The Importance of Being Flexible

On what do therapists agree? Assessing therapist evaluations of emotion regulation strategy effectiveness

OBJECTIVE

To develop more unified, process-based, and disseminable psychotherapy treatments, it is important to determine whether there is consensus among therapists regarding intervention strategies.

DESIGN

Because emotion regulation is a cornerstone of modern treatments and a thriving area of clinical research, we assessed therapists' ratings of the effectiveness of commonly studied emotion regulation strategies.

METHODS

Therapists (n = 582) read eleven vignettes describing stressful scenarios and rated the effectiveness of ten emotion regulation strategies in each scenario.

RESULTS

Across therapists, we found general consensus regarding the most (i.e., problem-solving) and least (i.e., concealing emotions) effective strategies. Cognitive/behavioural/third-wave therapists rated acceptance and distraction as more effective, and emotional expression and gathering information as less effective, than other therapists, Fs> 4.20, ps < .05, whereas hours of clinical experience were generally unrelated to strategy effectiveness ratings.

CONCLUSIONS

We discuss what these points of agreement and relative disagreement among therapists reveal about a more unified, process-based treatment approach and how these results can guide emotion regulation research.

PRACTITIONER POINTS

There is general consensus among practising therapists that problem-solving is the most effective emotion regulation strategy and expressive suppression is the least effective. However, CBT-oriented therapists rated acceptance and distraction as more effective than non-CBT-oriented therapists. Non-CBT-oriented therapists rated emotional expression and gathering information as more effective than CBT-oriented therapists. Years of experience were unrelated to ratings of emotion regulation strategy effectiveness.

Individual differences in emotion regulation prospectively predict early COVID-19 related acute stress

Preliminary prospective research suggests emotion dysregulation may confer vulnerability to poor stress responses. The present prospective study extends this research by examining both specific emotion regulation strategies and global emotion regulation difficulties in the context of acute stress following onset of the COVID-19 global pandemic in 119 young adults. As part of a larger study, emotion regulation was assessed prior to pandemic onset (January 2019 - February 2020) using two standard measures (Emotion Regulation Questionnaire, ERQ, Gross & John, 2003; Difficulties in Emotion Regulation Scale, DERS, Gratz & Roemer, 2004). A self-report assessment of acute stress was conducted 2-3½ weeks after the COVID-19 pandemic declaration. Results demonstrated cognitive reappraisal and expressive suppression (i.e., ERQ) were not individually predictive of acute stress; however, there was a significant interaction of suppression by reappraisal. Simple effects indicated suppression was negatively associated with acute stress only when reappraisal levels were high. Greater global emotion regulation difficulties (i.e., DERS), particularly nonacceptance of emotions and limited access to emotion regulation strategies, significantly predicted greater acute stress. These results provide further evidence of the temporal relationship between emotion dysregulation and stress reactions, and also suggest the expected effects of emotion regulation strategies may differ across contexts.

Association between gambling disorder and emotion (dys)regulation: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to provide a comprehensive evaluation of the role of emotion (dys)regulation in gambling disorder (GD). PsycINFO, PsycARTICLES, MEDLINE, Scopus, Web of Science, and PubMed were systematically searched for articles published until November 3, 2020. Forty-nine studies were considered for the systematic review; of these, 38 comprising 5242 participants met the inclusion criteria for the meta-analysis. Associations were found between GD and specific emotion regulation (ER) deficits, namely (1) nonacceptance of negative emotional states, (2) difficulties in maintaining goal-directed behaviors when faced with intense emotional contexts, (3) lack of clarity about emotional states (poor emotional awareness), (4) low impulse control in reaction to negative emotional states, and (5) difficulties in accessing adaptive ER strategies. We furthermore found that GD is associated with a tendency for emotional suppression, which is known as a maladaptive ER strategy and linked with reduced mindfulness abilities. Additional moderator analyses were conducted regarding age, gender, type of instrument used to measure GD, clinical status of the samples, and quality of the studies. Overall, the data demonstrated consistent and significant associations between GD and ER. This systematic review and meta-analysis mostly supports the conceptualization of GD as an addictive disorder characterized by ER deficits and stresses the need to develop interventions in ER deficits that are tailored to the specificities of GD.

Emotion network density is a potential clinical marker for anxiety and depression: Comparison of ecological momentary assessment and daily diary

OBJECTIVES

Using two intensive longitudinal data sets with different timescales (90 minutes, daily), we examined emotion network density, a metric of emotional inflexibility, as a predictor of clinical-level anxiety and depression.

DESIGN

Mobile-based intensive longitudinal assessments.

METHODS

119 participants (61 anxious and depressed, 58 healthy controls) completed ecological momentary assessment (EMA) to rate a variety of negative (NE) and positive emotions (PE) 9 times per day for 8 days using a mobile phone application. 169 participants (97 anxious and depressed and 72 healthy controls) completed an online daily diary on their NE and PE for 50 days. Multilevel vector autoregressive models were run to compute NE and PE network densities in each data set.

RESULTS

In the EMA data set, both NE and PE network densities significantly predicted participants' diagnostic status above and beyond demographics and the mean and standard deviation of NE and PE. Greater NE network density and lower PE network density were associated with anxiety and depression diagnoses. In the daily diary data set, NE and PE network densities did not significantly predict the diagnostic status.

CONCLUSIONS

Greater inflexibility of NE and lower inflexibility of PE, indexed by emotion network density, are potential clinical markers of anxiety and depressive disorders when assessed at intra-daily levels as opposed to daily levels. Considering emotion network density, as well as the mean level and variability of emotions in daily life, may contribute to diagnostic prediction of anxiety and depressive disorders.

PRACTITIONER POINTS

Emotion network density, or the degree to which prior emotions predict and influence current emotions, indicates an inflexible or change-resistant emotion system. Emotional inflexibility or change resistance over a few hours, but not daily, may characterize anxiety and depressive disorders. Inflexible negative emotion systems are associated with anxiety and depressive disorders, whereas inflexible positive emotion systems may indicate psychological health. Considering emotional inflexibility within days may provide additional information beyond demographics and mean level and variability of emotions in daily life for detecting anxiety and depressive disorders. ​.

Biological signatures of emotion regulation flexibility in children: Parenting context and links with child adjustment

Emotion regulation (ER) is a key facet of positive adjustment throughout the lifespan. Recent theoretical and empirical innovations suggest that current methods for assessing ER are limited, because they measure discrete strategy use instead of ER flexibility and are insensitive to ecologically valid social contexts that influence ER. This is particularly important for studying the impact of parenting on ER development during childhood. The current study (N = 93; 47 females; M_age = 6.98, SD = 1.12) examined child ER flexibility during a directed reappraisal task (DRT) with two parenting contexts: passive parent presence or active scaffolding. Two biological signatures of ER flexibility were measured: respiratory sinus arrhythmia (RSA), an index of physiological flexibility; and the late positive potential (LPP), an index of neurocognitive flexibility. Emotion regulation behavior was observed during a frustrating wait, and parents reported on child ER and adjustment. Greater ER flexibility indexed via the LPP and RSA both predicted observed ER during the frustrating wait, but only RSA predicted parent-reported trait ER and fewer adjustment problems. Emotion regulation flexibility indexed by the LPP was bolstered by parent presence and scaffolding of child ER during the DRT, but RSA measures were not sensitive to parenting context. Taken together, the results provide converging evidence for the conceptualization of ER in terms of physiological and neurocognitive flexibility in childhood. Furthermore, among school-aged children, while physiological flexibility broadly predicted parent-reported child adjustment, neurocognitive flexibility may be context-sensitive and predictive of concurrent observed ER.

