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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Anxiety Stress Coping. 2021 May 28;34(4):479–485. doi: 10.1080/10615806.2021.1929934

The Impact of Emotion Regulation Therapy on Emotion Differentiation in Psychologically Distressed Caregivers of Cancer Patients

Mai B Mikkelsen 1, Emma Elkjær 1, Douglas S Mennin 2, David M Fresco 3, Robert Zachariae 1,4, Allison Applebaum 5, Mia S O’Toole 1
PMCID: PMC8364870  NIHMSID: NIHMS1706801  PMID: 34047220

Abstract

Background and objectives:

Emotion differentiation is considered adaptive because differentiated emotional experiences are believed to promote access to the information that emotions carry, enabling context-appropriate emotion regulation. In the present study, secondary analyses from a recent randomized controlled trial (O’Toole et al., 2019) were conducted to investigate whether emotion differentiation can improve as a result of psychotherapy and whether improvements in emotion differentiation are associated with reduced distress.

Design and methods:

A total of 81 distressed caregivers of cancer patients were randomized to Emotion Regulation Therapy (ERT), an intervention aimed at improving emotion differentiation and facilitating healthy emotion regulation, or a waitlist condition. Emotion differentiation scores could be calculated for 54 caregivers.

Results:

Repeated measures ANOVAs revealed that ERT led to significant improvements in negative (η2 = 0.21, p = .012), but not positive emotion differentiation (η2 = <0.01, p = .973). Correlation analyses showed that improvements in negative emotion differentiation were not associated with changes in distress.

Conclusions:

The results suggest that negative emotion differentiation can improve as a result of psychotherapy. Further research is needed to clarify how improvements in emotion differentiation following therapeutic interventions relate to treatment outcomes such as distress.

Keywords: Emotion, emotion differentiation, caregiver, cancer, emotion regulation therapy

Introduction

Cancer has increasingly come to be recognized as a source of psychological distress not only for the cancer patient but also for their caregivers (Hodges et al., 2005). Meta-analyses suggest that caregivers of cancer patients experience substantial psychological distress, including high levels of anxiety and depression (Hodges et al., 2005). One possible source of distress among cancer caregivers has been proposed to be perseverative negative thinking such as worry (O’Toole et al., 2017; Simard et al., 2013). While perseverative negative thinking may provide perceived control over intense, negative emotions in the short term, it can lead to increased distress long-term because the information provided by the avoided emotions is not accessed and acted upon (Fresco & Mennin, 2013; Fresco et al., 2002).

Emotion regulation therapy (ERT) is an intervention developed to target perseverative negative thinking (Mennin & Fresco, 2015), making it a potentially valuable intervention for alleviating psychological distress in caregivers of cancer patients. Within the framework of ERT, the ability to differentiate between emotions (i.e., make fine-grained distinctions between emotions; Barrett et al., 2001) and training of emotion regulation skills represent central mechanisms of change. ERT aims at improving emotional and motivational clarity by teaching clients to differentiate between emotions and motivations in two ways: 1) clients are invited to pay attention to their emotions and motivations, and 2) through mindfulness, clients practice attention regulation followed by meta-cognitive regulation strategies (i.e., decentering and cognitive reappraisal). In sum, emotion differentiation constitutes a central outcome of ERT, playing an important role in alleviating psychological distress.

Emotion differentiation has traditionally been studied as a trait (i.e., as a stable characteristic of the individual; Erbas et al., 2018). However, recent work indicates that emotion differentiation may consist of both stable and variable components (Erbas et al., 2018; O’Toole et al., 2020), and that trait emotion differentiation may best be conceived of as density distributions of states (cf. Fleeson, 2001). Put differently, state emotion differentiation varies within a person across time and situations, and it is the distribution of these different states, that contributes to trait emotion differentiation (Erbas et al., 2018; Fleeson, 2001). This conceptualization implies that emotion differentiation may be malleable, making it a potentially relevant target for therapeutic interventions.

