Emotion Regulation and Vulnerability to Depression: Spontaneous Versus Instructed Use of Emotion Suppression and Reappraisal

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1 Emotion 2010 American Psychological Association 2010, Vol. 10, No. 4, /10/$12.00 DOI: /a Emotion Regulation and Vulnerability to Depression: Spontaneous Versus Instructed Use of Emotion Suppression and Reappraisal Thomas Ehring University of Amsterdam Jewgenija Schnülle and Silke Fischer University of Bielefeld Brunna Tuschen-Caffier University of Freiburg James J. Gross Stanford University Emotion dysregulation has long been thought to be a vulnerability factor for mood disorders. However, there have been few empirical tests of this idea. In this study, we tested the hypothesis that depression vulnerability is related to difficulties with emotion regulation by comparing recovered-depressed and never-depressed participants (N 73). In the first phase, participants completed questionnaires assessing their typical use of emotion regulation strategies. In the second phase, sad mood was induced using a film clip, and the degree to which participants reported to have spontaneously used suppression versus reappraisal to regulate their emotions was assessed. In the third phase, participants received either suppression or reappraisal instructions prior to watching a second sadness-inducing film. As predicted, suppression was found to be ineffective for down-regulating negative emotions, and recovered-depressed participants reported to have spontaneously used this strategy during the first sadness-inducing film more often than controls. However, the groups did not differ regarding the effects of induced suppression versus reappraisal on negative mood. These results provide evidence for a role for spontaneous but not instructed emotion regulation in depression vulnerability. Keywords: depression, vulnerability, emotion regulation, suppression, reappraisal Major depression is characterized by alterations in emotional functioning, including depressed mood and anhedonia (American Psychiatric Association, 2000). A number of authors have suggested that these alterations may be conceptualized as deficits in emotion regulation (Campbell-Sills & Barlow, 2006; Gross & Muñoz, 1995; Kovacs, Joormann, & Gotlib, 2008; Kring & Werner, 2004). In line with this view, it has been shown that self-reported difficulties in emotion regulation are related to current symptom levels of depression (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006a; Garnefski & Kraaij, 2006) as well as past depression (Ehring, Fischer, Schnülle, Bösterling, & Tuschen- Caffier, 2008). Although these findings are encouraging, empirical evidence for an emotion dysregulation view of depression vulnerability is still limited. In addition, emotion regulation is a very broad concept that encompasses a multitude of processes (see Gross & Thompson, 2007; Kring & Werner, 2004). It is therefore necessary to specify which aspects of emotion regulation are thought to be Thomas Ehring, Department of Clinical Psychology, University of Amsterdam; Brunna Tuschen-Caffier, Department of Psychology, University of Freiburg; Jewgenija Schnülle and Silke Fischer, Department of Psychology, University of Bielefeld; and James J. Gross, Department of Psychology, Stanford University. Correspondence concerning this article should be addressed to Thomas Ehring, Department of Clinical Psychology, University of Amsterdam, Roetersstraat 15, 1018 WB Amsterdam, the Netherlands. t.w.a.ehring@uva.nl involved in depression vulnerability, and to ground future research on a theoretical model that can account for the existing findings and generate specific hypotheses that can be tested experimentally. A Process Concept of Emotion Regulation To provide a conceptual framework for research on emotion regulation, Gross (2002) proposed a process model that specifies how emotions can be regulated at each of the many steps in the process through which emotions are generated. Using this framework, researchers have examined whether attempts to cognitively regulate emotion relatively early in the emotion-generative process (e.g., reappraisal) are more effective than attempts to behaviorally regulate emotion relatively late in the emotion-generative process (e.g., suppression). Findings indicate that whereas experimentally induced suppression of negative emotion was found to effectively reduce emotion expression, it was not effective in reducing the subjective feeling of emotion and came at the cost of increased physiological responding and memory impairment. By contrast, experimentally induced reappraisal was found to effectively reduce both expression and experience of emotion without negative effects on physiology or memory (Gross, 1998; Gross & Levenson, 1993, 1997; Richards & Gross, 1999, 2000, 2006; Roberts, Levenson, & Gross, 2008). Similarly, results from correlational studies show that the typical use of emotion suppression is related to more negative mood, worse interpersonal functioning, and higher levels of psychopathology, whereas the opposite is true for reappraisal (Dennis, 2007; Gross & John, 2003; Moore, Zoellner, & Mollenholt, 2008). 563

2 564 EHRING, TUSCHEN-CAFFIER, SCHNÜLLE, FISCHER, AND GROSS Applying the Process Model of Emotion Regulation to Depression Vulnerability Applying the process model of emotion regulation to depression suggests three interrelated hypotheses regarding the failure of depression-vulnerable individuals to adaptively regulate their emotions. First, depression vulnerability may be associated with more frequent use of emotion suppression and less frequent use of reappraisal, resulting in the maintenance of negative emotions triggered by negative life events or cognitions. This emotion regulation profile should be reflected in individuals typical patterns of emotion regulation use in everyday life. An important consideration is that situational demands to regulate emotions are not constant but fluctuate over time. Whereas it is certainly adaptive to down-regulate emotions in some situations (e.g., an exam, a job interview), it may be less appropriate to regulate emotions in other situations (see Bonanno, Papa, Lalande, Westphal, & Coifman, 2004). Earlier research