Automatic facial coding versus electromyography of mimicked, passive, and inhibited facial response to emotional faces

Decoding someone's facial expressions provides insights into his or her emotional experience. Recently, Automatic Facial Coding (AFC) software has been developed to provide measurements of emotional facial expressions. Previous studies provided first evidence for the sensitivity of such systems to detect facial responses in study participants. In the present experiment, we set out to generalise these results to affective responses as they can occur in variable social interactions. Thus, we presented facial expressions (happy, neutral, angry) and instructed participants (N = 64) to either actively mimic, to look at them passively (n = 21), or to inhibit their own facial reaction (n = 22). A video stream for AFC and an electromyogram (EMG) of the zygomaticus and corrugator muscles were registered continuously. In the mimicking condition, both AFC and EMG differentiated well between facial expressions in response to the different emotional pictures. In the passive viewing and in the inhibition condition AFC did not detect changes in facial expressions whereas EMG was still highly sensitive. Although only EMG is sensitive when participants intend to conceal their facial reactions, these data extend previous findings that Automatic Facial Coding is a promising tool for the detection of intense facial reaction.

The impact of acute exercise on implicit cognitive reappraisal in association with left dorsolateral prefronta activation: A fNIRS study

Despite findings showing that acute exercise may help enhance emotion regulation, the neurophysiological mechanisms of these effects remain poorly understood. In this study, we examined whether acute exercise influences cognitive emotion regulation, and, in particular, an implicit cognitive reappraisal. Twenty sedentary young women were randomly assigned to either a control group (n = 10) or an exercise group (n = 10). Participants underwent an implicit cognitive reappraisal task twice, before and after the 30-min acute exercise or control, alongside functional near-infrared spectroscopy recordings (NIRS). The left dorsolateral prefrontal cortex (dlPFC) and left orbital frontal cortex (OFC) were activated during implicit cognitive reappraisal at baseline, but only the left dlPFC activation was linked with behavioral performance. Acute exercise enhanced the activation of these regions, reflective of the partial neural bases of implicit cognitive reappraisal, in the left dlPFC and left OFC, but did not alter the behavioral performance. Results also showed that acute exercise moderated the positive effect of left dlPFC activation on implicit cognitive reappraisal performance; specifically, this effect was stronger in the exercise group. In conclusion, the enhanced activation of the left dlPFC by acute exercise and the increased link between behavioral performance and its neural indices may point to acute exercise as a promoter of implicit cognitive reappraisal.

Expressive suppression and cognitive reappraisal in veterans with PTSD: Results from the mind your heart study

OBJECTIVE

This study examined whether expressive suppression (ES), a maladaptive regulation strategy, was more strongly associated with PTSD diagnosis and symptom clusters in veterans than cognitive reappraisal (CR), an adaptive regulation strategy.

METHOD

In a cohort study, 746 participants recruited from VHA facilities completed Clinician Administered PTSD Scale-IV, Emotion Regulation Questionnaire, and Patient Health Questionnaire. Participants were categorized into groups: Current, Remitted/Lifetime, and Never PTSD.

RESULTS

One-way ANOVA revealed significant differences between Current PTSD and both Remitted and Never PTSD for ES, but not CR. The Remitted and Never PTSD groups did not vary significantly from each other and were collapsed into one group for regressions. Adjusting for sex, race, employment, and comorbid depression, binary logistic regression showed ES, but not CR, was associated with increased likelihood of Current PTSD (p < .001, OR: 1.43). ES was also significantly associated with increased odds of meeting criteria for all symptom clusters (ps < 0.001). CR was not significantly associated with meeting criteria for Current PTSD or any symptom cluster.

LIMITATIONS

Cross-sectional design and use of self-report limit causality inferences that can be drawn.

CONCLUSIONS

ES is associated with increased odds of Current PTSD diagnosis and symptom clusters. Veterans in the Remitted and Never PTSD groups did not differ significantly. Greater suppression of emotional expression is more strongly linked with PTSD criteria in veterans than decreased cognitive reappraisal.

Can Less Ever Be More? A Model of Emotion Regulation Repertoire of Social Support (ERROSS)

Do people really fare better if they can rely on many social ties? Research suggests that benefits of interpersonal emotion regulation (ER) can be derived from both large and small social networks. Building on the intrapersonal regulatory flexibility model, we propose the emotion regulation repertoire of social support (ERROSS) model that views effective socioemotional support as the combination of network size and ER strategies, resulting in a repertoire of ER resources one can draw on. Best outcomes in mental health should follow from both a large network and a diverse repertoire of strategies. ERROSS is applied as an example in the context of bereavement, and specific contributions of the model are highlighted.

Cultivating Affective Resilience: Proof-of-Principle Evidence of Translational Benefits From a Novel Cognitive-Emotional Training Intervention

Available evidence highlights the importance of emotion regulation (ER) in psychological well-being. However, translation of the beneficial effects of ER from laboratory to real-life remains scarce. Here, we present proof-of-principle evidence from a novel cognitive-emotional training intervention targeting the development of ER skills aimed at increasing resilience against emotional distress. This pilot intervention involved training military veterans over 5-8 weeks in applying two effective ER strategies [Focused Attention (FA) and Cognitive Reappraisal (CR)] to scenarios presenting emotional conflicts (constructed with both external and internal cues). Training was preceded and followed by neuropsychological, personality, and clinical assessments, and resting-state functional MRI data were also collected from a subsample of the participants. Results show enhanced executive function and psychological well-being following training, reflected in increased working memory (WM), post-traumatic growth (PTG), and general self-efficacy (GSE). Brain imaging results showed evidence of diminished bottom-up influences from emotional and perceptual brain regions, along with evidence of normalized functional connectivity in the large-scale functional networks following training. The latter was reflected in increased connectivity among cognitive and emotion control regions and across regions of self-referential and control networks. Overall, our results provide proof-of-concept evidence that resilience and well-being can be learned through ER training, and that training-related improvements manifested in both behavioral change and neuroplasticity can translate into real-life benefits.

Defining and measuring "psychological flexibility": A narrative scoping review of diverse flexibility and rigidity constructs and perspectives

Psychological flexibility (PF) is a popular construct in clinical psychology. However, similar constructs have existed since the mid-20th century, resulting in different terms, definitions and measures of flexibility, hindering the advancement of the field. The main measure of PF - the Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) - has also been heavily criticized. To move towards definitional consensus and improved measurement, we surveyed the literature to map PF and related-terms, examine definitional overlaps, and assessthe psychometric quality of prominent flexibility measures. A scoping review was conducted in two databases (PsycNET and SCOPUS). Twenty-three flexibility constructs appeared across 220 articles, and twelve measures were included and rated for quality. PF, psychological inflexibility (PI), and cognitive flexibility (CF) were most prominent. Definitional similarities among prominent flexibility constructs emerged, namely handling distress or interference, taking action, and meeting goals or values. The Personalized Psychological Flexibility Index (PPFI; Kashdan, Disabato, Goodman, Doorley, & McKnight, 2020) appears to be the best measure available to assess PF. Problems with the current use of the AAQ-II were apparent, hindering current knowledge of PF. Definitional consensus and measurement development are vital to advance the field. To this end, recommendations and next steps for researchers and practitioners are outlined.

