Affect Regulation Training 531 tions (Farb et al., this volume), neuropsy- least 4 to 6 weeks time to practice the skills- chotherapeutic translational approaches building exercises. ART can be delivered by (Grawe, 2006), principles used in problem- an ART-trained mental health professional, solving therapies (D’Zurilla & Nezu, 2010), such as a licensed psychotherapist with a and strength-focused interventions (Duck- master’s degree in medicine or psychology. worth, Steen, & Seligman, 2005; Grawe, Other, nonlicensed mental health profes- 2002), into a highly standardized and trans- sionals can also be trained to administer diagnostically oriented training program. ART, albeit not to individuals suffering from This program can be utilized (1) as a stand- acute mental disorders. Subsequently, we alone intervention (when working with outline the theoretical and empirical back- patients suffering from less severe or sub- ground of ART before we provide practical threshold mental disorders, with individuals explanations of how the relevant skills are at risk for developing mental health prob- delivered to participants. At the end of the lems, or with healthy individuals who sim- chapter, we review empirical evidence for ply desire to enhance their well-being) or (2) the effectiveness of ART and suggest future as an adjunctive intervention complement- directions for our research. ing any empirically validated treatment of mental disorders whenever a stronger focus The ART Model of Adaptive on enhancing general affect regulation skills Affect Regulation is desired. Although ART certainly shares The ART model of adaptive affect regu- some theoretical assumptions with many of lation was developed by synthesizing (1) the approaches just described and also uses established affect regulation theories (e.g., some of the interventions applied in these Gottman & DeClaire, 1997; Grawe, 2002, approaches, we believe that the uniqueness 2006; Gross, 1998; Larsen, 2000; Lazarus, and advantage of ART lies with its compre- 1991; Leahy, 2002; Saarni, 1999; Salovey hensive approach of incorporating specific & Mayer, 1990), (2) findings from studies strategies, interventions, and exercises into on the association between affect regulation a consistent training program that explic- and psychopathology (Berking & Wupper- itly and exclusively focuses on enhancing man, 2012), and (3) our extensive clinical general affect regulation skills—regardless experience. The purpose of this develop- of the patient’s particular disorder(s) (for ment was to provide a normative (i.e., pre- details see Berking & Whitley, 2013). scriptive) model explaining common failures in affect regulation and directions for inter- Inspired by Klaus Grawe’s (2006) trans- ventions to enhance affect regulation. In the lational ideas on the development of mental resulting model, adaptive affect regulation disorders, as well as the lack of transdiagnos- is conceptualized as a situation-dependent tic interventions to enhance general affect interaction between several affect regulation regulation skills at the time, we began to skills. Figure 31.1 illustrates an overview of develop ART in 2004. Since then, the train- the model. The skills included in the model ing has become quite popular in the German- are described below. speaking parts of Europe, where it is known as Training Emotionaler Kompetenzen 1. The ability to consciously perceive (TEK; Berking, 2010; www.tekonline.info). and be aware of affective states. The abil- The training was primarily developed as a ity to consciously perceive and be aware of group-based intervention (four to eight par- affective states is the basis of every effortful ticipants), but it can also be used in individ- attempt to regulate affective states. Effort- ual therapy. Although the program has only ful and conscious regulation may only play a been evaluated in adults, its application for small role in the daily routine of regulation adolescents is practicable after adapting the in a healthy individual, because implicit or procedures and materials to the needs and highly automatized processes are likely to capacities of this age group. The training, dominate the regulation process as long as which takes at least 18 hours to complete, these processes are able to maintain the indi- can be partitioned in various ways (e.g., two vidual’s affect in the comfort zone (Koole & 1.5-hour sessions or one 3-hour session per week over a 6-week period). From our expe- rience, however, participants should have at
532 INTERVENTIONS FIGurE 31.1. The ART model of adaptive affect regulation. Rothermund, 2011; Gyurak & Etkin, this tional experiences with the appropriate volume). However, if undesired affective semantic categories (e.g., “This feeling I am states cannot be down-regulated through experiencing is anger”). The availability of implicit processes, conscious information a differentiated system of cognitive repre- processing will be activated as a precious sentations of affective states and the ability resource reserved for solving problems in the to correctly assign an experience to a spe- self-management process (Mauss & Tamir, cific category helps the individual to build this volume). Becoming aware of affective and use knowledge about this state, which states may facilitate the use of affect regula- is often helpful for adaptive regulation. For tion skills requiring cognitive resources (e.g., example, recognizing an emotion as anger evaluating the degree of undesirability of the provides information about the nature and emotion, labeling the emotion, identifying purpose of the emotion (e.g., enhancing its causes) and hence foster adaptive regu- assertive behavior; fighting for one’s rights), lation. Conversely, the inability to become its potential risks (cueing aggression leading aware of one’s emotions impedes the utili- to sanctions through others) and benefits zation of cognitive problem-solving capaci- (getting what one wants, even if one has to ties, thus intensifying and prolonging the fight for it), as well as information on regu- unwanted affective state (e.g., Lane et al., lation strategies that are likely to be effec- 1996; Swart, Kortekaas, & Aleman, 2009). tive (potentially effective: distraction, relax- ation, reappraisal and compassion; likely to 2. The ability to identify and correctly be ineffective: prolonged exposure). Recog- label affective states. Identifying and label- nizing the emotion facilitates adaptive cog- ing affective states refers to matching emo-
Affect Regulation Training 533 nitive processing. Thus, this ability should comes from studies demonstrating that an foster effective affect regulation and hence individual’s expectation of successfully alle- mental health and well-being (Feldman- viating negative mood states is significantly Barrett, Gross, Christensen, & Benvenuto, associated with mental health (Catanzaro 2001). & Greenwood, 1994). In this context, it is noteworthy that ART skills should be under- 3. The ability to identify relevant main- stood as categories that include various sub- taining factors for current affective states. skills. This is particularly relevant for the Identifying relevant maintaining factors ability to modify affective states. For exam- refers to development of an inner working ple, most of the long list of positive activities model to explain factors that initially cued used in behavioral therapy for depression the current affective state and, more impor- can be seen as modification skills. It is also tantly, to identify the factors that maintain noteworthy that the effectiveness of specific the emotional state at that moment. In gen- modification skills differs across individuals eral, psychological treatment for mental and situations, and is likely to be moderated health problems should (a) normalize the by numerous individual and contextual fac- client’s experiences, (b) help to explain the tors (Bonanno, Papa, Lalande, Westphal, & occurrence of the problem, and (c) pro- Coifman, 2004). vide direction for successful coping. With an additional focus on affective states, the 5. The ability to accept and tolerate nega- model should include relevant and change- tive affective states when necessary. Accep- able factors such as the internal or exter- tance and tolerance of unwanted affective nal stimuli or situation cueing the emotion, states is a crucial skill whenever affective appraisal of the stimuli or situation, as well states cannot be changed or when changing as desires, beliefs, and goals relevant for the them would involve too high a cost (e.g., in appraisal. Understanding factors that ini- terms of time and energy). Although an opti- tially elicit and maintain an affective state mistic perspective about one’s abilities to helps to (a) give meaning to an aversive expe- modify affective states has clear advantages, rience, thereby making it easier to bear; (b) acknowledging that affective states are clarify whether the emotion can or cannot often very difficult to modify, or that they be changed (thus enhancing the acceptance sometimes cannot be modified, is equally of an emotion when necessary); and (c) iden- advantageous (Hayes, Strosahl, & Wilson, tify targets for effective modification of the 1999). Modifying undesired affective states affective state. is often difficult—particularly for patients suffering from mental disorders—and hence 4. The ability to modify affective states may threaten the need for control. To end actively. To modify affective states actively the aversive affective state and/or to restore is to effectively change the quality, intensity, a sense of control, the individual may engage and/or duration of an affective state into in dysfunctional strategies (e.g., suppres- a desired direction with the help of strate- sion) that help to avoid the aversive experi- gies that have no unwanted, long-term side ence but likely lead to unwanted long-term effects. This ability provides one of the most outcomes (e.g., Feldner, Zvolensky, Stickle, effective means for preventing the use of Bonn-Miller, & Leen-Feldner, 2006; Lev- dysfunctional strategies (i.e., strategies that itt, Brown, Orsillo, & Barlow, 2004). Con- have unwanted side effects). Moreover, effec- versely, the availability to accept, bear, or tive modification skills provide an empirical tolerate aversive affective states reduces basis for the expectation of being able to this need and hence the risk of engaging in modify unwanted affective states whenever maladaptive affect regulation (e.g., Wupper- necessary. Such an emotional self-efficacy is man, Neumann, & Axelrod, 2008). likely to reduce both anxiety about future aversive events and avoidance tendencies 6. The ability to approach and confront toward affective states. As a result, this situations that may cue negative affective expectation reduces general anxiety and the states. Approaching and confronting situa- willingness to experience emotionally chal- tions that may cue negative affective states lenging situations, thus facilitating further is often necessary to accomplish personally skills building. Evidence for this hypothesis relevant goals (Hayes et al., 1999). More-
534 INTERVENTIONS over, confronting these situations provides to manifest when individuals perceive that an opportunity to improve existing affect they have failed to regulate their emotions regulation skills and to develop new ones successfully. Such a critique usually cues (arrows 6a and 6b in Figure 31.1). Willingly further (secondary) negative affective states encountering occasional situations that cue (see Greenberg, 2004) that impede efforts to negative affective states to attain important cope with the undesired primary affective goals when necessary, ensures that one’s states. Conversely, a compassionate stance affect regulation skills are practiced on a toward oneself can help reduce the risk of regular basis and will be available and effec- being caught up in such a vicious cycle (Gil- tive in times of emotional anguish. More- bert, 2011). over, as this ability facilitates goal attain- ment, it helps to satisfy relevant needs and In addition to the list of skills and assump- thus reduces negative affect in the long run. tions about why these skills are important and how they interact, the ART model 7. The ability to support oneself compas- includes the hypothesis that modification sionately in distressing situations. All of and acceptance/tolerance skills are the the skills just described have the potential only skills in the model that are ultimately to increase emotional suffering in the short relevant for mental health. All other skills term. For example, consciously perceiving are not considered relevant by themselves unwanted affective states is usually associ- but only to the extent that they facilitate ated with an increase in the perceived inten- the successful application of modification sity of the emotional suffering. Identifying or acceptance/tolerance. This idea is based momentary feelings such as stress, fear, on research on rumination (e.g., Morrow anger, sadness, dysphoria, shame, and guilt & Nolen-H oeksema, 1990) and our clini- activates semantic concepts that likely to cue cal observation that many clients obviously further negative feelings. Working to under- experience their affective states consciously, stand undesired affective states can lead to analyze them, and work to explain them the processing of problems and the acknowl- but are unable to benefit from these activi- edgment of one’s inabilities to solve them, ties. On the contrary, excessive use of these which is likely to cue further deterioration strategies seemed to be partly responsible for of mood. Efforts to modify undesired affec- maintaining the mental disorder. Empirical tive states are often unsuccessful, or at least studies on the ART model, reviewed in the not as successful as expected or desired, next section, provide further preliminary hence cueing disappointment, frustration, support for this assumption. and eventually despair. Attempts to accept and tolerate an emotion are often associated Empirical Evidence for the ART with feelings of helplessness and hopeless- Model of Affect Regulation ness, and unrealistic fears of catastrophic After we conceptualized the ART model, we consequences assumed to occur when nega- developed and validated the Emotion Regu- tive affective states are no longer suppressed. lation Skills Questionnaire (ERSQ; Berking Moreover, confronting situations that cue & Znoj, 2008) to assess the skills included negative affective states to attain important in the model. This self-report instrument goals, by definition, cues negative affective utilizes a 5-point Likert scale to assess each states. As illustrated by these examples, the skill of the ART model (plus an additional process of applying adaptive affect regula- subscale assessing the ability to use body tion skills could lead to deterioration of sensations to identify experienced affective mood and trigger the use of dysfunctional states) with three items per scale. Addition- strategies. Therefore, self-soothing or self- ally, a total score can be computed as the encouraging strategies are needed as part average of all items. In several studies, the of the regulation process to prevent one’s ERSQ displayed adequate to good internal mood from deteriorating. Unfortunately, consistencies (Cronbach’s alpha = .82–.94). many individuals with mental disorders Results from exploratory and confirma- have a tendency to be strongly self-critical tory factor analyses provide support for the of perceived failures. In the process of affect regulation, this self-critical tendency is likely
Affect Regulation Training 535 assumed dimensionality of the measure. and the reduction of depressive symptoms in Moreover, sensitivity to change has been patients treated for major depressive disor- demonstrated in multiple samples of clients der (MDD; Radkovsky, McArdle, Bockting, undergoing psychotherapy, and all scales & Berking, under review). Finally, in both have demonstrated positive associations with a clinical and a nonclinical sample, success- measures of well-being and mental health, ful modification of undesired affective states and negative associations with measures of (partly) mediated the relationship between psychopathology and ER deficits (Berking, most ERSQ skills and psychopathology, but Ebert, Cuijpers, & Hofmann, 2013; Berking not for acceptance and psychopathology et al., 2011, 2012; Berking, Meier, & Wup- (Berking et al., 2012), which suggests that perman, 2010; Berking, Orth, Wupperman, only acceptance and tolerance are relevant Meier, & Caspar, 2008; Berking, Wupper- for mental health, regardless of whether man, et al., 2008; Berking & Znoj, 2008; these skills facilitate the modification of Ebert, Christ, & Berking, 2013). affective states. In summary, a growing body of evidence supports the hypotheses More specifically, all skills in the ART that the skills included in the ART model model have been shown to be cross- help maintain or restore mental health and sectionally associated with mental health in are thus promising for treatments of mental nonclinical samples (Berking et al., 2012; health problems. Berking, Wupperman, et al., 2008; Berking & Znoj, 2008), and clinical samples and non- Brief Description clinical controls report less successful appli- of the ART Program cation of all skills than do patients treated Support for the ART model led to the devel- for mental disorders (Berking et al., 2011; opment of the ART program, which inte- Berking, Wupperman, et al., 2008; Berking grates principles and interventions from et al., 2013). Additionally, an increase in various psychotherapeutic approaches to successful affect regulation during CBT was foster general affect regulation skills in indi- shown to be associated with greater symp- viduals likely to benefit from more adap- tom reduction (Berking, Wupperman, et tive ways of coping with unwanted affective al., 2008). The differences and correlations states. The following sections provide a brief reported in these studies were particularly description of the ART program (for a more strong for modification and acceptance/tol- detailed description, see Berking & Whitley, erance. This finding provides preliminary 2013). support for assumption that these skills are particularly relevant for mental health. General Structure Moreover, multivariate regression analyses ART first introduces participants to the identified only these two skills areas as mak- nature of affective states and their evolution- ing a unique contribution when predicting ary background, purposes, potential risks, treatment outcome from changes in affect and benefits, as well as the mechanisms regulation skills (e.g., Berking, Wupperman, involved in regulating affective processing. et al., 2008). Further research indicated that From our understanding of the mechanisms affect regulation skills assessed through the involved, seven skills have demonstrated ERSQ predicted subsequent indicators of effectiveness in facilitating adaptive coping psychopathology over a 2-week and a 5-year with affective states that are particularly period, whereas these indicators did not pre- challenging to manage. These skills include dict subsequent success in applying affect muscle relaxation, breathing relaxation, regulation skills (Berking, Orth, et al., 2008; nonjudgmental awareness, acceptance and Berking, Wirtz, Svaldi, & Hofmann, under tolerance, compassionate self-support, anal- review). This finding suggests that deficits ysis of affective states, and modification of in affect regulation skills are not merely a affective states. Each skill is practiced in a symptom of mental health problems but a long version, then shortened to a version relevant antecedent factor. that can be applied in very short periods of In two other studies, affect regulation skills assessed through the ERSQ predicted relapse during and after inpatient treatment for alcohol dependency (Berking et al., 2011)