suggests that depression vulnerability may be associated with reduced acceptance of negative emotions (Ehring et al., 2008), which should result in attempts to regulate emotions even in situations when this is not necessary or even not functional. Second, in addition to the general pattern of emotion regulation strategy use described above, depression-vulnerable individuals might be expected to differ from controls in their spontaneous application of particular forms of emotion regulation when in a depressed or sad mood (see also Nolen-Hoeksema, 2004). When sad mood is induced or triggered, depression-vulnerable individuals may spontaneously respond with emotion suppression, which can be expected to lead to an increase or maintenance of this mood. Whereas the first hypothesis can easily be assessed using selfreport questionnaires, the second hypothesis would best be tested using experimental inductions of sad mood. Third, in addition to using adaptive emotion regulation strategies less frequently than healthy controls, depression-vulnerable individuals may derive less benefit from using these strategies than healthy controls even when they do use them. Research has shown that depression is linked to a failure to inhibit negatively valenced information and to heightened levels of repetitive negative thinking, such as rumination (e.g., Joormann, 2005). It is possible that these deficits might interfere with the use of adaptive forms of emotion regulation such as reappraisal. The third hypothesis could be tested by an experimental study instructing participants to use emotion suppression versus reappraisal during an emotion induction task. In line with the third hypothesis, depression-vulnerable participants would be expected to benefit less from an instructed reappraisal manipulation during a sad-mood induction than controls, as indexed by a higher emotional response to the emotion induction. Evidence for Emotion Dysregulation in Depression Vulnerability Evidence concerning these predictions comes from a number of studies. First, symptom levels of depression in college students were found to be positively correlated with heightened levels of emotion suppression and reduced levels of reappraisal assessed with a trait emotion regulation questionnaire (Gross & John, 2003). A number of additional studies have shown levels of depression to be related to alterations in emotion functioning and emotion regulation, such as more frequent use of dysfunctional cognitive emotion regulation strategies (e.g., rumination, catastrophizing), less frequent use of functional cognitive strategies (e.g., positive reappraisal), reduced levels of emotional understanding and clarity, lack of emotion acceptance, and lowered expectancy to adaptively regulate emotions (Campbell-Sills et al., 2006a; Catanzaro, 1997; Catanzaro & Mearns, 1990; Flett, Blankstein, & Obertynski, 1996; Garnefski & Kraaij, 2006; Hayes et al., 2004; Rude & McCarthy, 2003). These correlational findings cannot establish whether emotion dysregulation is a risk factor for depression; however, there is emerging evidence that deficits in emotion regulation are not confined to acute episodes of depression but may be a more stable characteristic of depression vulnerability. In a recent study, recovered-depressed individuals reported significantly more emotion regulation difficulties, more frequent use of dysfunctional emotion regulation strategies, and less emotion acceptance than never-depressed controls (Ehring et al., 2008), consistent with the view that emotion regulation deficits are a risk factor for the development of repeated episodes of depression (Gross & Muñoz, 1995; Kring & Werner, 2004; Rude & McCarthy, 2003). Taken together, there is growing evidence for a relationship between alterations in trait emotion regulation and current or past symptom levels of depression. However, no study to date has directly tested whether depression vulnerability is related to increased use of emotion suppression and reduced use of reappraisal. A recent experimental study provides some evidence for the second hypothesis concerning spontaneous use of emotion suppression. Negative mood was induced with a film in a mixed sample of individuals suffering from depression and anxiety disorders who were compared with a healthy control individuals (Campbell-Sills et al., 2006a). Spontaneous emotion regulation strategies used during the film were assessed using a self-report questionnaire. Results showed that clinical participants reported significantly higher levels of emotion suppression during the film than controls, whereas no differences regarding reappraisal or any other emotion regulation strategy were found. In line with the process model of emotion regulation, high levels of spontaneous emotion suppression were related to high levels of negative emotion during the film as well as during a following recovery period. Although the finding is encouraging, it is important to note that a mixed-disorder sample was used in this study, with most participants suffering from an anxiety disorder. It therefore remains to be shown whether the results can be replicated using a homogeneous sample of depression-vulnerable individuals. No study to date has directly tested the third hypothesis stating that depression-vulnerable individuals should benefit less from instructed functional emotion regulation strategies (e.g., reappraisal) than controls. However, two recent experimental studies are of some relevance. In the first study, participants suffering from depression or an anxiety disorder were asked to watch a film eliciting negative mood (Campbell-Sills, Barlow, Brown, & Hofmann, 2006b). Shortly before the film, participants received either the instruction to apply a dysfunctional emotion regulation strategy during the film (emotion suppression) or a functional one (acceptance of emotions). When compared with acceptance, emotion suppression led to a significantly higher heart rate during the film