The Tension Between Cognitive and Regulatory Flexibility and Their Associations With Current and Lifetime PTSD Symptoms

In recent years, researchers have tried to unpack the meaning of the term flexibility and test how different constructs of flexibility are associated with various psychopathologies. For example, it is apparent that high levels of flexibility allow individuals to adaptively cope and avoid psychopathology following traumatic events, but the precise nature of this flexibility is ambiguous. In this study we focus on two central constructs: cognitive flexibility - the ability to recognize and implement possible responses to a situation- and regulatory flexibility - the ability to modulate emotional expression and experience across situations. We aim to explore the connection between cognitive and regulatory flexibility and evaluate their relative effect on PTSD symptoms. Trauma-exposed college students (N = 109, M age = 25.31, SD = 4.59) were assessed for cognitive and regulatory flexibility and current and lifetime PTSD symptoms. We predicted and found a relatively weak, yet significant, overlap between participants' cognitive and regulatory flexibility. Importantly, while both cognitive and regulatory flexibility were associated with lifetime PTSD symptoms, only cognitive flexibility was associated with current PTSD symptoms. The findings illuminate the possible value of differentiating between constructs of flexibility in predicting short and long-term effects of traumatic exposure and may pave the ground for developing personalized intervention methods.

Flexibility in using self-regulatory strategies to manage self-control conflicts: The role of metacognitive knowledge, strategy repertoire, and feedback monitoring

For regulating emotion, it has been shown that people benefit from being flexible in their use of emotion regulation strategies. In the current study, we built on research focused on regulatory flexibility with respect to emotions to investigate flexibility in the use of self-regulatory strategies to resolve daily self-control conflicts. We investigated three components of flexibility: (1) metacognitive knowledge, (2) strategy repertoire, and (3) feedback monitoring. In a 10-day experience sampling study, 226 participants reported whether they had, within the past hour, experienced a self-control conflict of initiating an aversive activity, persisting in it, or inhibiting an unwanted impulse in response to a temptation. Results support the hypothesis that higher levels of all three components of flexibility are associated with higher levels of success in managing daily self-control conflicts, except for strategy repertoire and feedback monitoring in conflicts of persistence. Results also support the hypothesis that higher levels of trait self-control are associated with higher levels of metacognitive knowledge and feedback monitoring for conflicts of initiation, but not for conflicts of persistence and inhibition. We found no evidence of an association between trait self-control and strategy repertoire. These findings demonstrate the importance of flexible strategy use during daily self-control conflicts.

Depression, Anxiety, and Stress Among Healthcare Workers During the COVID-19 Outbreak and Relationships With Expressive Flexibility and Context Sensitivity

This study aimed at investigating depression, anxiety, and stress symptoms among healthcare workers and examine the role of expressive flexibility and context sensitivity as key components of resilience in understanding reported symptoms. We hypothesized a significant and different contribution of resilience components in explaining depression, anxiety, and stress. A total sample of 218 Italian healthcare workers participated in this study through an online survey during the lockdown, consequently to the COVID-19. The Depression Anxiety Stress Scales-21 (DASS-21) was used to measure depression, anxiety, and stress; the Flexible Regulation of Emotional Expression (FREE) scale was used to measure the ability to enhance and suppress emotional expression; the Context Sensitivity Index (CSI) was used to measure the ability to accurately perceive contextual cues and determine cue absence. Demographic and work-related data were also collected. DASS-21 cut-off scores were used to verify the mental status among the respondents. Correlational analyses examined relationships between DASS-21, FREE, and CSI, followed by three regression analyses with depression, anxiety, and stress as dependent variables, controlling for age, gender, and work experience. Enhancement and suppression abilities, cue presence, and cue absence served as independent variables. The results showed a prevalence of moderate to extremely severe symptoms of 8% for depression, 9.8% for anxiety, and 8.9% for stress. Results of correlational analysis highlighted that enhance ability was inversely associated with depression and stress. Suppression ability was inversely associated with depression, anxiety, and stress. The ability to perceive contextual cues was inversely associated with depression and anxiety. The regression analysis showed that the ability to enhance emotional expression was statistically significant to explain depression among healthcare workers. In predicting anxiety, age, and the ability to accurately perceive contextual cues and determine cue absence made substantial contributions as predictors. In the last regression model, age, work experience, and the ability to suppress emotional expression were significant predictors of stress. This study’s findings can help understand the specific contributions of enhancement and suppression abilities and sensitivity to stressor context cues in predicting depression, anxiety, and stress among healthcare workers. Psychological interventions to prevent burnout should consider these relationships.

Expressive flexibility and anxiety

BACKGROUND

The ability to flexibly enhance and suppress emotional expressions plays an important role in emotion regulation and the fostering of social connections. Deficits in expressive flexibility have been linked with posttraumatic stress disorder and prolonged grief reactions. Previous studies have suggested that the ability to respond flexibly in the context of an immediate threat (a nonconscious prime) may be important. In this study we sought to extend this work by examining the impact of individual differences in anxiety on expressive flexibility.

METHODS

Eighty four participants with high and low trait anxiety viewed blocks of negative images with instructions to enhance or suppress emotional expressions. Across blocks one of three nonconscious primes (threat, safety, neutral) appeared before each image. Observers blind to the study's design rated participants' emotional expressiveness.

RESULTS

Repeated Measures Anova's showed that high trait anxiety was associated with lower levels in enhancement ability. Further, low trait anxiety was associated with less emotion in response to the threat prime irrespective of expressive instruction.

LIMITATIONS

This study was cross-sectional which precludes causal relationships. Participants were drawn from a student population and the generalizability to other populations will need to be established CONCLUSIONS: This study identified trait anxiety as factor that may contribute to expressive flexibility deficits. High trait anxiety is a feature of many clinical conditions. Strategies to target expressive flexibility may relevant to a range of anxiety related clinical conditions.

Expressive Flexibility and Dispositional Optimism Contribute to the Elderly's Resilience and Health-Related Quality of Life during the COVID-19 Pandemic

The COVID-19 outbreak had a negative impact on psychological status among elderly subjects, negatively affecting their health-related quality of life (HRQoL). Psychological factors that promote resilience might beneficially contribute also to promoting a better HRQoL among elderly subjects. The main purpose of the present study was to investigate the contribution of dispositional optimism and expressive flexibility on the HRQoL of elderly outpatients during the COVID-19 outbreak. The outpatients were recruited from October 2018 to October 2019, and then followed-up during April 2020, by evaluating their HRQoL. The baseline sample consisted of 141 elderly outpatients (mean age 80.31 ± 6.84 years); the final number of outpatients included in the follow-up evaluation was 104 (mean age 80.26 ± 6.39). Univariate and multivariate linear regressions were developed to explore significant associations with the physical and mental component of HRQoL. Baseline dispositional optimism was a predictor of the mental component of HRQoL at follow-up; the flexible suppression of emotional expression was a predictor of the physical component of HRQoL at follow-up. From a psychogeriatric perspective, the accurate assessment of psychological factors, such as dispositional optimism and expressive flexibility, might help physicians and psychologists to recognize additional patients' vulnerabilities during the current emergency.

