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Graduate Masters Theses
Doctoral Dissertations and Masters Theses
5-31-2017
Attentional and Emotional Consequences of
Emotional Acceptance and Suppression in an
Elevated Anxiety Sample
Natalie Arbid
University of Massachusetts Boston
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Arbid, Natalie, “Attentional and Emotional Consequences of Emotional Acceptance and Suppression in an Elevated Anxiety Sample”
(2017). Graduate Masters Theses. 418.
https://scholarworks.umb.edu/masters_theses/418
ATTENTIONAL AND EMOTIONAL CONSEQUENCES OF EMOTIONAL ACCEPTANCE
AND SUPPRESSION IN AN ELEVATED ANXIETY SAMPLE
A Thesis Presented
by
NATALIE ARBID
Submitted to the Office of Graduate Studies,
University of Massachusetts Boston,
in partial fulfillment of the requirements for the degree of
MASTERS OF ARTS
May 2017
Clinical Psychology Program
© 2017 by Natalie Arbid
All rights reserved
ATTENTIONAL AND EMOTIONAL CONSEUQENCES OF EMOTIONAL ACCEPTANCE
AND SUPPRESSION IN AN ELEVATED ANXIETY SAMPLE
A Thesis Presented
by
NATALIE ARBID
Approved as to style and content by:
________________________________________________
Lizabeth Roemer, Professor
Chairperson of Committee
________________________________________________
Sarah Hayes-Skelton, Associate Professor
Member
________________________________________________
Alice S. Carter, Professor
Member
____________________________________
David Pantalone, Program Director
Clinical Psychology Program
____________________________________
Jane Adams, Chairperson
Psychology Department
iv
ABSTRACT
ATTENTIONAL AND EMOTIONAL CONSEQUENCES OF EMOTIONAL ACCEPTANCE
AND SUPPRESSION IN AN ELEVATED ANXIETY SAMPLE
May 2017
Natalie Arbid, B.A. Loyola Marymount University
M.A. University of Massachusetts, Boston
Directed by Professor Lizabeth Roemer
Acceptance- based strategies have been incorporated into behavioral therapies for anxiety
and other disorders (e.g., Roemer & Orsillo, 2009). Experimental literature is in need of better,
more nuances assessment of the consequences of acceptance (Kohl, Rief & Glombiewski, 2012).
Therefore, this study specifically examined the way in which acceptance can increase attentional
flexibility and recovery from stress, which are important factors in the maintenance of anxiety
disorders (Cisler & Koster, 2010). This experimental study compared acceptance and
suppression of emotional experiences, following exposure to fearful stimuli (i.e., images and film
clip), to a control condition. Results indicated that there was no significant relation between
dimensional self-ratings of trait and state emotion regulation ability, trait acceptance,
disengagement from viewing distressing images, and recovery from distress. Experimental
v
analyses revealed that no emotion regulation strategy- acceptance or suppression- allowed
individuals to disengage and recover from the negative images significantly more quickly. Also
no emotion regulation strategy led to significantly lower levels of self-reported negative affect
and higher willingness to view more distressing images. However, nonsignificant trends of
medium to large effect sizes emerged, with unexpected correlational findings suggesting that
trait levels of experiential avoidance and emotion regulation difficulties were associated with the
ability to disengage from images, while acceptance instructions may have facilitated
disengagement following the task.
There were several limitations to this study. First the sample size was small limiting the
ability to detect effects of the independent variable (i.e., emotion regulation instructions). Also
randomization was not successful and the conditions were imbalanced on several key variables.
Lastly the mood induction was not successful in inducing fear in this sample, therefore limiting
ability to comment on participants’ reaction to distress and recovery from distress.
Given that there were several limitations to this study, it is important for future research to make
the study alterations recommended and conduct further research on this topic.
vi
ACKNOWLEDGMENTS
First and foremost I want to thank my mentor Liz Roemer for your support, guidance,
dedication, and belief in my abilities on this project. Your commitment to mentorship and my
personal and professional development is beyond anything I could have hoped for. Thank you
for being my full service mentor. I also want to thank all my lab- mates for your ongoing
support and kindness.
Thank you to my family for always being incredibly loving and supportive. You have
always rooted for me, and nurtured my desire to pursue my dreams (no matter how far away that
may take me). I also want to thank my partner Robert Hanna. Words can’t express how much I
have felt your love and encouragement. I feel incredibly luck to have you by my side.
