Internship report
Distraction and Reappraisal: Emotion Regulation and Choice in an Analogue Trauma Paradigm
Anu Hiekkaranta, 11353619 The University of Amsterdam Supervised by dr. Bram Van Bockstaele
Abstract
Emotion regulation (ER) is a key factor in the development and maintenance of posttraumatic stress disorder (PTSD). The current study examined the effectiveness of two ER strategies, distraction and reappraisal, and strategy preference in response to stressor reminders after exposure to different distressing film clips in an analogue trauma paradigm. In a forced ER task participants used reappraisal or distraction to regulate their emotions in response to stills from the film clips in both facilitated and non-facilitated conditions. In an ER choice task participants chose which of the two strategies they wanted to use, again in facilitated and non-facilitated conditions. Both reappraisal and distraction reduced distress and this reduction was moderately persistent at one week follow-up. We found no effects of strategy or facilitation on distress or on intrusive memory symptoms. Memory tests for clips in the forced ER task but not the ER choice task showed improved memory for peripheral and poorer memory for central items when ER had been facilitated. In the ER choice task, when ER was not facilitated, participants’ preferred strategy was distraction and when facilitated, reappraisal was chosen more often. Self-reported level of distress predicted strategy choice in both facilitated and
non-facilitated conditions. The results suggest that both reappraisal and distraction are beneficial in reducing negative affect evoked by reminders of a distressing event and that when the effort that needs to be invested in ER is lowered, reappraisal is preferred. These results provide insight for further
investigations of predictors of ER choice and suggest potential for ER training as intervention for psychopathologies characterized by compromised ER.
Distraction and Reappraisal: Emotion Regulation and Choice in an Analogue Trauma Paradigm
Most people experience a traumatic event, as defined by the Diagnostic and Statistical Manual of Mental Disorders, at least once in their lives (APA, 2013), and in the Netherlands 80% of adults report having experienced one or more such event (de Vries & Olff, 2009). While the majority of those exposed to traumatic events do not develop persistent symptomatology, for some, exposure to trauma is followed by the development of posttraumatic stress disorder (PTSD) (APA, 2013). Traumatic experiences are defined by strong emotional responses ranging from anger to fear, threat, horror, guilt, sadness, and disgust. Consequently, evidence supports the view that emotion regulation (ER), an individual’s efforts to exert control over the emotions they have, and over the intensity, and the duration of their emotions (Gross, 1998), is associated with the development and maintenance of PTSD (e.g. Bardeen, Kumpula, & Orcutt, 2013).
Previous research indicates that general emotion dysregulation and the use of maladaptive ER strategies are positively associated with the occurrence of PTSD symptoms and with their severity (e.g. Seligowski, Lee, Bardeen, & Orcutt, 2015; Ehring & Quack, 2010). These associations hold for not only complex early interpersonal trauma (Cloitre, Miranda, Stovall-McClough, & Han, 2005), but also later-in-life occurring single-event traumas (Ehring & Quack, 2010; Seligowski et al., 2015). Specifically, for those with PTSD, reminders of traumatic events can give rise to heightened emotional and physical reactivity and, in the most extreme cases, trigger emotionally intense, distressing, and re-occurring intrusions during which the trauma is re-experienced as if happening in the present (APA, 2013). Furthermore, generally heightened emotional responding has been associated with PTSD (e.g.
McDonagh-Coyle et. al, 2001; Veazey, Blanchard, Hickling, & Buckley, 2004), making evident that the demand for ER becomes greater in the aftermath of trauma (Mennin, 2005) and is critical for the management of symptoms and ultimately, recovery from PTSD.
In the process model of ER, Gross (1998) outlines the unfolding of emotions as a sequence with multiple phases. An external or internal emotion eliciting situation arises and attention is allocated accordingly. Valence and importance of the situation is then evaluated and as a result, psychological, physiological, and behavioural responses take place. These responses can modify the initial situation, creating a feedback loop between the first and final phase. An integral part of the model is that different strategies can be implemented to regulate emotions at these conceptually distinct, temporally ordered phases. Antecedent-focused strategies (situation selection, situation modification, attentional deployment, and cognitive change) intervene with emotion generation earlier in the process, while response-focused strategies (response modulation) target the fully generated emotion.
For survivors of trauma, some ER strategies, such as rumination, an attentional deployment strategy, are evidently counterproductive (for a review, see Nolen-Hoekseman, Wisco, & Lyubomirsky, 2008). Others, such as reappraisal and distraction, which have been shown to be effective in reducing negative emotions in non-clinical experimental conditions (e.g. Denny & Ochsner, 2014); Nolen-Hoekseman et al., 2008), have potential to alleviate symptoms. Reappraisal, a cognitive change strategy that requires engagement with the target stimulus or situation, refers to the process of reinterpreting or reframing an emotion or an emotion-eliciting situation to change its emotional intensity. Self-reported use of cognitive reappraisal has been associated positively with general physical and mental well-being (e.g. Cutuli, 2014). While the evidence also indicates that the engaging in reappraisal is associated with key neuroanatomical structures linked to PTSD (for a review see Kraus et al., 2009), at present, findings on the benefits of reappraisal on PTSD symptoms are inconsistent. A meta-analysis of PTSD
symptoms and ER strategies by Seligowski et al. (2015) did not find a significant effect for self-reported use of reappraisal, while a negative relationship between reappraisal use measured in real-time and the occurrence of PTSD symptoms has been observed (Shepherd & Wild, 2014). It has also been
demonstrated in a non-clinical sample that reappraisal training can result in ameliorating intrusive memories after watching a distressing film (Woud, Holmes, Postma, Dalgleish, & Mackintosh, 2012).
Distraction, an attentional deployment disengagement strategy, refers to regulating emotions via re-direction of attention to neutral or positive aspects of the emotion-eliciting situation or stimulus and thus interfering with the process of emotion generation earlier than in reappraisal (Gross & John, 2003). No studies on the use of distraction in relation to PTSD symptoms were included in Seligowski et al.’s (2015) meta-analysis and indeed, few experiments have investigated this association directly. However, a variety of methodologies have been adopted to show that compared with non-clinical samples, people with PTSD automatically direct their attention toward threatening stimuli rather than to neutral or positive stimuli (e.g. Bryant & Harvey, 1995). In sum, people with PTSD may be unable to successfully implement attention deployment strategies like the generation of a distracting thought or direction of visual attention elsewhere.