Typologies of coping in young adults in the context of the COVID-19 pandemic

The COVID-19 pandemic has created major upheavals in the lives of people worldwide. The virus has mostly affected elderly populations, but there may be corollary effects on young adults' psychosocial adjustment due to educational, economic, and occupational disruptions. Using latent class analysis, we examined unique typologies of coping in response to the pandemic among young adults. We used an expanded set of indicators including traditional measures of problem- and emotion-focused coping as well as measures of resilience and coping flexibility. We also examined whether class membership could be predicted by demographics, stress appraisal, and psychosocial characteristics including catastrophic thinking and impulsivity. The sample of 1,391 young adults (ages 18-35) was recruited via Amazon's Mechanical Turk (MTurk) and snowball methods from late-April to early-May 2020. Six classes were identified: (1) Resilient Flexible Problem-Focused Copers, (2) Resilient Inflexible Problem-Focused Copers, (3) Non-Resilient Flexible Problem-Focused Venters, (4) Non-Resilient Flexible Problem-Focused Copers, (5) Non-Resilient Flexible Non-Copers, and (6) Non-Resilient Inflexible Non-Copers. Using Class 1 as the reference class, we found perceived centrality and uncontrollability of the pandemic as well as catastrophic thinking and impulsivity were significant predictors of class membership. The mean levels of stress appraisal and psychosocial characteristics varied significantly between the classes, reinforcing the structural validity of these classes. The findings suggest the importance of training young adults to develop resilience and flexibility as well as specific coping skills that can help offset the psychological effects of dramatic lifestyle changes that may result from pandemics or other health crises in the future.

Cognitive reappraisal and expressive suppression relate differentially to longitudinal structural brain development across adolescence

Emotional disorders commonly emerge in adolescence, a period characterized by changes in emotion-related processes. Thus, the ability to regulate emotions is crucial for well-being and adaptive social functioning during this period. Concurrently, the brain undergoes large structural and functional changes. We investigated relations between tendencies to use two emotion regulation strategies, cognitive reappraisal and expressive suppression, and structural development of the cerebral cortex and subcortical structures (specifically amygdala and nucleus accumbens given these structures are frequently associated with emotion regulation). A total of 112 participants (59 females) aged 8-26 were followed for up to 3 times over a 7-year period, providing 272 observations. Participants completed the Emotion Regulation Questionnaire (ERQ), yielding a measure of tendencies to use cognitive reappraisal and expressive suppression at the final time point. Linear mixed model analyses were performed to account for the longitudinal nature of the data. Contrary to expectations, volumetric growth of the amygdala and nucleus accumbens was not associated with either emotion regulation strategy. However, frequent use of expressive suppression was linked to greater regionally-specific apparent cortical thinning in both sexes, while tendency to use cognitive reappraisal was associated with greater regionally-specific apparent thinning in females and less thinning in males. Although cognitive reappraisal is traditionally associated with cognitive control regions of the brain, our results suggest it is also associated with regions involved in social cognition and semantics. The continued changes in cortical morphology and their associations with habitual use of different emotion regulation strategies indicate continued plasticity during this period, and represent an opportunity for interventions targeting emotion regulation for adolescents at risk.

Ethnic-racial identity and posttraumatic stress disorder: The role of emotional avoidance among trauma-exposed community individuals

OBJECTIVE

There are ethnic-racial differences in the prevalence of posttraumatic stress disorder (PTSD). However, the factors underlying these differences are not well studied or understood. The goal of this study was to explore the relation of strength of ethnic-racial identity to PTSD. Specifically, we examined whether strength of ethnic-racial identity was indirectly related to PTSD symptom severity through positive and negative emotional avoidance.

METHOD

Participants were 401 trauma-exposed community individuals (M_age = 43.86 years; 70.1% female; 23.4% Asian, 23.7% Black, 25.1% Hispanic, 25.4% White).

RESULTS

Within the overall sample of ethnic-racial minorities, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathways of both positive and negative emotional avoidance was significant. However, these findings were not replicated within each of the specific racial-ethnic subsamples. Specifically, while strength of ethnic-racial identity was indirectly associated with PTSD symptom severity through both positive and negative emotional avoidance in the Black subsample, this indirect effect was only significant through the pathway of positive emotional avoidance in the Hispanic subsample, and was nonsignificant in the Asian and White subsamples.

CONCLUSIONS

Results underscore ethnic-racial differences in the way in which strength of ethnic-racial identity impacts PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The resilience paradox

Decades of research have consistently shown that the most common outcome following potential trauma is a stable trajectory of healthy functioning, or resilience. However, attempts to predict resilience reveal a paradox: the correlates of resilient outcomes are generally so modest that it is not possible accurately identify who will be resilient to potential trauma and who not. Commonly used resilience questionnaires essentially ignore this paradox by including only a few presumably key predictors. However, these questionnaires show virtually no predictive utility. The opposite approach, capturing as many predictors as possible using multivariate modelling or machine learning, also fails to fully address the paradox. A closer examination of small effects reveals two primary reasons for these predictive failures: situational variability and the cost-benefit tradeoffs inherent in all behavioural responses. Together, these considerations indicate that behavioural adjustment to traumatic stress is an ongoing process that necessitates flexible self-regulation. To that end, recent research and theory on flexible self-regulation in the context of resilience are discussed and next steps are considered.

Suppression May Improve Adaptation to Worry When Facing Uncertainty: Studying COVID-19 Pandemic

The COVID-19 pandemic has been associated with increased uncertainty, fear and worry in everyone's life. The effect of changes in daily life has been studied widely, but we do not know how emotion-regulation strategies influence adaptation to a new situation to help them overcome worry in the face of uncertainty. Here, 1,064 self-selected Farsi speaking participants completed an online battery of questionnaires that measured fear of virus and illness, worry, intolerance of uncertainty, and emotion regulation (two subscales: reappraisal, suppression). We also documented the number of daily COVID-19 cases and deaths due to COVID-19 on the day in which participants completed the questionnaire. Our findings suggest a correlation between contamination fear and the number of daily-confirmed cases (r = 0.11), and the number of reported deaths due to COVID-19 (r = 0.09). Worry mediated the relationship between intolerance of uncertainty and fear of virus and illness (b = 0.16, 0.1141 < CI < 0.2113). In addition, suppression moderated the relationship between intolerance of uncertainty and worry (p < 0.01). Our results suggest that suppression (at least in the short term) can be an adaptive response to the worry associated with uncertainty. Suppression can reduce worry, which in turn can decrease fear of contamination and improve adaptation to social distancing requirements. Although, the observed correlations were significant, but considering the sample size, they are not strong, and they should be interpreted cautiously.