536 INTERVENTIONS time (3 seconds to 3 minutes). The shortened ART skills are then chained together, creat- when the amygdala is activated by a situa- ing the ART sequence (see Figure 31.2). This tion that is interpreted as a potential threat, sequence can be used whenever participants it initiates physiological changes such as suffer from any undesired affective state. an increase in muscle tension and an accel- eration of breathing. Because such changes ART heavily relies on an intensive train- have occurred in the past when encountering ing regimen in which participants practice threatening situations, the muscle tension the whole ART sequence for 20–30 minutes and rapid breathing themselves may in turn daily and additionally engage in at least three have become danger signals to the amyg- short exercises (for 3 seconds to 3 minutes) dala (i.e., classical conditioning or the con- over a period of at least 6 weeks. To sup- cept of somatic markers; Damasio, 2000). port this practice, participants receive work- As a result, a vicious cycle may develop in sheets, handouts, and an information book- which the activation of the amygdala causes let during the training. Additionally, they increased muscle tension and rapid breath- receive specific audio files that guide them ing, which in turn causes further activation through the exercises of the ART sequence, of the amygdala and even more muscle ten- and a set of 140 text messages is automati- sion and further rapid breathing (for details cally sent to participants throughout the on how somatic processes are integrated into training. After participants have mastered information processing relevant for emotion the skills, the focus shifts to practicing in elicitation and maintenance, see Stemmler, daily life the learned skills to cope success- 2004; Teasdale & Barnard, 1993). When fully with challenging situations. participants realize that they are experienc- Muscle and Breathing Relaxation ing stress or negative affective states, they Every skills building module starts with a can break through these vicious cycles by short psychoeducation that explains how consciously relaxing their muscles and pur- different areas of the brain may mutually posefully calming their breathing. By engag- activate each other, thus forming neuroaf- ing in these exercises, they can reduce acti- fective vicious cycles that can override vation of the sympathetic system, the limbic processes responsible for down-regulating system, and the brainstem (Porges, 2007). undesired affective states. For example, After this vicious cycle has been intro- FIGurE 31.2. ART skills and ART sequence. duced and discussed with participants, we This is the prescriptive model of affect regulation introduce participants to progressive mus- as it is presented to participants. It includes the cle relaxation techniques (Jacobson, 1964) same skills as the ART model of adaptive affect combined with a simple exercise to calm regulation (Figure 31.1); however, for didactic breathing. Studies have consistently shown purposes, it presents them in a more concrete the effectiveness of muscle and breathing fashion, providing a step-by-step guideline for relaxation in the treatment of a variety of coping with undesired affective states. mental and physical disorders (e.g., Öst, 1987; Conrad & Roth, 2007). Addition- ally, with reduced limbic activity through breathing and muscle relaxation, a shift can occur that changes the focus from primar- ily amygdala-driven limbic- and brainstem- focused responses back to more prefrontal, cortical responses that are reflective rather than reactive (Arnsten, 2009). Thus, reduc- ing psychophysiological arousal with the help of muscle and breathing relaxation facilitates the subsequent use of techniques requiring more cognitive resources. Nonjudgmental Awareness When the amygdala detects potential threats, it alerts the prefrontal cortex (PFC),
Affect Regulation Training 537 which then focuses attention and con- is felt in the body. Finally, participants are scious processing on threat-relevant stimuli invited to check for additional feelings that (LeDoux, 2012). Such effortful process- might lie behind the most prominent one and ing aims to more validly evaluate potential repeat the same three-step process on them. threats and determine behavioral responses This technique of becoming aware of one’s most likely to be effective. However, if this affective states in nonjudgmental ways aims processing does not lead to a solution of to recruit cognitive resources to facilitate the problem, an ongoing focus on aversive effective affect regulation (Gyurak & Etkin, experiences may lead to an ongoing activa- this volume; Hariri, Mattay, Tessitore, Fera, tion of the amygdala. This activation may & Weinberger, 2003). Evidence for the effi- cause the PFC to focus even more attention cacy of nonjudgmental awareness includes on the problem (Amaral, Price, Pitkänen, & studies on the effectiveness of mindfulness- Carmichael, 1992; Gray & McNaughton, based interventions (Farb et al., this volume). 2000; Vuilleumier, Richardson, Armony, Driver, & Dolan, 2004), thus potentially Acceptance and Tolerance resulting in a cyclical reaction of even more of Affective States intense processing of problematic stimuli Challenging affective states, such as fear or and further activation in the amygdala. In anger, constitute threats to the goals of feel- attempt to prevent such a negative cycle, ing good and of being in control (Grawe, some individuals try to rigidly suppress 2006). Reponses of the amygdala toward “negative” thinking (Ottenbreit & Dob- such threats likely include the activation son, 2004). However, this strategy is likely of areas responsible for avoidance motiva- to have a paradoxical effect of increasing tion (Grawe, 2006). Under the influence the intensity of negative thinking instead of avoidance goals (Grawe, 2002, 2006), of reducing it (Wenzlaff & Wegner, 2000). people may rigidly focus on eliminating the Thus, instead of fighting negative thinking, “threatening” affective states. However, the we encourage participants simply to observe goal of getting rid of an undesired emotion the situation and their affective states with- is often difficult to attain. The emotion- out interpreting, judging, or reacting. This generating system often acts autonomously kind of mindfulness-based affect labeling of the areas of the brain that initiate con- has been shown to disrupt amygdala activity sciously controlled behavior (Amaral et al., (Lieberman et al., 2007) and to be effective 1992; see also the concept of core valuations as a reappraisal or distraction in the regula- outlined by Ochsner & Gross, this volume). tion of negative affect (Lieberman, Inagaki, Such a design can be hypothesized to have Tabibnia, & Crockett, 2011). provided a significant evolutionary advan- tage to our ancestors. If negative affective When applying this technique as ART states could simply be switched off through Skill 3, participants start by switching from conscious control, a strong temptation to regulating their breathing to simply observ- simple down-regulate unpleasant emotions ing it. Then, they start focusing on their without going through the trouble of engag- sensual experiences (sensations in the body, ing in the behavior the emotion is supposed sounds, odors, and visual perceptions); their to facilitate could interfere with the emo- thoughts (“What is the next thought that tions cueing adaptive behavior. Additionally, comes to mind?”); and their current salient emotional reactions often cause significant wishes, desires, and goals (“If everything changes in the body that take some time to was going exactly according to your wishes, dissipate and, as long as they are present, where would you be now? What would you may impede the ability to make emotional be doing now? Imagine this perfect scene. . . . changes (Teasdale & Barnard, 1993). It can Briefly name the wish or goal expressed in also been hypothesized that areas such as the this image”). At the end of this sequence, ventromedial PFC and the anterior cingulate participants are invited to be aware of cortex, which are assumed to help in down- their affective states without judging them. regulation of undesired emotions under the Instead, they are instructed to (1) find a influence of dorsal or lateral areas of the matter-of-fact label for this emotion (e.g., PFC, may get “hijacked” by strong emotions anger), (2) rate its intensity on a scale from 1 to 10, and (3) identify where the emotion
538 INTERVENTIONS in a way that leads to ruminative processing of emotion-r elated information and impedes do as long as I cannot change it; I know effective top-down emotion regulation that this emotion wants to provide me (Johnstone & Walter, this volume). with very relevant information; it wants to point out that . . . ; it aims to help me by In summary, for various reasons, it is enhancing my ability to . . . ; I also know often very difficult to control affective states that I have experienced many unpleas- consciously. Thus, rigid attempts to shut ant emotions in the past and have always down an undesired affective state instantly been able to get through this in one way or through sheer willpower may fail. Such another; finally, I know that this emotion unsuccessful attempts at attaining the salient will not last forever, I will only have to goal of eliminating an undesired affective tolerate it for so long.” state will likely cue amygdala activation and In the ART sequence, this kind of increase the salience of the goal (Martin, acceptance-enhancing self-talk is applied Tesser, & McIntosh, 1993; Rothermund, to affective states that have been perceived 2003). Because of the resulting increase in nonjudgmentally at the end of ART Skill negative arousal, the likelihood of attaining 3. Preliminary evidence for the therapeutic an increasingly salient goal is significantly potential for the skills of acceptance and tol- reduced. Thus, a vicious cycle may develop erance comes from research on the relevance in which fighting against the emotion only of avoidance for the development and main- makes it stronger. To prevent this vicious tenance of mental disorders (e.g., Berking, cycle, developing the ability to accept and Neacsiu, Comtois, & Linehan, 2009), from tolerate negative affective states is impor- studies demonstrating the effectiveness of tant (at least as long as such states cannot be mindfulness-b ased approaches (Farb et al., changed). To enhance acceptance and toler- this volume), and from acceptance and com- ance skills, ART first works to help partici- mitment therapy, in which acceptance of pants find a helpful definition of acceptance/ negative affective states and willingness to tolerance and to understand why these skills experience them is one of the primary aims are important. Then, participants develop of therapy (Hayes, Luoma, Bond, Masuda, their personal, five-step Acceptance and & Lillis, 2006). Tolerance Plan, which includes the follow- ing steps: (1) Consciously decide to work Compassionate Self‑Support on accepting the emotion; (2) strengthen in Emotionally Challenging Situations this decision by finding at least one reason The next vicious cycle starts when someone why acceptance is helpful; (3) work to see who feels stressed or upset begins to self- affective states as allies providing impor- blame or self-criticize. That person might tant information and supporting behavior think, “I can’t do anything right. I am a that might be used for effective coping with complete failure. Something is wrong with challenging situations (e.g., for an adap- me.” These statements are self-inflicted tive conceptualization of affective states, attacks that threaten the need to feel valued see Cosmides & Tooby, 2000); (4) become (Grawe, 2002), cueing additional negative aware of your ability to tolerate negative affective states (e.g., anger, shame, guilt) affective states for a certain period of time; associated with further activation of the and (5) realize that affective states are usu- amygdala (Longe et al., 2010). The activa- ally impermanent experiences that do not tion of the amygdala through self-criticism last forever and are likely to fade away (or at and additional negative feelings increases least decrease in intensity). the stress response, likely leading to more negative feelings, which in turn lead the per- At the end of the Acceptance and Toler- son to be even more self-c ritical. Activating ance Plan, participants devise a Personal a compassionate attitude toward oneself and Acceptance and Tolerance Statement, such engaging in self-supportive behaviors is an as the following, to use as self-talk, until effective strategy to preclude this vicious they feel that they can allow affective states cycle (Gilbert, 2011). ART participants learn to exist: how to provide compassionate self-support “I will work to accept this unpleasant emo- tion because this is the smartest thing to
Affect Regulation Training 539 by imagining themselves in a burdensome as crucial affective states, but we broadly situation accompanied by negative feelings. define these terms in the training (to avoid While reexperiencing these feelings, they burdening patients with the academic need learn to self-assess from the perspective of for clear classifications). Thus, these terms a kind and caring (albeit somewhat distant) include other affective states, such as stress inner observer. They are instructed to “let responses or moods. The general model the feeling of compassion toward themselves of how emotions (i.e., affective states) are arise from within,” which creates a strong elicited includes external or internal events and warm feeling of self-empathy, accompa- that cue the emotion; attention deployment nied by the desire to help and to end their toward and appraisals of these events; needs, suffering (Weissman & Weissman, 1996). wishes, and goals that are relevant for these The observing part should then approach appraisals; secondary emotions (Greenberg, the suffering part of the participant, sup- 2004) cued by appraising the primary emo- porting and comforting that part by nor- tion in a certain way; and body sensations, malizing the negative affective states, pro- motivational impulses, and behavior associ- viding encouragement, and maybe adding a ated with the emotion, all of which provide physical gesture of compassion (e.g., giving feedback into the emotion generating system oneself an imaginary hug). Preliminary evi- and thus affect the subsequent course of the dence for the effectiveness of interventions emotion. To clarify the course of subsequent that enhance compassionate self-support action, the worksheet ends with a summary has been found in several empirical studies of the short- and long-term advantages and (Hofman, Grossman, & Hinton, 2011). disadvantages of the emotion. Constructive Analysis ART trainers explain the model and help of Affective States participants to apply it to their own affective Under stress, the amygdala activates pro- states. Eventually, the skill will be included cesses that release stress hormones into the in the ART sequence in the form of the car- brain. An excessive release of such hormones ing inner observer from ART Skill 5, who can impair cognitive processing in other guides the suffering part of the client through brain areas, including the PFC and the hip- the analysis (“What situation prompted this pocampus (Huether, 1998; LeDoux, 2012), feeling?”; ”How did you interpret and evalu- which play important roles in the analysis ate the situation?”; “What was at stake in of affective states. The ability to identify this situation?”). Partly based on the find- the causes of one’s current feelings correctly ing that insight-oriented psychological leads to a greater sense of self-mastery and treatments have been shown to be effective control over one’s affective states. If through (e.g., Gibbons, Crits-Christoph, Barber, weakened prefrontal and hippocampal & Schamberger, 2007) and our own clini- functioning, the ability to self-a nalyze one’s cal experience, we hypothesize that simply affective states is diminished, a vicious cycle understanding challenging affective states develops in which the loss of orientation with the help of a model normalizes and and control further activates the amygdala, hence validates such states; that the impres- which in turn perpetuates the cycle. Thus, sion of having understood the problem cues maintaining or regaining a sense of mastery a general feeling of control and hope; and and control over one’s affective states in that offers of specific and promising ways stressful situations helps prevent the escala- to cope successfully with undesired states tion of negative affect. significantly contributes to the (short-term) reduction and/or acceptance of undesired In ART Skill 6, participants are trained affective states. to utilize the Analyzing Affective States Worksheet (depicted in Figure 31.3) to Effective Modification enhance the ability to identify correctly of Affective States the causes of one’s current emotions. The ART Skill 7 aims to empower participants worksheet is based on an integrative model to actively modify quality, intensity, or dura- of how affective states are cued and main- tion of an undesired emotion and restore tained. It focuses on emotions and feelings their sense of control. This skill, which pro-
