Abstract
This research aimed to validate an Emotion Regulation Training program cultivating resilience, strengthening interpersonal communication, and enhancing emotional intelligence. A community sample of 104 participants were assigned to either an intervention (n = 51) or nonactive control (n = 53) group matched by age and gender. In addition, data were gathered via a cognitive performance test conducted pre- and postmeasurement in a subset of the larger sample (n = 19 intervention, n = 19 control). Results revealed reappraisal significantly increased in the intervention group, which was associated with a decrease in depressive symptomology, worry, and suppression, and a concurrent increase in overall mental well-being, supporting the validation of the Emotion Regulation Training program.
Introduction
Emotions are among the most influential factors affecting well-being (Kotsou, Nelis, Grégoire, & Mikolajczak, 2011; Zhu, Gan, Yan, & Zhang, 2017) and cognitive functioning (Bebko, Franconeri, Ochsner, & Chiao, 2011; Gross, 2013). They are cardinal components of everyday life, positively or negatively influencing adaptive functioning, impacting intrapersonal and interpersonal skills such as group cohesion and self-confidence (Koole, 2009). Thus, in order to achieve emotional well-being and maintain optimal emotional functioning, it is imperative one regulates emotions in a manner that optimizes their beneficial aspects while limiting their detrimental components.
Emotion regulation refers to the heterogeneous processes implemented to regulate affective experience (Gross, 1998). It includes the regulation of emotions, both up and down, as one may decrease, amplify, or sustain positive and negative emotional states in a dynamic process that involves choosing an adaptive strategy that is contextually appropriate (Erber, Wegner, & Therriault, 1996; Ghafur, Suri, & Gross, 2018). Effective emotion regulation is crucial and may protect against mental disorders including anxiety (Cisler & Olatunji, 2012; E. Sloan et al., 2017) and depression (Davidson, Pizzagalli, Nitschke & Putnam, 2002; Visted, Vøllestad, Nielsen, & Schanche, 2018), while the inability to regulate emotions is debilitating and is a cardinal diagnostic feature in a large percentage of DSM-IV disorders (American Psychiatric Association, 1994). Consequently, evidence-based, preventative psychosocial interventions with concrete theoretical backgrounds are required due to the prevalent occurrence and detrimental impact of mental illnesses. Various programs have been established and implemented in order to address this need (e.g., National Registry of Evidence-Based Programs and Practices, 2018), and though these programs have proven effective in both nonclinical and clinical samples (Bolier et al., 2013; Renna, Quintero, Fresco, & Mennin, 2017; Sin & Lyubomirsky, 2009), general resilience programs focusing on community mental health promotion are still relatively scarce (Zeidner, Roberts, & Matthews, 2008). Resilience, within this context, refers to people’s ability to adapt to and deal with challenges while maintaining their mental health; developing resilience is considered a vital prevention strategy against mental illnesses (Chmitorz et al., 2018). Thus, it is imperative that theoretically based, systematically implemented, and rigorously evaluated programs using sound experimental designs are created for further application.
With these concerns in mind, the current research aimed to further validate a compact Emotion Regulation Training (ERT) program by applying it on a larger scale (LeBlanc, Ozer, Pourseied, & Mohiyeddini, 2017). The program was theoretically based on the Process Model of Emotion Regulation (Gross, 1998), which states there are numerous strategies one can utilize to modulate their emotional responses. These strategies are divided into two distinct categories known as antecedent and response-focused strategies. Antecedent strategies are implemented early during affect generation, whereas strategies focused on response occur late during the emotion generation progression, effecting behavioral responses (Gross, 1998). Research has shown response-focused strategies, including emotional suppression, are less effectual and are associated with negative social, cognitive, and health consequences when compared with antecedent-focused methods including cognitive reappraisal (English & John, 2013; Gross & John, 2003; Hofmann, Heering, Sawyer, & Asnaani, 2009; Kashdan & Steger, 2006).
