Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders
Introduction
Successful regulation of emotional states is important for social adjustment and overall well-being. Pursuing important life goals requires tolerance and management of a wide range of emotional states, some of which can be uncomfortable (e.g., anxiety about a first date or job interview). Unsuccessful regulation of emotions can impede individuals in pursuing their goals and maintaining desired life circumstances. Moreover, individuals who fail to develop flexible and effective emotion regulation skills may experience excessive and persistent emotions that interfere with their sense of well-being. Anxiety and mood disorders are partly characterized by excessive and persistent negative emotions, suggesting that ineffective regulation of emotion may play a role in their development or maintenance. Research on the subjective, physiological, and behavioral consequences of emotion regulation strategies therefore has crucial relevance to these disorders.
Despite the importance of understanding emotion regulation in individuals suffering from anxiety and mood disorders, the vast majority of extant research on emotion regulation has been conducted with non-clinical samples. These studies have produced several results that have potential implications for understanding pathological anxiety and depression. For example, habitual use of suppression to manage emotional experience has been associated with a range of negative outcomes including higher levels of negative affect, lower levels of positive affect, poorer social adjustment, and decreased well-being (Gross & John, 2003). Experimental investigations also have shown that although individuals can successfully inhibit the outward expression of emotion, this strategy does not alleviate subjective experience of emotion (Gross, 1998; Gross & Levenson, 1997). Moreover, suppression of emotional expression has been shown to increase sympathetic arousal to a greater degree than comparison conditions (Gross, 1998). The counterproductive effects of suppression have been documented across a variety of emotions including amusement, sadness, and disgust (Gross, 1998; Gross & Levenson, 1997).
Emotion suppression has recently been studied in conjunction with the concept of “experiential avoidance,” which refers to unwillingness to experience negatively evaluated feelings, physical sensations, and thoughts (Hayes et al., 2004). Individuals who possess high levels of this trait commonly rely on suppression, avoidance, and other control tactics to manage emotional experiences. Experiential avoidance has been found to correlate with self-reported levels of anxiety and depression (Hayes et al., 2004), suggesting that it may be an important feature of some cases of emotional disorder. Recent empirical studies have shown that otherwise healthy individuals who score high on experiential avoidance respond with greater emotional distress and more negative cognitions to emotion-provoking procedures such as biological challenges (Feldner, Zvolensky, Eifert, & Spira, 2003; Karekla, Forsyth, & Kelly, 2004) and emotional film clips (Sloan, 2004). These findings suggest that a persistent pattern of emotional suppression may be associated with increased rather than decreased reactivity to emotion-provoking stimuli. One study further documented that instructing participants to suppress their emotions led to increased distress in individuals high on experiential avoidance, but not for individuals low on this trait (Feldner et al., 2003). This suggests that suppression is particularly counterproductive for experientially avoidant individuals who may also be prone to anxiety and depression (Hayes et al., 2004).
The evidence linking emotion suppression to increases in negative affect and sympathetic arousal can be placed in the larger context of the literature on suppression of other states (e.g., thoughts, pain). In a classic study that inspired numerous other investigations of thought suppression, Wegner, Schneider, Carter, and White (1987) demonstrated that attempts to suppress thoughts about a white bear paradoxically increased the frequency of such thoughts during a post-suppression period in which participants were free to think about any topic. Subsequent research has established links between this rebound effect as a laboratory phenomenon and clinical disorders. For example, the rebound effect has been documented in anxious and depressed individuals (Janeck & Calamari, 1999; Wenzlaff, Wegner, & Roper, 1988), and in participants who are trying to suppress personally relevant negative material (Salkovskis & Campbell, 1994; Trinder & Salkovskis, 1994). Moreover, thought suppression has been associated with increased electrodermal responses to emotional thoughts (Wegner & Gold, 1995; Wegner & Zanakos, 1994), suggesting that it elevates sympathetic arousal.