Pointing to the potential malleability of emotion differentiation, Van der Gucht and colleagues (2019) reported improved emotion differentiation as a result of a mindfulness-based intervention in a sample of individuals experiencing varying levels of distress. To further assess the malleability of emotion differentiation and its role in the effects of ERT, the present study aimed to investigate the effect of ERT on emotion differentiation in a sample of distressed caregivers of cancer patients, and to examine whether improvements in emotion differentiation were associated with reduced distress. The present study involves a secondary analysis of data obtained from a randomized controlled trial assessing the efficacy of ERT tailored to distressed caregivers of cancer patients (ERT-C; O’Toole et al., 2019). This trial reported that distressed caregivers who received ERT-C, as compared to a waitlist condition, experienced significant reductions in symptoms of psychological distress (gs = .55–.96; O’Toole et al., 2019). For the present study, we hypothesized: 1) ERT-C leads to significant improvements in emotion differentiation in distressed caregivers of cancer patients, and 2) Improvements in emotion differentiation are associated with reduced distress.

Method

Participants and Procedure

The original trial was pre-registered at Clinicaltrials.gov (#NCT02322905) and the study protocol approved by the Regional Scientific Ethics Committee of Central Jutland (#1-10-72-430-14). A total of 81 informal caregivers to patients with lung, gastrointestinal, or gynaecological cancer were recruited through the Aarhus Hospital Oncology Department. The inclusion criteria included endorsement of: a) identifying as a caregiver of a cancer patient (no restriction regarding the nature of their relationship were applied), b) elevated levels of distress and perseverative negative thinking, and c) proficiency in the Danish language. Exclusion criteria were: a) active substance abuse and b) receiving other psychosocial interventions.

Eligible caregivers provided oral and written consent, completed a baseline questionnaire and a memory task, and were then randomized to one of two conditions: 1) ERT-C (8 weeks) or 2) waitlist condition (8 weeks). Caregivers in the waitlist condition were offered ERT-C after the waiting period. Caregivers completed a memory task pre-treatment and post-treatment (ERT-C) or pre-waitlist, pre-treatment, and post-treatment (waitlist condition). The memory task involved the caregivers recalling six events from their lives in which they experienced six different feelings (i.e., happiness, interest, peacefulness, sadness, anger, and anxiety) and rating their present emotional response to the memories (see supplementary material). Outcomes were distress symptoms assessed pre-treatment, post-treatment, and at three and six months post-treatment.

Emotion Regulation Therapy for Cancer Caregivers (ERT-C)

ERT-C is a manualized treatment consisting of eight weekly one-hour sessions (O’Toole et al., 2015). In the first four sessions, caregivers receive psychoeducation and work towards achieving emotional clarity through training the ability to differentiate between their emotions and motivations. In addition, caregivers practice emotion regulation skills (i.e., attention regulation and meta-cognitive regulation). In the remaining four sessions, caregivers practice applying regulation strategies when facing contrasting motivational impetuses (i.e., between approach and avoidance) during personally meaningful activities. The end goal is to assist the caregivers in establishing a more motivationally balanced approach during difficult life experiences. ERT-C was provided by trained masters- or doctoral students, who received weekly supervision. Adherence to the treatment protocol was high (see O’Toole et al., 2019 for elaboration).

Measures

Emotions in recalled events were assessed as caregiver’s ratings of five positive (happiness, enthusiasm, amusement, curiosity, pride) and five negative (shame, nervousness, anger, sadness, guilt) emotions in response to each event on five-point Likert scales (1 = not at all; 5 = very much).

Distress measures included the primary outcomes caregiver burden assessed with the Caregiver Reaction Questionnaire (Given et al., 1992; α = .58), distress assessed with the Hospital Anxiety and Depression Scale (Bjelland et al., 2002; α = .85), and worry measured with the brief Penn State Worry Questionnaire (Kertz et al., 2014; α = .84). Higher scores on these measures indicate higher burden, more distress, and more extensive worrying, respectively.

Statistical Analysis

Emotion differentiation was calculated as the consistency of correlations between emotion ratings of the same valence across the six recalled events from each of the memory tasks. Following Erbas et al. (2018), we obtained the differentiation indicators by calculating the intra-class correlation coefficients between negative and positive emotions. We then excluded negative coefficients and transformed the remaining coefficients using a Fisher’s Z transformation. Z-transformed values were reversed, such that higher values indicate better emotion differentiation.