The current training program followed a three-tiered process involving education, application, and bibliotherapy (supporting mental health through literature; LeBlanc et al., 2017). The intervention was operationalized as mental conditioning and viewed as a proactive way to enhance resilience, synonymous with using physical conditioning to enhance one’s physical health. It was employed via group training in everyday settings to optimize reach, scalability, and destigmatization. From a content perspective, various cognitive and behavioral techniques were introduced in order to accommodate individual differences, varying competency levels and personal preference. Cognitive techniques included reappraisal (John & Gross, 2004), expressive writing (EW) and mindfulness, coupled with behavioral techniques like diaphragmatic breathing and progressive muscle relaxation, which have been affiliated with positive health in both nonclinical and clinical samples (Alsubaie et al., 2017; Leyland, Rowse, & Emerson, 2019; Pennebaker & Chung, 2012; D. M. Sloan & Marx, 2018).
The objectives of the current study were twofold. First, the research aimed to further validate the main outcomes of an earlier study (see LeBlanc et al., 2017) in a larger sample, utilizing a quasi-experimental design, matching groups based on age and gender as this has been shown to significantly influence affect regulation and well-being (Gross & John, 2003). Second, in addition to self-report and questionnaire data, this study collected objective data; as memory and attention have been shown to be impacted by emotion regulation (Gross, 2007), a cognitive performance test was implemented to evaluate the impact the increased use of reappraisal had on performance.
Empirical research has demonstrated suppression of emotions is correlated with a reduction in working memory (Richards & Gross, 2000) and cognitive capability (Baumeister, Vohs, & Tice, 2007), while reappraisal has been shown to be linked with memory enhancements (Hayes et al., 2010; Jasielska et al., 2017) and improved performance (Jamieson, Mendes, Blackstock, & Schmader, 2010; Jamieson, Mendes, & Nock, 2013). The ERT program aimed to increase the use of adaptive coping techniques (e.g., reappraisal) while minimizing the employment of less adaptive strategies (e.g., suppression). Accordingly, a cognitive performance test was developed and employed pre- and postintervention to measure the performance of participants directly after viewing two emotionally evocative film clips. The rationale behind this was to determine if the intervention group would apply their ERT by using adaptive strategies such as reappraisal to foster mood repair, and if this would lead to a substantial performance increase when compared to the control group.
The development of adaptive emotion regulation competencies is paramount, as it has been associated with enhanced relationships on the interpersonal level, increased productivity at work, and positive health outcomes (Zhu et al., 2017) which promotes optimal human functioning, leading one to experience a more flourishing life (Keyes, 2007).
As mentioned previously, there is limited empirical evidence demonstrating the feasibility and utility of developing emotion regulation competencies in healthy adult samples, and thus, the current study attempts to contribute to this area by validating a recently designed training program (see LeBlanc et al., 2017). The training program is unique, as it employs a multidimensional methodology, teaches a diverse set of skills, and has shown preliminary success at providing a coping tool kit to effectively deal with life’s challenging events (LeBlanc et al., 2017). This program may have broader applications in alternative environments and could be implemented in community mental health centers as well as organizational and educational settings to promote mental health literacy and increase affect regulation competencies.
Method
Participants
A sample of 104 (n = 51 intervention, n = 53 control) participants recruited from the community were allocated to either the training or control condition, matched by age and gender (52 males and 52 females, Mage = 34.43, standard deviation (SD) = 13.41, range = 17–59 years; 97% of Caucasian descent). A stringent exclusion criterion was utilized and participants suffering from any clinical or psychiatric illnesses, who’s daily alcohol intake exceeded 10 units per day (where alcohol begins to reach toxic levels; National Health Service, 2018) or who abused illicit drugs were eliminated.
Instruments
A questionnaire package including a Consent Form, a General Information Questionnaire, the Emotion Regulation Questionnaire (ERQ), the Satisfaction with Life Scale (SWL), the Depression Anxiety and Stress Scale (DASS 21), the Schwartz Outcome Scale-10 (SOS-10), and the Penn State Worry Questionnaire (PSWQ) was used to collect data.
ERQ (Gross & John, 2003) is a 10-item psychometric tool that measures emotional suppression (4 items) and cognitive reappraisal (6 items). It is measured on a seven-point Likert-type scale (1 = strongly disagree; 7 = strongly agree). ERQ has demonstrated strong psychometric characteristics manifested through high Cronbach’s α values for reappraisal (α = .79) and suppression (α = .73), and high test–retest reliability (.70) for the respective subscales (Gross & John, 2003). It has also shown strong convergent (r = .88 with Negative Mood Regulation Scale; Catanzaro & Mearns, 1990) and discriminant validity (r = .76 to .88 with Big Five Inventory; John & Srivastava, 1999). In the current study, internal reliability values varied between .68 and .86.