Thank you to my committee for their time, energy, and thoughtful feedback. I am very
grateful for your guidance. I would also like to thank the University of Massachusetts Graduate
Student Association for funding this project. Without the Spayne Grant, I would not have been
able to compensate my participants.
Lastly I want to thank everyone who participated in this study because I could not have
done it without you.
vii
TABLE OF CONTENTS
ACKNOWLEDGMENTS …………………………………………………………………..
vi
LIST OF TABLES
……………………………………………………………………………..
ix
LIST OF FIGURES ……………………………………………………………………………
xiii
CHAPTER Page
1. SPECIFIC AIMS …………………………………………………………………
1
Overarching Goals and Hypotheses
…………………………………
3
Correlational Aims
………………………………………………………..
3
Experimental Aims ……………………………………………………….
4
2. BACKGROUND AND SIGNIFICANCE
……………………………….
5
Emotion Regulation ………………………………………………………
5
Models of Emotion Regulation
………………………………….
5
Emotion Regulation and Anxiety Disorders ………………..
7
Experiential Avoidance and Acceptance …………………….
8
Experiential Avoidance, Acceptance, and
Emotion Regulation …………………………………………………
10
Review of Experimental Studies of Experiential Avoidance and
Acceptance
……………………………………………………………..
13
Assessment of Recovery …………………………………………..
16
Assessment of Attention and Disengagement
………………
17
The Current Study
…………………………………………………………
18
3. METHODS …………………………………………………………………………
20
Broad Procedural Overview
……………………………………………
20
Recruitment
………………………………………………………………….
21
Participants
…………………………………………………………………..
22
Measures and Assessment
………………………………………………
23
Prescreening Measures
……………………………………………..
23
Emotional Interference Task and State Measures
…………
26
Procedures
……………………………………………………………………
30
Manipulation Check
…………………………………………………
32
Behavioral Assessment …………………………………………….
32
Restates Hypotheses
………………………………………………………
32
4. RESULTS …………………………………………………………………………..
34
Equivalence of Conditions on Key Variables
……………………
35
Manipulation Check
………………………………………………………
36
Correlational Results
……………………………………………………..
37
Experimental Results …………………………………………………….
40
viii
CHAPTER
Page
9. DISCUSSION ……………………………………………………………………
47
Limitations …………………………………………………………………..
50
Interpretations and Implications of Findings …………………….
52
Correlational Interpretations and Implications ………………….
52
Experimental Interpretations and Implications
………………….
55
APPENDIX
A. EMOTION REGULATION INSTRUCTIONS
……………………….
59
REFERENCES
………………………………………………………………………………
65
ix
LIST OF TABLES
Table
Page
1. Means and Standard Deviations of Untransformed Variables
of Interest …………………………………………………………………….
36
2. Zero Order Correlations AAQ, MEAQ, DERS, EIT1 ……………….
37
3. Correlations Controlling for Baseline Negative Affect ……………..
38
4. Zero Order Correlations DERS and EIT1
………………………………..
39
5. Correlations Controlling for Baseline Negative Affect ……………..
40
6. Means of EIT2 at 1s SOA
……………………………………………………..
41
7. Means of Recovery at EIT2 at 1s SOA
……………………………………
42
8. Means of Recovery at EIT2 at 4s SOA
……………………………………
44
9. Mean and Standard Deviations of EIT1 1ms and 4 ms SOA ……..
45
10. Means of Negative Affect
………………………………………………………
45
x
LIST OF FIGURES
Figure
Page
1. Unadjusted Means of Reaction Time During Recovery of EIT2
at 1ms SOA ………………………………………………………………….
43
2.
Unadjusted Means of Reaction Time During Recovery of EIT2
at 4ms SOA ………………………………………………………………….
44
1
CHAPTER 1
SPECIFIC AIMS
Research has consistently demonstrated that emotion regulation skills are important to
psychological well-being (Gross & Jazeieri, 2014). Emotion regulation is the process in which
individuals attempt to influence the emotions they have, when they have them, and how they are
expressed and experienced (Gross, 1998). This is a dynamic and temporal process that involves
the adjustment of emotional experiences before, during, and after an event elicits emotions; it
also includes the valuation or appraisal of one’s emotional experience (Gross, 2015). This
process can be relatively automatic or a habitual response pattern that happens in or outside
awareness (Amstadter, 2008), consciously or automatically (Mauss, Cook, & Gross, 2007), and
varies based on contextual and personal factors. Specifically, emotion regulation difficulties or
emotion dsyregulation has been linked to anxiety disorders such as Generalized Anxiety
Disorder (GAD; Mennin, Heimberg, Turk, & Fresco, 2005), Social Anxiety Disorder (SAD;
Aldao 2014; Turk, Heimberg, Luterek, Mennin, & Fresco, 2005), and Post Traumatic Stress
Disorder (PTSD;Tull, Gratz, Salter, & Roemer, 2004) – for a review see Amstadter (2008).