How Suppressed Anger Can Become an Illness: A Qualitative Systematic Review of the Experiences and Perspectives of Hwabyung Patients in Korea

Background: In the clinical field, anger has generally been studied in terms of aggressive behavior. However, in Asians, anger suppression is more common than anger expression. Hwabyung is a culture-related anger syndrome in Korea and is known to occur due to the continued repression of anger. Investigating Hwabyung should lead to a better understanding of the multiple dimensions of anger. To explore Hwabyung patients' experiences and perspectives, a meta-aggregation approach was used to conduct a systematic review and a qualitative synthesis. Methods: A systematic search was conducted in MEDLINE/PubMed, EMBASE, Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycARTICLES, and four Korean databases [Korean Medical Database (KMbase), Korean Studies Information Service System (KISS), National Digital Science Library (NDSL), and Oriental Medicine Advanced Searching Integrated System (OASIS)] in September 2020. Studies were included if they collected and analyzed qualitative data from Hwabyung patients. Qualitative research findings on the experiences and perspectives of Hwabyung patients in Korea were critically appraised and synthesized using the Joanna Briggs Institute methodology. Results: Seven eligible studies were included. The findings from those studies (i.e., theme or subtheme of qualitative research) were aggregated into categories (a group of similar findings) and synthesized findings (a group of categorized findings). Ultimately, 116 findings were aggregated into 15 categories. Finally, four synthesized findings were derived from the 15 categories: (i) anger arousal, (ii) blame, (iii) uncontrollable physical and emotional symptoms, and (iv) compromise and temporary coping. Conclusions: Patients with Hwabyung experience chronic anger through the complex cognitive processes involved in blame. Hwabyung negatively affects patients' physical, psychological, and social functions. Because Hwabyung patients feel as if they are losing control, due to emotional dysregulation and physical symptoms, professional support should be provided to facilitate their coping strategies. Further studies on Hwabyung can serve as a new model of pathological anger.

Yielding to social presence as a bioenergetic strategy

All life must strategically conserve and allocate resources in order to meet the challenges of living. Social Baseline Theory suggests that, for humans, social context and the social resources therein are a central ecology in human phylogeny. In ontogeny, this manifests in flexible bioenergetic strategies that vary in the population based on social history. We introduce yielding, a conservation process wherein we relax physiological investment in response to a challenge when in the presence of a relational partner. The availability of these conserved resources then impact response to subsequent challenges while alone and if this pattern is habitual, it can reciprocally influence strategies used to solve or cope with typical stress. We discuss neural targets of this resource conservation and reframe our lab's previous studies on the social regulation of neural threat responding within this framework. We then show functional magnetic resonance imaging (fMRI) data indicating the presence of relational partners decreases blood-oxygen-level-dependent (BOLD) response to threat in key targets of resource conservation (e.g, dlPFC, dACC, and insula) and that stronger signal reduction in these areas coincide with less BOLD in pre-frontal (vmPFC, dlPFC) and visuo-sensory integration (occipital cortex, precuneus, superior parietal lobule) regions during ostracism. Finally, we show that these neural relationships are associated with less use of self-regulation-based coping strategies two years post scanning. Taken together, we show the utility of yielding both as a concept and as a bioenergetic process which helps to conserve energy in this social primate.

Does neuroticism disrupt the psychological benefits of nostalgia? a meta-analytic test

Nostalgia, a sentimental longing or wistful affection for the past, confers self-oriented, existential, and social benefits. We examined whether nostalgic engagement is less beneficial for individuals who are high in neuroticism (i.e. emotionally unstable and prone to negative affect). Specifically, we tested whether the benefits of experimentally induced nostalgia are moderated by trait-level neuroticism. To address this issue, we conducted a high-powered individual participant data meta-analysis ( N = 3556, k = 19). We found that the benefits of nostalgia were not significantly moderated by neuroticism, as they emerged for both high and low neurotics. This finding upheld when the self-oriented, existential, and social benefits of nostalgia were analysed jointly and when they were analysed separately. Taken together, individuals high and low in neuroticism are equally likely to benefit psychologically from engagement in nostalgic reverie.

Anxiety and resilience in the face of natural disasters associated with climate change: A review and methodological critique

In the past two decades, climate change-related natural disasters, such as hurricanes, floods, and droughts have become increasingly frequent and severe, impacting the emotional and psychological well-being of those who are directly or indirectly exposed to them. Despite great interest in understanding differences in anxiety and resilience in response to natural disasters, enthusiasm appears to outstrip empirical clarity, as there remains considerable ambiguity as to determinants of resilient or pathological outcomes following exposure to natural disasters. In addition, there are several major methodological limitations in climate change and related natural disaster research, including the use of univariate analyses, cross-sectional design, and retrospective measures. Keeping these limitations in mind, we first review literature examining the mental health outcomes of natural disasters. Findings suggest that, overall, resilience is more common than pathological outcomes. Second, we use a multi-dimensional framework of resilience to selectively review factors at the event, individual, as well as family and community levels that could help inform resilient or pathological outcomes. Finally, we consider key limitations and future directions for research and practice in the field of anxiety and resilience in response to climate disasters.

Changes in geographic clustering of post-traumatic stress disorder and post-traumatic growth seven years after an earthquake in Cauquenes, Chile

Recent findings indicate that both disruptive Post-Traumatic Stress Disorder (PTSD) and healthy Post-Traumatic Growth (PTG) responses have some spatial distribution depending on where they are measured and the different degrees of exposure that people may have to a critical event (e.g., earthquake). Less is known about how these responses change as a function of space and time after these events. The objective of this study was to enter deeper into this relationship analysing how PTSD and PTG responses vary in their spatial distribution 6 and 7 years after an earthquake (such as the one that occurred on 27 February, 2010 in Cauquenes City, Chile). Spatial analyses based on Geographic Information Systems (GIS) were performed to detect global and local geographic clustering. Investigating 171 (2016) and 106 (2017) randomly selected adults from Cauquenes, we demonstrated that 7 years after the event only 4 variables were spatially clustered, i.e. personal mental strength, interpersonal relations, new possibilities and appreciation of life), all of them PTG dimensions; This result contrasted with the situation the previous year (2016), when 7 variables were clustered (total PTG, spiritual change, new possibilities, appreciation of life, PTSD symptoms, PTSD reactions and PTSD in total). The spatial identifications found could facilitate the comparison of mental health conditions in populations and the impact of recovery programmes in communities exposed to disasters.

Mental Well-Being During Pandemic: The Role of Cognitive Biases and Emotion Regulation Strategies in Risk Perception and Affective Response to COVID-19

Both cognitive appraisals of risks associated with the specific disease and affective response to crisis situations have been shown to shape an individual response to pandemics. COVID-19 pandemic and measures introduced to contain it present an unparalleled challenge to mental well-being worldwide. Here, we examine the relationship between self-reported cognitive biases (CB) and emotion regulation skills (ER), COVID-19 risk perception and affective response, and mental well-being (MWB). Five Hundred and Eleven individuals completed General Health Questionnaire, Emotion Regulation Questionnaire, Davos Assessment of Cognitive Biases Scale (DACOBS) as well as scales measuring COVID-19 risk perception and affective response during the initial days of the epidemic in Poland. We used path and bootstrapping analyses to examine the hypothesis that CB may shape MWB during COVID-19 pandemic both directly and indirectly by (i) decreasing ER capacity and (ii) by increasing COVID-19 risk perception and affective response. Negative effect of CB and positive effect of ER via cognitive reappraisal on MWB were observed in participants. Furthermore, in line with our hypothesis, we observed indirect effects of CB via increased COVID-19 risk perception and affective response and decreased use of reappraisal strategy, which all, in turn, were related to MWB. Finally, we found an indirect effect of CB on MWB through double mediation of suppression strategies and COVID-19 affective response. Results of the current study suggest that CB, which have been shown to be linked to a variety of mental health symptoms in non-clinical populations, may exacerbate the impact of the COVID-19 pandemic on mental health outcomes.

