in general rather than “expressive suppression” in particular. suppression also experienced higher levels of pain after a cold- In addition to comparing the use of suppression in individuals pressor test compared to individuals instructed to use distraction or with and without emotional disorders, we sought to better under- to focus on the pain sensations (Cioffi & Holloway, 1993). These stand the possible predictors and consequences of using suppres- results raise the question of whether suppression could be associ- sion to regulate negative emotions. While external factors such as ated with a similar persistence of negative emotion after exposure interpersonal demands may increase the importance of suppressing to an emotional stimulus. emotion (e.g., a person might need to suppress anger at her boss), In addition to the immediate effects of suppression on the we hypothesized that use of suppression is further influenced by emotional response, habitual use of suppression is associated with internal factors, such as enduring beliefs about emotions (e.g., experiencing less positive emotion and greater negative emotion “Showing negative emotions is a sign of weakness.”) and acute overall, worse interpersonal functioning, and lesser well being appraisals of emotions (e.g., “Feeling sad right now is wrong.”). (Gross & John, 2003). These findings contrast with the profile of Judgments of the acceptability of emotions constitute one type of individuals who habitually use another strategy—cognitive reap- acute emotion appraisal that can be reliably measured (Mayer & praisal—to manage emotions. Reliance on cognitive reappraisal Gaschke, 1988; Mayer & Stevens, 1994) and may be functionally correlates with more positive emotion and less negative emotion related to emotion suppression.