SWL (Diener, Emmons, Larsen, & Griffin, 1985) is a five-item psychometric tool measuring general life fulfillment on a seven-point Likert-type scale (1 = strongly disagree; 7 = strongly agree). SWL has demonstrated sound internal reliability (α = .87; Diener et al., 1985). Cronbach α values varied between .88 and .90 in the current research.
DASS-21 (Norton, 2007) is a questionnaire measuring depressive symptomology, anxiety, and stress (Lovibond & Lovibond, 1995). It is measured via a four-point Likert-type scale (0 = did not apply to me at all; 3 = applied to me very much, or most of the time). It has shown strong psychometric properties; the internal reliability values are .91, .84, and .90 for the anxiety, depressive symptomology, and stress scales (Mitchell, Burns, & Dorstyn, 2008). In addition, its construct validity has been confirmed (Henry & Crawford, 2005). In the current study, internal reliability values varied between .80 and .93.
SOS-10 (Blais et al., 1999) measures global, psychological well-being. It is a 10-item psychometric tool measured via a seven-point Likert-type scale anchored at 0 = never and 6 = all of the time or nearly all of the time. It has shown strong internal reliability (.96) and test retest reliability (r = .87) in nonclinical samples (Blais et al., 1999). Cronbach α values varied between .87 and .93 for the current study.
PSWQ (Meyer, Miller, Metzger, & Borkovec, 1990) is a psychometric tool considered the gold standard for assessing maladaptive worry. It has 16 items and employs a five-point Likert-type scale (1 = not at all typical of me and 5 = very typical of me). The PSWQ has sound test, retest reliability (r = .92), and internal reliability (α = .93; Meyer et al., 1990). Internal reliability varied between .94 and .95 in the current research.
Procedure
After attaining liability insurance and institutional review board’s approval, newspaper ads and public message boards were used to attract participants. Initially, 156 participants were recruited; however, 51 were excluded, 29 for failing the inclusion criteria and 22 for noncompletion of minimum program requirements, this culminated in an attrition rate of 21%, which is considered acceptable (Swift & Greenberg, 2012).
The statistical program G-Power (Faul, Erdfelder, Lang, & Buchner, 2007) was used and a power analysis was conducted: participants (n = 94) were required to demonstrate an effect size of 2 = .6, showing a significant variance between the control and intervention groups with a power of .90 (minimum, α = .05). Once a satisfactory number of participants advanced through the phase of screening (>94), a quasi-experimental design matching age and gender of participants was employed (Stuart & Rubin, 2008), after which the workshops began.
At the opening informational session, all participants in both conditions were provided a questionnaire package including a letter of intent, form of consent, debriefing forms, and questionnaires. Intervention group participants were advised attendance to a weekly, 1.5- to 2.0-hour workshop over the next four weeks. Workshops utilized a small group setting consisting of roughly 5 to 15 participants; groups were semistructured to increase ecological validity and reduce attrition, as a large time commitment was required from participants. All workshops were facilitated by the first author to warrant consistency of material and presentation style and a nonactive control group was employed. Following the baseline measurements, the control group remained inactive until the completion of the training program, after which both groups completed the questionnaire package for a second time.
During the four-week intervention, 2.5-hour semistructured workshops using a combination of cognitive behavioral therapy and mindfulness-based techniques were used within the ERT program (LeBlanc et al., 2017). In addition, a computer performance test was administered to 38 participants (19 treatment, 19 control), where matched pairs were chosen randomly from the larger sample (n = 104). The test procedure was based on studies conducted by Dillon, Ritchey, Johnson, and LaBar (2007), who administered memory tests to evaluate effects of emotion regulation on memory, and Goldin and Gross (2010), who used neuroimaging assessments to measure the influence mindfulness had on emotion regulation. The test was conducted to see whether suppression or rumination would affect participants’ memory processes, since it was shown that suppression and rumination (Gross & John, 2003) impair memory and attention processes, while reappraisal enhances memory and increased performance (Jamieson et al., 2010). The performance test included only a subset of the larger sample to maximize participation rates; the intervention was conducted in a naturalistic setting using a community sample and no incentive was provided, thus, only a subset of the sample was chosen to reduce attrition. The performance test was administered to participants after their viewing of an emotionally upsetting 3-minute film clip evoking sadness, adapted from Gross and Levenson (1995). The first clip was shown at preintervention, while the second clip was shown at postintervention. The emotion sadness was selected as the clips were viewed in a group where people are more inclined to suppressing their emotions among others. Thus, if the film were to produce tears and the participants were inclined toward suppressing their feelings due to group acceptance and social desirability, it is likely they would attempt to withhold their tears (Gross & John, 2003).
