Self-compassion enhances the efficacy of explicit cognitive reappraisal as an emotion regulation strategy in individuals with major depressive disorder

Highlights

• In depressed individuals, the efficacy of emotion regulation strategies is probably moderated by contextual factors.

• These contextual factors likely include the preparatory use of other emotion regulation strategies.

• The preparatory use of self-compassion as an emotion regulation strategy enhances the efficacy of cognitive reappraisal.

Abstract

Cognitive reappraisal has been shown to be an effective strategy to regulate depressed mood in healthy and remitted depressed individuals. However, individuals currently suffering from a clinical depression often experience difficulties in utilizing this strategy. Therefore, the goal of this study was to examine whether the efficacy of explicit cognitive reappraisal in major depressive disorder can be enhanced through the use of self-compassion and emotion-focused acceptance as preparatory strategies. Thereby, explicit cognitive reappraisal refers to purposefully identifying, challenging, and modifying depressiogenic cognitions to reduce depressed mood. To test our hypotheses, we induced depressed mood at four points in time in 54 participants (64.8% female; age M = 35.59, SD = 11.49 years) meeting criteria for major depressive disorder. After each mood induction, participants were instructed to either wait, or employ self-compassion, acceptance, or reappraisal to regulate their depressed mood. Depressed mood was assessed before and after each mood induction and regulation period on a visual analog scale. Results indicated that participants who had utilized self-compassion as a preparatory strategy experienced a significantly greater reduction of depressed mood during reappraisal than did those who had been instructed to wait prior to reappraisal. Participants who had used acceptance as a preparatory strategy did not experience a significantly greater reduction of depressed mood during subsequent reappraisal than those in the waiting condition. These findings provide preliminary evidence that the efficacy of explicit cognitive reappraisal is moderated by the precursory use of other emotion regulation strategies. In particular, they suggest that depressed individuals might benefit from using self-compassion to facilitate the subsequent use of explicit cognitive reappraisal.

Introduction

With a life-time prevalence of 16.6%, major depressive disorder (MDD) constitutes an important health problem (Kessler et al., 2005) that is associated with significant morbidity, mortality, disability, and emotional anguish for patients and their families (Murray & Lopez, 1997). Unfortunately, many patients fail to respond to empirically-based treatments (e.g., DeRubeis et al., 2005, Rush et al., 2006), and even those who do respond, remain impaired due to residual symptoms (Judd et al., 1998, Judd et al., 1997) or relapse (e.g., Thase et al., 1992, Vittengl et al., 2007). Given that deficits in emotion regulation (ER) have lately been discussed as a potentially maintaining factor in depression (Berking et al., 2013, Hofmann et al., 2012, Mennin et al., 2007), the efficacy of current treatments for MDD might be improved by focusing more strongly on teaching patients adaptive ER skills which in turn might facilitate recovery from depression (Mennin & Fresco, 2009).

Adaptive ER refers to a goal-directed and flexible application of ER skills with regard to environmental demands (Aldao et al., 2015, Gross, 2014, Sheppes et al., 2014). Consistent with this perspective on ER, the Adaptive Coping with Emotions (ACE) model (Berking & Whitley, 2014) conceptualizes adaptive ER as a situation-dependent interaction between the following ER skills: (1) the ability to be consciously aware of emotions, (2) the ability to identify emotions, (3) the ability to correctly label emotions, (4) the ability to identify what has caused and what maintains one's present emotions, (5) the ability to actively modify emotions, (6) the ability to accept and (7) tolerate undesired emotions when they cannot be changed, (8) the ability to approach situations that are likely to trigger negative emotions if necessary to attain personally relevant goals, and (9) the ability to provide compassionate self-support when working to cope with challenging emotions. The ACE model postulates that when it comes to the reduction of mental health problems, the ability to modify undesired emotions is most important among these skills (Berking & Whitley, 2014).