Patients with PTSD may benefit from the use of distraction in situations where immediate disengagement from a potential trigger or reminder of trauma is crucial in avoiding a distressing intrusion. In accordance with this view, attentional bias modification training has been shown to decrease intrusive memory symptoms (Verwoerd, Wessel, & de Jong, 2012). Interestingly, studies contrasting the use of reappraisal with distraction in non-clinical samples show that engagement with negative stimuli via reappraisal under highly distressing conditions can be both costly in terms of cognitive resources and less effective in regulating emotions compared to disengagement strategies like distraction (Sheppes, Catran, & Meiran, 2009; Sheppes & Meiran, 2008), challenging the clinical
consensus of reappraisal as a universally adaptive strategy. However, it has also been shown that while initially helpful in reducing negative affect, relying on attentional distraction may be maladaptive in the long-term (Kross & Ayduk, 2008). At present it is unclear whether in the context of regulating
emotions in response to reminders of distressing experiences, distraction is initially more effective than reappraisal, via its lower cognitive load, or whether over time reappraisal has a more lasting effect on distress and other traumatic stress symptoms.
Rather than one ER strategy being more adaptive than another, it may be the case that flexibly switching between strategies and choosing the most appropriate strategy is crucial. Recent theoretical accounts propose that the inability to flexibly employ different ER strategies characterises many psychopathologies (e.g. Troy & Mauss, 2011). Evidence suggests that different ER strategies result in different outcomes depending on the context (e.g. Gross, 1998, 2001; Gross & Thompson, 2007; Haines et al., 2016). However, few experiments have directly investigated ER choice in general and even fewer in the context of traumatic experiences. One such study was conducted on a sample of trauma-exposed fire-fighters. Levi-Gigi et al. (2016) found that low emotion regulatory flexibility correlated positively with PTSD symptoms. Less is known about ER choice and preference of strategy in response to specific reminders of emotionally distressing experiences. In a series of experiments on ER choice in non-clinical samples, Sheppes, Scheibe, Suri, and Gross (2011) and Sheppes et al. (2014) instructed participants on how to use distraction and reappraisal to regulate their negative affect. They then presented negative high- and low intensity pictures on the screen and asked participants which strategy (distraction or reappraisal) they wanted to apply to regulate their emotions. They found that when viewing high-intensity negative pictures, participants’ preferred strategy was distraction. In
contrast, low intensity pictures were regulated more often using reappraisal, highlighting the importance of strategy-situation fit.
In another experiment, Sheppes et al.’s (2014) manipulated the cognitive determinants of ER choice. In the same paradigm, participants were provided with cues that helped them regulate their emotions. For instance, upon choosing distraction for a picture of a traffic accident, participants were prompted to think about taking a shower. If the participant instead selected reappraisal for the same picture, they were prompted that the victim was alive and medics were on the scene to help her. They found that these facilitation cues increased overall choice of reappraisal, both for high and low intensity pictures. These findings indicate that generating reappraisals is cognitively more complex and thus distraction is preferred under conditions of higher distress, when fewer resources for ER are available.
The goal of our current study was to contrast reappraisal and distraction, both facilitated and non-facilitated, in both an instructed ER paradigm and a choice paradigm. To do so, we adopted the trauma film paradigm, which has been shown to produce mild short-term post-traumatic stress
symptoms and intrusions up to one week, providing an experimental model of a controlled trauma (James et al., 2016). Participants first watched a distressing film and were instructed to use either distraction or reappraisal in either facilitated or non-facilitated conditions to regulate their emotions in response to stills from the film. The facilitation was included in the current study to investigate the effect of lowering cognitive complexity of ER strategy generation on strategy effectiveness. We expected that both distraction and reappraisal would be effective in regulating negative affect. In addition, we expected that facilitation cues would increase the effectiveness of both strategies.
In the choice paradigm, participants were free to choose either reappraisal or distraction, again in both facilitated and non-facilitated conditions. We expected to replicate the results of Sheppes et al. (2011) and Sheppes et al. (2014) and to observe a distraction preference under non-facilitated
conditions and for this preference to change under facilitated conditions. Additionally, we expected a positive association between distraction choice and the initial distress ratings of the stills, with
distraction becoming gradually more popular with increased distress ratings. To study the effectiveness of facilitated and non-facilitated reappraisal and distraction over time, participants returned for a follow-up session one week later, during which they again rated their level of distress in response to the same stills. We hypothesised that distraction would be more effective to reduce acute levels of distress, but also that these reductions would prove less persistent over time. Participants also kept a diary of intrusive memories over the week where they recorded memories of different film clips. In order to investigate if memory of the films was affected by strategies that they had employed, memory tests for central and peripheral items of each film clip were administered at the follow-up session. Finally, participants were also asked to report on intrusive memory-related symptoms by filling a symptoms scale adapted to the trauma film paradigm. We expected that facilitation would lead the fewer intrusive memory symptoms and that reappraisal compared to distraction would be more effective in reducing symptoms. Finally, we expected that neither facilitation or strategy would affect memory of the clips.
Method Participants
Thirty-five participants (17 females, M age = 23, SD = 2.85) were recruited at the University of Amsterdam campus and via the lab website. Thirty participants completed the study in Dutch and 5 participants completed the study in English. Participants with blood or injury phobia and participants with traumatic experiences were excluded.