3 EMOTION REGULATION AND DEPRESSION VULNERABILITY 565 as well as significantly higher levels of persisting negative mood following a recovery interval. These results show that clinical participants benefit more from instructed acceptance than from instructed emotion suppression. In a recent study, the same design was used in a sample consisting of depressed patients only (Liverant, Brown, Barlow, & Roemer, 2008). In contrast to the findings by Campbell-Sills et al. (2006b), acceptance led to higher levels of negative emotion than suppression, which may indicate a reduced effectiveness of instructed acceptance as a functional strategy in depressed individuals. However, both studies are limited by the lack of a nondisordered control group that would allow establishing whether depressed or depression-vulnerable individuals indeed benefit less from functional emotion regulation than controls. The Present Study The aim of the present study was to directly test our three hypotheses regarding the role of emotion dysregulation in depression vulnerability. We operationalized depression vulnerability as the presence of at least one past episode of depression, thus comparing control participants with recovered-depressed participants. This design is frequently used in research into depression vulnerability as it allows a comparison of individuals with versus without depression vulnerability, while keeping current levels of depression constant (Ingram, Miranda, & Segal, 1998). The study consisted of three phases. In the first phase, participants completed questionnaires assessing their typical use of emotion suppression and reappraisal as well as their trait levels of emotion acceptance. In the second phase, they watched a sadnessinducing film clip, which was used to assess the degree to which participants spontaneously engage in emotion suppression versus reappraisal to regulate induced sadness. In the third phase of the study, participants watched another sadness-inducing film clip. Prior to viewing this film clip, they received instructions on how to regulate their emotions during the film. Half of the participants were instructed to suppress their emotions, whereas the other half were instructed to appraise the film in a way to experience less sadness. To match the emotion induced to the nature of depression, we chose film clips that had been shown in earlier research to reliably induce sadness with little other emotion. In addition, emotional reactivity was measured by comparing levels of negative mood immediately before and after the films as well as after a 2-min recovery period. The inclusion of a recovery period appears necessary as earlier studies have shown that instructed emotion regulation cannot only affect emotional responding during emotion induction, but also the speed of recovery from an emotion-eliciting event, operationalized as remaining levels of negative emotion following a recovery period (see Campbell-Sills et al., 2006b). This is also in line with ideas from the process model (Gross, 2002), which emphasizes that emotion regulation takes place as emotions unfold over time. Three hypotheses related to emotion regulation in depression vulnerability were tested. Depression vulnerability was expected to be related to higher levels of emotion suppression and lower levels of reappraisal as well as lower levels of acceptance of negative emotions in self-report questionnaires assessing trait emotion regulation (Hypothesis 1), higher levels of reported spontaneous emotion suppression and lower levels of reported spontaneous reappraisal during the first sadness-inducing film clip (Hypothesis 2), and reduced benefit from instructed reappraisal during the second sadness-inducing film clip (Hypothesis 3). Specifically, the difference in emotional reactivity to the film between the reappraisal and emotion suppression conditions was expected be significantly smaller in recovered-depressed participants than in never-depressed controls. In addition, we expected to replicate prior findings regarding the effects of emotion suppression versus reappraisal on emotional reactivity across groups (Gross, 2002). Specifically, instructed reappraisal during the second film clip was expected to lead to lower levels of negative emotion than emotion suppression across groups (Hypothesis 4). Earlier research has shown that spontaneous emotion suppression is related to higher levels of negative emotions, whereas spontaneous reappraisal is related to lower levels of negative emotions (e.g., Campbell-Sills et al., 2006a; Gross & John, 2003). In secondary analyses, we tested whether these findings could be replicated when looking at the relationship between reported levels of spontaneous emotion suppression as well as reappraisal during Film 1 and emotional reactivity to this film. In addition, we tested whether these relationships were moderated by depression vulnerability status. Participants Method Participants were 73 currently nondepressed university students (72.6% women; age: M years, SD 3.73; 100% Caucasian). Thirty participants (41.1%) had experienced at least one major depressive episode in the past (recovered-depressed group), whereas 43 (58.9%) had never been depressed (never-depressed group). Participants were allocated to the groups on the basis of the results on the Affective Disorders section of the Structured Clinical Interview for the DSM IV (SCID; German version: Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1997) that was carried out by trained interviewers. Participants in the recovered-depressed group had experienced an average of 2.44 episodes of depression (SD 2.03, range: 1 11). The last depressive episode had occurred on average 3 years before the assessment (SD 3.06, range: 6 months 10 years). Further inclusion criteria for both groups were a current Beck Depression Inventory (BDI) score 10 and age between 18 and 35 years. Exclusion criteria were current major depressive episode, current suicidal thoughts, history of psychosis or mania, or selfinjurious behavior. The groups did not differ in sex, 2 (1, N 73) 1.40, p 24, relationship status, 2 (1, N 73) 1.75, p 39, or BDI scores, t(71) 1.38, p.17 (see Table 1). However, participants in the recovered-depressed group were on average 2.14 years older than those in the never-depressed group, t(71) 2.50, p Materials Depression. The BDI (German version: Hautzinger, Bailer, Worall, & Keller, 1995) was used to assess current symptom levels 1 Controlling for age did not alter the pattern of findings reported here.