540 INTERVENTIONS Analyzing Emotions Preceding Emotional Vulnerability Needs Goals Prompting How did I feel emotionally & physically at the Desires Situation time the situation occurred? Expectations What happened? (facts only!) 3 Why is this so important to me? What is at stake? 2 Attention, Interpretation, & Evaluation 5 What caught my attention? How did I interpret the situation? What was my evaluation of the situation? 4 Is the emotion part of an old pattern? What can I call this pattern? 6 Old Response Pattern Emotion in the Body Emotion Secondary Emotion How and where do I feel the emotion in 1 How do I appraise the primary emotion? my body? 7 How does this make me feel about my emotion? 8 Advantages of Emotion Impulses to Act Disadvantages of Emotion Short-term Long-term 9 Short-term Long-term 11 Behavior 12 10 FIGURE 31.3. The Analyzing Affective States Worksheet. To reduce the complexity wherever possible, the distinction between affect and emotions is not addressed in the training. Instead, the terms emo- tions and feelings are used in a very broad sense (e.g., with regard to feeling stressed out and relative to various mood states). Although the worksheet is fairly complex, participants who have been trained intensively in its use have rated it as one of the most helpful components of ART. Typical explanations for its popularity include “It gets everything I somehow felt was relevant for how I feel on one sheet of paper.” vides a step-by-step process to modify affec- that cue the target emotion. Then, they put tive states, is based on the general problem- the plan into practice and evaluate the out- solving model (D’Zurilla & Nezu, 2010) come. With regard to the latter, patients are and utilizes the Modification of Affective also taught a plan for how to deal effectively States Worksheet depicted in Figure 31.4. with unsuccessful modification attempts (see bottom right-hand corner of Figure Based on the long- and short-term advan- 31.4), because such failures often lead to a tages and disadvantages of the emotion sum- complete disengagement from functional mary from the Analyzing Affective States regulation endeavors and the use instead of Worksheet, the Modifying Affective States impulsive strategies that might effectively Worksheet first requires participants to set improve one’s mood in the short run but are as a goal how they would rather feel. Then, associated with negative long-term outcomes for each relevant maintaining factor (i.e., (e.g., engaging in avoidance, substance use, each box of the worksheet), participants worry, depressogenic thinking). brainstorm how changes in these areas could help cue the target emotion. After partici- After the model is introduced and prac- pants have identified as many helpful ideas ticed with a couple of examples, Skill 7 as possible for each box, they select the most is included in the ART sequence. At this promising ideas to plan specific behaviors point, the compassionate, helping part of
Affect Regulation Training 541 Modifying Emotions Preceding Emotional Vulnerability Needs Goals Prompting How can I improve my physical and emotional Desires Situation health? Expectations How can I change the situation? 3 Are other needs, goals, etc. really more important? 2 Attention, Interpretation, Can I reduce the significance of this and Evaluation need, goal, etc. to a lower level of significance? How else can I look at this situation? 5 4 What would be a more adaptive new pattern? What can I call this new pattern? 6 Old Response Pattern Emotion in the Body Emotion Secondary Emotion How can I foster changes in my body 1 Can I change how I think about the that would trigger the target emotion? emotion (in order to feel better about the 7 emotion)? 8 Effective change process: Behavior Failure/Partial Success: 1. Identify target feeling 9 1. Reward yourself for trying! 2. Brainstorm ideas about how 2. Try more of the same Strategy #1 (Use the Blues) – Identify the helpful actions suggested 3. Try other strategies to activate target feeling by the emotion and then implement them. 4. Change target or 3. Make a plan 4. Put plan into action Strategy #2 (Opposite Action) – Identify the unhelpful action suggested by accept and tolerate 5. Success: Reward yourself the emotion and then engage in the opposite behavior. Strategy #3 (Distraction) – Do something pleasurable to distract yourself. The goal is distraction, NOT avoidance! FIGURE 31.4. The Modifying Affective States Worksheet. When using distraction as a behavior- oriented modification strategy, it is explained to participants that the same behavior can be considered (dysfunctional) avoidance or distraction, which can be a very effective modification strategy, depend- ing on one’s willingness to experience the affective state to be regulated (“As long as we could also face the undesired state we are free to use distraction”); ART facilitates the adaptive use of distraction by focusing on experiencing and accepting unwanted affective states in ART Skills 3 and 4 prior to focus- ing on modification. “Opposite Action”: See Linehan (1993). the self (established in Skill 5) guides the ies have been conducted in a variety of psy- vulnerable part of the self (also established chotherapeutic settings and early results in Skill 5) in modifying negative affective are promising. One published study (Berk- states (“How do you actually want to feel in ing, Wupperman, et al., 2008) involved 289 this situation?”; “What is your target emo- patients from a mental health hospital. The tion?”; “How could you change the situa- patients all received 6 weeks of CBT supple- tion to achieve your target emotion?”). As mented with additional multidisciplinary such, ART Skill 7 builds on the other skills treatment as necessary. A randomly selected of the ART sequence and utilizes the gen- subgroup of patients was offered the option eral problem-solving framework to modify to replace four treatment sessions of CBT per undesired affective states. week with an abbreviated version of ART during a 3-week period. Results showed that Efficacy of ART at the end of the 6-week treatment, patients Research on the effectiveness of ART is still who had participated in ART displayed sig- in the early stages. However, several stud- nificantly greater improvement of affect reg- ulation skills than patients who had received CBT only. Additionally, patients participat-
542 INTERVENTIONS ing in ART showed a significantly greater cope with an experimentally induced depres- decrease in symptoms of depression and sive mood were more effective in reducing negative affect, as well as greater treatment the mood’s intensity than the spontane- gains in positive affect. ous regulation control condition (Fischer, Kirchner, Kandl, Hiller, & Berking, 2012; Similar results were found during a recent, Kowalsky et al., 2013). Although all these completely randomized controlled trial with studies provide significant support for the a sample of over 400 inpatient participants assumed efficacy of ART, additional stud- who met diagnostic criteria for MDD. In ies are dearly needed to clarify further the this study, the effectiveness of CBT was sig- populations that benefit from ART, and nificantly improved by supplementing tradi- whether and to what extent these benefits tional CBT with the ART program (Berking exceed those of other bona fide treatments. et al., 2013 ). Additional gains in the CBT + ART condition were particularly strong Future Directions for ART with regard to the abilities of acceptance, Several limitations in our basic research on tolerance, compassionate self-support, and affect regulation, ART as a clinical inter- modification. All these strategies have been vention, and our studies evaluating the effi- hypothesized to be particularly important cacy of ART need to be addressed in future for mental health (see the section on empiri- research. For example, basic research initi- cal evidence for the ART model). In another ated by our group has made extensive use of study (Berking et al., 2010), a group of police self-reports in an area that, at least in part, officers participated in ART. Prior to the is difficult to assess through introspection training, their affect regulation skills were (e.g., the ability to identify one’s emotions significantly lower than those of a control correctly). Moreover, the ERSQ asks partici- sample. After participation in the training, pants whether they can successfully apply the police officers’ affect regulation skills certain skills to their feelings or emotions. had increased to the point that they no lon- Because a depressed patient might refer to ger differed from the controls. These effects different emotions than would a partici- did not occur in the control condition. pant suffering from an anxiety disorder, the Moreover, in a recent quasi-experimental instrument refers to different affective states study, a combination of ART and CBT was in different participants, and the extent that effective for treating patients with medically these particular difficulties are valid indi- unexplained somatic symptoms (Gottschalk cators of their general emotion regulation & Rief, 2012). skills is unclear. Additionally, many assump- tions in our model (e.g., that the application Finally, in experimental studies with of promising affect regulation skills itself clinical and nonclinical samples, we found can contribute to short-term mood deterio- evidence for the short-term effectiveness of ration) are largely grounded in theory and/ specific ART skills. For these studies, we or clinical experience, and need to be inves- developed an experimental paradigm in tigated in more detail empirically. which health-relevant affective states are repeatedly induced with the help of a combi- With regard to ART as a clinical inter- nation of music and the Velten Mood Induc- vention, it is noteworthy that in spite of tion Procedure (1968). After each induc- the obvious advantages of transdiagnostic tion phase, participants are instructed to interventions (e.g., easier to disseminate in use affect regulation skills, such as the ones a cost-effective group setting), the disad- included in the ART model. Before and after vantages of potentially neglecting relevant each induction and regulation, participants characteristics of particular disorders have rate the intensity and acceptability of the to be carefully considered. Moreover, from affective state. To control for order effects, our clinical work, we developed the impres- the complete permutation of all possible sion that using theories and findings from combinations of strategies and control con- the neurosciences to derive health-relevant ditions is implemented over the total sample. affect regulation skills helps to engage par- Using this paradigm in a healthy sample of ticipants in the systematic training routine. undergraduates and a clinically depressed sample, we found that in both samples the ART-based audio instructions on how to
Affect Regulation Training 543 However, we also learned that finding the dated a modified version of the ERSQ called right balance between a clinically help- the Affect Regulation Skills Questionnaire ful and a scientifically valid neuroaffective (ARSQ; Ebert et al., 2013), which assesses model of affect regulation is often difficult affect regulation skills separately for various to attain. For example, anthropomorphiz- affective states.1 This measure helps to clar- ing relevant brain areas (e.g., by using the ify whether individuals differ in their affect expression “The amygdala only wants to regulation skills across different affective protect you”) can be a very effective psycho- states, and it helps to identify which skills therapeutic intervention, but the approach for which affective states are most important is inadequate in the context of pure scien- for maintaining or restoring mental health. tific explanations. Additionally, we have to acknowledge that remaining up-to-date with Currently we are also limited in our the latest findings in the rapidly developing attempts to use findings from the affective field of the neurosciences, while simultane- neurosciences to improve psychotherapeutic ously conducting large randomized clinical interventions. We acknowledge that we are trials, represents a remarkable challenge. unlikely to become cutting-edge experts in During the time it takes to develop a treat- two research fields as vast as the neurosci- ment program, write a treatment manual, ences and treatment development and evalu- raise the funds for efficacy trials, and con- ation. Thus, we are currently looking for duct and publish the results of those trials, neuroscience experts who share our inter- neuroscientific findings and theories used est in translational research. By collaborat- for developing the treatment program are ing with experts in the neurosciences, we likely to be out of date. aim to enhance further the validity of the translational approach used in ART and With regard to efficacy research, it is of thereby bridge the current gap between basic note that in clinical populations we have research and clinical application. investigated ART exclusively as an adjunc- tive intervention, which is in line with our With regard to the need for more efficacy assumption that the characteristics of spe- trials, in two, large, multicenter trials we are cific disorders must also be considered currently investigating whether ART can when offering transdiagnostic interventions also be used as an effective stand-alone treat- enhancing general emotion regulation skills. ment for MDD and/or binge-eating disorder However, the current lack of studies evaluat- (BED). In these trials we use experimental, ing ART as a stand-alone intervention also biological, observer-b ased, and ambulatory prevents us from clarifying which disorders momentary assessments of affect regula- can be treated effectively with interventions tion skills, in addition to retrospective self- focusing exclusively on enhancing such skills. report measures. Moreover, through mul- We should also note that because of the lack tiple assessments and designs that include an of multiple assessments and untreated con- untreated control condition, we will be able trol conditions, we have not yet been able to conduct meaningful mediation analyses. to conduct meaningful mediation analyses To clarify whether all parts of the program clarifying the extent to which ART exerts are necessary to obtain the desired effects, positive effects through improving affect we are currently conducting a dismantling regulation skills as hypothesized. Finally, study, in which we compare an ART version it is noteworthy that the current ART pro- that focuses exclusively on acceptance and gram teaches a broad range of affect regu- versions that focus exclusively on modifica- lation skills, which takes about 18 hours to tion or on both acceptance and modifica- complete. From a theoretical and a treat- tion. Additionally, we acquired funding for a ment dissemination perspective, an essential large, multicenter trial in which the efficacy subsequent step will be to clarify whether all of CBT + ART is compared with traditional parts of the program are necessary to obtain CBT in a sample of patients suffering from the desired effects. medically unexplained somatic symptoms. To overcome these limitations, we have We are also exploring technology enhance- initiated several research projects. For ments to ART. Text messages have been example, to address the measurement prob- used since 2004 to support participants in lems, we have recently developed and vali- their daily skills practice. Since then, numer- ous innovations have been presented in the
544 INTERVENTIONS rapidly developing field of computerized Berking, M., Neacsiu, A., Comtois, K. A., & psychological treatment. For example, we Linehan, M. M. (2009). The impact of expe- are currently finalizing an interactive online riential avoidance on the reduction of depres- version of ART, as well as several serious sion in treatment for borderline personality games that can be used to practice ART disorder. Behaviour Research and Therapy, skills in a leisurely fashion. We hope that 47(8), 663–670. these endeavors will help individuals in need of more effective affect regulation to acquire Berking, M., Orth, U., Wupperman, P., Meier, and continuously practice the most effective L., & Caspar, F. (2008). Prospective effects of strategies and thereby overcome their mental emotion regulation on emotional adjustment. health problems and thereby improve their Journal of Counseling Psychology, 55(4), well-being and satisfaction with life. 485 – 494. Note Berking, M., Poppe, C., Luhmann, M., Wup- permann, P., Jaggi, V., & Seifritz, E. (2012). 1. An English version of the ARSQ can be Emotion-regulation skills and psychopathol- obtained from Matthias Berking. ogy: Is the ability to modify one’s negative emotions the ultimate pathway by which all References other skills affect symptoms of mental disor- ders? Journal of Behavior Therapy and Exper- Amaral, D. G., Price J. L., Pitkänen, A., & Car- imental Psychiatry, 43, 931–937. michael, S. T. (1992). Anatomical organiza- tion of the primate amygdaloid complex. In Berking, M., & Whitley, B. (2013). Affect regula- J. P. Aggleton (Ed.), The amygdala: Neuro- tion training. New York: Springer. biological aspects of emotion, memory and mental dysfunction (pp. 1–66). New York: Berking, M., Wirtz, C., Svaldi, J., & Hofmann, Wiley-Liss. S. (under review). Emotion regulation skills predict symptoms of depression over five years American Psychiatric Association. (2013). Diag- in individuals at risk for depression. Behav- nostic and statistical manual of mental disor- iour Research and Therapy. ders (5th ed.). Washington, DC: Author. Berking, M., & Wupperman, P. (2012). Emotion Arnsten, A. F. T. (2009). Stress signaling path- regulation and mental health: Recent findings, ways that impair prefrontal cortex structure current challenges and future directions. Cur- and function. Nature Reviews Neuroscience, rent Opinion in Psychiatry, 25(2), 128–134. 10(6), 410–422. Berking, M., Wupperman, P., Reichardt, A., Beck, J. S. (1995). Cognitive therapy: Basics and Pejic, T., Dippel, A., & Znoj, H. (2008). beyond. New York: Guilford Press. Emotion-regulation skills as a treatment tar- get in psychotherapy. Behaviour Research and Berking, M. (2010). Training emotionaler Therapy, 46(11), 1230–1237. Kompetenzen (2nd ed.). Berlin/Heidelberg: Springer-Verlag. Berking, M., & Znoj, H. (2008). Entwicklung und Validierung eines Fragebogens zur stan- Berking, M., Ebert, D., Cuijpers, P., & Hofmann, dardisierten Selbsteinschätzung emotionaler S. (2013). Emotion-regulation skills training Kompetenzen (SEK-27) [Development and val- enhances the efficacy of cognitive behavioral idation of a standardized self-report measure therapy for major depressive disorder. Psycho- assessing emotional competencies]. Zeitschrift therapy and Psychosomatics, 82, 234–245. für Psychiatrie Psychologie und Psychothera- pie, 56(2), 141–153. Berking, M., Margraf, M., Ebert, D., Wupper- mann, P., Hofmann, S., & Junghanns, K. Bogdan, R., & Pizzagalli, D. A. (2006). Acute (2011). Emotion regulation skills as a predic- stress reduces reward responsiveness: Impli- tor of relapse during and after treatment of cations for depression. Biological Psychiatry, alcohol dependence. Journal of Consulting 60(10), 1147–1154. and Clinical Psychology, 79(3), 307–318. Bonanno, G. A., Papa, A., Lalande, K., Westphal, Berking, M., Meier, C., & Wupperman, P. M., & Coifman, K. (2004). The importance of (2010). Enhancing emotion-regulation skills being flexible: The ability to both enhance and in police officers: Results of a pilot controlled suppress emotional expression predicts long- study. Behavior Therapy, 41(3), 329–339. term adjustment. Psychological Science, 15(7), 482 – 487. Catanzaro, S. J., & Greenwood, G. (1994). Expectancies for negative mood regulation, coping, and dysphoria among college students.