Materials Aversive films
We used six film clips that have been used in previous studies to induce emotional distress. The clips were each approximately two minutes in duration. Three raters converged on an average intensity rating for each clip. Four clips, matched in intensity, were used in the forced ER task. The clips were thematically distinct and featured four topics: war, self-harm, sexual violence, and torture. The war clip consisted of scenes of real-life footage depicting American soldiers talking about war, footage of seriously injured children, bodies, and other victims of war (Krans, Näring, & Becker, 2009). The self-harm clip was a fictional scene, “The Big Shave” by Martin Scorsese (1967) depicting a man shaving himself in the bathroom with a razor, making cuts in his face until cutting his own throat (e.g. Verwoerd et al., 2012). The sexual violence clip depicted a fictional scene of a violent sexual assault from the film “Irreversible” directed by Gaspar Noe (e.g. Weidmann, Conradi, Gröger, Fehm, & Fydrich, 2009). The torture clip consisted of graphic fictional scenes of torture of teenagers from the film “Salo o le 120 giornate di Sodoma” by Pier Paolo Pasolini (e.g. Kindt & van den Hout, 2003). Two clips, also thematically distinct, were used in the ER choice task. The first clip consisted of real-life footage of an aftermath of a road traffic accident in the US with fatal and serious injuries (Krans, Brown, & Moulds, under review). The second clip consisted of a fictional graphic and brutal murder taking place in a night club, also from the film “Irreversible” (e.g. Verwoerd, de Jong, & Wessel, 2008). All film clips were presented on a 19-inch monitor, with the sound settings identical. All film clips were between 26 and 32 cm high and 30 cm wide.
Film Stills
Uncued Stills. Fifteen film stills per clip were selected as analogue trauma reminders, resulting in a total of 90 stills. All stills were taken from parts of the clips that were negative, emotional, and intense in content. Of the stills selected from each clip, ten were considered to be of the most intense parts of the clip (e.g. scenes of a disfigured corpse being pulled from a car) and five from less intense, but also emotionally distressing parts of the scenes (e.g. a woman with no visible serious physical injuries being treated by first aid responders).
Cued Stills. The same 15 stills from each clip were also modified to have two cued versions, one with a distraction cue and a second with a reappraisal cue. The distraction cues consisted of a
transparent thin layer of white overlaid on the still, leaving one focus point as it was in the original still (as in Urry, 2010). Critically, this focus point was always on a neutral part of the picture. Each
reappraisal cue consisted of a brief reappraisal sentence that appeared below the film still. The sentences provided either an elaborated framework for the still, e.g. “This girl only suffered a concussion and is safe and well now” or a neutral perspective, e.g. “Imagine yourself as a doctor arriving at the scene ready to help”. The reappraisal sentences were inspired by the sentences used by Sheppes et al. (2014).
Questionnaires
The Traumatic Events Questionnaire (TEQ), a 12-item checklist adapted from the
Posttraumatic Diagnostic Scale (Vrana & Lauterbach, 1994) assessing nine themes of traumatic events related to serious accidents (e.g. car accident), news of serious injury of death of close friends or family, and experiences of physical or sexual abuse. Unspecified traumatic events were also included.
COPE inventory. Distraction and reappraisal related subscales from the COPE inventory, a questionnaire about the use of coping styles (Carver, Scheider, & Weintraub, 1989), were used. The distraction subscale consisted of four items, for example, “I go to the movies of watch TV, to think about it less.” (α = .62, in the current study), and the reappraisal subscale consisted of four items, for example, “I look for something good in what’s happening.” (α = .82, in the current study). Responses were given on a four-point Likert scale (1 = “I usually don’t do this at all”, 4 = “I usually do this a lot”).
Beck Depression Inventory-II (BDI-II; Beck, Steer & Brown, 1996), a 21-item self-report questionnaire assessing depression symptoms and their severity, as in previous trauma film studies. The internal consistency has been shown to be high (α = .90) and test-retest reliability has also been found to be high (Beck et al., 1996).
Spielberger Trait Anxiety Scale (STAI-T; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983), 20-item self-report questionnaire assessing dispositional anxiety, as in previous trauma film studies. The internal consistency of the STAI-T has been shown to be high (α = .88) (Barnes, Harp, & Jung, 2002).
Impact of Movie Scale (IMS). The Impact of Movie Scale (Verwoerd, Wessel, de Jong,
Nieuwenhuis, & Huntjens, 2011), a version of the Impact of Events Scale (Horowitz, Wilner & Alvarez, 1979), adapted to the trauma film paradigm, was used to measure trauma analogue symptoms related to each film clip. In the IMS, participants were instructed to respond to 11 statements about the film clips (e.g. ”Images came up spontaneously”). The answers were given on a four-point scale with the weights 0, 1, 3 and 5 assigned to items, resulting in total scores ranging from 0 to 55. The internal consistency of the scale has been shown to be high (Cronbach’s α = .90; Verwoerd et al., 2011).
Forced Emotion Regulation Task
The tasks were programmed using Inquisit software (Draine, 2004).
Preview Distress Rating. Participants were shown 60 stills from the four clips allocated to the forced ER task, for 3000 ms each, after which they rated their level of distress in response to each on a scale from 1-9. (1 = “not intense at all”, 9 = “very intense”). The stills were presented in a randomized order.
Distraction Strategy Instruction. A brief psychoeducation on the two strategies followed the previews. Participants were first explained how to use their attention to focus on parts of a situation or stimuli that evoked little or no emotions and that when prompted to use the distraction strategy (aandacht afleiden = “distracting attention” in the Dutch version of the experiment), they should keep looking at the picture while directing their attention to non-emotionally relevant parts of the picture. Participants were provided with general examples of distraction, e.g. that they could look at any neutral part of the picture, such as a license plate of a car or a tree in the background. The instructions
explained that as they would be prompted to use this strategy, a focus point on a neutral part of the picture would be presented in some trials and that they would need to use this strategy without help on other trials.
Reappraisal Strategy Instruction. In the reappraisal instructions participants were explained how to change the negative meaning of a picture or a stimulus by reinterpreting it and that when prompted to use reappraisal (in Dutch, herinterpreteren = “reinterpret”), they should keep looking at the picture but to try to reinterpret the content in such a way that it became more neutral. Participants were provided with general examples of reappraisals, e.g. that they could reinterpret a scene by imagining that they were a photographer doing their job, or that help was on the way. Participants were informed that on some trials a reinterpretation sentence would be presented to aid reappraising and that in other trials they would have to use reappraisal without help. Scripts for the instructions for both strategies are provided in Appendix 1.
