Introduction
Emotion Regulation
The term ‘Emotion regulation’ outlines the way in which individuals have influence over their emotions: what they experience, how they experience these and how they choose to express them. Emotions can be automatic or conscious responses to a set of stimuli. An emotional stimulus triggers a set of emotion response ‘tendencies’ which influence the way in which we respond to the stimuli as detailed above. Emotions do not govern our responses completely, only provide a set of responses, eliciting choice in the way we act: this malleability in the set of ‘tendencies’ is what permits us to regulate our emotions, and can explain the individual differences in emotion regulation tendencies, (Gross, 2002).
Effective emotion regulation “…consists of the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals”, (Thompson, 1994, pp.27-28). Successful emotion regulation has been found to be linked with an understanding of one’s own emotions and the emotions of others, alongside the causes and consequences of emotions, (Cummings, 1987; Denham, 1998; Eisenberg et al., 1993). Central to mental health, emotion regulatory processes contribute towards supporting or disrupting the individual’s ability to work, relate to others and enjoy oneself, (Gross & Munoz, 1995). These processes, observed from early childhood, have been found to affect a child’s social competency, lasting throughout their development, into adulthood, (Rydell, Thorell & Bohlin, 2003).
Emotion dysregulation is characterised by a deficit in either the up-regulation or down-regulation of emotions, (Parrott, 1993), and has been found to be linked to over 75% of the classifications of psychopathology found in the DSM-IV (American, Psychiatric Association, 1994; Jazaieri, Urray & Gross, 2013). Individuals who have a deficit in their ability to regulate their emotions are at an increased risk of psychopathology (Aldao, Nolen-Hoeksema, & Schweizer, 2010). Considering the impact that emotion regulation difficulties appear to have on mental health, this research study has been conducted to contribute to the existing knowledge exploring the nature of this impact .Due to the nature of impact that emotion regulation appears to have on mental health highlights the importance of further investigation into this area of research.
Emotion regulation strategies are the techniques which individual employ in order to cope with emotionally stimulating situations. Research previously identified strategies such as reappraisal and problem solving as adaptive across many contexts, reducing stress and generating positive interpretations and solutions to stressful situations, (Gross, 1998). Maladaptive appraisal processes and poor problem solving abilities have been found to have strong associations with depression and anxiety, (Billings & Moos, 1981; D’Zurilla, Chalng, Nottingham & Faccinni, 1998; Kant, D’Zurilla, & Maydeu-Olivares, 1997) and thus, effective therapies designed to treat these disorders, such as Cognitive Behavioural Therapy focus on teaching reappraisal skills and development of effective problem solving techniques, (Beck, Rush, Shaw & Emery, 1979).
Avoidance and Suppression have been identified as maladaptive strategies of emotion regulation, which increase the risk of psychological distress and depression/anxiety symptoms, (Carver, Scheier & Weintraub, 1989; Hayes et al, 1996). Strategies such as suppression as an attempt to control or constrict emotional responses have close links with many psychological disorders, (Hayes et al, 1996). Individuals who apply strategies of control/suppression run the risk of experiencing further difficulties in regulating their emotions, due to the increased levels of arousal creating a more ‘intense’ emotional response for them to regulate, (Gross & Levenson, 1997). Linehan, (1993), however claimed that it was acceptance rather than control which accounted for these difficulties and that a lack of acceptance of one’s own emotions is associated with greater deficits in emotion regulation, (Hayes, Strosahl & Wilson, 1999). Research into mindfulness has explored this acceptance of emotions; Mindfulness involves individuals being present in the moment with their emotions, holding a non-judgemental stance in which thoughts feelings and sensations are accepted as they occur, (Aldao, Nolen-Hoeksema, & Schweizer, 2010). Mindfulness-based therapies, utilising this approach have been found to be effective in the treatment of many psychological disorders, suggesting that acceptance and awareness of emotions may influence emotion regulation, (Breslin, Zack, & McMain, 2002; Kristeller, Baer, & Quillan-Wolever, 2006; Roemer, Orsillo & Salters-Pedneault, 2008; Segal, Willians & Teasdale, 2002).