A common way in which individuals manage their emotional experience, and a
maintenance factor in several anxiety disorders, is avoidance. A specific type of avoidance is the
avoidance of internal experiences, such as emotions, thoughts, and bodily sensations. This
unwillingness to stay in contact with internal sensations is known as experiential avoidance (EA;
Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). EA has been the focus of several
acceptance-based behavioral therapies (ABBTs), including Acceptance and Commitment
Therapy (ACT; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). The success of these therapies
has been in part due to their focus on the reduction of EA and the cultivation of acceptance.
2
Acceptance is understood in opposition to EA and is defined as an allowance of internal
experiences without efforts to rid oneself of them; it also includes a quality of relating to one’s
internal experiences by turning toward them in an open, nonjudgmental way (Hayes et al., 2006;
Hayes, Strosahl, et al., 2004). Several investigations have found that reduction of EA and
increases in acceptance predict treatment response, reduce anxiety symptomology, and are an
overall mechanism of action (Hayes, Orsillo & Roemer, 2010; Arch & Craske, 2008; Arch,
Wolitzky-Taylor, Eifert, & Craske, 2012a; Twohig et al., 2010; Niles et al., 2014).
There has been an increase in the number of experimental studies that have attempted to
dismantle ABBTs and investigate acceptance and experiential avoidance outside of treatment. A
meta-analysis of these studies found that acceptance was not significantly associated with
psychopathology, yet effect sizes were small to medium and in the predicted direction, possibly
indicating a need for better assessment of the construct (Aldao, 2010). In another meta-analysis
(Kohl, Rief, & Glombiewski, 2012) acceptance failed to demonstrate general superiority over
other emotion regulation strategies, but the large amount of variability in type of manipulation,
outcome measures, and comparison groups allowed for no firm conclusions and heeds cautious
interpretation of the null findings. This evidence points to the need for better, more nuanced
assessment of the construct. Acceptance is not the reduction of symptoms, but it is a change in
the relationship to the experience. Therefore, conclusions based on acceptance’s effects on
down-regulation of negative affect or other symptoms may be limited by this narrow outcome
measurement. As such, I assessed acceptance in terms of recovery from distress, attentional
disengagement from threat, negative affect, and behavioral action, to better capture the ways in
which acceptance is effective and to expand on the experimental literature of EA and acceptance.
3
I was particularly interested in understanding the impact acceptance and experiential
avoidance have on attention while an individual is engaged in an emotionally distressing task and
their impact on recovery from emotional arousal. Emotional and expressive suppression have
been used as proxy measures of experiential avoidance, therefore I used emotional suppression in
this investigation as it most closely models EA. I examined whether acceptance could facilitate
individuals’ ability to disengage and flexibily move attention from emotionally arousing (i.e.,
fearful) images and recover from this heightened arousal. An attentional interference task helped
elucidate if acceptance allowed individuals to have an emotional experience, while still engaging
and disengaging in other activities.
Overarching Aims and Hypotheses
Correlational Aims
1. Examine how dimensional self-ratings of trait1 emotion regulation and acceptance are related
to the heightened ability to disengage from and recovery following an emotionally arousing task.
a. It was hypothesized that emotion regulation abilities would be positively related to
ability to disengage and recover from an emotionally arousing task.
b. It was hypothesized that acceptance would be positively associated with ability to
disengage and recover from an emotionally arousing task.
c. It was hypothesized that state emotion regulation abilities would be positively related
to ability to disengage and recover from an emotionally arousing task.
1 The term trait is used in the adult emotion regulation literature to describe the ways in which
individuals use these strategies habitually on their own without the impact of an intervention.
This is usually assessed via self-report.