Practise Phase. Participants practised distraction and reappraisal strategies in one cued and one uncued example picture each. The example pictures were unrelated to the themes in the distressing clips. To ensure compliance with instructions and understanding of the two strategies, participants only proceeded to the ER phase once they had verbally provided an example of distraction and of a reinterpretation for the uncued practice pictures. When deemed necessary, the experimenter could correct these examples and restart the practice phase.
Forced Emotion Regulation Phase. For each participant, the sets of stills from each of the four clips (sexual violence, war, torture, and self-harm) in the forced ER task were randomly allocated to one of four conditions. The conditions were: uncued distraction, cued distraction, uncued
reappraisal, and cued reappraisal. In the uncued trials, the stills were presented without facilitation, while in the cued trials, distraction cues or reappraisal sentences appeared on the screen. The ER phase consisted of 15 trials per picture type, resulting in a total of 60 trials. The stills were presented in a random order. Before each still was presented, the to-be-used strategy was presented on the screen for 2000 ms, after which the still appeared. For the uncued stills, participants looked at the still using the strategy as instructed for 8000 ms, after which they rated their level of distress again as in the preview distress rating phase. For the cued stills, the uncued still was presented for 1000 ms, after which the cue appeared along with the still for another 7000 ms (see Figure 1). Participants then rated their level of distress as in the uncued trials.
Figure 1. Example trials: cued and uncued distraction trials in the forced ER task.
Emotion Regulation Choice Task
For each participant, the two sets of stills from the clips in the choice task (personal violence and road traffic accident clips) were randomly allocated to correspond to either the cued or uncued
condition. Participants were instructed that in this part of the experiment, they would be able to choose the ER strategy themselves. After four practise trials, 30 choice trials were presented. Each trial began with a preview of 3000 ms, after which participants rated their level of distress as in the forced ER task. Then, they were instructed to choose which of the two strategies (distraction or reappraisal) they wanted to use, while they were also informed whether a cue would be available or not. After indicating
their choice by clicking their chosen strategy on the screen, the cued and uncued trials proceeded as in the forced ER task and the stimuli presented in the emotion regulation phase always corresponded to the participants’ choice. After each ER choice trial, participants rated their level of distress again, as in the forced ER task. The 30 stills, 15 per picture type (cued or uncued), were presented in a random order (see Figures 2 and 3).
Figure 2. Cued example trial in the ER choice task with distraction chosen by the participant.
Intrusion Diary. Participants were given an A4-format diary and were asked to write down any intrusions they experienced of the different film clips for one week following the trauma induction (as in previous studies, Holmes et al., 2004). Participants were given elaborate instructions on the
characteristics of an intrusive memory and on how to record intrusions in the diary. Participants were also asked to indicate which film clip the intrusion was about and how intense the intrusion was on a scale from 1-10 (1 = “not at all”, 10 = “extremely”). Instructions were given to record the intrusion as soon as possible after it had occurred. The primary dependent variable was the total number of intrusions per clip recorded over the week.
Memory test. Participants memory for the clips was tested at one week follow-up. The memory test included six peripheral and three central true/false statements. The central questions probed participants’ memory for main events in the clips, e.g. “There were medics on the scene.” The peripheral questions probed memory of details in the scenes, e.g. “A girl was wrapped in a yellow blanket.” The questions were formulated in neutral manner. A total central and peripheral accuracy score was calculated for each participant per clip.
Procedure
Upon entering the lab, participants were given basic information about the procedure and were
informed of the graphic content of the films (as in previous studies, e.g. Holmes, Brewin, & Hennessey, 2004). They then filled in the TEQ. Participants who answered yes to any of the items regarding the themes in the clips were excluded, with the exception of participants who had experienced a minor traffic accident or an unrelated minor incident listed in the TEQ that they did not consider serious or traumatic. Participants were informed that they could end their participation at any time and were asked to sign their informed consent. They then proceeded to complete the BDI-II and STAI-Trait
questionnaires.
Baseline Mood Assessment. Before watching the film clips, participants rated how anxious, disgusted, sad, angry, stressed, and happy they felt at present on a scale of 1 to 9 (1 = “not at all”, 9 = “very much”).
Distressing Film. The six clips were presented in a randomized order in a darkened laboratory room. Participants were instructed to keep watching the screen for the entire duration of the film.
Mood Manipulation Check. After viewing all the clips, participants rated their mood again as in the baseline mood assessment, to ensure that the films had induced negative affect.
Forced ER Task. First, in the preview phase, participants were asked to rate their level is distress in response to the stills from the four clips allocated to the forced ER task. They were then
given the distraction instructions followed by the reappraisal instructions. Participants then practised the strategies with and without cues. An experimenter was present during the practise phase and participants were able to request additional instructions and examples. The experimenter exited the room when participants begun the forced ER phase. Participants then downregulated their emotions in the 60 trials where ER strategy (distraction or reappraisal) was pre-determined.
ER Choice Task. The forced ER task was immediately followed by the ER choice task. Participants were familiarised with the task in the practise phase with cued and uncued stills. They completed the ER choice practise phase without the presence of an experimenter. Participants then downregulated their emotions in the 30 choice trials where ER strategy (distraction or reappraisal) was chosen by the participant.
Diary Instructions. After they had completed both ER tasks, participants were given the intrusion diaries and instructions for how to fill in the diary.
One week later, participants returned to the lab and handed in their intrusion diaries. They then completed the IMS for each film clip in a randomized order. Next, all memory tests were presented in a random order, such that questions regarding peripheral and central items were mixed, as well as
questions regarding different clips. Then, participants again rated their level of distress in response to the uncued 90 stills, as they had in the preview phases during the first session. The stills were presented in a randomized order. Finally, participants were debriefed and either paid €20 or awarded course credit for participation. Session 1 lasted approximately 75 minutes and session 2 approximately 30 minutes.