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Chapter 32 Mindfulness Interventions and Emotion Regulation Norman A. S. Farb Adam K. Anderson Julie A. Irving Zindel V. Segal Mindfulness training (MT) represents the of mindful emotion regulation, integrating secular adaptation of Buddhist contem- contributions from Western psychological plative practices aimed to reduce suffer- research and Buddhist contemplative theory. ing and foster well-being. Over the past From these perspectives, mindfulness can be three decades, MT interventions have been viewed as a regulatory strategy that operates increasingly recognized for their ability to primarily at the level of attention deployment, reduce psychological distress across a vari- subsequently promoting a unique blend of ety of clinical disorders (Baer, 2003; Bohl- regulatory techniques. Next, we discuss how meijer, Prenger, Taal, & Cuijpers, 2010; mindfulness is developed through attention Grossman, Niemann, Schmidt, & Walach, training, reviewing emergent research on the 2004). They have been particularly effective cognitive and neural mechanisms associated in promoting adaptive emotion regulation with MT interventions. Psychologically, the in affective disorders such as anxiety and primary mechanism in MT interventions is depression (Hofmann, Sawyer, Witt, & Oh, the promotion of present-moment awareness, 2010; Piet & Hougaard, 2011), and appear which is realized through the cultivation of to promote self-regulated behavior and posi- interoceptive attention and an attitude of tive emotional states (Brown, Ryan, & Cre- acceptance toward experience. Neurosci- swell, 2007). Our understanding of mind- entifically, three mechanisms of training ful emotion regulation is imperfect, but it is are evident: (1) increased access to sensory supported by a recent groundswell of exper- representation; (2) decreased activation of a imental and clinical research (for detailed network for habitual self-elaboration; and, reviews, see Holzel et al., 2011; Shapiro, in longer term practitioners, (3) increased Carlson, Astin, & Freedman, 2006). attentional stability and decreased reactivity to emotion provocation. Finally, we review This chapter outlines the theoretical foun- some of the best-validated MT interventions, dations of mindfulness, the mechanisms by discussing their clinical benefits and limita- which MT appears to support adaptive emo- tions, and exploring future directions for tion regulation, and its most prevalent forms research in this field. of delivery. We begin by exploring definitions 548
Mindfulness Interventions and Emotion Regulation 549 What Is Mindful be achieved: the complete extinction of suf- Emotion Regulation? fering. Mindfulness has been described as “the awareness that arises from paying attention Mechanistically, the primary tenet of on purpose, in the present moment and non- the Buddhist psychological framework is judgmentally to things as they are” (Wil- that the mind may only hold one object at liams, 2007, p. 47). This definition distin- a time. Therefore, attention deployment to guishes mindfulness from regulatory efforts the firt three foundations limits conceptual to improve the hedonic tone of experience, elaboration that triggers or extends nega- such as using cognitive reappraisal to make tive emotion (Silananda, 1998). Thus, in the an image of suffering appear less aversive face of an emotional challenge, mindfulness (Gross, 2002). Instead, mindfulness pro- includes the somewhat paradoxical regula- motes exploratory attention to momentary tory instruction to focus directly upon one’s experience regardless of its unpleasantness. negative feelings; by focusing on a feeling Such exploration creates opportunities for rather than its inciting attentional object, a insight into one’s mental habits, reducing person diminishes the elaborative appraisal automatic efforts to control or manipulate that iteratively incites negative feeling. Over feeling states. Indeed, the Pali term vipas- time, it is argued, the habitual tendency sana, which is the origin of the English to engage in negative appraisals will itself term mindfulness, literally means “insight” diminish, as one internalizes the practice (Bischoff, 1996). To describe how such of nonjudgmental attention. Of course, let- insight occurs, we present a mindfulness ting go of past events, particularly aversive theory that is consistent with both Buddhist ones, is often easier said than done. Thus, and secular models of emotion regulation. Buddhist psychology has a rationale for using meditation formally to train attention. Mindfulness from a Buddhist/ Mindfulness from a Buddhist perspective Contemplative Model of Mind is therefore a practical rather than mystical Much of Buddhist theory on mindfulness regulatory strategy, complete with its own is contained in a discourse known as the psychological account of emotion regula- Maha Sattpatthana Sutta, which translates tion. The phenomenological description of to “the Great Discourse on the Foundations how attention deployment leads to the atten- on Mindfulness” (Silananda, 2002). Within uation of negative emotions provides a rich this history of the Buddha’s teachings, mind- set of hypotheses compatible with Western fulness rests upon four contemplative foun- psychological models of emotion regulation. dations that represent necessary targets for attentional focus. These foundations are (1) Mindfulness from a Psychological the body, (2) feelings, (3) the mind or con- Science Perspective sciousness, and (4) the Dhammas, or mental The idea of attention deployment as emo- qualities. It is telling that these first three tion regulation is not foreign to scientific foci explicitly exclude conceptual elabora- accounts of emotion regulation. For exam- tion or judgment but instead entail the allo- ple, the process model distinguishes between cation of attention to concretely perceived multiple strategies for regulation that can experiences, such as physical sensations, occur before and after emotional awareness, emotional responses, and thoughts. The distinguishing broadly between antecedent- fourth category, the Dhammas, describes focused and response-focused regulation the optimal attitudes and common pitfalls (Gross, this volume). Generally speaking, surrounding mindful attention to objects the earlier one regulates emotion following in these first three categories. In effect, this stress perception the better: For example, fourth category serves as a set of top-down the antecedent-focused strategy of cognitive regulatory goals for effective mindfulness reappraisal appears to be a healthier regu- practice. It is asserted that it is only through latory strategy than the response-focused the correct practice of attention deployment strategy of expressive suppression, leading that the pinnacle of emotion regulation may to lower stress-related symptoms (Gross & John, 2003; Moore, Zoellner, & Mol- lenholt, 2008). However, most research
550 INTERVENTIONS on antecedent-focused emotion regulation new aspects of a situation to be perceived, focuses on appraisal processes, a relatively effectively altering situation construal. This late regulation strategy for cognitive change. altered situation perception then permits the Few studies have examined earlier forms of generation of novel responses rather than regulation such as attention deployment, and mapping experiences into a preexisting con- those that do tend to focus on distraction ceptual field. The iteration between “top- (Gross, this volume), a withdrawal-oriented down” attentional control and “bottom-u p” strategy often employed in the face of high- sensation forms the basis for how mindful- intensity emotional challenge (Sheppes, this ness promotes insight and limits appraisals volume). of suffering (Teasdale & Chaskalson, 2011). Since responses following such iteration Mindfulness substantively contributes are more finely tuned to the idiosyncratic to psychological models of emotion regu- demands of the situation, they can be more lation by advancing a regulatory model of adaptive and appropriate than habitual reac- approach-oriented attention deployment tions (Figure 32.1C). Thus, despite its pri- (Figure 32.1A). Unlike distraction, mindful- mary focus on the deployment of attention, ness is characterized by acceptance rather mindfulness appears to impact additional than withdrawal from aversive emotional stages of the regulatory process: It intro- experience (Kabat-Zinn, 1982). Through duces novel regulatory intentions, facilitates MT, participants learn nonjudgmental novel appraisals of emotional experience, attention to present-moment sensation, and promotes expression rather than sup- returning attention their situation rather pression of emotional responses. than progressing to appraisal processes and responses (Figure 32.1B). By engaging What Makes Mindful Emotion cognitive resources in effortful attention Regulation Unique? deployment, mindfulness limits the recruit- Framing mindfulness within the process ment of habitual secondary appraisals and model does not undermine the unique con- reactions. The disruption of automatic reac- tions and return to sensory attention allows Antecedent-Focused Response-Focused Emotion Regulation Emotion Regulation FIGURE 32.1. A process model account of mindful emotion regulation. Mindfulness can be situated in Gross’s (2002) process model of emotion regulation, acting primarily on attention deployment (Panel A). Attention redeployment allows new situation perception, without requiring an immediate emo- tional response, thereby promoting the flexible generation of novel appraisals and responses (Panel B). The repeated redeployment of attention to sensation serves to interfere with and eventually extinguish habitual appraisals (Panel C).
Mindfulness Interventions and Emotion Regulation 551 tribution of mindfulness to existing mod- A third unique contribution of mindful els of emotion regulation. Mindfulness is emotion regulation is its ability to promote unique in promoting meta-awareness of a trajectory of self-change. Mindfulness emotion regulation strategies, detecting and requires an intensive investment: As dis- disrupting rumination, and in creating a tra- cussed below, participants in MT interven- jectory for self-c hange. We describe each of tions are asked to engage in meditative prac- these capacities in detail below. tices for about an hour a day for 8 weeks or more, with the explicit goal of increasing First, mindfulness serves as a meta- mindfulness throughout daily life. Partici- strategy: While MT practices begin with an pants are asked to take on attitudinal quali- emphasis on attention deployment, this atten- ties in a trait-like manner. While salutary tional focus is designed to cultivate awareness MT effects have been observed after train- of regulatory habits. In acknowledging these ing periods as brief as 20 minutes a day for 3 habits, a person is then better able to choose days (Zeidan, Gordon, Merchant, & Gool- flexibly between regulatory responses rather kasian, 2010), longitudinal benefits of mind- than automatically defaulting to particular fulness are more frequently reported follow- strategies. Perhaps because of its adaptive ing training periods of weeks or more. It is nature, mindfulness often leads to superior unknown whether formal training regimens regulatory effects when compared to exist- involving reappraisal or suppression gener- ing forms of regulation mentioned in the ate similar levels of self-reported change, process model, such as expressive suppres- although there is reason to believe that that sion (Liverant, Brown, Barlow, & Roemer, MT employs unique mechanisms for effect- 2008), rumination (Arch & Craske, 2006), ing change, as discussed more fully below. or distraction (Goldin & Gross, 2010). This is not to disparage the value of any of the How Does MT Work? aforementioned techniques, but rather to Attending nonjudgmentally to negative suggest that mindfulness may enhance regu- emotion is often easier said than done. lation by increasing flexibility in regulatory For this reason, mindfulness is viewed as strategy selection. By cultivating an attitude a skill that requires training and practice. of curiosity in response to an emotional chal- Like other traditions in the growing “third lenge, mindfulness provides an opportunity wave” of cognitive psychotherapy tech- to tailor regulatory responses to address niques (Hayes, 2004), MT is designed to both personal coping capacity and fluctuat- promote self-awareness of the interpretive ing situational demands. context that drives a person’s maladaptive reactions. Yet, unlike talk-therapy interven- A second unique contribution of mindful- tions, MT employs formal meditation prac- ness to emotion regulation is its ability to tice to achieve these aims. In mainstream disrupt rumination or rehearsal of negative interventions such as cognitive-behavioral emotional triggers. By widening attention to therapy (CBT), insight is a stepping-s tone to focus on the evolving nature of emotional the main therapeutic focus: The recognition experience, mindful attention disrupts cog- of maladaptive patterns of appraisal allows nitive elaboration on negative events. Many their replacement with adaptive alternatives. of us have had the experience of ruminating In MT, however, increased awareness into at length over a perceived slight. By mind- automatic reaction patterns is itself the goal fully attending to momentary experience of the intervention. It is fair to wonder then: rather than rehearsing an upsetting memory, How does awareness alone promote adap- negative emotions are permitted to subside. tive behavior? In this section, we outline Consistent with this theory, research sug- how MT impacts attention, and through gests that mindfulness is particularly effec- such effects improves the well-being of its tive for reducing dysphoric rumination, practitioners. outperforming relaxation training control groups in several cases (Feldman, Gree- To strengthen attention, MT begins with son, & Senville, 2010; Jain et al., 2007). By concentrative attention practices that often attending to negative emotions rather than focus on physical sensations, such as fine- treating them as a problem to be solved, mindfulness reduces suffering by limiting cognitive elaboration on aversive events.
552 INTERVENTIONS grained “body scans,” in which individuals the attentional practices themselves, and the attend to physical sensation from specific use of these practices to foster an attitude body parts, or feelings of respiration (Kabat- of acceptance and nonreactivity to negative Zinn, 1990). Such concentrative practices emotion (Shapiro, Carlson, Astin, & Freed- may already hold some regulatory benefits, man, 2006). At a mechanistic level, mind- because intense focal attention on a particu- fulness can be explained by the effects of the lar object may help to dissolve self–object attentional practices themselves, detailing boundaries (Lutz, Slagter, Dunne, & David- how mindful attention alters the preexist- son, 2008), and thereby help to suspend pat- ing relationship between events and subse- terns of self-absorbed rumination. However, quent self-attribution, limiting automatic mindfulness practices then transition from self-evaluative processing (Frewen, Evans, focal attention to open monitoring, wide- Maraj, Dozois, & Partridge, 2008). To pro- spread attention to all sensations, thoughts, vide a complete account of how mindfulness and emotions. Open-m onitoring practices impacts each aspect of emotion regulation, aim to increase awareness of the transi- we present intention, attention, perception, tory nature of experience, yielding insight implication, and attitude in a single concep- into one’s own habitual patterns of distrac- tual model (Figure 32.2). tion and reaction. Encouragingly, short- term mindfulness interventions appear to While empirical research has focused on increase the ability to notice changes in the how mindfulness alters cognition through sensory field and refocus attention appro- attention training, it is important to rec- priately (Jha, Krompinger, & Baime, 2007; ognize that the success of such practices Schmertz, Anderson, & Robins, 2009), and depends on a participant’s motivation and may preserve working memory capacity that expectations for such training. The gen- would ordinarily degrade in times of stress eration of a proper intention is critical to (Jha, Stanley, Kiyonaga, Wong, & Gelfand, the success of contemporary MT practices 2010). (Kabat-Zinn, 1990; Shapiro & Schwartz, 2000); participants must expect to have Of course, the ability to engage in open, some benefit from the practice to engage mindful attention is not purely an acquired consistently in a novel and intensive practice skill; we are all mindful of different things of restructuring cognitive habits. Within the during the day. Nonjudgmental, open meditative practices themselves, intentions awareness has been shown to arise natu- serve as a foundation for the direction of ralistically, particularly in conjunction with attention; by formally setting an intention to positive moods (Fredrickson & Branigan, attend to one’s body or breath, a wander- 2005). The tendency to be mindful may vary ing mind becomes indicative of a correctable widely from person to person, as attested to loss of attention. Central to holding “right by recently developed mindfulness scales, intention” in mindfulness is the promotion which also demonstrate that these trait indi- of participant autonomy, that participants ces of mindfulness appear to increase with are ultimately accountable to themselves for meditative practice (Baer et al., 2008; Lau et their self-improvement efforts. For example, al., 2006; Walach, Buchheld, Buttenmuller, in therapeutic contexts, MT emphasizes Kleinknecht, & Schmidt, 2006). Conversely, daily, self-directed practice rather than rely- trait mindfulness may also predict respon- ing on the clinician for directing inquiry siveness to MT and the specific attention and generating new appraisals. Mindfulness tasks therein (Shapiro, Brown, Thoresen, & teachers provide the occasional reminder to Plante, 2011), suggesting a reinforcing cycle check for mind wandering during these prac- among central components of mindful inten- tices, but with decreasing frequency over the tions, attention practice, and attitudes. weeks of a mindfulness course. Instead, par- ticipants are entrusted with an increasing Central Components of MT responsibility for monitoring and reallocat- Mindfulness-based interventions appear to ing attention during meditation. Indeed, it operate at multiple stages of emotion regu- has been argued that one yardstick of mind- lation. At a higher-o rder, conceptual level, ful intentions may be participants’ willing- MT represents an interplay between par- ness to ascribe personal responsibility for ticipants’ intentions for self-improvement, their reactions to stressful events (Lakey, Kernis, Heppner, & Lance, 2008).