An Affective and Cognitive Toy to Support Mood Disorders

Affective computing is a branch of artificial intelligence that aims at processing and interpreting emotions. In this study, we implemented sensors/actuators into a stuffed toy mammoth, which allows the toy to have an affective and cognitive basis to its communication. The goal is for therapists to use this as a tool during their therapy sessions that work with patients with mood disorders. The toy detects emotion and provides a dialogue that would guide a session aimed at working with emotional regulation and perception. These technical capabilities are possible by employing IBM Watson’s services, implemented into a Raspberry Pi Zero. In this paper, we delve into its evaluation with neurotypical adolescents, a panel of experts, and other professionals. The evaluation aims were to perform a technical and application validation for use in therapy sessions. The results of the evaluations are generally positive, with an 87% accuracy for emotion recognition, and an average usability score of 77.5 for experts (n = 5), and 64.35 for professionals (n = 23). We add to that information some of the issues encountered, its effects on applicability, and future work to be done.

Examining five pathways on how self-control is associated with emotion regulation and affective well-being in daily life

OBJECTIVE

Self-control is positively connected to well-being, but less is known about what, on the mechanistic level, explains this association. We hypothesized five pathways how this connection could be explained by emotion regulation, that is, by facilitating (a) strategy effectiveness, (b), adaptive strategy selection, (c) situation selection, (d) strategy variability, or (e) social sharing.

METHOD

To explore these pathways, we integrated two ambulatory assessment data sets (N = 250 participants, N = 22,796 observations) that included assessments of participants' emotions and their emotion regulation efforts.

RESULTS

We found that self-control was positively associated with affective well-being. Moreover, momentary but not trait self-control was associated with favoring adaptive and interpersonal strategy selection and less emotion regulation in general as well as with increased variability across strategies. However, these emotion regulation facets could not sufficiently explain the association between self-control and affective well-being.

CONCLUSIONS

Our main conclusion is that emotion regulation is not a mediator of the strong relation between self-control and affective well-being. Instead, we found evidence for the affective benefits of employing ways of emotion regulation that are less taxing mentally, which we discuss in light of current knowledge about self-control and emotion regulation.

The Suppression Paradox: A Cross-Cultural Comparison of Suppression Frequency, Suppression Ability, and Depression

The habitual use of expressive suppression (suppression frequency) is consistently associated with a number of negative outcomes, but paradoxically, the ability to suppress when there is a situational need (suppression ability) is usually linked to positive outcomes. The two sides of the paradox, suppression frequency and suppression ability, have been found to be unrelated. Given that these findings have emerged in largely western samples, the present studies examined whether the coupling of suppression frequency and ability depends on cultural contexts, and whether this can explain the previously established cultural difference in the costs of suppression frequency. In an initial study, we examined the relations among suppression frequency, suppression ability, and depression in a Chinese sample (Study 1; N = 310), and then, using two new samples, we compared these relations between Chinese and the US samples (Study 2; N = 392). Results showed that suppression frequency was related to depression in two distinct ways. In both cultures, suppression frequency had a direct, positive association with depression. In Chinese culture only, however, suppression frequency also had an indirect association, such that higher suppression frequency was related to higher suppression ability and in turn related to fewer depressive symptoms. Our findings show that suppression frequency is related to suppression ability only among Chinese participants, and can serve as a potential explanation for why suppression frequency is less related to depression in Chinese culture.

Bidirectional effects between expressive regulatory abilities and peer acceptance among Chinese adolescents

The current study examined potential bidirectional effects between adolescents' expressive regulation (the ability to enhance and suppress overt emotional behavior in line with situational demands) and peer interactions via two experiments. Experiment 1 tested the hypothesis that adolescents' expressive regulation affects their social acceptance from peers. Participants (N = 147) were randomly divided into three conditions and watched video clips in which a same-sex partner differed in his or her levels of expressive enhancement and suppression abilities. Results showed that participants reported greater liking of the partner when he or she was able to flexibly enhance and suppress emotional expressions in line with situational demands compared with when either one of these abilities was impaired. Experiment 2 then examined whether peer rejection reduced participants' enhancement and suppression abilities. We manipulated participants' feelings of rejection through a virtual Cyberball game. Following this manipulation (N = 100; Inclusion vs. Exclusion), we tested participants' expressive enhancement and suppression abilities, as well as their natural expressivity, via an observational task. Peer exclusion resulted in lower levels of enhancement ability and natural expressive behaviors but did not impair suppression ability. The results of these experiments suggest that both expressive enhancement and expressive suppression are important for adolescents to obtain higher peer acceptance. In addition, peer exclusion also caused impairments in expressive regulation, specifically reduced enhancement abilities. In summary, these results evidenced the bidirectional effects between expressive regulation and peer acceptance.

Free Your Mind: Emotional Expressive Flexibility Moderates the Effect of Stress on Post-Traumatic Stress Disorder Symptoms

Servicemen are exposed to high levels of stress as part of their daily routine, however, studies which tested the relationship between stress and clinical symptoms reached inconsistent results. The present study examines the role of expressive flexibility, which was determined according to the ability to enhance or suppress either negative or positive emotional expression in conflictual situations, as a possible moderator between stress and Post-Traumatic Stress Disorder (PTSD) symptoms. A total of 82 active-duty firefighters (all men, age range = 25–66, M = 33.59, SD = 9.56, range of years in duty service = 2–41, M = 14.37, SD = 11.79), with different duty-related repeated traumatic exposure, participated in the study. We predicted and found that firefighters with low, but not high, expressive flexibility showed a significant positive correlation between duty-related traumatic exposure and PTSD symptomology (t(81) = 3.85, p < 0.001). Hence, the greater the exposure the higher level of symptoms they exhibited. In addition, we found a difference between the moderating roles of suppressing positive and negative emotional expression, as high but not low, ability to suppress the expression of negative emotions (t(81) = 1.76, p > 0.05), as low but not high, ability to suppress the expression of positive emotions (t(81) = 1.6, p > 0.05), served as a protective factor in buffering the deleterious effect of repeated traumatic exposure. The results provide a pivotal support for the growing body of evidence that a flexible emotional profile is an adaptive one, in dealing with negative life events. However, while there is a need to update behavior, the direction of the adaptive update may differ as a function of valance.