4 566 EHRING, TUSCHEN-CAFFIER, SCHNÜLLE, FISCHER, AND GROSS Table 1 Participant Characteristics Never depressed Recovered depressed Variable Suppression (n 21) Reappraisal (n 22) Suppression (n 15) Reappraisal (n 15) Sex, n (%) Female 14 (66.67) 15 (68.18) 13 (86.67) 11 (73.33) Male 7 (33.33) 7 (31.82) 2 (13.33) 4 (26.67) Mean (SD) age (years) (2.86) (3.43) (4.86) (3.50) Relationship status, n (%) Single 16 (76.19) 14 (63.64) 9 (60) 9 (60) In relationship 5 (23.81) 8 (36.36) 6 (40) 6 (40) Mean (SD) BDI score 4.95 (3.44) 4.23 (2.64) 6.60 (2.00) 4.40 (2.29) Note. BDI Beck Depression Inventory. of depression. The BDI is a 21-item self-report questionnaire of depression severity with established reliability and validity in clinical and nonclinical samples (Hautzinger et al., 1995). Trait emotion regulation. Participants completed the Emotion Regulation Questionnaire (ERQ; Gross & John, 2003; German version: Abler & Kessler, in press), which assesses the typical use of emotion suppression (four items, e.g., I keep my emotions to myself ) versus reappraisal (six items, e.g., When I want to feel less negative emotion, I change the way I m thinking about the situation ). Each item is rated on a scale from 1 (strongly disagree) to 7 (strongly agree). The scale has been shown to possess good psychometric properties (Abler & Kessler, in press; Gross & John, 2003). Internal consistencies in the current study were satisfactory (emotion suppression:.81; reappraisal:.74). In addition, the Nonacceptance subscale of the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004; German version: Ehring et al., 2008) was used to assess lack of emotion acceptance (six items, e.g., When I m upset, I become irritated with myself for feeling that way ; in this study.67). The DERS is a multidimensional measure of emotion regulation with established reliability and validity (Gratz & Roemer, 2004; Ehring et al., 2008). Film stimuli. Three film clips were used in this study. One film clip (1.5 min, soundless) shows nature scenery and elicits a relatively neutral emotional state. In line with earlier studies (e.g., Gross & Levenson, 1997), this film was included to accustom participants to the laboratory. The other two film clips were used to induce sad mood. The first one (2 min 51 s, with sound) was taken from the film The Champ (Lovell & Zeffirelli, 1979) and shows the distress of a young boy who witnesses his father s death. The second one (3 min 36 s, with sound) was taken from the film Return to Me (Tugend & Hunt, 2000) and first shows a happy married couple dancing on a party and then the husband mourning his wife who has just died in a car accident on the way home from the party. Both films have been shown in earlier research to elicit sad mood with little other emotion (Rottenberg, Ray, & Gross, 2007). The sequence of the films was the same for all participants. All films were presented on a cm TV screen and the sound was presented via headphones. Distraction task. Between the first and the second sadnessinducing films, participants completed a distraction task, which aimed to bring participants mood back to baseline levels. The task was adapted from an earlier task used by McFarland and Buehler (1998) and Joormann, Siemer, and Gotlib (2007). Participants were presented with a list of 40 words and were asked to use the letters of one word to generate two shorter words (e.g., introduction: donut, notion), whereby they did not have to use all letters of the word and were allowed to use some of the letters twice. The task lasted 3 min. Experimental manipulation. The first sadness-inducing film (The Champ) was used to assess spontaneously used emotion regulation strategies. Therefore, all participants received the same neutral instructions taken from Gross (1998): We will now be showing you a short film clip. It is important to us that you watch the film clip carefully until in the end. However, if you find the film too distressing, just say stop and the investigator will stop the film. The second sadness-inducing film (Return to Me) was used to investigate the effects of experimentally induced emotion regulation strategies. Participants were randomly allocated to either an emotion suppression condition or a reappraisal condition, stratified by sex. To ensure comparability with the bulk of earlier experimental studies on emotion regulation, we adapted the instructions for both conditions from Gross (1998). In the emotion suppression condition, participants received the following instructions: We will now be showing you another short film clip. It is important to us that you watch the film carefully until the end. However, if you find the film too distressing, just say stop and the investigator will stop the film. This time, if you have any feelings as you watch the film, please try your best not to let those feelings show. In other words, as you watch the film clip, try to behave in such a way that a person watching you would not know that you were feeling anything. Watch the film clip carefully, but please remember not to let your feelings show. Participants in the reappraisal condition received the following instructions: We will now be showing you another short film clip. It is important to us that you watch the film clip carefully until the end. However, if you find the film too distressing, just say stop and the investigator will stop the film. This time, please try to adopt a neutral and unemotional attitude as you watch the film. In other words, as you watch the film, try to concentrate on what you are seeing objectively.

5 EMOTION REGULATION AND DEPRESSION VULNERABILITY 567 Imagine that you are a director and watch the film in terms of the technical aspects of the film, how certain moods are produced, and what cuts and camera angles are used. Watch the film clip carefully, but please remember to think about what you are seeing in such a way that you don t feel anything at all. State emotion regulation. The Strategies Questionnaire was used to assess the degree to which participants used emotion suppression and reappraisal while watching the film and during the immediate postfilm period (for a similar operationalization, see Egloff, Schmukle, Burns, & Schwerdtfeger, 2006). The questionnaire was developed for the current study and consisted of two items assessing emotion suppression ( I tried not to let my feelings show ; I tried to suppress my emotions ;.84) and two items assessing reappraisal ( I thought about the film in a way that helps me to experience less emotion ; I tried to adopt an unemotional attitude toward the film ;.70). Participants were asked to rate the items on a scale from 0 (strongly disagree) to 6 (strongly agree). Participants filled in the Strategies Questionnaire four times (after Film 1, after the recovery interval following Film 1, after Film 2, and after the recovery interval following Film 2). For each film, average scores were computed from the two assessments (immediately after the film, after recovery interval) and analyses are reported for these average scores. 