Mindfulness Interventions and Emotion Regulation 553 FIGURE 32.2.╇ Broader regulatory consequences of mindfulness. Mindfulness effects extend beyond attention deployment in modulating stress responses. Different stages of the process model for emotion regulation are displayed for conventional (top panel) and mindful (bottom panel) stress responses. Con- ventionally, stressful situations are construed as demanding a regulatory response, prompting attention to the stressor, dysphoric appraisals, and generation of negative emotional responses. Mindfulness acts on all four of these phases: Mindful intentions cast stressful situations as opportunities to prac- tice; mindful attention broadens the field of awareness to include changes in sensation; and mindful attitudes promote appraisals of engagement and responses of acceptance rather than an obligatory dysphoric stance. The second major factor in MT inter- native self-eÂ
554 INTERVENTIONS disengages automatic evaluative responses provide widespread therapeutic benefits. to sensations, feelings, and thoughts. In this How can attention to the breath and other fashion, a negative emotion or disparaging physical sensations promote a broadening thought about oneself is treated as a momen- of attention and reduction of automatic pat- tary experience with no more self-d iagnostic terns of reactivity? Furthermore, one may value than an itch upon the skin. question the importance of attending to emo- tional appraisals in the first place. Emotions While the relationship between intention, hold a natural capacity to capture attention attentional practices, and attitude can be (Ohman, Flykt, & Esteves, 2001); why then seen as a linear progression in the cultiva- would practice in attending to emotions help tion of mindful emotion regulation skills, in regulating them? To address these ques- realistically these components are mutually tions, we expand upon a theoretical model reinforcing (Shapiro et al., 2006). Below we (Bishop et al., 2004) of how mindful atten- discuss how the interplay among these com- tion directly supports adaptive emotion reg- ponents creates a mechanism for promoting ulation based on two major principles: (1) stress tolerance and well-being. attention to the present: broad attention to present-m oment sensation, with an empha- Psychological Mechanisms sis on body sensation rather than cognitive of Mindfulness Training deliberation; and (2) nonjudgment: the sus- A recent review of the research literature pension of judging experience to be intrinsi- links MT to improved attention, body cally good or bad in favor of a more general awareness, emotion regulation, and altered attitude of acceptance. Together, these prin- self-perception (Holzel et al., 2011). How ciples mutually support the gradual process MT practices generate these positive changes of reconfiguring attention and cognition, may, however, benefit from further clarifica- extinguishing maladaptive patterns of reac- tion. It may seem strange, for instance, that tivity, and introducing cognitive flexibility repeated attention to body sensations should in the response to stress (Figure 32.3). FIGURE 32.3. The two foundations of mindful attention: Attention to the present and nonjudgment. Together they support a suspension of self-critical evaluation and are revelatory of reactivity habits. Over time, such information can yield insights that afford the creation of novel and more adaptive stress responses, help to dismantle existing patterns of reactivity, and can prevent the formation of novel conditioned or “knee-jerk” reactions to stress.
Mindfulness Interventions and Emotion Regulation 555 Attention to the Present challenge adaptively. The formal practice of The cultivation of momentary awareness is mindfulness meditation offers ample oppor- central to mindfulness practices. Through tunity to cultivate nonjudgment. Mind wan- repeated exercises in attending to the sensa- dering is inevitable during the attempted tions of the breath or different regions of the maintenance of interoceptive attention, body, participants are encouraged to develop prompting from participants a range of interoception, an awareness of momentary negative reactions, such as self-criticism, sensations from inside the body. These sen- anxiety, frustration, or dejection. Rather sations then act as an access point for under- than deny, suppress, or distract attention standing one’s reactions to the world as from these lapses and subsequent feelings, they unfold; rather than conceptually inter- participants are encouraged to notice and preting or predicting responses to events, accept all experience, including attentional participants are encouraged to explore lapses and feelings of frustration. This atti- their actual reactions “in real time,” using tude of acceptance then allows a more rapid interoceptive attention to monitor changes return to present-moment sensation than in body sensation from moment to moment. would be expected from digression into self- While myriad factors determine the efficacy recrimination. of a mindfulness intervention, attention to interoceptive sensation is important for sev- The practice of nonjudgment also has eral reasons. First, focusing on body sensa- important implications for emotion regula- tion helps to suspend evaluative processes, tion beyond formal meditation practices. disrupting the habitual progression from By focusing on noticing changes in experi- sensation to appraisal by redirecting atten- ence rather than formulating reactions, an tional resources from such processes. Sec- attitude of nonjudgment limits the asso- ond, in the absence of habitual evaluation, a ciation between initial appraisals of failure person extends the time course of appraisal, or challenge and subsequent dysphoric or reducing the need to quickly map events on a avoidant secondary appraisals. This cur- preexisting conceptual field, thereby disem- tailing feature of nonjudgment is critical to powering deeply entrenched dysphoric inter- recovery from affective and substance use pretations. Third, interoception serves as an disorders, in which inciting mental apprais- indication of physiological stress: By notic- als habitually lead to self-d estructive men- ing one’s breathing, heartbeat, muscle tone, tal and behavioral habits (Scher, Ingram, or digestion change, one can gain insight into & Segal, 2005). Indeed, both dispositional one’s own emotional appraisals and notice and treatment-related increases in mindful- the kinds of situations that trigger automatic ness predict greater facility in letting go of reactions. Finally, this sensitivity to environ- negative thoughts (Frewen et al., 2008), and mental triggers allows for the revelation of lower levels of avoidance and rumination reactive habits, because intrusive cognitive (Kumar, Feldman, & Hayes, 2008). This failures of interoceptive attention provide an development of nonjudgment can be thought opportunity to notice where the mind goes of as two complementary and related capaci- when it wanders. Perhaps because interocep- ties: acceptance of experience and decenter- tive perceptual details are so distinct from ing from attributing self-r elevance to experi- thoughts and evaluations, these details act ence, which together support the outcomes as attentional “anchors” for perception that of interoceptive attention described ear- make mind wandering more apparent. lier. First, acceptance indicates a willing- ness to tolerate outcomes even when they Nonjudgment diverge from intentions, limiting the auto- The cultivation of present-moment attention matic expansion of evaluative reactions. For is complemented by an intention to refrain example, one study of a mindfulness inter- from judgment and cognitive reactivity. vention reported improved quality-of-life, Nonjudgment supports formal meditation depression, and fatigue scores in a multiple practice, and also works with attention to sclerosis population, but unaltered ratings of the present moment to regulate emotional physical symptoms, such as lower and upper limb mobility (Grossman et al., 2010), sug- gesting that the symptom acceptance train- ing reduced broader secondary appraisals to
556 INTERVENTIONS produce a training benefit. Second, decenter- 2001). Together, these psychological mecha- ing involves reducing reliance on conceptual nisms promote and sustain flexibility in the self-appraisal as the primary determinant regulatory response to emotional challenge. of well-being. Instead, such self-appraisal is viewed on par with physical sensation, a Neural Mechanisms momentary experience that does not imply of Mindfulness Training the existence of a temporally extended, The notion that MT cultivates a qualita- enduring self. Recent research suggests that tively distinct approach to emotion regula- the ability to view one’s emotional reac- tion is supported by emerging neuroscience tions from a more objective viewpoint is a research. Traditionally, emotion regulation critical determinant of whether reflection on such as reappraisal has been associated with emotion can be constructive or degenerate the prefrontal cortex (PFC), which tends into maladaptive rumination (Kross, Gard, to be active during the manipulation and Deldin, Clifton, & Ayduk, 2012). evaluation of information (Ochsner, Bunge, Gross, & Gabrieli, 2002). The PFC in turn Together, attending to the present and appears to be component of a broader fron- cultivating a nonjudgmental attitude mutu- toparietal attention network associated with ally reinforce one another: Present-m oment directing attention to external objects, fil- attention provides a context in which to tering the endless stream of sensory infor- practice nonjudgment, and nonjudgment mation based on its motivational relevance enhances the stability of attention. Beyond (Corbetta & Shulman, 2002). In a sense, supporting each other, these two principles this well-defined attention system seeks to can account for many of the benefits attrib- fix sensory information as a set of objective uted to MT. First, mindfulness enables the facts that can be judged as being good or bad extinction of reactive habits by removing depending upon their relationship to a per- conditioned appraisal responses from their son’s goals. In the case of an undesired out- triggering stimuli and replacing them with come, cognitive reappraisal directs attention interoceptive attention. For example, MT toward changing one’s interpretive context has helped chronic pain sufferers to reduce to mitigate the obligatory emotional impact subjective reports of distress, although the of contextually derived failure appraisal on intensity of pain sensation ratings themselves the self. did not change (Morone, Greco, & Weiner, 2008; Rosenzweig et al., 2010). Second, by Mindfulness, however, argues for a quali- reducing reactive habits, mindfulness affords tative shift away from attachment to exter- new, creative appraisals, allowing a person nal outcomes. To do so, there is an attempt to approach experiences with a sense of to shift attention away from attentional hab- curiosity and exploration. Novel appraisals its that link external sensations to concep- then may extend to include previously unat- tual manipulation and elaboration. Instead, tended positive elements, including inter- MT teaches individuals to direct attention personal relationships, enjoyment of daily internally, to representation of visceral activities, or compassion toward oneself and components of emotion, as supported by a others (Allen, Bromley, Kuyken, & Sonnen- distinct neural pathway for interoception, berg, 2009; Kuyken et al., 2010). Third, con- the sensation of the body’s internal state, tinued mindfulness practice prevents future including signals from the breath (Farb, stress conditioning and provides competing Segal, & Anderson, 2013; Farb et al., 2007), knowledge of constantly changing intero- and heartbeat (Lutz, Greischar, Perlman, & ceptive sensations that weakens the need Davidson, 2009). Through reliance on the to turn to conceptual evaluations (Kabat- transitory and unelaborated representations Zinn, 1990). The suspension of engagement of internal body states, MT may appeal to a in automatic conceptual evaluation during relatively unconditioned system in the sense stress can thereby prevent further condition- that such physical sensations do not have the ing of dysphoric cognition. For example, same level of association with conceptual participants completing MT reported signif- elaboration or regulatory reactivity. Indeed, icant reduction in their experience of daily one reason that many mindfulness practices hassles and distress compared to a control involve interoceptive attention is that such group (Williams, Kolar, Reger, & Pearson,
Mindfulness Interventions and Emotion Regulation 557 practices improve the stability and frequency attention-controlling brain regions (Brewer with which one perceives the transitory and et al., 2011), again denoting an improved reinterpretable nature of human experience ability to resist distraction and to effectively (Baer, Smith, Hopkins, Krietemeyer, & deploy attention. Toney, 2006; Brown et al., 2007; Ivanovski & Malhi, 2007; Kabat-Zinn, 1982). In advanced stages, there is evidence to suggest that mindfulness training may Recent research evidence supports the itself become automatic and promote trait- idea that MT improves interoceptive access like effects. An intriguing neuroimaging by decoupling sensory cortices from brain study examined the meditative state across networks involved in the habitual evaluation a range of practice experience (Brefczynski- and elaboration of experience. Activation of Lewis, Lutz, Schaefer, Levinson, & David- cortical midline regions such as the medial son, 2007). Relatively novice meditators prefrontal cortex (mPFC) appear are asso- demonstrated pervasive cortical and limbic ciated with self-referential evaluation (Farb activation relative to controls when entering et al., 2007; Kelley et al., 2002), depres- a meditative state, typical of engagement in sive rumination (Farb, Anderson, Bloch, & an effortful and resource intensive cogni- Segal, 2011), and negative mood (Farb et al., tive process. However, advanced meditators 2010; Goldin & Gross, 2010). MT appears (with more than 10,000 hours of practice) to reduce both rumination (Ramel, Goldin, showed little neural change during medita- & Carmona, 2004) and cortical midline tion, suggesting that their default state may activation (Farb et al., 2010; Goldin, Ramel, have become something akin to mindful & Gross, 2009); furthermore, mindful attention. Thus, the long-term effects of MT attention can begin to reduce mPFC acti- may involve a reconfiguration of the brain’s vation even in untrained individuals (Farb information processes to dwell primarily in et al., 2007). Meditation has been linked unelaborated sensation, in contrast to the to extensive cortical deactivations (Baeren- highly automated pattern of cognitive elabo- sten et al., 2010; Ives-D eliperi, Solms, & ration found in most studies of Westerners Meintjes, 2011; Lazar et al., 2000), suggest- to date. ing its importance for disengaging concep- tual processing. Following training, par- Therapeutic Applications ticipants demonstrate a reduced connection of Mindfulness between sensory and evaluative cortices, but The first documented clinical effect of MT greater connectivity within sensory cortices was reducing the suffering of patients with and between the brain’s executive control chronic pain (Kabat-Zinn, 1982). Sub- regions and sensory cortices (Farb et al., sequent research has confirmed that the 2007, 2013; Kilpatrick et al., 2011). affective appraisal of pain is altered when experienced through an open, mindful state A third important neural mechanism by (Perlman, Salomons, Davidson, & Lutz, which MT promotes effective emotion regu- 2010). Freed from pain-reactive, negative lation is by enhancing attention control in appraisals about one’s self-worth and quality more experienced meditators. In one study, of life, cognition can be engaged construc- 3 months of intensive meditation training tively toward the cultivation of empathy and was associated with reduced variability in compassion (Leary, Tate, Adams, Allen, & low frequency brain signal electroencepha- Hancock, 2007). lographic (EEG) activity (Lutz, Slagter, et al., 2009). These brain changes were cor- The reframing of painful or otherwise related with reduced variability in reaction upsetting experiences is especially impor- time in a focused attention task, suggesting tant in mood disorders. The effortful down- that this stabilization of neural activity rep- regulation of negative emotion is perceived resents a more stable cognitive workspace in as more difficult by patients with a mood which to perceive and manipulate sensory disorder (Keightley et al., 2003), for whom objects. Furthermore, long-term meditators self-compassion seems like a worthwhile but demonstrated reduced network strength in unachievable strategy (Pauley & McPherson, the cortical midline default network associ- 2010). An important clinical implication of ated with conceptual elaboration and mind wandering but enhanced connectivity within