Evidence also exists that attempts to suppress pain are unproductive. Cioffi and Holloway (1993) exposed participants to a cold-pressor pain induction and assigned them to either focus on the sensations in their hands, distract themselves by thinking of their rooms at home, or suppress thoughts and feelings related to the pain. During the pain induction, the suppression group demonstrated greater increases in electrodermal activity than the other two groups. Moreover, after the pain induction ended, pain recovery was slowest in the suppression group. Participants in the suppression group also manifested increased heart rate relative to the other groups in anticipation of a second pain induction, and lower self-efficacy for withstanding the pain of the second induction.
The results of thought and pain suppression studies converge with the results of recent emotion suppression studies to suggest that suppression produces paradoxical increases in unwanted experience and arousal. The thought and pain suppression literatures also highlight additional avenues for study of emotion suppression. Importantly, these studies suggest that some of the most important effects of suppression may occur after efforts to suppress have terminated. Increases in unwanted thoughts occur during a post-suppression period (e.g., Wegner et al., 1987), and pain continues for suppressors during a post-suppression recovery period (Cioffi & Holloway, 1993). Therefore, one objective of the present study is to examine the effects of emotional suppression that may persist after an emotion induction.
An approach that has been studied recently in conjunction with emotional suppression is emotional acceptance (e.g., Eifert & Heffner, 2003; Hayes, et al., 1999; Levitt, Brown, Orsillo, & Barlow, 2004). Acceptance-oriented approaches encourage individuals to experience their emotions, thoughts, and bodily sensations fully without trying to change, control, or avoid them (Hayes, Strosahl, & Wilson, 1999). Acceptance entails openness to internal experiences and willingness to remain in contact with those experiences even if they are uncomfortable. Acceptance is an apt comparison condition for emotional suppression because it involves welcoming all types of internal experience as opposed to pushing experiences away.
An additional rationale for studying acceptance is the growing clinical interest in this approach. Mindfulness and other acceptance-oriented strategies have been incorporated into a number of promising behavioral treatments for anxiety and depression (Hayes, Strosahl et al., 1999; Roemer & Orsillo, 2002; Segal, Williams, & Teasdale, 2002). Several recent studies suggest that this orientation to emotions promotes good outcomes in individuals with psychological disorders (Bach & Hayes, 2002; Hayes, Strosahl et al., 1999; Heffner, Eifert, Parker, Hernandez, & Sperry, 2003). Acceptance also predicts better adjustment and functioning in individuals with chronic pain (McCracken, 1998).
Despite the apparent therapeutic value of acceptance, more empirical research is needed to fully understand the effects of acceptance on the subjective, physiological, and behavioral aspects of the emotional response. Such research would aid in providing a solid empirical basis for acceptance-oriented therapies, and in elucidating their mechanisms of change. Hayes et al. (1999) suggested that laboratory inductions be utilized to provide this basis. In a preliminary study, they showed that participants who received an acceptance-oriented rationale prior to a cold-pressor task displayed greater pain tolerance than individuals who received suppression-oriented or placebo rationales. Subjective experience of pain did not differ across the conditions, even though the suppression-oriented rationale targeted this domain.
More recently, Eifert and Heffner (2003) compared the effects of acceptance and suppression rationales on responses of females high in anxiety sensitivity, a known risk factor for panic (e.g., Schmidt, Lerew, & Jackson, 1997). Prior to breathing carbon dioxide-enriched air, participants were exposed to acceptance-oriented instructions, suppression-oriented instructions, or no instructions. Participants randomly assigned to the acceptance group manifested less intense fear and less catastrophic thinking during the procedure than participants in the suppression and no instructions groups. They also demonstrated less behavioral avoidance, as evidenced by lower levels of termination of the experimental procedure and greater willingness to return for another session. Levitt and colleagues (2004) recently replicated this experiment with a sample of individuals diagnosed with panic disorder. They found similar benefits of acceptance in this clinical sample including decreased subjective distress during the challenge and increased willingness to undergo another symptom provocation.