2 Mood. The Negative Mood subscale of the Positive and Negative Affect Schedule (PANAS; German version: Krohne, Egloff, Kohlmann, & Tausch, 1996) was used to assess negative mood (10 items; e.g., frightened, ashamed ) and was taken at seven different points during the session (before the neutral film, before each sadness-inducing film, immediately after each sadnessinducing film, and after each recovery interval following the films). Reliability and validity of the PANAS have been shown to be high (Krohne et al., 1996), and in this sample, alphas ranged from.77 to.83. Procedure Participants attended one session. Written informed consent was obtained from the participants at the beginning of the session. On arrival, participants were seated in a comfortable chair in front of a TV. Participants then filled in the BDI, ERQ, and DERS. Next, the Affective Disorders section of the SCID was given to allocate participants to the never-depressed and recovered-depressed groups. They then filled in the first PANAS. Next, participants watched the neutral film, followed by the second PANAS administration. After that, participants watched the first sadness-inducing film (The Champ), after which they filled in the third PANAS and the Strategies Questionnaire. This was followed by a 2-min recovery period, after which participants were asked to fill in the PANAS and the Strategies Questionnaire again (this time focused on the rest period). Next, the distraction task was carried out to bring participants mood back to baseline. After that, participants again completed the PANAS, which was followed by the instructions for emotion suppression or reappraisal according to the experimental condition to which they had been randomized. After that, they watched the second sadness-inducing film (Return to Me), followed by the PANAS and the Strategies Questionnaire. After a 2-min recovery period, participants completed the PANAS and the Strategies Questionnaire for the last time. During all tasks that did not involve direct interaction with the participants, the experimenter withdrew to a room that was separated from the laboratory by a curtain. At the end of the session, participants were debriefed. The experimenter made sure that participants felt well before they left. Results Preliminary Analysis: Response to Neutral Film A 2 (time: prefilm, postfilm) 2 (group: never depressed, recovered depressed) mixed model analysis of variance (ANOVA) with the PANAS scores as the dependent variable was conducted to investigate participants response to the neutral film. The aim of the film was to accustom participants to the laboratory. Results showed a significant main effect of time, F(1, 71) 58.97, p.001, p 2.45; participants reported significantly less negative mood after the film than before. However, neither a main effect of group nor a Group Time interaction emerged, Fs 1.8, ps.18, p 2 s.03. Hypothesis 1: Group Differences in Trait Emotion Regulation Three t tests were conducted to assess whether recovereddepressed participants differed from never-depressed controls in trait suppression, reappraisal, or emotion acceptance (see Table 2). No differences between groups were found for ERQ suppression, t(70) 0.64, p.53, d 0.15, or ERQ reappraisal, t(70) 0.77, p.44, d However, recovered-depressed individuals showed significantly higher scores for emotion nonacceptance on the DERS than never-depressed controls, t(70) 2.00, p.05, d Hypothesis 2: Group Differences in Spontaneous Emotion Regulation (Film 1) Two independent samples t tests were computed to test the hypothesis that recovered-depressed participants would spontaneously use different emotion regulation strategies during the first sadness-inducing film than never-depressed controls. In the first t test, emotion suppression as measured with the Strategies Questionnaire was the dependent variable. In line with Hypothesis 2, results showed that recovered-depressed participants reported suppressing their emotions significantly more than never-depressed controls, t(71) 2.11, p.05, d 0.50 (see Table 2). In the second t test, reappraisal was the dependent variable. In contrast to Hypothesis 2, no significant group difference was found for this variable, t(71) 1.20, p.23, d Hypotheses 3 and 4: Effect of Group and Instructed Emotion Regulation on Emotional Reactivity (Film 2) Manipulation check. Before testing the hypotheses, a manipulation check was carried out testing whether the experimental induction of emotion regulation strategies during Film 2 was successful. Therefore, a 2 (condition: suppression vs. reappraisal) 2 (group: never depressed vs. recovered depressed) 2 2 Results did not change when including the separate scores as repeated measures.

6 568 EHRING, TUSCHEN-CAFFIER, SCHNÜLLE, FISCHER, AND GROSS Table 2 Trait and Spontaneous Emotion Regulation by Group Variable Never depressed (n 43) Recovered depressed (n 30) M SD M SD Trait emotion regulation ERQ Suppression ERQ Reappraisal DERS Nonacceptance Spontaneous emotion regulation during Film 1 Emotion suppression Reappraisal Note. ERQ Emotion Regulation Questionnaire; DERS Difficulties in Emotion Regulation Scale. (type of strategy: suppression vs. reappraisal) mixed model ANOVA was conducted. Condition and group were betweensubjects factors and type of strategy was the within-subject factor. A significant Condition Type of Strategy interaction emerged, F(1, 69) 23.31, p.001, 2 p.25. Follow-up paired sample t tests were conducted for each condition separately. In the suppression condition, participants reported engaging in significantly higher levels of emotion suppression (M 3.39, SD 1.30) than reappraisal (M 2.71, SD 1.36), t(35) 3.00, p.01, d In contrast, participants in the reappraisal condition reported engaging in significantly higher levels of reappraisal (M 3.75, SD 1.02) than emotion suppression (M 3.05, SD 1.26), t(36) 3.80, p.001, d Neither the main effect of group nor any interaction involving this factor was significant, Fs 1.7, ps.20, 2 p s.03. Taken together, these results show that emotion suppression versus reappraisal was successfully manipulated during Film 2. Test of Hypotheses 3 and 4. To test the effects of depression vulnerability and instructed emotion regulation on the emotional response to the second film, we conducted a 2 (group: never depressed vs. recovered depressed) 2 (condition: suppression vs. reappraisal) 3 (time: prefilm, postfilm, postrecovery) mixed model analysis of covariance with the PANAS Negative Mood scale as the dependent variable and the BDI sum score as a covariate (see Table 3). 