Independent t-tests were applied to compare baseline differences in emotion differentiation between ERT-C and the waitlist condition. To compare change in emotion differentiation between ERT-C and the waitlist condition, 2 (group: ERT-C vs. waitlist condition) × 2 (time: pre vs. post waitlist/treatment) repeated measures ANOVAs were conducted. To assess whether change in emotion differentiation was associated with distress measures, correlation analyses were computed with change in differentiation (pre- to post-treatment), change in outcomes from pre- to post treatment (short-term effects), and change in outcomes from pre-treatment to six-month follow-up (long-term effects). Change in differentiation and outcomes were operationalized as residualized gain scores (cf. Cronbach & Furby, 1970).

Effect sizes from repeated measures ANOVAs were expressed as partial eta-squared (η2), where values of .1, .6, and .14 were taken to denote small, medium, and large effect sizes, respectively. Effect sizes from t-tests were expressed as Cohen’s d, where values of .2, .5, and .8 were taken to denote small, medium, and large effect sizes, respectively (Cohen, 1988).

Results

Eighty-one caregivers were randomized. Emotion differentiation for at least one time point could be calculated for 54 (66.7 %) caregivers (26 in the ERT-C condition; 28 in the waitlist condition). The mean age of the 54 caregivers was 45.15 (SD = 15.77). Most caregivers were women (74.1 %) caring for male patients (63.4 %). Twelve caregivers (22.2 %) dropped out. Dropouts did not differ from completers in age (p = .321), gender (p = .934), or pre-treatment worry (p = .717). Completers reported more pre-treatment perseverative negative thinking than dropouts (completers: M = 13.29, SD = 3.41; dropouts: M = 10.83, SD = 2.52; t(52)=2.31, d = 0.76, p = .025).

Treatment Effects on Emotion Differentiation

Independent t-tests indicated no statistically significant differences in baseline negative emotion differentiation, d = 0.27, p = .380, or baseline positive emotion differentiation, d = 0.07, p = .824, between the ERT-C condition and the waitlist condition. The results of the repeated measures ANOVAs suggested a statistically significantly greater increase in negative emotion differentiation in the ERT-C condition compared to the waitlist condition (η2 = 0.21, p = .012; see Table 1), while there was no difference for positive emotion differentiation (η2 = <0.01, p = .973). There were no differences in treatment effects of ERT-C on outcomes between those in the ERT-C condition and those in the waitlist condition after they received ERT (see O’Toole et al., 2019), and the groups were therefore combined to assess short- and long-term effects. This was done to avoid type-II errors associated with small sample sizes.

Table 1.

Descriptives and Results from Analyses Assessing the Acute Treatment Effect of ERT-C on Emotion Differentiation

Negative emotion differentiation
Variable ERT-C Waitlist Acute treatment effects
Time × Group
Pre-treatment Post-treatment Pre-waitlist Pre-treatment F p η 2
Mean differentiation (SD) 0.25 (0.21) 0.31 (0.23) 0.30 (0.20) 0.25 (0.20) 7.17 .012 0.21
Positive emotion differentiation
Variable ERT-C Waitlist Acute treatment effects
Time × Group
Pre-treatment Post-treatment Pre-waitlist Pre-treatment F p η 2
Mean differentiation (SD) 0.10 (0.06) 0.10 (0.07) 0.12 (0.11) 0.12 (0.12) <0.01 .973 <0.01
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Note: Mean emotion differentiation scores reflect intra-class correlation coefficients subtracted from 1; higher scores indicate better emotion differentiation. Results from analyses of acute treatment effects were based on z-transformed emotion differentiation scores.

Short-term Associations between Emotion Differentiation and Outcomes

As ERT only led to significant improvements in negative emotion differentiation, associations between emotion differentiation and outcomes were only investigated for this indicator (see Table 2). The results indicated that improvements in negative emotion differentiation were not associated with changes in distress symptoms from pre-treatment to post-treatment.

Table 2.

Results from Correlation Analyses Assessing Associations Between Change in Negative Emotion Differentiation and Short-term and Long-term Changes in Distress Outcomes.

Total sample mean scores Short-term effects, correlation with NED1 Long-term effects, correlation with NED1
Outcome, M (SD) Pre-treatment Post-treatment 6-month follow-up r p r p
Caregiver burden 35.24 (11.46) 29.72 (13.40) 31.68 (17.88) −.14 .492 −.08 .733
Distress 18.56 (6.78) 11.71 (7.91) 13.55 (9.05) .07 .725 .12 .603
Worry 51.62 (8.94) 42.27 (8.40) 47.09 (10.70) .30 .127 −.06 .781
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Note: NED = Change in negative emotion differentiation from pre-treatment to post-treatment.