4
Experimental Aims
2. Determine which emotion regulation strategies- acceptance or suppression- would allow
individuals to better disengage and recover from an emotionally arousing task.
a. It was hypothesized that those instructed to use acceptance strategies would better
disengage and recover from an emotionally arousing task compared to those using
suppression or no strategy.
b. It was hypothesized that those instructed to use acceptance would report lower levels
of negative affect at the end of the study.
c. It was hypothesized that those instructed to use acceptance would be more willing to
view another set of images in the task.
5
CHAPTER 2
BACKGROUND AND SIGNIFICANCE
In this review I investigate current understandings of emotion regulation and how they
relate to anxiety disorders. I focus specifically on how experiential avoidance (EA) and
acceptance can play a role in modulating emotional experience. Next, I review the experimental
literature on acceptance and EA, highlighting the strengths and weaknesses of the current
literature and explain how this investigation can improve and expand on these studies. Finally, I
review the specific ways in which I assessed the impact of acceptance and how these more
nuanced assessment methods can help us better understand acceptance and its impact on
individuals with anxiety disorders.
Emotion Regulation (ER)
Models of Emotion Regulation. There are several conceptualizations of emotion
regulation (ER) in the literature (Thompson, 1994; Berking, 2008; Gross, 1998,2015; Gratz &
Roemer, 2004). In a recent editorial review, Tull and Aldao (2015) explain that the
commonalities in these understandings are their conceptualization of emotion regulation as a way
in which individuals have an influence over, and respond to their emotional experience. Here, I
provide a small sample of the ways in which emotion regulation can be understood before
focusing specifically on experiential avoidance and acceptance.
Some models of emotion regulation include extrinsic and intrinsic processes that monitor,
evaluate, and modify emotion to accomplish goals (Thompson, 1994). Another describes specific
dimensions of adaptive emotion regulation that include awareness, understanding, and
acceptance of emotional experience, the ability to act in accordance with goals, and the ability to
6
use different strategies flexibly (Gratz & Roemer, 2004). Synthesizing and building upon some
of these theories, Berking et al. (2008) proposed a model that is built on the assumption that
mental health is the ability to modify emotions in a desired direction and accept and tolerate
undesired emotions. This theory conceptualizes adaptive emotion regulation as an interaction of
nine specific skills, including identification and awareness of emotional experience, consciously
processing emotions/being aware of emotions, identification and labeling emotions, interpreting
emotion related body sensations correctly, understanding the prompts of emotions, supporting
oneself in emotionally distressing situations, actively modifying negative emotions in order to
feel better, accepting emotions, being resilient to /tolerating negative emotions, and confronting
emotionally distressing situations in order to attain important goals.
Lastly, there is a temporal process model (Gross, 1998) that describes how individuals
use strategies to influence their emotional experience before, during, and after they experience
emotions. These conceptualizations are all useful and the utility of each depends on the research
question at hand. When the question is framed around the positive, negative, short-term and
long-term consequences of emotion regulation strategies, Gross’ process model of emotion
regulation (Gross, 1998a, 1998b) is the most widely used (Gratz, Weiss, & Tull, 2015).
The Gross model includes five strategies, divided into two categories of regulation
strategies: antecedent-focused strategies that occur before the emotional response and response-
focused strategies that occur after the emotional response. An extended version of this model has
been developed, which includes a valuation system (Gross, 2015). This valuation system is the
appraisal of our internal and external worlds, and the use of that information to determine
whether stimuli or experiences are indifferent, good, or bad (Gross, 2015). This valuation
system is used within the whole model, both in the antecedent and response strategies.
7
Experimental work most often uses this model as a whole to help operationalize emotion
regulation. Therefore I have framed this investigation within the Gross process model (Gross,
1998a, 1998b), while also using others to help measure trait emotion regulation abilities (Gratz &
Roemer, 2004).