The test of performance also included a digital game designed to affect the brain’s memory and attention centers. This required participants to view an image on a card in order to memorize it. After they felt confident they did so, they pressed spacebar, where they acknowledged if the card being displayed on the screen corresponded to the previously viewed card. Cards were presented randomly during the computer test, with participants controlling the necessary time for memorizing each card. Participants were provided instructions for playing the game and were allowed to try two practice rounds to get used to the protocols of the game. They were then moved to a viewing room and shown the first video clip. Upon completion of the film, they were returned to the computer laboratory to play the game two times more. The procedure was repeated following the conclusion of the experiment (postintervention), but a different video clip was utilized, again adapted from Gross and Levenson (1995), to avoid habituation to the original clip and thereby a possible decrease in emotional impact (Strenziok et al., 2010). This procedure was identical for both the intervention and control groups.
In order to control for potential extraneous variables that could mediate pre- and postintervention results, no changes were asked to be made to the schedules of the participants aside from the four-week intervention program. The researchers closely monitored the timely following of the workshop program, and it was made sure that no communication was established between members of the control and intervention groups in order to prevent transfer of information that could mediate the results.
Treatment
The workshops covered various topics such as emotion identification, emotion regulation, reappraisal, mindfulness, emotional suppression, positive self-talk, rumination reduction via EW, and relaxation through progressive muscle relaxation. The overarching goal of the ERT program (LeBlanc et al., 2017) was to promote the use of adaptive strategies of emotion regulation in participants through education while discouraging the use of less adaptive techniques such as emotional suppression. This principal aim was hypothesized to increase mental well-being.
Workshops
Workshop 1—Introduction to Emotion Regulation involved labeling and categorizing emotions according to behavioral, cognitive, and physiological components. Emotion regulation was defined, and adaptive strategies were outlined and activities demonstrating the advantages of cognitive reappraisal in comparison with emotional suppression were completed.
Workshop 2—EW involved journalizing one’s most profound feelings and thoughts associated with vital and unique life experiences (Pennebaker & Beall, 1986). Through an adaptation of the EW paradigm, this session’s goal was to reduce excessive rumination (Mohiyeddini, 2005).
Workshop 3—Mindfulness trained participants to “pay attention in a particular way: on purpose, in the present moment and non-judgmentally” (Kabat-Zinn, 1994, p. 4). During this workshop, basic mindfulness principles were outlined and activities like the 3-minute breathing space were completed.
Workshop 4—Self-talk paired with Cue-Controlled Relaxation: In the final workshop, diaphragmatic breathing and cue-controlled relaxation and positive self-talk were taught. This workshop revisited previously discussed concepts of reappraisal and cognitive restructuring. Participants critically evaluated their thinking by identifying unrealistic and distorted thought patterns. Once identified, distorted thought patterns were challenged and reframed, after which a final worksheet focusing on key achievements, personal strengths, and positive affirmations were completed. The final segment of this workshop briefly introduced cue-controlled relaxation, progressive muscle relaxation, and diaphragmatic breathing.
Debriefing
Once the intervention was completed, participant debriefing occurred both verbally and in written format. Furthermore, during the debriefing phase of the study, confidentiality of, and one’s right to withdraw information was reiterated.