558 INTERVENTIONS these findings is that for patients with mood myalgia, multiple sclerosis, psoriasis, and disorders, instructions to reappraise cogni- HIV (Chiesa & Serretti, 2010). MT has also tively or otherwise regulate negative emotion been of benefit in older populations, par- may be ineffective. In depression, powerful ticularly in improving the coping skills of and habitual dysphoric interpretations may familial caregivers (Oken et al., 2010). be activated during such regulatory efforts, leading to rumination, in which elaborating The recent proliferation of MT in clinical on negative affect ironically perpetuates dys- contexts has been supported by the creation phoric mood (Nolen-H oeksema, 2000; Wat- of manualized therapeutic interventions. kins, Moberly, & Moulds, 2008). Customized interventions now exist that employ MT techniques to address the needs If the engagement of a patient’s cognitive of specific clinical populations, such as those faculties only serves to exacerbate negative suffering from issues of pain, depression, mood states, one might question how any and addiction. The standardization of these behavioral intervention can effect positive interventions has been critical for clinical change. Since cognitive elaboration efforts research, allowing a consistent application may automatically trigger negative self- MT to be evaluated in specific clinical con- judgments that cannot be voluntarily over- texts. Below, we discuss some of the most ridden, MT provides an alternative to such widely researched therapeutic interventions elaborative habits. Through the cultiva- of mindfulness, detailing their background, tion of attention to unelaborated, present- format, and target populations. moment sensation, mindfulness presents patients with a task that does not require Mindfulness‑Based Stress Reduction the deployment of cognitive evaluation and Background elaboration. Furthermore, by explicitly Mindfulness-based stress reduction (MBSR) practicing nonjudgment, patients can begin was developed as an outpatient program to recognize and disengage from conceptual at the University of Massachusetts Medi- judgment in response to their sensory expe- cal School in 1979, based on creator Jon riences. Kabat-Zinn’s personal experience with vipassana (insight) meditation, a practice Critically, mindful emotion regulation that originated in the millennia-old Thera- does not aim to inhibit elaborative process- vada Buddhist tradition. The first published ing through thought avoidance, a regulatory report on MBSR described reduced pain and strategy that ironically predicts dysphoric symptoms of negative mood in a group of affect (Ottenbreit & Dobson, 2004). In 51 patients with chronic pain (Kabat-Zinn, MT, attention is instead positively directed 1982). Since that time, MBSR has been stan- toward present-moment sensation, pro- dardized with broad efficacy in reducing viding a nonconceptual and nonthreaten- chronic pain and stress. ing attentional focus that does not rely on cortical midline activity. Depression can Format be thought of as a combination of both MBSR is delivered as an 8-week program. approach deficits and heightened avoidance Participants attend weekly group sessions motivation (Trew, 2011); mindfulness tar- with between 10 and 30 participants, where gets both types of motivation, replacing the they are introduced to formal mediation tendency to avoid negative experiences with practices, gentle yoga, and psychosocial an exploration of these experiences’ constit- education. The program also includes a day uent sensations. of silent meditation retreat that falls in the latter half of the course. Group members As one might expect from such a funda- are asked to practice yoga and/or medita- mental mechanism of action, mindful emo- tion for approximately 40 minutes a day for tion regulation strategies can be applied homework, along with reflection and journ- to a variety of contexts extending beyond aling exercises. Formal meditation practices pain and depression. One recent review catalogued beneficial psychological effects of mindfulness-based interventions in the treatment of anxiety disorders, substance abuse, cancer, heart disease, arthritis, fibro-
Mindfulness Interventions and Emotion Regulation 559 include breath monitoring; body scans (the to health care professionals, improving their progressive direction of attention to differ- ability to cope with stress (Irving, Dobkin, ent parts of the body); and diffuse direction & Park, 2009). Finally, adapted forms of the of attention to sounds, thoughts, feelings, MBSR program have improved mental func- and bodily sensations. Group sessions gen- tion and reduced stress in primary caregiv- erally last for 2.5 hours and focus on group ers of people with terminal diseases such as meditation practice and discussion of these dementia (Oken et al., 2010) and advanced- practices. However, other commonly dis- stage cancer (Lengacher et al., 2012). cussed themes include stress and the body, habitual patterns of reactivity, and creative Mindfulness‑Based Cognitive Therapy ways to respond to stress. Group dialogue Background on difficulties in performing practices and Mindfulness-based cognitive therapy insights gained are also valuable compo- (MBCT) was developed to target the specific nents of an MBSR course. During these dia- challenges inherent in chronic mood disor- logues, instructors model key components ders. Major depressive disorder, a leading of mindful awareness, such as noticing the cause of disability worldwide (Gelenberg, body sensations that accompany different 2010), has a chronic, cyclical nature due to thoughts and impulses. high risk of relapse. Presently, maintenance pharmacotherapy is the most widely imple- As part of the weekly homework, courses mented approach to reducing relapse risk in often include diary exercises, which are later depression (Kupfer et al., 1992). However, discussed in the group setting. Commonly, long-term antidepressant use involves prob- participants spend a week taking notice of lems with drug tolerance and side effects, pleasant events, then a week on unpleasant and does not target the dysphoric cognition events, and another week on monitoring that contributes to relapse risk in response stressful communications. However, com- to future stressors. Individuals with a his- mon even to these externalized practices, tory of depressive illness, including those there is an emphasis on how these events in remission, are prone to increased cogni- occurred from an interoceptive perspective tive reactivity, a pattern of increased nega- (i.e., how one felt in one’s body during these tive self-judgment in response to emotion events). There are no hard-and-fast rules for challenge. Dysphoric cognitive reactivity course compliance, although participants appears to be an important determinant who are absent are typically contacted by of depressive relapse, along with genetics, course instructors to probe commitment to environment, and social support (Segal et course participation. Participant retention al., 2006). However, such reactivity may in MBSR is generally high, with 80% of be modifiable; addressing these patterns of enrolled participants generally completing dysphoric thinking may provide posttreat- the course (Farb et al., 2007; Kabat-Zinn, ment protection against relapse (Paykel et Lipworth, & Burney, 1985). al., 1999). Target Population While Beck’s (1979) formulation of cogni- In healthy individuals (i.e., those without tive therapy focused on modifying underly- a specific medical or psychiatric diagno- ing dysfunctional attitudes and core beliefs, sis), MBSR appears to yield substantial but Ingram and Hollon (1986) argued that pro- nonspecific reductions in reported levels of phylactic effects following remission are stress, in addition to specific reductions in dependent on enhancing an individual’s abil- levels of rumination and anxiety (Chiesa ity to take a distanced, disidentified perspec- & Serretti, 2009). Research suggests that tive from depressive thoughts (i.e., decenter- MBSR promotes well-being across a vari- ing). To create a therapy that maximized ety of clinical conditions, including chronic long-term prophylactic effects, Segal, Wil- pain, anxiety, fibromyalgia, cancer, psoria- liams, and Teasdale (2002) expanded on the sis, and coronary artery disease (Baer, 2003; existing CBT framework to create MBCT, Grossman et al., 2004). A third stream of which uses mindfulness practices to develop research suggests that MBSR benefits extend
560 INTERVENTIONS participant ability to engage in decentered nance antidepressant medication in prevent- attention. ing depressive relapse, with both surpassing the performance of a placebo control condi- Format tion (Segal et al., 2010). The MBCT program involves medium-size groups (between eight and 13 participants). While originally designed to prevent The length of sessions ranges between 2 and relapse during remission, MBCT has also 2.5 hours in order to accommodate session shown efficacy in the treatment of acutely content flexibly and any clinical issues that depressed patients, including those with may arise. Participants are also offered a treatment-resistant depression (Barnhofer et full-day “silent retreat” between the sixth al., 2009; Eisendrath, Chartier, & McLane, and seventh weeks of the program. Every 2011). MBCT has also been adapted for session is initiated with a meditation to children ages 9–13 (Semple, Lee, Rosa, & ground participants in “being” mode and Miller, 2010), and for adults over age 65 help them to transition out of the business (Smith, Graham, & Senthinathan, 2007). and “doing” mode of their everyday lives. MBCT may be appropriate for patients Meditation practices include the body scan, with other mood disorders, but special gentle yoga, and mindful walking, as well as care must be taken to ensure that patients sitting meditation practices with foci such have adequate capacity to cope with nega- as the breath, sounds, body sensations, and tive emotions during the meditation process thoughts. Each session includes a review of (Germer, Siegel, & Fulton, 2005). the home practice, in addition to group dis- cussion of insession mindfulness practices. Mindfulness‑Based Relapse Prevention MCBT also features the 3-minute breath- Background ing space, a condensed version of formal Mindfulness-based relapse prevention mindfulness meditation in which partici- (MBRP), an intervention developed to target pants broadly inventory mood and quality relapse vulnerability in substance use disor- of thought, shift attention to the breath, ders (Marlatt & Gordon, 1985), is modeled then return to broad attention on sensation after MBCT to help people recognize inter- and cognition. The inclusion of the 3-min- nal triggers to addictive behavior without ute breathing space offers an opportunity to responding to them. The course features a integrate practice mindfulness in situations central theme of distinguishing between pri- where entrenched patterns of dysphoric cog- mary emotional experience and secondary nition make extended meditation difficult appraisals, with an emphasis on the idea that or impossible. It also affords participants a if the primary experiences can be accepted, chance to “check in” with themselves dur- secondary appraisals of coping inadequacy ing the day, limiting patterns of rumination. will lose power to trigger relapse behaviors. While initially incorporated into MBCT, the 3-minute breathing space is increasingly Format making its way into MBSR and related MT The intervention takes place over eight interventions. weekly sessions and introduces many of the same formal meditation techniques Target Population described in MBSR and MBCT. The focus MBCT was designed as prophylactic sup- of the group sessions centers on three major port in prevention of depressive relapse. In themes: Sessions 1–3 employ MT to provide two large, randomized control trials, MBCT awareness of how automatic patterns of has been shown to be efficacious for patients reactivity lead to relapse behavior; Sessions with three or more past episodes of depres- 4–6 focus on implementing mindfulness sion by halving relapse rates better than did techniques in high-risk or trigger situations a treatment-as-usual control condition (Ma to prevent thoughts from triggering relapse & Teasdale, 2004; Teasdale et al., 2000). behaviors; Sessions 7 and 8 focus on inte- In a more recent, large-scale trial, MBCT grating mindfulness practice into daily life was been shown to be as effective as mainte-
Mindfulness Interventions and Emotion Regulation 561 to provide continued development of self- itation practice but instead includes a variety care skills to protect against relapse in the of meditative exercises that may be custom- future. ized to a client’s needs and abilities. Accep- tance and commitment therapy (ACT) also Similar to the 3-minute breathing space eschews formal meditation techniques but that is central to MBCT, MBRP introduces places a strong emphasis on viewing expe- a “SOBER” breathing space (Stop, Observe, riences with a sense of acceptance or non- Breathe, Expand, Respond) designed to judgment, while focusing efforts on chang- allow participants to observe the arousal ing behaviors rather than thoughts, feelings, of urges and respond skillfully rather than and sensations. In both DBT and ACT, there habitually. By maintaining awareness of the is much greater emphasis on the adjustment urge, the participant somewhat ironically of behavior than in mindfulness-b ased inter- prevents his or her response to the urge, ventions, providing more therapist-led struc- allowing it to follow a homeostatic time ture around plans of action. course and eventually subside. Similar to the positive and negative events diary in MBSR, Contraindications MBRP employs an “awareness of triggers” Despite the promise of MT interventions in diary. By fostering awareness of thoughts, a variety of clinical domains, it is important feelings, sensations, and behaviors during to remember that these techniques have only the arousal of drug cravings, the diary helps been validated with specific ailments. In fact, to create recognition of triggering situations. original MT studies excluded individuals with active substance abuse, psychotic disor- Target Population ders, eating disorders, obsessive–compulsive MBRP targets people with a history of sub- disorder (OCD), and borderline personality ject use disorders, generally subsequent to disorder (BPD). The reasons for such exclu- completion of an intensive detoxification sion criteria were manifold; individuals with and rehabilitation program. In a recent study acute depression often experience compro- comparing the effects of MBRP to stan- mised attention and concentration, which dard relapse-prevention treatment, MBRP may pose significant challenges when learn- group participants showed lower rates of ing an already challenging practice, while relapse and greater levels of acceptance and individuals with OCD, BPD, and active sub- mindful awareness than those in the stan- stance abuse might find long formal medi- dard treatment group (Bowen et al., 2009). tation practices difficult to tolerate due to Importantly, subsequent research suggests intensively distressing intrusive thoughts, that reductions in craving following MBRP impulses, cravings, or a general tendency were mediated by increases in acceptance toward states of emotional dysregulation and mindful awareness (Witkiewitz, Bowen, (Hayes, 2004; Linehan, 1993). Moreover, in Douglas, & Hsu, 2013). these populations, reliance on emotion regu- lation strategies such as avoidance may be Other Interventions deeply ingrained, and the approach-oriented Incorporating Mindfulness nature of mindfulness practices may initially Many other contemporary therapeutic be difficult to tolerate. Effective treatments interventions incorporate aspects of MT such as cognitive therapy for acute depres- in a broader clinical protocol. Dialectical sion or DBT for BPD exist and have a strong behavior therapy (DBT; see Neacsiu, Bohus, evidence base (Beck, 1979; Linehan, 1993). & Linehan, this volume) is modeled on the Moreover, they are tailored to fit the needs central struggle between acceptance of the and tolerances of the individuals enrolled in present moment and desire for change. MT such programs. For example, the develop- is an important facet of this therapy, help- ment of mindfulness skills is a significant ing participants develop radical acceptance component of training in DBT skills. How- of a problematic situation in order to direct ever, skills practices are shorter and more efforts skillfully toward adaptive change. varied, building up over the course of sev- Unlike the interventions discussed earlier, eral months rather than in 8 weeks as in the DBT does not require extensive formal med- formats of MBSR and MBCT.
562 INTERVENTIONS Clinicians and expert meditation teach- and such access can be facilitated through ers alike have suggested various precau- attention training. Critically, engagement of tions when treating individuals who have sensory attention seems to disengage brain a significant history of trauma with MBSR networks involved in habitual elaborative and MBCT. Crane and Williams (2010) processing, allowing for the extinction of have discussed the importance of preexist- automatic stress reactions while strengthen- ing “grounding skills” for those individuals ing networks for the control of attention. who may be at-risk of experiencing intrusive thoughts or being particularly cognitively With elements of mindfulness now being reactive. Additionally, they suggest prepar- identified in a variety of other “new wave,” ing such individuals for the fact that distress health-p romoting practices such as Tai Chi, may arise, in light of evidence that a tendency yoga, and, more generally, in psychothera- toward brooding and cognitive reactivity peutic practice, the challenge before us is is predictive of dropout in MBCT. Patients to justify the spread of these techniques. As planning to engage in this type of intensive such, it is increasingly necessary to provide MT require the skills necessary to redirect an empirically replicable model of the core their attention should it become drawn into components of mindful emotion regula- destabilizing memories or overwhelming tion. Such a model will distinguish neces- affective states prior to commencing the sary regulatory elements from intervention MBCT program. A recent review of the lit- elements that are simply customary, and erature examining reports of adverse events help to assuage criticisms that mindfulness and contraindications for mindfulness-based involves ushering mysticism into Western, approaches found that the topic had been rel- evidence-based medicine. For example, the atively neglected (Dobkin, Irving, & Amar, relative contributions of attitude, intention, 2012) and warrants further investigation. and attention are unknown. It may be the case that daily exercises in setting benefi- Concluding Remarks cial self-intentions account for many of the Interest in mindful emotion regulation has salutary effects of mindfulness, allowing increased rapidly in recent years, especially one to dispense with much of the medita- as contemplative models of mind have been tive practice and instead engage in habits increasingly supported by modern psy- of self-a ffirmation. Alternatively, it may be chological science. This has enhanced our that attentional improvements are necessary understanding of emotion regulation in two precursors to the experience of insight and major ways: (1) It informs research on atten- improvements in well-being. Finally, it may tion deployment as a form of emotion regu- be the commitment to regulating experience lation, without resorting to distraction from with an attitude of acceptance that really emotion; and (2) it has begun substantively pays benefits, with meditative exercises to connect scientific inquiry to broader simply helping to reinforce this commit- issues in emotion regulation, such as how ment. While there is suggestive evidence that flexibility in regulation techniques serves the three core elements of mindfulness— as a “meta-regulatory” skill, or how inten- attitude, intention, and attention—are criti- tion and commitment to a regulatory goal cal ingredients, it will be important to find increase realization of longitudinal improve- better ways to measure their relative contri- ments in regulatory capacity. Psychologi- butions to advance the science of mindful- cally, the study of MT provides a window ness and determine its potential for integra- into the mechanisms of personal growth, tion into secular Western life. combining elements of attention, intention, and attitude to form an upward spiral of reg- References ulatory efficacy. Neurobiologically, the study of mindfulness helps to validate the idea that Allen, M., Bromley, A., Kuyken, W., & Sonnen- sensory attention recruits a distinct intero- berg, S. J. (2009). Participants’ experiences ceptive attention pathway. This pathway of mindfulness-based cognitive therapy: “It appears to be amenable to voluntary access, changed me in just about every way possible.” Behavioral and Cognitive Psychotherapy, 37(4), 413–430.