Emotion Regulation and Anxiety Disorders. As the study of emotion regulation has
grown, so has an understanding of the role emotion regulation plays in anxiety and stress
disorders (Amstadter, 2008). Importantly, psychologists have learned that emotion dysregulation
plays a vital role in the experience of those with these disorders. For instance, individuals with
generalized anxiety disorder (GAD) report higher levels of intense emotions, difficulty
understanding emotions, negative reactivity to their emotional state, and maladaptive emotional
response management (Mennin, Heimberg, Turk, & Fresco, 2002; Turk, Heimberg, Luterek,
Mennin, & Fresco, 2005). Similarly, research has shown that individuals with social anxiety
disorder (SAD) have difficulty identifying emotions, pay less attention to emotions, have
difficulty repairing negative mood states, are fearful of experiencing emotions (Turk et al.,
2005), and use expressive suppression (Werner, Goldin, Ball, Heimberg, & Gross, 2011) more
than nonclinical samples. Also, posttraumatic stress disorder (PTSD) has been associated with
thought suppression (Tull, Gratz, Salters, & Roemer, 2004; Lee, Witte, Weathers, & Davis,
2015) and avoidance of internal experiences (Lee et al., 2015). Preliminary evidence suggests
that obsessive- compulsive disorder (OCD) symptoms (e.g., washing, checking, doubting,
obsessions, ordering) are related to a poor understanding of emotions, fear of positive and
negative emotions, and fear of anxiety, which are features of the emotion dysregulation (Stern,
Nota, Heimberg, Holaway, & Coles, 2014). These symptoms also relate to difficulties with
impulse control, limited access to strategies for emotion regulation, and a lack of emotional
8
clarity (de la Cruz et al., 2013). As this evidence suggests, emotion regulation is crucial to
understanding the maintenance factors for several anxiety disorders. Specifically, negative
reactivity to and avoidance of emotional experience is a common factor among these disorders.
Methods, such as acceptance, that target reactivity to and avoidance of emotions are often
components of treatments for these disorders (e.g., Twohig et al., 2010; Osman, Wilson,
Storaasli, & McNeil, 2006; Arch and Craske, 2008; Niles et al., 2014). For this reason,
experiential avoidance and acceptance were the focus of this investigation.
Experiential Avoidance and Acceptance. Experiential avoidance (EA) is the
unwillingness to remain in contact with private internal experiences, such as thoughts, bodily
sensations, emotions, memories or behaviors, along with the effort or action taken to alter the
form or frequency of these internal experiences (Hayes, Wilson, Gifford, Follette, & Strosahl,
1996). Avoidance of painful memories, experiences, or emotions is a natural part of the human
experience. Individuals are motivated to avoid or get rid of these negative internal and external
experiences because of the psychological discomfort they cause. Although avoidance can be
adaptive (e.g., avoiding physical danger), when it becomes a habitual manner of responding to
emotional material or experiences that are not necessarily dangerous, rigid behavioral and
emotional patterns can develop. In particular, individuals with anxiety disorders often experience
intrusive, distressing thoughts, attend to threatening material more often, and have strong beliefs
that these experiences are unavoidable, and therefore use avoidance as a way to cope (Salters-
Pedneault, Tull, & Roemer, 2004). Avoidance of emotional material does not allow individuals
to engage with these internal experiences in a new way that facilitates new learning to take place
(Salters-Pedneault et al., 2004). These habitual patterns of avoidance can spread to a wide range
of contexts and eventually become maladaptive, not allowing for new and corrective learning to
9
take place, fostering disengagement from life, and restricting valued actions (Roemer & Orsillo,
2009). Experiential avoidance becomes negatively reinforcing because it seems effective in
eliminating distressing internal experiences in the short-term, but the long-term paradoxical
effects are that it actually increases distress and restricts individuals’ lives (Hayes et al., 1996;
Lee et al., 2010; Wegner, 2011).
As evidence of the pervasiveness of experiential avoidance among the anxiety disorders
mounted, it became a target of several behavioral treatments, such as Acceptance and
Commitment Therapy (ACT; Hayes et al., 1999) and other Acceptance-Based Behavioral
Therapies (ABBTs; Roemer, Orsillo, & Salters-Pednault, 2008). With the success of these
treatments, investigations on how they actually work, or through which mechanism they produce
change, have shown strong evidence that the reduction of EA is a mechanism of action (Hayes-
Skelton, S. A., Usmani, A., Lee, J. K., Roemer, L., & Orsillo, S. M., 2012; Arch & Craske 2008;
Niles et al., 2014). The reduction of experiential avoidance has been captured with the concept of
experiential acceptance. Experiential acceptance2 refers to the allowance of internal experiences,
the ability to notice and pay attention to internal experiences, and the ability to turn towards
these experiences in a nonjudgmental way (Hayes et al., 1996). In an ABBT for individuals with
GAD, Hayes, Orsillo and Roemer (2010) found that the larger session-by-session increases in
acceptance reported by clients over the course of therapy, the more likely that they were later
considered a treatment responder. When cognitive behavioral therapy (CBT) and ACT were
compared in treating individuals with heterogeneous anxiety disorders, improvements in EA
occurred across both conditions and the ACT group reported significantly less EA at the 12-
month follow up (Arch et al., 2012b). In another randomized clinical trial for individuals
2 Experiential acceptance and acceptance are interchangeable. For the remainder of the document
acceptance will be used.