Results Sample Characteristics
Participants scored in the non-clinical spectrum on both the BDI-II (M = 7.63, SD = 7.39) and the STAI-trait (M = 34.54, SD = 5.93).
Manipulation Check
Participants’ ratings on all mood scales were combined into a general negative mood score, with happiness scores reversed. A paired samples t-test was conducted to compare negative mood pre- and post trauma film viewing. Negative mood was significantly lower in pre- (M = 2.05, SD= 0.65)
Data preparation
To study the effects of Time, Strategy and Facilitation on levels of distress evoked by the trauma stills, distress ratings of the stills in each condition were collapsed into an average distress score for each participant for three time points; preview, downregulation, and follow-up. Separate averages were calculated for the forced ER task and the choice ER task. Trials where distress was rated as 1, the lowest possible value on the scale, during the preview rating of the still were excluded because they did not allow for any downregulation of negative affect. 132 trials in total were excluded across all
participants. For some participants, removing the pictures with preview ratings of 1 resulted in less than 10 observations in specific cells of the design. We opted to remove these cells completely. Due to the repeated measures design, this resulted in a total N of 29 for the distress rating analyses in the forced ER task and a total N of 31 in the ER choice task.
Assumptions
Assumption of sphericity was checked for all relevant analyses and unless mentioned otherwise, Mauchley’s W was non-significant, indicating that the assumption was met.
Distress in the Forced ER Task
In the forced ER task, a within subjects factorial ANOVA with three factors was conducted to compare the main effects of Strategy (reappraisal vs. distraction), Facilitation (uncued vs. cued), and Time (preview vs. downregulation vs. follow-up) as well as the interaction effects on the mean distress ratings (Table 1). There was a significant main effect of Time on across all conditions, F(2, 56) = 56.36, p = .001, f = 1.42. The main effects of Strategy and Facilitation were not significant, both Fs < 1. There were no significant interactions. A trend analysis showed a significant linear relationship between Time and distress ratings, t(1,56) = 6.58, SE = .18 p = .001. Distress decreased over time from preview (M = 5.86, SD = 1.77) to downregulation rating (M = 3.27, SD = 1.51) and follow-up (M = 4.24, SD = 1.94). There was also a significant quadratic component reflecting an increase in distress from
downregulation to the one-week follow-up rating, t(56) = 8.33, SE = .18, p = .001. In summary, the data showed no effect of Strategy or Facilitation on distress, but only a main effect of Time, for which a combined trend including a negative linear and a positive quadratic components were found, such that distress ratings decreased from preview to downregulation and increased again moderately at follow-up.
Distress in ER Choice Task
For distress ratings in the choice ER task, a repeated measures factorial ANOVA with Facilitation and Time as within subjects factors was conducted (Figure 4). The main effect of
Facilitation was not significant, F < 1. There was a significant effect of Time, F(2,60) = 49.56, p = .001, f = 1.29. The interaction was not significant, F < 1. As in the forced ER task, a trend analysis showed a significant linear relationship between Time and distress, t(60) = -4.12, SE = .14 p = .001. Distress decreased over time linearly from preview rating (M = 5.27, SD = 1.31), to downregulation (M = 3.34, SD = 1.20) and follow-up (M = 4.47, SD = 1.67). Again, the quadratic trend of Time on distress was also significant, t(60) = 9.01, SE = .14, p = .001. In summary and in line with the results of the forced ER task, the data showed no effect on facilitation on distress ratings, but a combined linear and quadratic trend indicating that emotion regulation decreased distress strongly from preview to downregulation and distress increased again moderately at the follow-up measurement.
Figure 4. Mean distress ratings in the ER choice task at preview, immediately after downregulation, and at follow-up. 2 3 4 5 6 7
Preview Downregulation Follow-up
Di st re ss Uncued Cued
Choice of Strategy
As in the analyses for distress, only the trials were participants rated the trauma film still as a 2 or higher in preview distress were included in the analyses for preference of strategy. This did not result in the exclusion of any participants. In the uncued choice condition, on average, participants chose to regulate their emotions using reappraisal 36.5% of the time and distraction 63.5% of the time (SD = 22.39%). In the cued choice condition, on average, participants chose reappraisal 57.2% of the time and attention 42.8% of the time (SD = 29.36%).
A mixed effects logistic regression with Facilitation (cued, uncued) and preview distress ratings as predictors of strategy choice (distraction/reappraisal) was conducted in R using glmer function from package lme4. The interaction between Facilitation and preview distress rating was also included in the model. Fixed effects were set for subjects and random effects for Facilitation and preview distress rating (see Figure 5 for the pattern of results, see Appendix 2. for model specifications). Facilitation was a significant predictor of strategy choice, p = .002. Holding preview distress constant, the odds of choosing reappraisal in the cued condition over the odds choosing reappraisal in the uncued condition were 2.84. Distress ratings also significantly predicted choice, p = .001. Holding condition at fixed value, there was a 14 % decrease in the odds of choosing reappraisal for every unit of increase in preview distress rating. The interaction between condition and distress was not significant, p = .89.
Figure 5. The average proportion of reappraisal choices as a function of distress in cued and uncued conditions. 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 2 3 4 5 6 7 8 9 Pr opor tion of R ea ppr ai sa l C hoi ce s Distress Uncued Cued
Impact of Movie Scale
Forced ER task. We calculated a total IMS score for each clip for each participant. Scores deviating more than three standard deviations from the mean were excluded, resulting in the exclusion of one score from each condition in the forced ER task. For IMS scores related to clips in the forced ER task, a repeated measures ANOVA was conducted to with Strategy and Facilitation as within subjects factors. No effects were statistically significant, all Fs < 1 (see Table 2 for means and standard deviations).
ER Choice task. For the IMS scores regarding clips in the ER choice task, total scores were again calculated, and one score was excluded as an outlier in the uncued choice condition. A paired samples t-test was conducted to compare the means for cued and uncued conditions. Shapiro-Wilks test indicated that the assumption of normality was violated, W = .88, p = .002. However, sample size was considered sufficient to allow a robust t-test. The means between the cued (M = 7.79, SD = 10.00) and uncued (M = 7.37, SD = 9.93) conditions did not differ significantly, t(33) = .588, p = .56.