One of the most widely studied ER skills aiming at modifying negative emotions is cognitive reappraisal (CR; e.g., Gross, 2002; Gross and John, 2003, McRae et al., 2012). CR has been defined as cognitively “construing a potentially emotion-eliciting situation in a way that changes its emotional impact” (Gross & John, 2003, p. 349). According to cognitive theories of depression, dysfunctional cognitive processes play an important role in the development and maintenance of depression (Beck and Haigh, 2014, Teasdale and Barnard, 1993; for critical reviews, see; Coyne & Gotlib, 1983 or; Haaga, Dyck, & Ernst, 1991). Hence, replacing depressogenic automatic appraisals with alternative evaluations of the situation (i.e., CR) can be assumed to have the potential to reduce negative emotions and associated symptoms in depression (Gotlib & Joormann, 2010). Several forms of CR exist (McRae, Ciesielski, & Gross, 2012). An explicit form of CR that is - among other cognitive strategies - often used in traditional cognitive (behavioral) therapy for depression consists of: (a) becoming aware of the thoughts cueing undesired affective states, (b) reflecting upon/testing the validity/consequences of these thoughts, (c) purposefully developing more valid/helpful thoughts, and (d) using these thoughts to modify one's feelings (e.g., Beck, 2011). This form of CR is not equal to the more complex process of cognitive restructuring, but may contribute to the restructuring of dysfunctional beliefs and thus the reduction of depression in the long-term. Empirical support for the anti-depressive effects of CR comes from studies indicating that CR is negatively associated with depression in non-clinical samples, both concurrently (see e.g. Aldao and Nolen-Hoeksema, 2010, Aldao et al., 2010, Garnefski and Kraaij, 2006, Garnefski et al., 2003) and prospectively (e.g., Kraaij, Pruymboom, & Garnefski, 2002). Further evidence originates from studies demonstrating that experimentally induced CR helps healthy and recovered depressed individuals to reduce negative emotions (e.g., Ehring et al., 2010, Rood et al., 2012) and from studies showing that cognitive (behavioral) therapy is an efficacious treatment for depression (Butler et al., 2006, Cuijpers et al., 2013, Dobson, 1989). However, some empirical findings also indicate that individuals scoring high on indicators of neuroticism (as trait found to be associated with depression; Jylhä & Isometsä, 2006) and depressed individuals themselves have difficulties in reappraising negative emotions (Barnow et al., 2011, Ehret et al., submitted, Ng and Diener, 2009a, Ng and Diener, 2009b). CR relies heavily on cognitive executive functions – which are likely to be impaired in depressed individuals (Fossati et al., 2001, Gotlib and Joormann, 2010). Moreover, accessing more helpful cognitions by reappraising an emotion eliciting situation is a challenging task when these cognitions are incongruent with emotional and somatic states associated with depression (Gotlib and Joormann, 2010, Joormann and Siemer, 2004, Singer and Salovey, 1988). Hence, prior research also shows that depressed individuals do not always benefit from CR (Arditte and Joormann, 2011, Diedrich et al., 2014).

These arguments and the inconsistent findings in the literature about the efficacy of CR raise the question whether factors moderating the efficacy of CR in depressed individuals can be identified. Unfortunately, research on the efficacy of ER strategies has so far neglected the moderating effects of contextual factors (Aldao, 2013, Coifman and Bonanno, 2010). Because of the dynamic nature of the ER process - likely involving the sequential or coactive implementation of multiple ER strategies during a given period of time - the complementary use of other ER strategies appears to be a promising candidate for such a significant contextual factor (Aldao, 2013, Berking, 2007, Berking and Schwarz, 2013, Berking and Whitley, 2014, pp. 19–27). Consistently, the ACE model includes the hypothesis that the efficacy of modification-focused strategies such as CR may be moderated by ER strategies used prior to (or in combination with) CR (Berking & Whitley, 2014). More specifically, Berking and Whitley (2014) assume that compassionate self-support and acceptance of one's current feelings are two ER strategies that may facilitate the utilization of modification-focused strategies such as CR. According to commonly applied definitions, compassion refers to the “sympathetic consciousness of others' distress together with a desire to alleviate it” (Merriam-Webster, 2014). Hence, self-compassion can be defined as a compassionate response towards one's own suffering (Berking & Whitley, 2014, p. 22; Berking, 2007, Gilbert, 2009, Weissman and Weissman, 1996). The concept of emotion-focused acceptance involves the openness to internal affective experiences and the willingness to remain in contact with them even if they are painful (Campbell-Sills, Barlow, Brown, & Hofmann, 2006). Both self-compassion and acceptance have been shown to effectively reduce the intensity of challenging affective states in depression (Diedrich et al., 2014, Liverant et al., 2008, MacBeth and Gumley, 2012, Singer and Dobson, 2009).