In the current study, we sought to further explore the effects of suppression and acceptance in participants with anxiety and mood disorders. Participants were randomly assigned to listen to audiotapes encouraging them to either accept or suppress their emotional reactions. After participants heard the acceptance or suppression instructions, they applied these instructions while watching an emotion-provoking film. Subjective and physiological responses were measured before, during, and after the film.
For both acceptance and suppression groups, we expected the films to provoke increases in subjective distress and skin conductance (a measure of sympathetic activation), and decreases in respiratory sinus arrhythmia (a measure of parasympathetic activation). We also measured heart rate, which is an index of joint sympathetic and parasympathetic activation that may reflect somatic activity, mental effort, emotional arousal, and/or orientation to stimuli (Larsen, Schneiderman, & Pasin, 1986). Given the multiple determinants of heart rate, the impact of the film on this variable was less certain; however, numerous studies have shown that participants with anxiety disorders manifest increased heart rate in response to experimental stressors (e.g., Elsesser, Sartory, & Tackenberg, 2004; Hofmann, Newman, Ehlers, & Roth, 1995).
The effect of deliberate suppression on subjective distress during the film was uncertain, given that some studies have shown increased subjective distress associated with suppression during emotion provocation (e.g., Feldner et al., 2003) and others have not (e.g., Gross, 1998). Our primary hypothesis regarding subjective distress was based on results from thought and pain suppression studies showing that suppression leads to poorer recovery from the undesired experience (e.g., Cioffi & Holloway, 1993; Wegner et al., 1987). We therefore predicted that individuals who suppressed their emotions would have more residual negative affect after the film than individuals who accepted their emotions.
Although some investigations have failed to find elevated sympathetic activation in individuals attempting to suppress emotions (Eifert & Heffner, 2003; Levitt et al., 2004), we predicted that suppression would be associated with increased sympathetic arousal given the similarity of our emotion-provoking stimuli to those used in other experiments that found this effect (Gross & Levenson, 1997; Gross, 1998). Evidence of increased sympathetic arousal in the suppression group was expected to be apparent in increased skin conductance levels and heart rate compared to the acceptance group. Finally, we speculated that suppression would be associated with decreased parasympathetic responding compared to acceptance, given that low vagal tone has been associated with other ineffective strategies for controlling arousal (i.e., worry; cf. Lyonfields, Borkovec, & Thayer, 1995).
Section snippets
Participants
The sample consisted of 60 patients who presented for assessment at the Center for Anxiety and Related Disorders at Boston University. There were equal numbers of men and women who participated, and the average age was 35.33 (SD=11.74, range=18–63). Participants were largely Caucasian (88.3%), with smaller numbers of individuals identifying as Asian (6.7%), Hispanic (1.7%), and multi-racial (3.3%).
To be eligible for the study, patients had to be diagnosed with a current anxiety or mood
Pre-experiment group differences
The groups that resulted from the random assignment procedure were compared on demographic characteristics, clinical characteristics, and pre-film affective status. No between-groups differences were apparent in gender, χ2 (1, N=60)=0.00, p=1.00, age, t (58)=-0.90, p=.37, or ethnic minority status, χ2 (1, N=60)=1.46, p=.23. The groups did not differ in the average severity of principal diagnoses, t (58)=−1.42, p=.16, the average number of diagnoses per participant, t (58)=0.00, p=1.00, or the
Discussion
The current study examined the effects of emotional suppression and acceptance in a sample of individuals with anxiety and mood disorders who were exposed to an emotion-provoking film. The study adds to the small body of existing literature (e.g., Levitt et al., 2004) that applies experimental paradigms involving directed emotion regulation to clinical samples. Research on the effects of different regulation strategies is particularly relevant to individuals with anxiety and mood disorders, who
Acknowledgments
This research is based on the first author's dissertation, which was supported by the Clara Mayo Fellowship at Boston University. The authors would like to thank Tibor P.A. Palfai and Lizabeth Roemer for their guidance and contributions, and James Long for his technical assistance. During the preparation of this manuscript, the first author was supported by NIMH Grant T32 MH 18399-19.
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