Results
For reappraisal, a paired samples t test in the intervention group showed a noteworthy mean score increase, t(50) = 2.55, p ≤ .01, preintervention to postintervention. Moreover, the results showed a significant increase, t(50) = 5.83, p ≤ .00, in satisfaction with life scores over time. Further reductions were found for stress, t(50) = 3.26, p ≤ .002, preintervention to postintervention and for anxiety, t(50) = 3.36, p ≤ .002, preintervention to postintervention. Moreover, a significant decrease was found for worry, t(50) = 2.37, p ≤ .02, preintervention to postintervention. Mental health indicators for the control group showed no significant changes. Table 1 shows the descriptive statistics of the psychometric questionnaires used in collecting data, while Table 2 shows the bivariate correlations for the intervention group comparing reappraisal with all mental health indicators measured.
Descriptive statistics of the study variables measuring mental health indicators in the intervention and control groups in Study 2.
Note: N = 104. SD: standard deviation; ERQ: Emotion Regulation Questionnaire; DASS: Depression, Anxiety and Stress Scale; SOS: Schwartz Outcome Scale; PSWQ: Penn State Worry Questionnaire.
Bivariate correlations between reappraisal and mental health indicators for the intervention group over time.
Note: A one (1) after the variable represents a pretest score while a two (2) represents a posttest score. N = 51.
*p < .05. **p < .01.
Validation results: Performance test
Two independent samples t tests were run for the performance test to compare the intervention and control groups (n = 38). These tests, based on the number of correct responses and postmeasurement reaction times, revealed meaningful differences between the groups, t(37) = 5.41, p ≤ .01, and, t(37) = 3.11, p ≤ .004, respectively. Moreover, for the intervention group (n = 19), paired samples t tests revealed noteworthy increases in correct response numbers (M = 47.6, SD = 9.0, preintervention; M = 53.2, SD = 11.4, postintervention), t(18) = 4.82, p ≤ .01, d = .55, and reaction times, t(18) = 3.79, p ≤ . 01, d = .34, from pretest (M = 710.4, SD = 231.7) to posttest (M = 630.9, SD = 240.9).
Discussion
The current study tried to extend the findings of a previous study testing the effectiveness of the ERT program (Leblanc et al., 2017). Since the initial study relied solely on self-reported, questionnaire data, the current study sought to validate the initial findings while also gathering more objective data, via a computer performance test, further demonstrating its effectiveness.
Baseline analysis revealed the control and intervention groups differed significantly in both overall well-being and life satisfaction; the intervention group manifested meaningfully higher levels for both components. The groups also differed in their depression, anxiety, worry, and stress levels, with the intervention group showing considerably higher levels of all components. In the previous study, similar results were obtained after the application of the ERT program, where the intervention group showed significantly higher levels of life satisfaction and lower levels of depression, anxiety, and stress compared to the control group (Leblanc et al., 2017). The current study’s results show that the ERT program proposed by Leblanc et al. (2017) is indeed effective in a larger sample, thus validating the application of the program.
It is possible the observed intervention and control group discrepancy may be caused by a moderate floor effect (dependent variable measurements resulting in very low scale scores) in the intervention group (Lammers & Badia, 2005). This finding, in part, may be the result of the study’s utilization of a matched pairs research design (nonrandom); this could imply participants actively seeking enrollment in the ERT program were under a substantial amount of stress or experiencing low life satisfaction prior to enrollment. Thus, in an attempt to counter this effect, future research could employ randomization.
These findings are parallel to the World Health Organization’s (2004) mental health definition, which asserts it is not only the absence of psychopathology but rather a “state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community.” Thus, the increase in positive psychological assets (reappraisal and satisfaction with life) are significant and align with the burgeoning positive psychology literature, where recent research has demonstrated psychological resilience is a dynamic construct that can be developed through directed intervention (Chmitorz et al., 2018; Renna et al., 2017). Two meta-analyses, in support (Bolier et al., 2013; Sin & Lyubomirsky, 2009), have demonstrated the efficacy of interventions of positive psychology, determining they enhance subjective and psychological well-being while reducing depressive symptomology with relatively sustainable effects at the short-term follow-up. Relatedly, research in both organizational and educational settings has demonstrated the importance and efficacy of preventative mental health interventions (Kalra et al., 2012; Jorm, 2012). For example, Tan et al. (2014) conducted the first systematic review of universal, preventive interventions in organizational settings. The authors determined mental health promotion initiatives, particularly those with a strong cognitive behavioral component, significantly enhanced workplace well-being. Similarly, an international review commissioned by World Health Organization determined mental health promotion interventions had a moderate to strong positive impact on mental health in both educational and community settings (Barry, Clarke, Jenkins, & Patel, 2013). Thus, when considered in the context of the aforementioned literature, the current findings provide support for further investigation into the efficacy of the ERT program in alternative environments, such as organizational and educational settings, to test its feasibility and flexibility in order to elucidate the scope of its reach.