Trauma
Almost a third (31.4%) of adults in the UK claim to have experienced a trauma at least once in their lifetime, (Adult Psychiatric Morbidity Survey, 2014), with around 25-30% of this group going on to develop Post-Traumatic Stress Disorder (PTSD), (National Institute for Health and Care Guidance, 2005). However, following trauma, individuals experience a high incidence of issues including: difficulties with regulation of affect and impulses, memory and attention, self-perception, interpersonal relations, somatization and systems of meaning, (van der Kolk, Roth, Pelcovitz, Sunday & Spinazzola, 2005). Considering that these deficits are not indicative of or encompassed within the classification of a PTSD diagnosis, it is important to consider a wider spectrum of deficits which may be evident in individuals following trauma.
These deficits are not necessarily encompassed within the DSM criteria for PTSD and therefore a wider spectrum of deficits must be considered when treating individuals who have experienced trauma.
Complex PTSD, a sibling diagnosis proposed for use in the ICD-11, (Maercker et al., 2013) is explored to encompass a greater spectrum of deficits experienced by individuals following trauma. Complex PTSD features the core symptoms of PTSD alongside: affective dysregulation, negative self-concept and disturbances in relationships which represent ‘disturbances in self-organization. In recent research a larger group of individuals who have experienced trauma appeared to fall in the classification of complex PTSD compared to a small number whose symptoms were explained by PTSD. Individuals who were classified in the complex PTSD group reported experiencing greater frequency and greater number of different types of childhood trauma as well as a greater accumulation of stressful life events consistent with greater functional impairments in the aforementioned domains, with the greatest of these found in family and relationship problems, (Karatzias, et al, 2017). This highlights the complexity of the deficits experienced by individuals following trauma which has clinical utility when exploring the nature of their presentation and treatment suitability.
Trauma and Emotion Regulation
There is substantial evidence which associates early exposure to traumatic events with many psychological disorders including: anxiety, depression, post-traumatic stress, somatization, and cognitive disorders, identity disturbances and emotion regulation (Briere, 2004; Friedman, Keane, & Resick, 2007; Briere & Rickards, 2007; van der Kolk et al, 1996), although traumatic life events later in life are also contributing factors to psychological disturbances (Ford, 1999). Research has since been developed to examine why these links between trauma and psychopathology exist. Following trauma, individuals are said to experience post-traumatic emotional states which have been linked to an overwhelming of emotion regulation skills, (and have linked the experience of trauma with post-traumatic emotional states with an overwhelming of emotion regulation skills, Briere & Scott, 2006) suggesting that emotion regulation may provide an explanation for the development of psychopathology following following traumatic events, (Powers, Cross, Fani & Bradley, 2014).
Following trauma, some individuals experience intrusion of thoughts and emotions relative to the event and tend to utilize avoidance strategies, which are characteristic of emotion regulation difficulties, (Horowitz, Wilner & Alvarez, 1979). In an attempt to further identify specific emotion regulation deficits in victims of early traumatic events, research was conducted on childhood victims of sexual abuse found that these individual tended to have a decreased ability to understand and regulate their emotions, more negative views about their emotional support systems and greater levels of interpersonal conflict, specifically when expressing anger to their peers and sadness to their parents (Shipman et al. 2005). In a similar study, children who had experienced neglect were also found to have a diminished ability to understand their emotions, specifically negative states, such as anger, fear and sadness. Consequentially, these children had expectations that their mothers would respond negatively to the expression of such emotions, and as a result, possibly developed a tendency to withhold these emotions, (Shipman, Zeman, Penza, & Champion, 2000). This highlights both that individuals who have experienced trauma or maltreatment have an impaired ability to identify and regulate their emotions, specifically the more difficult ones, and tend to use avoidance as an emotion regulation strategy. Repeated interpersonal traumatization has been evidence to be particularly detrimental to emotion regulation abilities in which negative emotion states are triggered by avoidance strategies, leading to a disruption in the emotion regulatory processes involved in restoring equilibrium, (Pearlman & Curtois, 2005). These processes may be linked to the risk of re-victimization, evident in individuals following trauma (Dvir, et al, 2014; Fergussion, Horwood & Lynskey, 1997).