3 Results of the Mauchly s test indicated a deviation from the sphericity assumption; therefore, the Greenhouse Geisser adaption of the degrees of freedom was applied. In line with Hypothesis 4, a significant Time Condition interaction emerged, F(1.81, 134) 3.53, p.05, 2 p.05. Follow-up tests still controlling for BDI scores showed that whereas the groups did not significantly differ at the prefilm baseline, F(1, 69) 1.39, p.24, 2 p.02, participants in the reappraisal condition experienced significantly less negative mood during the film than those in the emotion suppression condition, F(1, 70) 9.66, p.01, 2 p.12, and there was a trend for a similar effect following the recovery period, F(1, 70) 3.31, p.07, 2 p.05. However, in contrast to Hypothesis 3 the three-way interaction was not significant, F(1.81, 134).71, p.48, 2 p.01, which showed that the effects of emotion suppression versus reappraisal on emotional reactivity to the film did not differ between never-depressed and recovered-depressed individuals. All other main effects and interactions were nonsignificant, Fs 2.4, ps.09, p 2 s.04. Secondary Analysis: Effect of Spontaneous Emotion Regulation and Group on Emotional Reactivity (Film 1) A last set of analyses tested the effect of spontaneous emotion regulation participants reported to engage in during Film 1 as well as its interaction with depression vulnerability status on emotional reactivity to the film. First, two residualized mood scores were computed by regressing (a) the PANAS scores during the film and (b) the PANAS scores after the recovery period on the prefilm PANAS scores. Then, four different regression analyses were conducted: (1) dependent variable (DV): residualized PANAS scores during the film; independent variables (IVs): group (scored as a dummy variable), spontaneous emotion suppression reported during the film (as continuous variable), and the interaction term (Group Emotion Suppression); (2) DV: residualized PANAS scores during the film; IVs: group, spontaneous reappraisal, interaction term (Group Reappraisal); (3) DV: residualized PANAS scores after recovery; IVs: group, emotion suppression, interaction term (Group Emotion Suppression); (4) DV: residualized PA- NAS scores after recovery; IVs: group, reappraisal, interaction term (Group Reappraisal). In all analyses, the main effects of group were nonsignificant, ts.50, ps.60, s.06. However, all analyses revealed significant effects of spontaneous emotion regulation on residualized mood scores. In line with the expectations, high levels of emotion suppression during Film 1 were related to high levels of negative mood during the film, t(72) 4.31, p.001,.48, and during the recovery interval, t(72) 3.46, p.001,.40. Surprisingly, high levels of reappraisal during Film 1 were also related to high levels of negative mood during the film, t(72) 3.46, p.001,.39, and during the recovery interval, t(72) 2.90, p.01,.33. When looking at residualized negative mood scores during the recovery interval, there was also a trend for an interaction between group and emotion suppression, t(72) 1.89, p.06,.21. Follow-up tests showed that high levels of emotion suppression were related to higher levels of mood only for recovered-depressed participants, t(29) 4.22, p.001,.62, but not for those who had never been depressed, t(42) 1.12, p.27,.17. The interaction terms in the three other regression analyses were not significant. Discussion This study aimed to test the idea that depression vulnerability is linked to alterations in emotion regulation. Three hypotheses re- 3 Participants in the suppression versus reappraisal conditions during Film 2 did not significantly differ regarding demographic variables. However, participants in the suppression condition during Film 2 had significantly higher BDI scores than participants in the reappraisal condition, F(1, 69) 5.09, p.03, p 2.07 (see Table 1). Therefore, this variable was entered as acovariateinanalysesincludingtheconditionfactor.thisdidnotchangethe results when compared with the ANOVAs without BDI score as a covariate.

7 EMOTION REGULATION AND DEPRESSION VULNERABILITY 569 Table 3 Effects of Instructed Emotion Regulation on Emotional Responding (Film 2) Never depressed Never depressed Suppression (n 21) Reappraisal (n 22) Suppression (n 15) Reappraisal (n 15) Variable M SD M SD M SD M SD PANAS Negative Mood Prefilm Postfilm Postrecovery Note. PANAS Positive and Negative Affect Schedule. garding emotion dysregulation in depression vulnerability were derived using Gross s (2002) process model of emotion regulation. Depression Vulnerability, Trait Emotion Regulation, and Spontaneous Emotion Regulation It was expected that recovered-depressed individuals would typically and spontaneously choose more dysfunctional emotion regulation strategies when compared with never-depressed controls. Our first test of this idea was to compare the groups scores on trait self-report measures of emotion regulation. In line with the hypothesis, recovered-depressed individuals reported being less accepting of their emotions than controls. However, the groups did not differ in their trait levels of emotion suppression and reappraisal. A second test of this idea was to examine participants spontaneous emotion regulation following the experimental induction of a sad mood. Consistent with our hypothesis, recovered-depressed participants reported to have suppressed their emotions in response to the sadness-inducing film significantly more than the control group. This finding provides support for the idea that depression vulnerability is related to a dysfunctional use of emotion regulation strategies (see Ehring et al., 2008; Gross & Muñoz, 1995). Emotion suppression has been found to be an unsuccessful emotion regulation strategy and to be related to increased physiological arousal and memory deficits (Gross, 2002). It is conceivable that an excessive use of emotion suppression, for example, in response to depressive symptoms triggered by negative life events, may contribute to the maintenance of these symptoms. However, it is noteworthy that the recovered-depressed group showed elevated levels of reported emotion suppression only in response to the experimental mood induction but not on the trait self-report questionnaire. One intriguing possible explanation for this discrepancy may be that depression-vulnerable individuals do not suppress all types of emotion, but only specifically depression-related emotions, such as sadness. This may explain the fact that group differences were found only for the degree of reported emotion suppression related to the sadness-inducing film, but not the trait self-report measure that refers to all types of emotions. Future research should directly test this possibility. Depression Vulnerability and the Effects of Instructed Emotion Regulation Our third hypothesis predicted that in addition to using dysfunctional emotion regulation strategies more frequently than controls, recovered-depressed individuals should also benefit less from the use of reappraisal as a functional strategy. This was based on earlier findings showing problems with the inhibition of negatively valenced information in depression (e.g., Joormann, 2005). The hypothesis was not supported as the