Intrusions
A total score for the number of intrusions for one week was calculated for each film clip separately. Total scores that were three standard deviations above the mean were excluded from analysis. This resulted in the exclusion of two participants from the cued distraction condition, one
participant from the cued choice condition and one participant from the uncued choice condition. Participants who reported no intrusions for a specific clip received a score of zero for that condition.
In the forced ER task, a repeated measures ANOVA was conducted with Strategy and Facilitation as within subjects factors on the number of intrusions. No effects were statistically significant, all Fs< 1.06, all ps > .31 (see Table 3). In the ER choice task, a paired samples t-test was conducted to compare the total number of intrusions between cued and uncued conditions. There was no significant difference in the number of intrusions for uncued (M = 2.08, SD = 2.47) and cued (M = 2.35, SD = 2.67) conditions, t(33) = 0.59, p = .556.
Intrusion Intensity
Nine participants reported at least one intrusion for each clip in the forced ER task and 17 participants reported one or more intrusions for both clips in the choice ER task. Due to the limited number of data points per condition, intrusion intensity was not analysed for intrusions regarding clips in the forced ER task. For intrusion intensity for clips it the choice ER task, a paired samples t-test was conducted to compare the means between cued and uncued conditions. There was no significant difference in the intensity of intrusions between cued (M = 3.47, SD = 2.36) and uncued (M = 3.38, SD = 2.16) conditions, t(16) = 0.21, p = .840. It should be noted that the Shapiro-Wilks test was significant, indicating a violation of the assumption of normality, W = .843, p = .008, however, the sample size was considered large enough to allow for a robust t-test.
Memory
Memory, Forced ER. For memory of clips in the forced ER task, two repeated measures factorial ANOVAs were conducted with Strategy and Facilitation as within participants factors on memory scores for central and peripheral items separately.
Figure 5. Memory for central and peripheral items for clips in the forced emotion regulation task. A significant main effect of Facilitation on memory of central items was observed, F(1,34) = 4.50, p = .04, f = 0.36. The main effect of Strategy was not significant, and neither was the interaction, both Fs < 1. As shown in Figure 5, participants scored lower on central memory items in the cued condition (M = 2.31, SD = 0.67) compared to the uncued condition (M = 2.53, SD = 0.58), regardless of strategy. For peripheral items, the main effect of Facilitation was also significant, F(1,34) = 4.15, p = .05, f = 0.35. Furthermore, the effect of Strategy was also significant, F(1,34) = 4.95, p = .033, f = 0.38 (see Figure 5). The interaction was only marginally significant, F(1,34) = 3.04, p = 0.09, f = 0.30.
Participants scored on average higher in the cued conditions (M = 4.34, SD = 1.25) compared to the uncued conditions (M = 3.93, SD = 1.33), suggesting an opposite pattern for memory on peripheral and central items. The presence of cues improved memory for peripheral items and impaired memory for central items. For peripheral memory items, the participants scored on average higher in the reappraisal conditions (M = 4.37, SD = 1.29) compared to the distraction conditions (M = 3.9, SD =
0 0,5 1 1,5 2 2,5 3 Cued Uncued Ce nt ra l M em or y Distraction Reappraisal 0 1 2 3 4 5 6 Cued Uncued Pe ri phe ra l M em or y Distraction Reappraisal
1.29). However, given the medium effect size1 for the interaction, the main effects of Strategy and
Facilitation on memory for peripheral items should be interpreted with caution. As shown in Figure 5, the hampered memory for distracted and uncued film clips seems to be primarily driven by the poor memory scores for the clip with uncued distraction.
Memory, ER Choice Task. For the two clips in the choice ER task, paired samples t-tests were conducted to compare the means between cued and uncued choice conditions on central and peripheral memory separately. There was no significant difference in central memory scores between uncued (M = 2.66, SD = 0.59) and cued (M = 2.51, SD = 0.66) conditions, t(34) = 1.00, p = .324. In a similar vein, the difference between peripheral memory scores for uncued (M = 3.83, SD = 1.29) and cued (M = 4.03, SD = 1.15) conditions was not significant, t(34) = 0.60, p = 0.552. It should be noted that the Shapiro Wilks test was significant for both t-tests, indicating a violation from normality in the central memory scores, W = .86, p = .001 and peripheral memory scores, W = .91, p = .005., however, the sample sizes were considered sufficient to allow for a robust t-test.
Exploratory analyses
COPE-inventory. In an exploratory analysis, we investigated whether participants’
self-reported use of strategies correlated with their choices of strategy in the cued and uncued conditions in the ER choice task. Strategy preference scores were calculated for cued and uncued conditions
separately, by subtracting the total of distraction choices from the total of reappraisal choices within cued and uncued conditions. Positive scores thus reflect a preference for reappraisal, while negative scores reflect a distraction preference. In the uncued condition, the average strategy preference was 1.49, SD = 7.8 and in the cued condition -3.86, SD = 6.23. For the COPE inventory, the scores for items regarding each strategy were added up to a total distraction score and a reappraisal score. Participants scored on average 11.63 (SD = 2.73) on the reappraisal related items, and 8.66 on the distraction related items (SD = 2.65). There was a positive correlation between reappraisal preference in the uncued condition and self-reported COPE inventory reappraisal score, r =.41, p = .015. No other significant correlations were observed, all rs < .12, all ps > .05.
1 Cohen (1992) recommends the following interpretation of effect sizes for Cohen’s f: f = .10 as a small effect, f = .25 as a medium effect, and f = .40 as a large effect.