Resting State Cortico-Limbic Functional Connectivity and Dispositional Use of Emotion Regulation Strategies: A Replication and Extension Study

Neuroimaging functional connectivity analyses have shown that the negative coupling between the amygdala and cortical regions is linked to better emotion regulation (ER) in experimental task settings. However, less is known about the neural correlates of ER traits or dispositions. The present study aimed to: (1) replicate the findings of differential cortico-limbic coupling during resting-state depending on the dispositional use of emotion regulation strategies. Furthermore, the study aimed to: (2) extend prior findings by examining whether differences in cortico-limbic coupling during resting-state predict experiential and neuronal ER success in a standard ER task. To this end, N = 107 healthy adults completed the Emotion Regulation Questionnaire (ERQ), underwent an 8-min resting-state fMRI acquisition, and completed a reappraisal task during fMRI. Functional connectivity maps of basolateral and centromedial amygdala nuclei were estimated with a seed-based approach regarding associations with regions of the prefrontal cortex and were then correlated with ERQ scores as well as experiential and neuronal ER success. All hypotheses and the analysis plan are preregistered at https://osf.io/8wsgu. Opposed to prior findings, we were not able to replicate a correlation of dispositional ER strategy use with functional connectivity between the amygdala and PFC regions (p > 0.05, FWE-corrected). Furthermore, there was no association of experiential and neuronal reappraisal success with functional connectivity between amygdala and insula as well as PFC (p > 0.05, FWE-corrected). The present preregistered study calls into question the reported association between individual differences in resting-state cortico-limbic connectivity and dispositional use of ER strategies. However, ongoing advances in functional brain imaging and distributed network approaches may leverage the identification of reliable functional connectivity patterns that underlie successful emotion regulation.

Childhood maltreatment and expressive flexibility: specific effects of threat and deprivation?

While childhood maltreatment has been consistently associated with a high risk for psychopathology, the mechanisms underlying this relation are still unclear. Dysfunctional emotion regulation has been singled out as a potential mechanism and recent perspectives emphasise the importance of measuring flexibility over habitual patterns of regulating strategies when assessing it. The present study has investigated the relation between childhood maltreatment and expressive flexibility, the ability to control emotional expression according to situational demands. Participants completed a retrospective self-report maltreatment questionnaire, which measured levels of childhood abuse and neglect, and an experimental task, which measured expressive flexibility. Depressive symptoms and trait anxiety were also evaluated. Results indicated an association between childhood maltreatment and reduced expressive flexibility. When investigated separately, both abuse and neglect were associated with reduced expressive flexibility, but when analyzed concurrently, only the former relation remained significant. Expressive flexibility negatively correlated with depressive symptoms. Our findings suggest that childhood maltreatment, a distal risk factor for psychopathology, impacts expressive flexibility, a form of emotion regulation flexibility.

Psychological interventions to foster resilience in healthcare students

BACKGROUND

Resilience can be defined as maintaining or regaining mental health during or after significant adversities such as a potentially traumatising event, challenging life circumstances, a critical life transition or physical illness. Healthcare students, such as medical, nursing, psychology and social work students, are exposed to various study- and work-related stressors, the latter particularly during later phases of health professional education. They are at increased risk of developing symptoms of burnout or mental disorders. This population may benefit from resilience-promoting training programmes.

OBJECTIVES

To assess the effects of interventions to foster resilience in healthcare students, that is, students in training for health professions delivering direct medical care (e.g. medical, nursing, midwifery or paramedic students), and those in training for allied health professions, as distinct from medical care (e.g. psychology, physical therapy or social work students).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, waiting list, usual care, and active or attention control, in adults (18 years and older), who are healthcare students. Primary outcomes were resilience, anxiety, depression, stress or stress perception, and well-being or quality of life. Secondary outcomes were resilience factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

MAIN RESULTS

We included 30 RCTs, of which 24 were set in high-income countries and six in (upper- to lower-) middle-income countries. Twenty-two studies focused solely on healthcare students (1315 participants; number randomised not specified for two studies), including both students in health professions delivering direct medical care and those in allied health professions, such as psychology and physical therapy. Half of the studies were conducted in a university or school setting, including nursing/midwifery students or medical students. Eight studies investigated mixed samples (1365 participants), with healthcare students and participants outside of a health professional study field. Participants mainly included women (63.3% to 67.3% in mixed samples) from young adulthood (mean age range, if reported: 19.5 to 26.83 years; 19.35 to 38.14 years in mixed samples). Seventeen of the studies investigated group interventions of high training intensity (11 studies; > 12 hours/sessions), that were delivered face-to-face (17 studies). Of the included studies, eight compared a resilience training based on mindfulness versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. universities, foundations), or a combination of various sources (four studies). Seven studies did not specify a potential funder, and three studies received no funding support. Risk of bias was high or unclear, with main flaws in performance, detection, attrition and reporting bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare students receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.43, 95% confidence interval (CI) 0.07 to 0.78; 9 studies, 561 participants), lower levels of anxiety (SMD -0.45, 95% CI -0.84 to -0.06; 7 studies, 362 participants), and lower levels of stress or stress perception (SMD -0.28, 95% CI -0.48 to -0.09; 7 studies, 420 participants). Effect sizes varied between small and moderate. There was little or no evidence of any effect of resilience training on depression (SMD -0.20, 95% CI -0.52 to 0.11; 6 studies, 332 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.15, 95% CI -0.14 to 0.43; 4 studies, 251 participants; very-low certainty evidence). Adverse effects were measured in four studies, but data were only reported for three of them. None of the three studies reported any adverse events occurring during the study (very-low certainty of evidence).

AUTHORS' CONCLUSIONS

For healthcare students, there is very-low certainty evidence for the effect of resilience training on resilience, anxiety, and stress or stress perception at post-intervention. The heterogeneous interventions, the paucity of short-, medium- or long-term data, and the geographical distribution restricted to high-income countries limit the generalisability of results. Conclusions should therefore be drawn cautiously. Since the findings suggest positive effects of resilience training for healthcare students with very-low certainty evidence, high-quality replications and improved study designs (e.g. a consensus on the definition of resilience, the assessment of individual stressor exposure, more attention controls, and longer follow-up periods) are clearly needed.

Psychological interventions to foster resilience in healthcare professionals

BACKGROUND

Resilience can be defined as the maintenance or quick recovery of mental health during or after periods of stressor exposure, which may result from a potentially traumatising event, challenging life circumstances, a critical life transition phase, or physical illness. Healthcare professionals, such as nurses, physicians, psychologists and social workers, are exposed to various work-related stressors (e.g. patient care, time pressure, administration) and are at increased risk of developing mental disorders. This population may benefit from resilience-promoting training programmes.

OBJECTIVES

To assess the effects of interventions to foster resilience in healthcare professionals, that is, healthcare staff delivering direct medical care (e.g. nurses, physicians, hospital personnel) and allied healthcare staff (e.g. social workers, psychologists).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, 11 other databases and three trial registries from 1990 to June 2019. We checked reference lists and contacted researchers in the field. We updated this search in four key databases in June 2020, but we have not yet incorporated these results.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults aged 18 years and older who are employed as healthcare professionals, comparing any form of psychological intervention to foster resilience, hardiness or post-traumatic growth versus no intervention, wait-list, usual care, active or attention control. Primary outcomes were resilience, anxiety, depression, stress or stress perception and well-being or quality of life. Secondary outcomes were resilience factors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, assessed risks of bias, and rated the certainty of the evidence using the GRADE approach (at post-test only).