In support of the primary hypothesis, the performance test findings indicated significant improvements in accuracy and reaction times for the intervention group. In contrast, no significant changes in reaction times were found for the control group; however, a significant improvement in the number of questions answered correctly was found at the follow-up measurement. Due to the learned affects from completing the test eight times, this was an expected finding for both groups (Kantowitz, Roediger, & Elmes, 2014). However, within the intervention group, a gain of 1.16 correct answers over the control group was found and a total mean score of 4.95 correct answers higher was obtained when compared with the control condition. Thus, from an objective standpoint, a superior performance was demonstrated by the intervention group. One possible explanation for this finding is that the intervention group, after receiving the ERT, may have become more adept at regulating their emotions after viewing the emotionally evocative videos. It is possible the intervention group chose adaptive regulation strategies, such as reappraisal, which has been associated with memory improvements (Hayes et al., 2010; Jasielska et al., 2017) and enhanced performance (Jamieson et al., 2010, 2013). However, further research utilizing large sample sizes and biological markers of stress, like salivary cortisol (Bozovic, Racic, & Ivkovic, 2013), would help to strengthen these findings.
The current study, along with its strengths, also has some limitations as well. Utilizing a homogenous sample would be one limitation; the sample in the current research did not include people with clinical mental illnesses or alcohol and/or substance abuse problems. Thus, further studies including people above the clinical threshold and taking into account the emotion regulation strategies they use is warranted. Moreover, gathering questionnaire data not only by self-reports but also from multiple sources, such as peers, colleagues, or family members, both pre- and postinterventions would strengthen and enhance the current findings. Although the quasi-experimental design was appropriate for the research question in this study, conducting further studies with different experimental designs would help better generalize the findings of the research and even further validate the program. Also, though the matched sample design used in the study with age and gender for the intervention and control groups was fitting for the research, using matched sample design with mean scores would further strengthen the study findings. Although the memory task procedure used in the study was based on previous studies (Dillon et al., 2007; Goldin & Gross, 2010), its usage in the specified manner was fairly recent. Further usage of this procedure would help enhance its validity and reliability. Moreover, similar research can be conducted in the future with different methods to be able to compare the generalizability of the results. During the research, all of the workshops were facilitated by the same person to affirm consistency; however, future research could be conducted with different researchers for intervention and control groups facilitating the workshops to ensure changes in results occur due to a treatment effect rather than a therapist effect. In addition, in an attempt to gather objective data, a performance test was utilized after an emotionally evocative clip was viewed; however, whether or not the film elicited a sad emotional state, and the coping method employed by the participants after viewing the film was not explicitly measured, which could be problematic as both emotional sensitivity and regulation have been shown to be highly variable (Gross & John, 2003; Larsen & Ketelaar, 1991). Due to this variability and inherent dynamicity of affect, future research should seek to gather data using measures that include biological markers of reactions concerning stress like salivary cortisol (Bozovic et al., 2013) to further increase objectivity.
Conclusion
The current study validated the results of a previous study (LeBlanc et al., 2017) with a sample which was larger and matched based on age and gender. This study demonstrated cognitive reappraisal and life satisfaction significantly increased, while depression, anxiety, and stress were significantly reduced in the intervention group. Moreover, in the event of an emotionally provocative occurrence, which was watching a sad video for the current study, the intervention group, compared with the control condition, was able to control their emotions, demonstrating superior performance postintervention. As such, the current study shows that it could be useful to modify certain components of people’s lives like perceived stress levels and subjective well-being to a certain extent. From a pragmatic perspective, the compact intervention equipped participants with practical tools that cultivated improved cognitive performance and emotional well-being. This line of research may have broader implications as well; from a public health perspective, it may be beneficial to examine how the impact of evidence based, cost-effective, preventative initiatives can be expanded in order to increase mental health literacy, emotion regulation, and self-efficacy within the greater community.