Discussion
It has been established that difficulties with emotion regulation (ER) are a key symptom of many psychopathologies, including PTSD, but less is known about which ER strategies are effective in ameliorating symptoms and about choice of strategy in response to emotions evoked by reminders of intense stressors. The aim of the current study was to investigate the effect of two strategies, distraction and reappraisal (Gross, 1998) in a trauma film paradigm (James et al., 2016). We expected that both strategies would reduce negative affect evoked by reminders and that facilitation of ER would further reduce negative effect. Furthermore, we hypothesized that distraction would reduce acute distress more, but that this effect would be less persistent than reappraisal over time. In a similar vein, we expected that using reappraisal would lead to fewer intrusive memory symptoms than using distraction, and that facilitation of both strategies would further reduce symptoms. Memory was expected to remain unaffected by strategy or the presence of facilitation. In addition, we expected that when given the choice between using distraction or reappraisal, distraction would be preferred when no facilitation was provided. We expected that reappraisal would be chosen more often when facilitation was offered. Finally, we hypothesized that the popularity of distraction over reappraisal would increase as the level of distress evoked by reminders of the distressing film increased.
Reappraisal and distraction were found to be equally effective in reducing distress experienced in response to reminders of the film clips. A large and immediate reduction in distress was observed after implementation of either strategy, and this reduction was moderately persistent when distress was rated again after one week. This suggests that while different mechanisms are likely to account for the effectiveness of the two strategies, both reappraisal and distraction effectively reduce distress evoked by reminders of intense stressors. Contrary to our expectations, the effectiveness of either strategy was unaffected by the presence of ER cues. In both the instructed and the choice ER task, a significant immediate reduction in distress was found after both facilitated and non-facilitated ER, suggesting that the provided facilitation was not advantageous in reducing distress. It also is possible that the lack of differences between the effectiveness of strategies and between cued and uncued conditions was, in part, the result of the within participants design adopted in this experiment. Participants learned about both strategies at the same time and used the strategies in a fully mixed order in both tasks. That is, participants may have used strategies flexibly in response to the stills regardless of the instructions, resulting in difficulty detecting differences in effectiveness. Indeed, a distraction strategy can easily be implemented in concurrence with a reappraisal, and many reappraisals can be applied across different clips. Facilitated and non-facilitated trials were also presented in a mixed order. It is likely that, to some extent, facilitation resulted in a training effect such that participants became better at regulating their
emotions via distraction and reappraisal throughout the task also when they used the strategies without cues.
To our knowledge, the current study is the first to investigate choice of ER strategy in the context of an experimental model of trauma. The results confirmed our predictions: When no facilitation with ER was available, participants preferred distraction over reappraisal and when facilitation was provided, participants showed a preference for reappraisal. This preference could not be accounted for by a difference in the effectiveness of strategies when cued or uncued. Indeed, as the results of the forced ER task show, the two strategies were found to be equally effective. Self-reported level distress also predicted strategy preference. When rated more distressing, participants were more likely to prefer distraction and as preview distress decreased, reappraisal became more popular. These results nicely replicate the findings that, in non-facilitated conditions, distraction is preferred over reappraisal in response to high-intensity negative stimuli and in comparison, when facilitation is offered, reappraisal is chosen more often regardless of intensity (Sheppes et al., 2011; 2014). In
addition, unlike in the previous experiments using IAPS (Lang & Bradley, 2007) pictures that were pre-allocated to binary high- and low intensity conditions based on normative ratings, we used the
participants’ more continuous self-reported distress ratings at each trial to predict strategy choice. No differences between the number of intrusions recorded in the intrusion diary or PTSD-analogue symptoms as measured by the IMS (Impact of Movie Scale, Verwoerd et al., 2011) were observed when different strategies were used, or when strategies were cued compared to when they were uncued. Again, it is possible that this lack of differences resulted from the within participants design. For example, many participants reported intrusions collectively for a number of clips or all clips at once (e.g., reporting that an intrusion of one clip prompted intrusions about other clips) suggesting that the memories of the stressor clips were associated to such an extent that it was likely to result in some difficulty in detecting differences in intrusive memory symptoms.
In line with our expectations, neither central or peripheral memory of the clips in the ER choice task was not affected by the presence of cues. However, contrary to our expectations, for clips used in the forced ER task, memory for peripheral details was significantly better when ER had been facilitated. Peripheral memory was not affected by the presence of cues for the clips in the reappraisal conditions, as evident from identical mean scores. Memory for peripheral details tended to be the lowest when distraction had been used without cues, although it should be noted that this result was just failed to reach significance. Using distraction without help in our paradigm, analogous to distracting oneself in the event of being confronted by a reminder of an actual distressing event, led to reduction in one’s memory of the context of the event (i.e. environmental details, chronology of events). Theoretical accounts and evidence from previous trauma film studies suggest that contextual representations of
distressing events are critical in sustaining a link between the perceptual and conceptual representations (Brweing, Dalgiesh, & Joseph, 1996; Brewin & Burgess, 2014, for theory and review). This link can be crucially protective from emotional vulnerability to traumatic stress evoked by distressing events. Indeed, the lack of contextualization of the trauma memory has been suggested to be a hallmark of PTSD (e.g. Brewin & Burgess, 2014). Our results suggest that using distraction without help may increase the chance of dissociation of the memory of an intense stressor from its context. Furthermore, it is possible that peripheral details were better remembered when cues were used, due to lowered cognitive load demanded by the ER itself, resulting in more elaborated processing of the details surrounding the stressor.
A different pattern was observed for memory of central items for clips in the forced ER task: Contrary to expectations, memory was better for central items for clips where emotions evoked by film stills had been regulated via uncued strategies. It may be the case that reappraisals altered memory of events, and likewise that cued distraction resulted in less exposure to the stills and thus poorer memory of central items. Conversely, these results may be explained by the nature of the questions. The
true/false items in the central memory test for the clips in the forced ER task focused almost
exclusively on the most distressing and intense parts of the clips (e.g. “The man used a knife to cut his own throat”), or likely trauma “hot spots” (e.g. Grey, Holmes, & Brewin, 2001), while the peripheral memory questions were mainly about less intense or neutral details (e.g. “The man had an earring”). Thus, these results do not necessarily imply that important events are forgotten, but that trauma hot spots may become less salient in memory when facilitation for ER with effective strategies is provided. Nonetheless, the finding that uncued distraction tended to impair memory for peripheral items the most, leaving memory for central items attached should be interpreted with caution, considering that in our study no other measures indicated that uncued distraction was less beneficial in alleviating distress when compared to cued distraction and reappraisal conditions. In addition, the difference in central memory scores, while significant, was relatively minor in practise.