Emotional Schema
Acceptance of emotions happens when an emotion has been activated, individuals are then presented with a choice of what to do with this emotion, either normalising or pathologizing it leading to further options as previously explained (response tendencies) of how to manage and express this, (Leahy, 2002). This explanation highlights the differences in the way individuals conceptualize emotions (have different schemas about emotions). Emotional Schemas are subjective phenomena but are thought to be compiled of, or influenced by the following: Validation by others, Comprehensibility, guilt, Simplistic view of emotion, Higher values, Control, Numbness, Rational, Duration, Acceptance, Consensus, Rumination, Expression and Blame, (Leahy, 2002). These 14 constructs compile emotion schema theory (Leahy, 2016), a meta-experiential model which proposes that an essential part of emotion experience is the individual’s interpretation and evaluation of their own emotions. Emotion schema model describes that emotions and cognitions are very closely interlaced, (Leahy, 2016): they are consequences of cognition, (Beck,1976), can provoke cognition (Greenberg, 2002) and are an object of cognition, (Leahy & Wupperman, 2015).
Emotional schemas have been found to impact on psychopathology, with anxiety relating to schemas surrounding guilt, rumination, having less comprehensibility of emotions, less consensus with other’s on emotion, a simplistic view of emotions, a belief in lack of control over emotions and a lack of acceptance, (Leahy, 2002). Depression was also related to schemas about guilt, lack of comprehensibility, perception of less control, a belief that the emotions would have a long duration, less consensus of emotions of others and greater levels of rumination, (Leahy, 2002).
Maladaptive schemas about emotions have been found to impact on the emotional problems found in individuals following trauma which were found to be indicative of anxiety and depression, (Wright, Crawford & Castillo, 2009). Schemas of vulnerability to harm, defectiveness/shame, and self-sacrifice, as outlined by Young (1990), were found to mediate the relationship between emotional abuse and neglect and anxiety and depression, (Wright, Crawford & Castillo, 2009).
Given that a person’s beliefs about emotions may mediate between success and a lack of recovery from trauma it is essential to explore further the nature of this relationship in a range of samples.
Emotion Schema, Emotion Regulation and Trauma
As identified by Janoff-Bulman in 1989 people’s assumptive worlds (schema) are affected by trauma and that this effect can remain true many years following the negative event. Emotional schemas have been found to consciously affect the way in which emotions are regulated; Individuals who believe that their emotions are malleable tend to engage better in effective emotion regulation (Gross & John, 2003) and the way in which these beliefs influence behaviour are stronger following trauma or in situations where threat is perceived, (Dweck, 2000). Similarly, those who harbour negative theories about their own emotions will employ problematic strategies such as ruminating, worrying or blaming self or others, (Leahy, 2016), highlighting the importance of the strategies which occur when an emotion is activated. Utilising strategies that consciously accept and engage with the choices involved when an emotion is activated such as mindfulness techniques have been found, in neuroimaging studies to increase the ability to regulate emotional responses via prefrontal cortical inhibition of the amygdala, (Keng, Smoski & Robins, 2011).
Emotional Schema Therapy (EST) utilises techniques to change dysfunctional emotional regulation patterns through the identification and modification of emotional schema, (Leahy, Tirch & Napolitano, 2011). EST has provided an effective tool for the treatment of war veterans who suffered from PTSD by decreasing negative emotional schema and increasing positive schema and developing adaptive emotion regulation strategies, specifically acceptance, also decreasing some maladaptive emotion regulation strategies such as rumination, self-blaming and catastrophizing, (Naderi, Moradi, Hasani & Noohi, 2015). Highlighting the importance of emotional schemas in emotion regulation strategies following trauma, this relationship is worth experiencing further.
Social Cognition/Mentalization
Social cognition is the process by which individuals perceive, interpret and process information about the social world, (Penn, Addington & Pinkham, 2005). Otherwise known as reflective functioning or mentalizing, this is built on to explain an individual’s ability to interpret and reflect on the mental states of the self and others, including their thoughts, wishes, desires and needs, (Auchincloss & Samberg, 2012).