10
diagnosed with OCD, ACT was compared to progressive relaxation training (Twohig et al.,
2010). Participants in the ACT condition showed significantly greater reductions in experiential
avoidance from pre-treatment to post-treatment compared with progressive relaxation training
participants. Dalrymple and colleagues (2007) conducted a waitlist control study with a group of
individuals diagnosed with social anxiety disorder who received ACT and exposure. The authors
found that earlier decreases in EA predicted later symptom change.
There is strong empirical support for the increase of acceptance and decrease of EA in
ABBTs, especially for individuals diagnosed with various anxiety disorders. This evidence
points to acceptance being an important mechanism of change in manualized or comprehensive
treatments (Roemer & Orsillo, 2002). Further research is needed to elucidate the specific ways in
which acceptance brings about symptom change in these clinical samples. With an experimental
design, this investigation determined the effects acceptance has on individuals who are
experiencing elevated levels of anxious arousal and general anxiety.
Experiential Avoidance, Acceptance, and Emotion Regulation
Integration of the experiential avoidance, acceptance, and emotion regulation literature
can be helpful in investigating these constructs in the context of an experimental study. There is
theoretical and empirical evidence that EA and acceptance are opposing ways to regulate one’s
emotional experience (Hofmann & Asmundson, 2008; Blackledge & Hayes, 2001; Webb, Miles,
& Sheeran, 2012). Using Gross’s (1998) process model, there is disagreement as to whether
acceptance is an antecedent focused strategy (Webb, Miles, & Sheeran, 2012), a response
focused strategy (Hofmann & Asmundson, 2008) or a combination of both (Wolgast, Lars-
Gunnar, & Viborg, 2013; Liverant, Brown, Barlow, & Roemer, 2008). Webb and colleagues
(2012) conceptualize acceptance as an antecedent focused strategy that involves cognitive
11
change. This classification stems from an understanding of acceptance as reappraisal of the
emotional experience (Webb et al., 2012). Acceptance as an antecedent strategy implies an
internalization of this approach toward internal experiences and emotion generation. In other
words, this is when acceptance becomes an established habitual pattern of approaching and
responding. We could also understand this as the use of acceptance within an experimental
framework where individuals are instructed to use acceptance before an emotional reaction. On
the other hand, among individuals first beginning an ABBT, acceptance can be used as a
response strategy to help change the already established problematic relationships to one’s
internal experience. This dichotomous view of acceptance can be helpful to operationalize it in
these instances, but is also problematic because it does not capture the complexity of acceptance
used across multiple contexts (i.e., when implemented before an emotional experiences, used
after an emotionally triggering event, and even during an emotional experience). Acceptance can
be understood as actually both antecedent and response focused, depending on the context and
the interaction between the environment, the individual, and their ability to implement aspects of
acceptance when needed. Acceptance incorporates elements of antecedent-focused emotion
regulation via reappraisal of the acceptability of emotional experience and response-focused
emotion regulation when allowing the experience of emotion without attempts to alter or
suppress it (Wolgast, Lars- Gunnar, & Viborg, 2013; Liverant, Brown, Barlow, & Roemer,
2008).
Revisiting Gross’s (2015) updated process model of emotion regulation, it more clearly
states that emotion regulation is not linear but a cyclical process. A strategy is implemented, we
receive feedback either from ourselves or the environment about its usefulness, we form a
valuation or judgment of its efficacy, and finally make a decision about when, where, and how it
12
may be implemented again. Acceptance can be used as an emotion regulation strategy to
approach an interaction, then used after the interaction, and finally can be used to approach our
own emotions in response to the interaction. Placing acceptance into this cycle sheds light on the
multiple understandings of acceptance and the complexities of operationalizing it.