In an exploratory analysis, we showed that self-reported use of reappraisal as a coping strategy was positively associated with preference for reappraisal in the uncued condition. However,
interestingly, this was not the case for self-reported use of distraction, and neither coping preferences were associated with choice of strategy when facilitation of strategy was available. These findings suggest either that self-reported use of distraction is not a valid measure of actual use, or that our operationalization of distraction did not entirely overlap with the strategy as assessed by the COPE. In addition, the lack of associations between self-reported strategy use and strategy choice under facilitated conditions suggest that interventions like computerized training have the potential to change strategy preferences. Particularly so, considering the finding that reappraisal was as effective as distraction and
that reappraisal became preferred when it was facilitated, regardless of how much participants reported using reappraisal in general. As previous research indicates, reappraisal is generally a beneficial strategy in the long run (Kross & Ayduk, 2008). Conceptually, distraction is unlikely to ameliorate traumatic memories or complex associated emotions like guilt or sadness. The preference for reappraisal may be increased when participants are first provided evidence in the form of experience, that while reappraisal appears to require more effort, it is as effective a strategy as distraction.
In addition, the finding that self-reported preferences do not hold when computerized facilitation is offered, has useful implications for decreasing the use of strategies known to be maladaptive. By explicitly showing patients with PTSD or other psychopathology characterised by emotion dysregulation, in a computerized training paradigm, that reappraisal can become less effortful when facilitation is offered, we could provide the motivation to prefer it over unhelpful strategies, such as rumination and thought suppression (Seligowski et al., 2015). However, an initial step in investigating potential for a therapeutic intervention with other strategies, would be to again measure self-reported strategy preferences in a non-clinical sample followed by exposure to distressing stimuli that
participants can choose to regulate with reappraisal and, for example, thought suppression, in cued and uncued ER conditions. We would expect a similar pattern of choice preferences as observed in the current study, such that reappraisal would become more popular when cues are presented and that self-reported strategy use does not predict choice when strategies are cued.
Furthermore, to investigate under which conditions the choice preferences observed in the current study are present, an extension of the choice paradigm would be to show participants the beginning of a number of short distressing clips and ask them to rate the evoked level of distress in cued and uncued conditions. Then, participants would be instructed to choose the ER strategy (i.e. reappraisal or distraction; or e.g. reappraisal or suppression) to regulate their emotions with for the rest of the clip. We would expect that due to the lower cognitive load of strategies like distraction and suppression, they would be preferred when clips are rated more distressing and no help with ER is provided. Using negative clips of varying intensity would show if reappraisal would be chosen more often as clips are rated less distressing on a continuous scale, and if providing facilitation with ER could make choosing reappraisal more popular also with more distressing clips, as we showed with film stills in the current study.
To further investigate the effectiveness of facilitation, methodological improvement is necessary. The adoption of a between-subjects design, including a control group, could help detect potential differences in effectiveness of the two strategies and determine if the use of any strategy, no ER instructions, or psychoeducation would still result in the same pattern of distress ratings. That is, in the current study we cannot determine whether exposure to stressor reminders ameliorates affect in the
same manner as using an ER strategy does. In addition, in the current design we cannot definitively conclude that the two strategies are equal in effectiveness or that facilitation is ineffective in this context, as it is possible that strategies were used simultaneously regardless of instructions and that facilitation resulted in a training effect. Comparing groups, in the same paradigm as in the present study, who used only one strategy in only a cued or only an uncued condition, with each other and with a control group would remove these confounds.
Additionally, in this experiment the distraction cues were always placed on a neutral part of the stressor film still. Another adjustment could be to provide distraction training as an intervention in a similar analogue trauma paradigm with one group being trained to focus their attention on neutral parts of the stressor film still and the other trained to focus their attention on threatening parts of the still. Comparison between these groups could be informative in investigating if inducing changes in
attention with training results in changes in vulnerability to an intense stressor, such as a distressing film and specifically, if experimentally induced distraction style can reduce (neutral training) and increase (negative training) PTSD-analogue symptoms in response to an analogue-trauma event.
A similar intervention with the reappraisal strategy could provide further insight into the
usefulness of facilitation. Previous research has shown that initial experience-related appraisals often set in motion a cascade of appraisals and reappraisals that have far-reaching repercussions beyond the experience itself (Gross & Thompson, 2007). In addition, studies on reactions to highly distressing events have shown that, for example, appraising the self as guilty or as consequently impaired by distressing events is linked to increased occurrence of intrusive memories of the event (e.g. Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). Thus, we would expect that training negative reappraisals following a distressing film would result in greater emotional vulnerability, measured by the level of intrusive memory symptoms and distress evoked by reminders. Likewise, we would expect that training positive or neutral reappraisals would lower distress and result in fewer PTSD-analogue symptoms. This comparison would provide a test of change in emotional vulnerability induced by experimental manipulation of reappraisals. Such a difference in emotional vulnerability, and a reduction in distress via neutral or positive reappraisal training comparable to what we observed, would suggest that in the current experiment, neutral and positive reappraising had resulted in increased resilience. As shown by Woud et al., (2012), computerized implicit positive, compared with negative, reappraisal training after watching a highly distressing film reduced traumatic stress symptoms. As such, explicit training with stills from a distressing film (i.e. reminders of the specific stressor) would be expected to show similarly results.
In sum, the current study replicated the choice preference and the effect of valence of negative stimuli on ER strategy choice found by Sheppes et al. (2011) and Sheppes et al, (2014) in the trauma
film paradigm. In our study, a continuous measure of negative valence was found to predict choosing distraction over reappraisal to regulate emotions. In addition, distraction was preferred when help with ER was not provided, relative to when help was not available. Importantly, we found that distraction and reappraisal were both effective strategies to reduce distress evoked by reminders of high intensity stressors, and that participants also were able to regulate their emotions using these strategies without help.
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