effects of instructed reappraisal versus emotion suppression did not differ between the groups. Instead, the results suggest that recovered-depressed individuals are equally effective as controls in using reappraisal as a functional emotion regulation strategy when they are instructed to do so. Several alternative explanations for this finding are possible. These include the possibility that depression vulnerability may only be linked more to a problematic choice of emotion regulation strategies but not alterations in the effectiveness of using functional ones. It is also possible that failures to effectively use functional strategies such as reappraisal may be confined to individuals suffering from an acute episode of depression but are not found in currently nondepressed but depression-vulnerable individuals. Alternatively, depression vulnerability may be associated with specific patterns of emotion dysregulation, with deficits in some forms of adaptive emotion regulation but not others. Whereas depression-vulnerable individuals are as effective as controls in using reappraisal when cued to do so, they may still be less effective in using other functional emotion regulation strategies, such as situation selection, allocation of attention, acceptance, or social sharing. Future research is needed to decide between these views. In addition, it should be noted that accepting the null hypothesis is problematic, especially in small-sized samples. Therefore, future studies will need to investigate these issues using much larger sample sizes. It appears unlikely that the lack of differential findings regarding instructed emotion regulation is due to failures in the experimental induction of emotion regulation strategies. First, the manipulation check showed that participants in the suppression condition reported significantly higher levels of emotion suppression than reappraisal, whereas this was reversed in the reappraisal condition. However, as this manipulation check was based on self-report measures, it cannot be ruled out that these results might partially reflect demand characteristics. Therefore, the effects of induced emotion regulation on emotional experience need to be taken into account, as well. Reassuringly, the basic effects of induced emotion suppression versus reappraisal on emotional experience found in earlier research were replicated (Hypothesis 4). Across groups, significantly lower levels of negative mood during

8 570 EHRING, TUSCHEN-CAFFIER, SCHNÜLLE, FISCHER, AND GROSS the film were found in the reappraisal condition than the emotion suppression condition, and this difference still held up after the recovery period. This replication of findings in a recovered-depressed population represents an important extension of prior work. An earlier study with acutely depressed individuals found that emotion suppression was related to less emotional reactivity when compared with emotion acceptance, a supposedly functional strategy (Liverant et al., 2008). However, the study lacked a nondisordered control group, which makes it impossible to decide whether the results are specific for participants with depression or whether they may be due to the specific operationalization used. The results of the current study suggest that emotion suppression is an equally dysfunctional strategy in both recovered-depressed and neverdepressed individuals. However, as described above, recovereddepressed individuals report that they spontaneously use emotion suppression more frequently than controls, which may contribute to depression vulnerability in this group. Secondary Analyses: Effect of Spontaneous Emotion Regulation on Emotional Reactivity In secondary analyses, we tested the effect of spontaneous emotion regulation during Film 1 on emotional reactivity to the film. In line with earlier findings (Campbell-Sills et al., 2006a), reported spontaneous emotion suppression reported during Film 1 was significantly related to higher emotional reactivity to the film, which supports the view that emotion suppression is a dysfunctional emotion regulation strategy. It is interesting that there was a trend for an interaction between reported spontaneous use of emotion suppression and group on levels of negative emotion during the recovery interval. For recovered-depressed participants, high levels of reported emotion suppression during Film 1 were related to a longer maintenance of negative mood following the film, whereas no such relationship was found for never-depressed controls. This finding may indicate that spontaneous emotion suppression may have more negative effects in depressionvulnerable individuals than in controls. However, as the interaction term was only significant at a trend level, caution is required when interpreting this finding. In contrast to the expectations, high levels of reported spontaneous reappraisal were also related to higher emotion reactivity to the film. Several explanations for this puzzling finding are conceivable. First, the items developed for the current study to assess spontaneous reappraisal may not have succeeded in exclusively capturing the functional nature of the strategy, but may have also been endorsed by individuals engaging in attempts to suppress their emotion. Alternatively, spontaneous attempts to reappraise may have different effects on emotional reactivity than instructed use of this strategy. Future studies are needed to directly test the different views. Implications for Prevention and Treatment The results of the current study suggest that depressionvulnerable individuals spontaneously show a more dysfunctional pattern of emotion regulation than controls, especially an excessive use of emotion suppression, but are as successful as controls at regulating their emotions in a functional way when they are instructed to do so. If replicated in future research, this finding may have important implications for prevention and treatment of depression. Specifically, the results suggest that it is promising to use interventions aimed at promoting functional emotion regulation in treatment and prevention. Two different types of interventions targeting this process have been suggested in the literature. The first approach focuses on increasing acceptance for negative emotions and helping clients to disengage from dysfunctional strategies such as emotion suppression, experiential avoidance, or rumination. Examples are acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999) or mindfulness-based cognitive therapy for relapse prevention in depression (Teasdale et al., 2000). Both therapies assume that depression is maintained by excessive attempts at controlling one s negative emotions and thoughts. Consequently, the treatments include strategies to promote acceptance and mindfulness that encourage patients to give up attempts at regulating their emotions. Mindfulness-based cognitive therapy has been found to be effective in preventing relapse in formerly