In this investigation I used a response- focused conceptualization of acceptance for
several reasons. First, the target sample is individuals experiencing elevated levels of anxious
arousal and generalized anxiety. These individuals may already experience difficulties with their
internal experiences and therefore instructing them to approach their reactions in an accepting
way will require a response-focused approach. For example, as mentioned earlier, novices in
treatment initially use acceptance as a response modulation strategy. Since a broader aim of this
investigation is to better understand the effects of a component of treatment (i.e., acceptance), I
used clinical work as a reference point. Secondly, I understand acceptance and cognitive
reappraisal or cognitive change as related but distinct concepts (Wolgast, 2013; Hofmann &
Asmundson 2008). Although acceptance is usually used in response to negative judgment of
response patterns, it does not promote a reappraisal of this response or situation into something
better or worse. Acceptance includes attempts to place no value judgment on internal experiences
and to understand them merely as responses. For example, using cognitive reappraisal would
involve reinterpreting a failing grade on an exam as being due to the difficulty of the test instead
of one’s lack of studying and preparation. In contrast, the use of acceptance would involve
allowing oneself to feel disappointed, acknowledge these feelings as feelings, and approaching
oneself gently without harsh judgment.
Before turning toward how both acceptance and experiential avoidance have been
evaluated in the experimental literature, I explain how EA is operationalized. Experiential
13
avoidance has been tested via the use of suppression of both internal experiences and external
output. Internal or emotional suppression is the suppression of internal experiences, such as
thoughts, memories or emotions (e.g., instructing people to suppress their internal emotional
response/experience). External or expressive suppression is the elimination of facial and other
outward signs of emotion (e.g., instructing people to conceal their facial expression when
emotions arise). Both internal and external suppression have been shown to have paradoxical
effects; in the short-term, suppression can alleviate distress, while the long-term effects cause an
increase in the symptoms (Wegner et al 1987; Abramowitz, Tolin & Street, 2001). I focused on
internal or emotional suppression in this investigation since it most aligns with the definition of
EA.
Review of Experimental Studies of Experiential Avoidance and Acceptance. A body
of experimental literature investigates the emotional, physiological, and behavioral consequences
of suppression and acceptance. Tull, Jakupcak, and Roemer (2010) found that men using
emotional suppression compared to allowance of emotions experienced higher levels of distress
after listening to situations of men failing to conform to gender role norms (gender role stress-
related distress). Moreover, responding to these situations, men using emotional suppression had
significant increases in heart rate, and 23.5% of them were unwilling to participate in the
experiment again (compared to 0% in the emotional allowance group). In a group of individuals
diagnosed with anxiety and depression, those who were instructed to use emotional suppression
had poorer recovery in that negative affect subsided to a lesser extent compared to those who
used emotional acceptance in response to an aversive film clip (Campbell-Sills, Barlow, Brown,
& Hofmann, 2006). Also the heart rate of both the suppression and acceptance groups increased
from anticipation to recovery, yet participants in the suppression group showed an increase in
14
HR from anticipation to exposure, and a decrease in HR from exposure to recovery. Hofmann,
Heering, Sawyer, and Asnaanu (2009) also found that when individuals were asked to use
suppression (both expressive and emotional suppression) while giving a speech, they reported
higher anxiety than those in the reappraisal group and increased heart rate compared to both
reappraisal and acceptance. There was no difference in levels of reported anxiety between the
acceptance and reappraisal group and no difference between the acceptance and suppression
groups. During a CO2 challenge, participants with panic disorder using acceptance reported
significantly less anxiety than those in the suppression group, controlling for resting state anxiety
(Levitt, Brown, Orsillo, & Barlow, 2004). Also individuals in the acceptance group were more
willing to participate in a second challenge than those in the suppression and control groups, with
no difference between the suppression and control groups. In an investigation comparing
cognitive reappraisal and acceptance in a healthy sample, participants in both conditions reported
significantly less negative emotion when compared to a control condition in response to fear and
sadness film clips (Wolgast, Lundh, & Viborg, 2011). Both of these strategies were also related
to less behavioral avoidance as measured by reluctance to view the same film clip again.
Importantly, there was no association between self-reported negative emotion and avoidance in
the acceptance condition, indicating that those using acceptance had a higher tolerance for
aversive emotional experiences and were possibly less likely to resort to avoidance (Wolgast et
al., 2011).
This evidence suggests that experiential suppression is related to increases in distress,
poorer recovery from elevated levels of negative affect, and higher levels of self-reported
anxiety. On the other hand, evidence points to acceptance relating to more rapid recovery from
aversive stimuli, lower levels of self-reported anxiety, and more behavioral willingness to engage