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Part IX Health Implications
Chapter 33 Emotion Regulation and Gene Expression Steven W. Cole Inhibiting the expression of emotions has such as cardiovascular, neurodegenerative, long been believed to undermine physi- metabolic, and neoplastic diseases (Finch, cal health, and recent developments in our 2007; Sterling, 2004). ability to map neural–immune interactions at the genomic level have begun to identify Emotion Regulation potential biological bases for such effects. and Human Health This chapter reviews basic research linking As far back as the second century A.D., the emotional inhibition (or suppression; I use Greek physician Galen noted that people the terms interchangeably) to physical ill- who were emotionally inexpressive seemed ness and outlines an emerging theoretical to be at increased risk of cancer (Siegel, paradigm in “social genomics” that sheds 1968). Subsequent epidemiological studies light on both the biological mechanisms underscored this observation (Gross, 1989; of such effects and their potential evolu- Mund & Mitte, 2012) and expanded the tionary origin. This perspective construes range of health risks associated with emo- emotion regulation as one component of a tional inhibition to include cardiovascular broader set of biobehavioral adaptations and immune-related diseases (Bell, Jas- that have emerged in response to the evo- noski, Kagan, & King, 1990; Cohen, Doyle, lution of a hypersocial “life history strat- Skoner, Rabin, & Gwaltney, 1997; Cohen, egy” for humans (Darwin, 1872; McDade, Doyle, Turner, Alper, & Skoner, 2003; Cole, 2003; Richerson, Boyd, & Henrich, 2010; Kemeny, & Taylor, 1997; Cole, Kemeny, Wilson, 2012). The social–neural–genomic Taylor, & Visscher, 1996; Denollet, Gidron, programs that evolved to mediate this adap- Vrints, & Conraads, 2010; Denollet, Ped- tation likely held little health cost under ersen, Vrints, & Conraads, 2006; Denol- primordial conditions in which trauma and let et al., 1996; Ironson, O’Cleirigh, Weiss, infection were our primary causes of death Schneiderman, & Costa, 2008; Kagan, (Finch, 2010). However, in the very differ- 1994; Kagan, Snidman, Julia-Sellers, & ent social, physical, and cultural environ- Johnson, 1991; Mund & Mitte, 2012). ments that we now inhabit, these biological Recent experimental studies also suggest programs may functionally connect every- that the active expression of emotions can day “civilized” social behavior to low-level mirror the effects of suppression and reduce anticipatory threat reactions that can aggra- vate many drivers of “modern mortality,” 571
572 HEALTH IMPLICATIONS the risk of minor illnesses (Booth, 2012; chemical response to external stimuli (e.g., Frattaroli, 2006; Pennebaker, 1988). The neurotransmission or immune response). disease risks associated with emotional inhi- Absent their transcription, DNA genes have bition range widely in their specific biology no effect on health or behavioral pheno- and in their overall health significance, but types. With the advent of a sequenced human they share in common one basic teleological genome and the emergence of DNA microar- puzzle: Why has the human body evolved to ray and sequencing technologies, scientists lose vitality when we inhibit the expression can now survey the expression of all human of our emotions? genes simultaneously and map the specific subset of genes that is actively expressed in Surprisingly, mechanistic answers to this RNA within a given cell at a given point in question have emerged more rapidly than time. One surprising finding from such stud- true functional explanations. It is now easer ies of functional genomics is that the expres- to understand how emotional inhibition sion of a given gene is often more an excep- might affect human health than why that tion than the rule. Cells are highly selective should be so. Much of our growing mecha- about which genes they express, and our nistic insight stems from dramatic techni- DNA encodes a great deal more genetic cal advances in molecular genetics, and our potential than is realized in RNA and pro- growing ability to understand physical dis- tein (Djebali et al., 2012). As such, the subset ease in terms of changing patterns of human of genes that is expressed in RNA—the cell’s gene expression (Cole, 2009; Finch, 2007; transcriptome—can be interpreted as the Miller, Chen, & Cole, 2009). The equation product of a cellular decision-making pro- of disease with gene expression dynamics cess regarding which particular sets of genes represents an oversimplification to be sure. would be most adaptive to express under the However, construing health and disease prevailing circumstances. Mechanistically, through the lens of molecular genetics has these decisions are mediated by protein tran- the significant heuristic advantage of con- scription factors that bind to specific DNA necting these dynamics to theoretical and sequences in the regulatory region (or pro- teleological perspectives derived from evo- moter) of a gene. Most transcription factors lutionary biology. Harnessing the tremen- target a large number of genes that contrib- dous technical infrastructure of molecular ute in different and often partially overlap- genomics offers opportunities to understand ping ways to a common biological process not only how social inhibition affects health (e.g., multiple genes encoding receptors, sig- but also why that connection should have naling molecules, and transcription factors emerged in the first place. The keys to real- that collectively allow a particular cell to izing this opportunity lie in understanding recognize and respond to a neurotransmit- how genes change their behavior in response ter or microbe). As such, transcription fac- to our psychological experiences. tors are best construed as activating general gene transcriptional programs or gene mod- Genetics versus Genomics ules rather than acting on specific individual As genes have come to be understood as con- genes in isolation. crete DNA sequences rather than abstrac- tions inferred from inheritance, it has What evolutionary theory adds to this become increasingly apparent that social mechanistic picture is a set of principles for and psychological factors can regulate the determining which genes should be coacti- activity or expression of human genes (Cole, vated by a given transcription factor (i.e., 2009). DNA encodes the potential for cellu- the inclusion–exclusion structure or inten- lar behavior, but that potential is only real- sion of a particular gene module) and which ized if the gene is expressed—if the DNA transcription factors should be activated in is transcribed into RNA (Figure 33.1). It is response to the stimuli present in the cell’s RNA and its subsequent translation into environment. In other words, transcription protein that shapes a cell’s structure and factors and their “target gene modules” identity, and endows its functional capaci- constitute a biochemical stimulus–response ties such as movement, metabolism, and bio- program, and the development of the whole system of such programs encoded in a genome represents the product of evolution-
Emotion Regulations and Gene Expression 573 Social Environment Central Health & nervous system Behavior Peripheral nervous system Endocrine system Receptor Protein Signal transduction Transcription RNA DNA factor Coding region TGA[G/C]TCA Promoter Gene FIGURE 33.1.╇ Social signal transduction. Socioenvironmental processes regulate human gene expres- sion by activating CNS processes that subsequently influence hormone and neurotransmitter activity in the periphery of the body. Peripheral signaling molecules interact with cellular receptors to activate transcription factors, which bind to characteristic DNA motifs in gene promoters to initiate (or repress) gene expression. Only genes that are transcribed into RNA actually impact health and behavioral phenotypes. Individual differences in promoter DNA sequences (e.g., the [G/C] polymorphism shown here) can affect the binding of transcription factors and thereby influence genomic sensitivity to socio- environmental conditions. Adapted from Cole (2009). ary trial and error in adapting to changing growth factors, hormones, or neurotrans- environmental conditions. Some “constitu- mitters). tive” transcription factors show steady levels of activity and act mainly to continue the For both types of transcription factor, expression of genes that confer a cell’s par- the mapping of an individual factor onto its ticular biological identity (e.g., maintaining distinctive subset of “target genes” confers the expression of neuron-Âd
574 HEALTH IMPLICATIONS a sort of evolutionarily acquired program- ferences in basal levels of SNS activity (Cole, ming, or a “wisdom of the genome” regard- Kemeny, Fahey, Zack, & Naliboff, 2003; ing which genes are most adaptive to express Kagan, 1994; Kagan, Reznick, & Snidman, in a given type of environment. 1988), suggesting that dispositional differ- ences in peripheral autonomic activity might Accumulating data on the specific recep- potentially act on a tonic, daily basis to alter tor systems that activate particular tran- basal physiological homeostasis. A growing scription factors also allow a set of more body of experimental research largely paral- specific inferences regarding the extracel- lels findings from the individual-dÂ
Emotion Regulations and Gene Expression 575 Neural Regulation of Human inflammation (e.g., IL1B, IL6, IL8, TNF) Gene Expression and decreased expression of genes involved The potential for psychosocial regulation in innate antiviral responses (IFNB and of human gene expression first emerged in IFI, MX, and OAS gene families), and the the context of studies analyzing the effect of production of a specific type of antibody social stress and SNS neurotransmitters on (immunoglobulin G1 [IgG1]) (Cole, 2009, viral genomes such as herpes simplex viruses 2010; Irwin & Cole, 2011; Miller, Chen, & (Glaser, Kiecolt-Glaser, Speicher, & Holli- Cole, 2009). Each type of adversity is also day, 1985; Jenkins & Baum, 1995; Kupfer associated with other transcriptional altera- & Summers, 1990; Leib, Nadeau, Rundle, tions that are relatively unique to that condi- & Schaffer, 1991; Padgett et al., 1998; Ras- tion. However, this core CTRA pattern of mussen, Marsh, & Brill, 1957; Schuster, proinflammatory and anti-antiviral tran- Chasserot-Golaz, Urier, Beck, & Sergeant, scriptome shift has emerged much more con- 1991), human immunodeficiency virus (HIV- sistently than would be expected by chance. 1; Capitanio, Mendoza, Lerche, & Mason, Similar patterns also emerge in response to 1998; Cole et al., 1997; Cole, Kemeny, Tay- experimentally imposed adversity in ani- lor, Visscher, & Fahey, 1996; Sloan et al., mal models of social instability, low social 2007), Epstein–Barr virus (Glaser et al., rank, and social threat or defeat (Cole et al., 1985; Yang et al., 2010), cytomegalovirus 2010, 2012; Irwin & Cole, 2011; Sloan et (Glaser et al., 1985; Prosch et al., 2000), and al., 2007; Tung et al., 2012). the Kaposi’s sarcoma-associated human her- pesvirus 8 (Chang et al., 2005). As obligate Given the statistical challenges of mul- parasites of human host cells, viruses have tiple hypothesis testing across roughly evolved within a microenvironment struc- 21,000 genes, different “social genomics” tured by our own genome. If social processes studies rarely find identical sets of differ- and SNS neurotransmitters can regulate the entially expressed genes. Where consistent expression of viral genes, it stands to reason patterns do become salient is in subsequent that our own complement of roughly 21,000 bioinformatic analyses extracting common genes might be modulated as well. functional themes from the lists of tens to hundreds of differentially expressed genes in Over the past 5 years, a series of genome- each study (e.g., Gene Ontology annotations wide transcriptional profiling studies has regarding shared biological functions and found that extended periods of psycho- analyses of transcription control pathways logical or social stress are often associated regulating expression of multiple genes) with a specific pattern of change in gene (Cole, 2010). The recurrence of these core expression within immune cells. Across proinflammatory–anti-antiviral biological several distinct types of adversity such as themes across both different adverse envi- social isolation (Cole, Hawkley, Arevalo, ronments and different mammalian species & Cacioppo, 2011; Cole et al., 2007; Cre- suggests that the immune system of social swell et al., 2012), imminent bereavement mammals is programmed to generate a (Miller et al., 2008), low socioeconomic CTRA response whenever individuals expe- status (SES; Chen, Miller, Kobor, & Cole, rience extended periods of stress, threat, or 2011; Chen et al., 2009), early life social uncertainty (Antoni et al., 2012; Cole et al., deprivation (Miller, Chen, Fok, et al., 2009), 2012; Irwin & Cole, 2011). This general late life social adversity (Cole et al., 2010), transcriptional program may be expressed traumatic stress (O’Donovan et al., 2011), somewhat variably at the level of individual diagnosis with a life-threatening illness gene transcripts depending upon specifics (Antoni et al., 2012; Cohen et al., 2012), of individual history, genetic background, and experimentally imposed social threat and particulars of the current environment (Cole et al., 2010; Cole, Arevalo, Rugge- (Cole, 2010). However, the broader bio- rio, Heckman, & Suomi, 2012; Sloan et al., logical principle of increase inflammation 2007, 2010), circulating immune cells (leu- and suppress interferons and IgG1 seems kocytes) show a conserved transcriptional to be programmed into the basic stimulus– response to adversity (CTRA) involving response logic of the human genome (at least increased expression of genes involved in as expressed in the receptor/transcription factor logic of leukocytes).