1

Analyses were conducted with residualized gain scores based on z-transformed emotion differentiation scores, and residualized gain scores for change in outcomes from pre-treatment to post-treatment (short-term effects) and pre-treatment to six-month follow-up (long-term effects).

Long-term Associations between Emotion Differentiation and Outcomes

The results from correlation analyses assessing long-term effects suggested that improvements in negative emotion differentiation were not associated with changes in distress symptoms from pre-treatment to six-month follow-up (see Table 2).

Discussion

The primary purpose of the present study was to assess whether ERT-C would lead to significant improvements in emotion differentiation. Consistent with our hypotheses, distressed caregivers receiving immediate ERT-C, as compared to a waitlist condition, increased their ability to differentiate between negative emotions. Immediate ERT-C did, however, not lead to improvements in positive emotion differentiation. This finding suggests that ERT is successful in achieving the goal of teaching distressed clients who experience elevated levels of perseverative negative thinking to differentiate between their negative emotions. As such, the results provide support for the notion that negative emotion differentiation is malleable, which is consistent with previous literature suggesting that emotion differentiation may consist of both stable and malleable components (O’Toole et al., 2020; Van der Gucht et al., 2019). The results further provide support for the use of memory tasks to assess change in emotion differentiation. Compared to experience sampling, memory tasks are less burdensome, making it a valuable method for future research on emotion differentiation in distressed populations.

Concerning our second hypothesis, that improvements in emotion differentiation would be associated with treatment effects on distress, the findings revealed that improvements in negative emotion differentiation were not associated with short-term or long-term changes in distress. Given the design and the small sample size of the present study, we were not able to further investigate the relationship between emotion differentiation and changes in distress. However, we consider it a promising avenue for future research. For example, in light of the present findings indicating that negative emotion differentiation may be malleable, experimental studies may manipulate negative emotion differentiation and assess changes in distress in order to clarify the causal relationship between the two. Furthermore, Van der Gucht and colleagues (2019) found that state and trait mindfulness mediated the effect of psychotherapy on negative emotion differentiation, pointing to the value of investigating potential mediators when studying emotion differentiation in the context of psychotherapy. Hence, future research may employ study designs that allow for testing potential mediators.

The finding that ERT did not lead to improvements in positive emotion differentiation may be attributed to people differentiating more between negative than positive emotions (Erbas et al., 2016) possibly leaving more room for improvement in negative emotion differentiation, or that emotion differentiation was practiced by reviewing events from the caregivers’ lives, and as the caregivers were distressed they may have reviewed more negative events in sessions.

Limitations

First, the sample size was relatively small, thereby heightening the risk of type-II errors. Second, the gender distribution of participants was skewed towards women. Although the distribution is comparable to the general distribution in samples of caregivers (e.g., Pinquart & Sörensen, 2006), caution is warranted when generalizing the results to male caregivers. Third, the drop-out rate was relatively high but similar to previous trials (O’Toole et al., 2017). Fourth, emotion differentiation was not assessed during the follow-up period, leaving any changes in this period undetected. Lastly, given the study design, it is not possible to draw causal conclusions about the relationship between emotion differentiation and changes in distress.

Conclusion

The present findings indicate that negative emotion differentiation can improve as a result of psychotherapy. Further research is needed to clarify how improvements in emotion differentiation relate to treatment outcomes such as distress.

Supplementary Material

Supp 1

Funding:

Dr. Fresco was supported by NHLBI under Grant R01HL119977, NCCIH under Grant R61AT009867, NIMH under Grant R01MH118218, and NICHD under Grant R21HD095099. Dr. O’Toole and Dr. Mikkelsen were supported by the Danish Cancer Society under grants R119-A7545 and R96-A6385.

Footnotes

Disclosure of interest: The authors report no conflicts of interest.

Data availability:

https://osf.io/8d9qc/?view_only=06e1d825c03a4e7fac157f17b203da88

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supp 1
NIHMS1706801-supplement-Supp_1.docx (15.2KB, docx)

Data Availability Statement

https://osf.io/8d9qc/?view_only=06e1d825c03a4e7fac157f17b203da88

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