MAIN RESULTS

We included 44 RCTs (high-income countries: 36). Thirty-nine studies solely focused on healthcare professionals (6892 participants), including both healthcare staff delivering direct medical care and allied healthcare staff. Four studies investigated mixed samples (1000 participants) with healthcare professionals and participants working outside of the healthcare sector, and one study evaluated training for emergency personnel in general population volunteers (82 participants). The included studies were mainly conducted in a hospital setting and included physicians, nurses and different hospital personnel (37/44 studies). Participants mainly included women (68%) from young to middle adulthood (mean age range: 27 to 52.4 years). Most studies investigated group interventions (30 studies) of high training intensity (18 studies; > 12 hours/sessions), that were delivered face-to-face (29 studies). Of the included studies, 19 compared a resilience training based on combined theoretical foundation (e.g. mindfulness and cognitive-behavioural therapy) versus unspecific comparators (e.g. wait-list). The studies were funded by different sources (e.g. hospitals, universities), or a combination of different sources. Fifteen studies did not specify the source of their funding, and one study received no funding support. Risk of bias was high or unclear for most studies in performance, detection, and attrition bias domains. At post-intervention, very-low certainty evidence indicated that, compared to controls, healthcare professionals receiving resilience training may report higher levels of resilience (standardised mean difference (SMD) 0.45, 95% confidence interval (CI) 0.25 to 0.65; 12 studies, 690 participants), lower levels of depression (SMD -0.29, 95% CI -0.50 to -0.09; 14 studies, 788 participants), and lower levels of stress or stress perception (SMD -0.61, 95% CI -1.07 to -0.15; 17 studies, 997 participants). There was little or no evidence of any effect of resilience training on anxiety (SMD -0.06, 95% CI -0.35 to 0.23; 5 studies, 231 participants; very-low certainty evidence) or well-being or quality of life (SMD 0.14, 95% CI -0.01 to 0.30; 13 studies, 1494 participants; very-low certainty evidence). Effect sizes were small except for resilience and stress reduction (moderate). Data on adverse effects were available for three studies, with none reporting any adverse effects occurring during the study (very-low certainty evidence).

AUTHORS' CONCLUSIONS

For healthcare professionals, there is very-low certainty evidence that, compared to control, resilience training may result in higher levels of resilience, lower levels of depression, stress or stress perception, and higher levels of certain resilience factors at post-intervention. The paucity of medium- or long-term data, heterogeneous interventions and restricted geographical distribution limit the generalisability of our results. Conclusions should therefore be drawn cautiously. The findings suggest positive effects of resilience training for healthcare professionals, but the evidence is very uncertain. There is a clear need for high-quality replications and improved study designs.

Flexible Emotionsregulation: Theoretische Modelle und Empirische Befunde

Zusammenfassung. Emotionsregulationsstrategien werden häufig unabhängig von dem Kontext der Verwendung in adaptiv und maladaptiv klassifiziert. Aktuelle empirische Studien und theoretische Modelle der flexiblen Emotionsregulation hinterfragen diese Kategorisierung und versuchen, die Adaptivität von regulatorischen Strategien stärker kontextbezogen zu untersuchen. In dem vorliegenden Artikel geben wir eine selektive Übersicht über dieses Forschungsgebiet und gehen dabei auf folgende zwei Fragestellungen ein: (1) Welche Rolle spielen Kontextfaktoren bei der Adaptivität von Emotionsregulationsstrategien? (2) Wie kann flexible Emotionsregulation konzeptualisiert und erfasst werden? Aus den vorgestellten empirischen Befunden und theoretischen Modellen leiten wir Implikationen für zukünftige ambulatorische und experimentelle Untersuchungen flexibler Emotionsregulation ab.

COVID-19: Psychological flexibility, coping, mental health, and wellbeing in the UK during the pandemic

The COVID-19 pandemic has profoundly altered the daily lives of many people across the globe, both through the direct interpersonal cost of the disease, and the governmental restrictions imposed to mitigate its spread and impact. The UK has been particularly affected and has one of the highest mortality rates in Europe. In this paper, we examine the impact of COVID-19 on psychological health and well-being in the UK during a period of 'lockdown' (15th-21st May 2020) and the specific role of Psychological Flexibility as a potential mitigating process. We observed clinically high levels of distress in our sample (N = 555). However, psychological flexibility was significantly and positively associated with greater wellbeing, and inversely related to anxiety, depression, and COVID-19-related distress. Avoidant coping behaviour was positively associated with all indices of distress and negatively associated with wellbeing, while engagement in approach coping only demonstrated weaker associations with outcomes of interest. No relationship between adherence to government guidelines and psychological flexibility was found. In planned regression models, psychological flexibility demonstrated incremental predictive validity for all distress and wellbeing outcomes (over and above both demographic characteristics and COVID-19-specific coping responses). Furthermore, psychological flexibility and COVID-19 outcomes were only part-mediated by coping responses to COVID-19, supporting the position that psychological flexibility can be understood as an overarching response style that is distinct from established conceptualisations of coping. We conclude that psychological flexibility represents a promising candidate process for understanding and predicting how an individual may be affected by, and cope with, both the acute and longer-term challenges of the pandemic.

Sex-Specific Relationships Between Interoceptive Accuracy and Emotion Regulation

Over the last years, there has been a resurge in the interest to study the relationship between interoception and emotion. By now, it is well established that interoception contributes to the experience of emotions. However, it may also be possible that interoception contributes to the regulation of emotions. To test this possibility, we studied the relationship between interoception and emotion regulation in a sample of healthy individuals (n = 84). We used a similar heartbeat detection task and a similar self-report questionnaire for the assessment of interoceptive accuracy and emotion regulation as in previous studies. In contrast to previous studies, we differentiated between male and female individuals in our analyses and controlled our analyses for individual characteristics that may affect the relationship between interoceptive accuracy and emotion regulation. We found sex-differences in interoceptive accuracy and emotion regulation that amounted to a sex-specific relationship between interoceptive accuracy and emotion regulation: Whereas interoceptive accuracy was related to reappraisal but not to suppression in male individuals, interoceptive accuracy was unrelated to reappraisal and suppression in female individuals. These findings indicate that the relationship between interoception and emotion regulation is far more complex than has been suggested by previous findings. However, these findings nonetheless support the view that interoception is essential for both, the regulation and experience of emotions.

Effects of Age and Gender in Emotion Regulation of Children and Adolescents

Emotional regulation, understood as the skills and strategies needed to influence and/or modify the emotional experiences, has a very remarkable implication within numerous emotional and behavioral disorders in childhood and adolescence. In recent years there has been a significant increase in research on emotional regulation, however, the results are still divergent in terms of differences in emotional regulation in relation to age and gender. This study aimed to assess emotional regulation in adolescents in relation to their age and gender. Two hundred and fifty-four adolescents from eight schools in the Valencian Community and aged between 9 and 16 years participated in the study. The adolescents completed the Cognitive Emotion Regulation Questionnaire and the FEEL-KJ questionnaire. We analyzed the differences in emotional regulation strategies and a latent emotional regulation variable in two age groups (9-12 years and 13-16 years) and by gender. The results suggested that children and pre-adolescents in the 9-12 year group obtained lower scores in the emotional regulation strategies than the 13-16 year group. Girls reported higher scores on the use of emotional regulation strategies when experiencing sadness, anxiety and anger than boys, and on the overall average of regulation according to these specific emotions. Age, but not gender, had a major effect on scores for the latent variable of emotion regulation. An interaction effect between age and gender was identified in the latent emotion regulation scores. Girls tended to have higher scores than boys when they were younger and lower scores than boys when they were older. These results could be relevant for designing prevention and intervention programs for adolescents and at different ages.