576 HEALTH IMPLICATIONS A key role for psychological experience in an evolutionarily adaptive “defensive pro- triggering the CTRA dynamic is suggested gram” that redeploys the immune system’s by results from several small randomized transcriptional resources to “allostatically controlled experiments showing that stress- anticipate” (Sterling, 2004) the changing reducing interventions can reverse CTRA patterns of microbial exposure historically transcriptional dynamics in human immune associated with changing life circumstances cells (Antoni et al., 2012; Black et al., 2013; (e.g., increased risk of wound-related bacte- Creswell et al., 2012). A key role for the SNS rial infection during periods of acute threat in mediating these effects is suggested by vs. increased risk of viral contagion during cellular studies showing that CTRA-related extended periods of close social contact; transcriptional dynamics can be mimicked Cole et al., 2011; Irwin & Cole, 2011). by pharmacological agents that activate Because antiviral and proinflammatory gene the beta-adrenergic receptor systems tar- modules are, to some extent, mutually exclu- geted by SNS neurotransmitters and can be sive (Amit et al., 2009; Negishi et al., 2012; blocked by pharmacological antagonists of O’Connell et al., 2004; Shahangian et al., those receptors (Cole et al., 2010; Collado- 2009; Tian et al., 2012), the immune system Hidalgo, Sung, & Cole, 2006; Hanke, Pow- must “choose” which gene module to favor ell, Stiner, Bailey, & Sheridan, 2012; Wohleb at any given time. The CTRA dynamic sug- et al., 2011). Moreover, the specific pattern gests that that choice is informed in part by of up-regulated inflammatory gene expres- the broader physiological and environmental sion and down-regulated antiviral- and conditions surrounding the individual (i.e., antibody-related gene expression observed organism-level adaptive fitness), as perceived in studies of human social adversity maps by the CNS and distributed into peripheral very closely to the effects of SNS pharma- tissues via the SNS (Cole et al., 2011; Irwin cology in laboratory experimental studies, & Cole, 2011). However, when the CTRA whereas other stress-responsive systems defensive program is chronically stimu- that might potentially mediate such effects, lated, the resulting proinflammatory–anti- such as glucocorticoid hormone release from antiviral shift in leukocyte transcriptional the HPA axis, activate very different gene equilibrium may promote the complex pat- expression programs (Irwin & Cole, 2011). tern of “modern mortality” diseases involv- In fact, several studies have implicated a ing elements of both up-regulated immune selective reduction in glucocorticoid signal- function (e.g., inflammation-related diseases ing in contributing to the proinflammatory such as heart disease, neurodegenerative dis- component of the CTRA profile (Cole et al., eases, and some types of cancer) and down- 2007; Hanke et al., 2012; Miller et al., 2008; regulated immune function (e.g., impaired Wohleb et al., 2011). These observations do response to vaccines and viral infections) not rule out a potential effect of glucocorti- (Finch, 2007). The complex pattern of up- coids in other types of stress-mediated gene and down-regulated gene modules associ- expression dynamics (e.g., responses to more ated with the CTRA underscores the fact severe, overwhelming stressors that elicit that stress is not broadly immunosuppres- defeat/withdrawal responses; Henry, 1992; sive, but instead selectively suppresses some Lundberg & Frankenhaeuser, 1980; Sapol- groups of immune response genes (e.g., Type sky, 1994). However, the general patterns of I interferons and some immunoglobulin transcriptional alteration associated with the genes) while simultaneously activating oth- chronic and highly prevalent socioenviron- ers (e.g., proinflammatory cytokines) (Irwin mental risk factors for human disease (social & Cole, 2011). isolation, low SES, etc.) appear to parallel most closely the profiles of gene expression Beyond the CTRA dynamic in leuko- induced by beta-adrenergic receptor sig- cytes, stress biology can also regulate gene naling in experimental cellular and animal expression in a wide variety of other tissues, models (Irwin & Cole, 2011). including the CNS (Karelina et al., 2009; Karssen et al., 2007; Weaver, Meaney, & Why should CTRA-related gene modules Szyf, 2006), peripheral immune system have evolved to become sensitive to beta- organs such as the lymph nodes and spleen adrenergic signaling from the SNS? CTRA (Cole et al., 2010; Sloan et al., 2007), and transcriptional dynamics appear to represent diseased tissues such as ovarian cancers and
Emotion Regulations and Gene Expression 577 stroke-wounded brain tissues (Karelina et biological mechanism for effects of emo- al., 2009; Lutgendorf et al., 2009). Given tion regulation on human health (Miller, the much smaller number of social genomics Chen, & Cole, 2009), however, this equa- analyses targeting such solid tissues, and the tion of emotion regulation with gene regula- relative difficulty in ascertaining the func- tion also suggests a broader set of questions tional significance of specific transcriptional regarding the origins and consequences of alterations outside the well-charted terri- emotion regulation in general physiological tories of the immune response, it has been function (i.e., independent of its impacts on much more difficult to map the specific gene somatic disease). programs modulated in these tissues and to deduce their associated teleological rationale One distinctive feature of gene transcrip- (e.g., are these tissue “defensive programs” tion as an “output” from psychological pro- analogous to the leukocyte CTRA, or do cesses is its simultaneous role as an “input” they represent some other type of functional into the future biological characteristics of adaptation specific to the organ system the individual (Cole, 2009). Genes can act involved?). However, it is clear that the social recursively in the sense that they alter the environment surrounding an individual can nature of the molecular machinery that con- modulate broad swaths of gene activity in trols their own expression. Figure 33.2 out- a diverse array of bodily tissues via CNS- lines some of the developmental implications mediated interpretations of the environment of such recursion in allowing environmental as safe/accommodating or threatening/hos- conditions (including psychological percep- tile/uncertain. tions and emotional expression) to become embedded in the molecular biology of the Emotion Regulation individual in ways that affect subsequent and Gene Regulation perceptual, emotional, and neurobiological At the time of this writing, no published responses to future environmental condi- studies have directly examined the effects of tions. For example, if one period of emo- emotional inhibition on human gene expres- tional suppression results in altered patterns sion. However, coupling the two domains of gene expression in the brain, and some of research reviewed here suggests a natural of those regulated genes include molecules hypothesis regarding how chronic emotional that mediate the perception of social threat suppression might influence physical health and its transduction into gene expression via systematic changes in gene expression. (receptors, signal transduction molecules, To the extent that (1) emotional suppres- transcription factors, etc.), then the individ- sion activates the SNS and (2) the SNS acti- ual’s subsequent psychological response to a vates gene expression programs such as the fixed social or emotional stimulus may well CTRA, chronic emotional suppression may differ from what it would have been other- induce a repetitive or temporally extended wise, purely as a function of that individu- bias in basal gene expression profiles that al’s history of exposures earlier in life. This simultaneously increases vulnerability to recursive feedback dynamic provides one inflammation-related diseases (e.g., car- biological pathway by which early life social diovascular and neoplastic diseases) and and psychological conditions can become decreases immune response to vaccines and embedded in an individual’s basic neuro- viral infections. Assuming this plausible biological characteristics and subsequently conjunction holds true empirically, emotion influence later patterns of psychological regulation can be construed as an indirect experience and biological development form of gene regulation. Moreover, the spe- (Cole, 2009). Recursive feedback dynamics cific pattern of gene expression modula- also help clarify how particularly acute tran- tions that would be predicted based on this sient events can induce persisting alterations hypothesis corresponds quite closely to the in neurobiological homeostasis (e.g., as in profile of specific disease risks that has been posttraumatic stress disorder [PTSD]). linked to inhibition in empirical epidemio- logical studies. Beyond providing a plausible Because genes can recursively regulate their own molecular triggers and produc- tion machinery, there exists great potential for nonlinear regulatory dynamics in which initially small stimuli have quantitatively
578 HEALTH IMPLICATIONS Behavior1 Time 1 Environment1 Body1 RNA 1 Time 2 Environment2 Body2 Behavior2 RNA 2 Time 3 Environment3 Body3 Behavior3 RNA 3 FIGURE 33.2. RNA as a molecular medium of recursive development. Social conditions at one point in time (Environment1) are transduced into changes in behavior (Behavior1) and gene expression (RNA1) via CNS perceptual processes that trigger systemic neural and endocrine responses (medi- ated by Body1). Those RNA transcriptional dynamics can alter the molecular characteristics of cells involved in environmental perception or response, resulting in a functionally altered Body2. Body2 may respond differently to a given environmental challenge than would the previous Body1, resulting in different behavioral (Behavior2) and transcriptional responses (RNA2). The effect of RNA tran- scriptional dynamics on persisting cellular protein and functional characteristics provides a molecular framework for understanding how socioenvironmental conditions in the past may continue to affect current behavior and health, and how those historical conditions interact with current environments to shape our future trajectories (e.g., Body3, Behavior3, RNA3). Because gene transcription serves as both a cause of social behavior (by shaping Body) and a consequence of social behavior (a product of Environment × Body), RNA serves as the physical medium for a recursive developmental trajectory that integrates genetic characteristics and historical–e nvironmental regulators to shape individual biologi- cal and behavioral responses to current environmental conditions. Adapted from Cole (2009). or temporally disproportionate effects. unknown. However, as studies of CNS Whether this actually happens or not in any gene expression grow in number, sophis- given situation depends largely on the feed- tication, and neuroanatomical precision, back structure of the specific gene networks new insights will rapidly emerge regarding involved. To the extent that receptors, signal the recursive architecture of the genome as transduction molecules, and transcription expressed in the brain structures mediating factors number among those genes empiri- emotional experience and behavior. Even cally modulated by a given stimulus, some in the absence of ideal longitudinal studies form of feedback recursion is likely to occur. that directly map system dynamics, much However, recursion alone does not guaran- may be learned by simply observing the pat- tee nonlinear amplification. Whether that tern of changes induced by a single stimulus feedback is positive (amplifying), negative event. To the extent that stimulus changes (damping), or nonexistent depends largely the expression of genes with known recur- on the empirical pattern of connections sive capacity (e.g., genes encoding receptors, among gene products, or the “wiring dia- signal transduction molecules, transcription gram” of the human genome as expressed factors, or epigenetic modulators) the poten- in a given cell type (i.e., the specific set of tial for feedback and nonlinear dynam- receptors, signaling molecules, and tran- ics becomes substantially greater, and the scription factors expressed in a given cell, or specific pattern of up- and down-regulated potentially induced in that cell in response recursive molecules can provide some indi- to environmental stimuli). Outside of the cations regarding the positive versus nega- immune system, the wiring diagram of the tive feedback elements of the system. As human genome remains almost completely those wiring diagrams become increasingly
Emotion Regulations and Gene Expression 579 well mapped, the network structure of such Hofer, 1984). To the extent that emotional systems may identify particularly influen- suppression undermines one’s sense of true tial recursive regulators that would provide connection to others and more general faith highly leveraged targets for interventions to in humanity, the social costs of suppression block the temporally propagating effects of may well represent its most caustic health early life adversity and acute trauma in adult effect. life. Beyond such clinical implications, there also emerges a much broader set of questions The bulk of the research on emotion regu- regarding how the gene regulation inherent lation and health has focused on the long- in emotion regulation might developmen- observed relationship between emotional tally modify the “behavior factory” of the suppression and illness. However, it is worth CNS, and the role that occasional tactical considering how health and biology might suppression may play in laying a molecu- be affected by the other broad class of emo- lar foundation for chronic suppression or tion regulation strategies involving refram- dampened emotional experience. ing or reappraisal (Gross, 2002). Much of the psychophysiological research suggests Given that emotion regulation is an intrin- that reappraisal has relatively little impact sically social adaptation (Darwin, 1872), on SNS activity (Gross, 2002; Gross & Lev- how might suppression affect an individual’s enson, 1993), and the equation of gene reg- social relationships? A growing body of evi- ulation with SNS activation might thus be dence suggests that chronic emotional sup- taken to imply that reappraisal-b ased emo- pression may significantly undermine the tion regulation has relatively little effect on number and quality of one’s social connec- gene expression and health. A separate lit- tions to others (Butler et al., 2003; English, erature on the psychology of stress and the John, Srivastava, & Gross, 2012; Gross, role of reappraisal-based coping strategies 2002; Gross & John, 2003; Mauss et al., would also support that hypothesis (Laza- 2011; Srivastava, Tamir, McGonigal, John, rus & Folkman, 1984; Sapolsky, 1994). & Gross, 2009). Experiences of social con- However, at the level of the CNS, where nection vs. disconnection can also affect gene expression dynamics may also play a gene expression (Cole et al., 2007, 2011), and role in establishing the basic machinery of were in fact the context in which the CTRA perception, interpretation, and behavioral gene expression dynamic was first observed. response, it does seem likely that the habit- As such, the health effects of emotional sup- ual use of reappraisal strategies may poten- pression may stem at least in part from their tially affect the molecular biology of neural effects in reducing an individual’s sense of development and plasticity. This might be social connection to others. Indeed, micro- particularly true within the brain struc- acts of emotional suppression may kindle a tures involved in appraisal itself, the struc- broader change in other people’s regard for tures involved in metacognition or executive the individual that comes to assume a tem- function processes that would control the poral scope and situational breadth much deployment of reappraisal processes into greater than original biological insult cre- the ongoing stream of conscious experience, ated by a transient act of suppression. In and potentially also in the neurobiologi- this sense, the most significant biological cal structures that mediate stress responses implications of emotion regulation may (e.g., involving functional down-regulation well stem from its impact on an individual’s or desensitization of these structures). To social identity and degree of healthy attach- the extent that habitual and adaptive reap- ment to others. Moreover, individual acts of praisal processes build a different brain at emotional suppression can also activate the the neuromolecular level, those biological SNS in surrounding social partners (Butler developments themselves will likely be struc- et al., 2003), implying a contagious dimen- tured at least in part by differential activa- sion extending beyond the suppressor’s own tion of specific gene modules. Moreover, the body. A wide variety of theoretical perspec- general modularity of brain function implies tives note the fundamental role of secure that these neurogenomic impacts of habitual social bonds in maintaining human health reappraisal (e.g., in down-regulating threat and well-being (Berkman & Kawachi, 2000; circuits in the limbic system, up-regulating Bowlby, 1983; Cacioppo & Hawkley, 2009; analytic or appraisal systems, and possibly
580 HEALTH IMPLICATIONS reducing the need for intense conscious con- trolled inhibitory processes) may well spill blueprints that help us do that. And to the over into other domains of experience, thus extent that we fail to adaptively manage the altering the activity of any other response experience and expression of our emotions, systems that make use of the same func- the genome also appears to carry molecular tional brain modules. Again, the specific blueprints that may help defend us against empirical structure of the gene networks the near-term social–biological costs of that involved remains to be mapped. However, failure, but only by mortgaging the molecu- we now have available a growing analytic lar underpinnings of our long-term vitality. and technical infrastructure for discovering the genomic mechanisms of appraisal-b ased Acknowledgments emotion regulation once empirical transcrip- tome data become available. These consider- Preparation of this chapter was supported by ations underscore the importance of devel- grants from the National Institutes of Health oping experimental animal models that can (Nos. AG028748, AG033590, CA116778) and potentially recapitulate at least some basic benefited greatly from the insightful comments features of the perception/appraisal and sup- of James Gross. This review is dedicated to pression/reappraisal systems. More broadly, George Freeman Solomon, a pioneer in the field to the extent that reappraisal produces a of psychoneuroimmunology and a deeply wise, more fundamentally human and behavior- compassionate, and curious observer of human ally adaptive CNS, it may well have salutary nature and its braided strands of emotion, inhibi- effects on peripheral gene expression and tion, and health. health that extend far beyond a neutral basal state of physiological homeostasis. References Much remains to be learned about the Amit, I., Garber, M., Chevrier, N., Leite, A. molecular mechanisms and biological impli- P., Donner, Y., Eisenhaure, T., et al. (2009). cations of human emotion regulation. How- Unbiased reconstruction of a mammalian ever, what we can say from the data already transcriptional network mediating pathogen at hand is that, in a highly social species responses. Science, 326(5950), 257–263. such as humans, issues of expressing and concealing emotional reactions cut deeply Antoni, M. H., Lutgendorf, S. K., Blomberg, and fundamentally to the core of what it B., Stagl, J., Carver, C. S., Lechner, S., et al. means to be a participant in the human race. (2012). Transcriptional modulation of human In that sense, it is perhaps not so surprising leukocytes by cognitive-b ehavioral stress man- that our conscious and unconscious efforts agement in women undergoing treatment for to manage the experience and expression breast cancer. Biological Psychiatry, 71(4), of our emotions may have deep implica- 366–372. tions for our health. If the genome is a lens through which health can be understood, it Appleton, A. A., & Kubzansky, L. D. (this vol- is even more surely a molecular blueprint for ume, 2014). Emotion regulation and car- helping humans navigate the complexities of diovascular disease risk. In J. J. Gross (Ed.), our physical and social worlds (Fox Keller, Handbook of emotion regulation (2nd ed., 2012). In that regard, it comes as no surprise pp. 596–612). New York: Guilford Press. if the deepest regions of our internal biology, and the very function of our own individual Bell, J. R., Jasnoski, M. L., Kagan, J., & King, D. human genomes, are inextricably bound S. (1990). Is allergic rhinitis more frequent in up in our experience of the external social adults with extreme shyness?: A preliminary world around us, the emotional experiences study. Psychosomatic Medicine, 52, 517–525. it evokes in us, and our emotional expres- sions back to that world. Genomes exist fun- Berkman, L. F., & Kawachi, I. (2000). Social damentally to help us succeed as humans, epidemiology. New York: Oxford University and to the extent that requires the effective Press. regulation of our emotional experience, the human genome must carry some molecular Black, D. S., Cole, S. W., Irwin, M. R., Breen, E., St. Cyr, N. M., Nazarian, N., et al. (2013). Yogic meditation reverses NF-kappaB and IRF-related transcriptome dynamics in leuko-
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