depressed individuals (Ma & Teasdale, 2004; Teasdale et al., 2000). The second approach targeting emotion regulation in the context of depression aims to explicitly train patients in adaptive ways to regulate emotions and then practice these emotion regulation skills (e.g., Berking et al., 2008; Harley, Sprich, Safren, Jacobo, & Fava, 2008). The rationale for these inventions is that depressionvulnerable individuals are assumed to lack skills to adaptively regulate their emotions and would therefore benefit from a training of functional emotion regulation. There is preliminary evidence that such an approach may be beneficial for the treatment of depression (Berking et al., 2008; Harley et al., 2008). On the basis of the results of the current study, a combination of both approaches appears promising. As depression-vulnerable individuals report a lack of acceptance and excessive use of emotion suppression, the increase of acceptance and mindfulness should improve emotion regulation in this group. However, it may be useful to combine this with strategies from the second approach that aim to increase the flexibility and efficacy of emotion regulation by promoting the use of adaptive emotion regulation strategies in situations where emotion regulation is required. On the basis of the current results, we hypothesize that depressionvulnerable individuals need to improve their choice of emotion regulation strategies rather than skills to effectively use them when they are cued to do so. Limitations and Future Directions Although the results of the current study are promising, several limitations bear noting. First, the sample size in the current study was modest, especially for detecting the three-way interaction predicted by the third hypothesis. This suggests that this negative finding be treated with caution. The small sample size may also possibly account for the fact that the groups defined by depression vulnerability overall showed fewer differences than similarities. Future studies including larger samples are needed to test whether the absence of some of the hypothesized effects were due to low statistical power or the fact that the hypotheses were incorrect. Second, only the Affective Disorders section of the SCID was administered. Therefore, it is possible that some participants were suffering from comorbid disorders, such as anxiety disorders.

9 EMOTION REGULATION AND DEPRESSION VULNERABILITY 571 Future studies should include larger samples to ensure adequate power to detect group differences. In addition, research is needed to assess the relative contribution of different forms of psychopathology to emotion regulation difficulties. A third limitation is that the effects of instructed emotion regulation on emotion exclusively relied on self-reported feelings of emotion. Earlier research by Gross and colleagues has shown that reappraisal and suppression differ in their autonomic and neural correlates (Goldin, McRae, Ramel, & Gross, 2008; Gross, 2002); therefore, future studies should include emotion expression and physiological responses as dependent variables. In addition, future research should investigate the relationship between emotion regulation strategies, other personality traits, such as neuroticism, and other emotion-related variables, such as emotional reactivity. Similarly, the results regarding spontaneous use of emotion regulation strategies also relied exclusively on participants self-report. No data are available on the accuracy with which this measure reflects actual regulation strategy use during the films. Fourth, the current study compared recovered-depressed and never-depressed individuals but not currently depressed individuals. The advantage of this approach is that the two groups differ regarding their vulnerability to depression, as indexed by past major depressive episodes, but not regarding current levels of depression. However, our design does not permit conclusions about characteristics of emotion regulation in currently depressed individuals. Future studies should therefore include a group of currently depressed participants in addition to recovered-depressed and never-depressed individuals. In addition, although the comparison of recovered-depressed and never-depressed individuals is frequently used to investigate factors involved depression vulnerability (Ingram et al., 1998), it is not without drawbacks. Most important, any group differences could reflect a scar effect of having been depressed rather than a marker for vulnerability. Furthermore, as our sample was rather young, it cannot be ruled out that individuals in the never-depressed group are vulnerable to developing depression in the future. To obtain more conclusive evidence, future studies will need to use prospective designs, in which vulnerability factors are assessed in individuals who have never been depressed and used to predict future onset of depression. In addition, future studies should not be restricted to university students with a limited age range but include samples with a larger age range and a larger variety of educational backgrounds. Fifth, because of the lack of a control group without the induction of a specific emotion regulation strategy, results of the current study do not allow us to ascertain whether the difference between the strategies during Film 2 was due to the functional effects of reappraisal, the dysfunctional effects of emotion suppression, or both. However, results from earlier studies suggest that when looking at subjective feelings of emotion as the dependent variable, reappraisal is effective in reducing emotion, whereas emotion suppression does not have an impact on this level (e.g., Gross, 1998). Nevertheless, future studies should include a control group without explicit emotion regulation instructions. Finally, to ensure comparability with the bulk of earlier experimental studies into emotion regulation, we used definitions and instructions suggested by Gross (1998) for the experimental induction of emotion regulation strategies. For example, we instructed participants in the emotion suppression condition to suppress the expression of their emotions. However, depressionvulnerable individuals may not only suppress their emotion expression but also the subjective feeling of emotions. Future research should directly compare the effects of expressive suppression, suppression of feelings, and their combination. In addition, given the group difference on trait nonacceptance found, future studies should also include a measure of state (non) acceptance participants engaged in while watching the films. Despite these limitations, the results of the current study provide important new evidence for the idea that individuals vulnerable to depression tend to spontaneously use more dysfunctional emotion regulation strategies, but are as effective as controls in using functional strategies when instructed to do so. 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