Reasons to assume that self-compassion can also be used to facilitate CR in depressed individuals include the following. First, compassion involves empathy which can be considered a basic affective response (Singer & Lamm, 2009) that is generated in affect generating systems and taxes the resources of these systems (Singer, Seymour, O'Doherty, Kaube, Dolan, & Frith, 2004). As the affect-generating systems have limited processing capacities (Teasdale & Barnard, 1993), eliciting an affective compassionate response (i.e., empathy) towards the self can be assumed to replace affective states that are typically associated with depression (e.g., depressed mood) and that have been shown to interfere with accessing and utilizing positive cognitions (e.g., Joormann and Gotlib, 2007, Koster et al., 2010, Segal et al., 2006). Secondly, the compassionate response includes a supportive attitude towards the suffering self which can be assumed to interfere with depressogenic self-criticism likely to be cued during challenging tasks (such as utilizing CR) in depression-prone individuals (Gilbert et al., 2004, Luyten et al., 2007, Mongrain and Leather, 2006). Thirdly, the action tendency associated with compassion is to help the suffering individual (Leiberg, Klimecki, & Singer, 2011). Therefore, self-compassion can be assumed to strengthen the motivation to engage in promising self-help strategies (such as CR) even if they are difficult to initiate and maintain (Berking & Whitley, 2014, p. 22). This effect may be particularly important in depressed individuals likely to suffer from motivational deficits when it comes to active problem solving (McFarland, Shankman, Tenke, Bruder, & Klein, 2006).

Additionally, it has been argued that the positive effects of self-compassion are less strongly affected by an increase in depressed mood (or other affective states associated with depression) than are CR and emotion-focused acceptance (Berking & Whitley, 2014, p. 23; Diedrich et al., 2014). Whereas an increase of negative affect interferes with the activation and utilization of positive cognitions (e.g., Joormann and Gotlib, 2007, Koster et al., 2010, Segal et al., 2006) and the acceptance of an undesired mood state becomes more difficult as the intensity of this mood state increases (Diedrich et al., 2014, Singer and Dobson, 2009), compassion grows even stronger when the affective state the observed person suffers from deteriorates (Hein & Singer, 2008). The latter may be explained by human desire to be happy and free of suffering (Neff, 2011). The greater suffering is, the greater the discrepancy between a current and a desired affective state is, as well. This in turn, may lead to having a greater empathetic wish and tendency to relieve suffering, i.e. to be compassionate. Preliminary evidence for this assumption comes from a study showing that, when compared with CR, the use of self-compassion was less effective in reducing mild-to-moderate depressed mood but more effective in reducing strongly depressed mood (Diedrich et al., 2014). Assuming that negative emotions are most intense at the beginning of an intentional regulation process in which several strategies are utilized sequentially, these findings suggest that using self-compassion might be a promising choice at the beginning of such a process that also utilizes CR albeit at a later stage. However, precursory effects of self-compassion on the efficacy of subsequent CR have not yet been investigated.

Acceptance of one's current emotions has been proposed as another adaptive ER strategy for depression as it might help depressed individuals to reduce the gap between a current aversive affective state and a desired affective state by lowering the desired state and hence reducing the extent to which depressed individuals are likely to become depressed over their current affective state (Berking & Whitley, 2014, pp. 137–139; Teasdale & Barnard, 1993, pp. 212–214). With regard to potential preparatory effects on CR, it can be assumed that acceptance of undesired affective states reduces the pressure to down-regulate these states and the fear of regulation failure which may interfere with adaptive regulation (Berking & Whitley, 2014, pp. 137–139; Eifert and Heffner, 2003, Feldner et al., 2006). Thus, accepting unwanted affective states may also facilitate the successful application of change-focused strategies such as CR. However, as it can also be argued that enhancing acceptance may reduce the motivation to work for change and may even cue feelings of hopelessness and resignation (Kraaij et al., 2002), the arguments for positive precursory effects of acceptance on CR appear less stringent than the arguments for positive effects of self-compassion. Empirically, the efficacy of acceptance as a precursory strategy for CR has not yet been investigated.

In sum, despite growing insight into the importance of context variables in the efficacy of ER strategies (Aldao, 2013, Berking and Schwarz, 2013, Coifman and Bonanno, 2010) there are no studies investigating how the efficacy of specific ER strategies in depression depends on the precursory use of other strategies. Thus, in the present study we aimed to examine whether the efficacy of explicit CR in depressed individuals can be further improved by engaging these individuals in self-compassion or emotion-focused acceptance prior to engaging them in CR. More specifically, we predicted that – when compared to a waiting-control condition – the guided use of self-compassion or emotion-focused acceptance would lead to a greater reduction of depressed mood during subsequent explicit CR.