Impairments in the ability to mentalize have been discussed thus far to have implications for the development of Psychopathology, specifically: Borderline Personality Disorder, Eating Disorders, the development and maintenance of Depression and Anti-Social Personality Disorder, (Bateman & Fonagy, 2004; Bateman & Fonagy, 2008; Berking & Wupperman, 2012; Luyten, Fonagy, Lemma & Target, 2012; Fischer-Kern, et. al, 2013; Skårderud, 2007). Impairments in mentalizing are characterized by hypomentalizing, an inability to reflect in a complex manner about one’s own or another’s mind and hypermentalizing, the ability to generate complex representations of their mental states, however without sufficient evidence to support these. Genuine mentalizing ability is characterized by a realistic representation of one’s own and others’ mental states, and the recognition of the opaqueness of these. Individuals may however over play their recognition and understanding of mental states and thus researchers must be aware of this. In short, social cognition assessing how certain an individual is about their mental states and those of others. A type of meta-cognitive model of mental states, reflective functioning offers suggestion that certainty/uncertainty about emotions, linked to emotional schemas, has an impact on the ability to accept and manage emotions, Fonagy et al, (2016) found that certainty about emotions on the reflective functioning questionnaire was positively associated with Mindful Awareness Attention Scale, whilst uncertainty was negatively associated with this. This highlights the relationships between ability to regulate emotions and social cognition/ emotional schema. This suggests that those who are mindfully aware/more certain of their mental state, characterised as having a more genuine mentalising ability may have a reduction in emotion regulation difficulties, considering the evidence that practicing mindfulness has been found to reduce emotion regulation difficulties, (Roemer, Williston & Rollins, 2015).
Research conducted into the mentalization ability of adolescents with Borderline Personality Disorder have found that the relationship between over-mentalizing and BPD traits were mediated by emotion regulation difficulties, accounting for a large percentage of BPD traits, (43%), (Sharp et al, 2011).
Social Cognition/Mentalization, Emotion Regulation, Emotional Schema and Trauma
Neuroimaging research has identified that the medial prefrontal cortex, the precuneus/posterior cingulate cortex and the temporo-parietal junction work together to construct the network associated with mentalizing, (Atique et al, 2011; Corradi-Dell’Acqua, Hofstetter & Vuilleumier, 2014). Following trauma, the high levels of arousal lead to a temporary reduction in the activation in part of this network, disabling the ability to mentalize, (Arneston, 1998) and continued exposure to high levels of arousal may lead to a reduction in the threshold for mentalizing, creating a long term effect on mentalizing ability, (Mayes, 2000). Following repeated victimization of childhood maltreatment, children were found to be at higher risk of depression; a ‘shutting down’ of reflective functioning as a defence mechanism to repeatedly high levels of arousal led to children having lower levels of mentalization and experiencing higher levels of dissociation, (Ensink, Bégin, Normandin, Godbout & Fonagy, 2017). As a consequence, mentalization-based treatments have been proposed for use with individuals suffering from depression, (Foa, 1997) and Borderline Personality Disorder, (Bateman & Fonagy, 2010) following trauma. This offers evidence for the contribution of mentalizing in psychopathology, and as previously suggested, may be a consequence of the development of maladaptive emotion regulation strategies.
Research has shown that following trauma, individuals are found to experience higher levels of the maladaptive emotion regulation strategy, suppression and have higher arousal levels when attempting to reduce their negative emotions, Shepherd & Wild, 2014). As discussed previously, increased arousal decreases functioning networks responsible for mentalizing, suggesting that the ability to mentalize and regulate emotions are both affected by trauma/ PTSD symptoms.
Alexithymia, an inability to label emotions has also been found to be higher in individuals who have experienced early traumatization when compared with controls (McLean et al, 2006), associated with a deficit in the ability to recognise and accept emotions is characteristic of emotion regulation difficulties, low levels of emotional intelligence and a limited ability to mentalize, specifically about emotions.
Rationale
As explored, trauma has an impact on an individual’s ability to regulate their emotions, the schemas they form about their emotions (and the mental states of others) and their ability to mentalize. This research project, however aims to test whether trauma predicts emotion dysregulation in a general population and whether emotion schema and social cognition (ability to mentalize) mediate this relationship. It is expected that there will be a strong positive association between trauma and emotion regulation difficulties. Trauma will be negatively associated with social cognition and the ability to mentalize, and trauma will be positively associated with emotional schema when measured as a composite score of ‘negative beliefs about emotions’. Social cognition and emotional schema will also be expected to account for a large proportion of the variance explained in emotion regulation and will mediate the relationship between trauma and emotion regulation difficulties.