A mediational model relating affect intensity, emotion inhibition, and psychological distress

BEHAVIOR THERAPY 32, 519-536, 2001

A Mediational Model Relating Affect Intensity, Emotion Inhibition, and Psychological Distress

THOMAS R. LYNCH

CLIVE J. ROBINS

JENNIFER Q. MORSE

ELIZABETH D. KRAUSE

Duke Universi~

A growing empirical literature suggests that attempts to suppress, inhibit, or avoid private experience (e.g., thoughts, feelings) can be problematic. The purpose of this study was to examine a model in which inhibition of thoughts and emotion was predicted to mediate the relationship between the trait of negative affect intensity and acute psychological distress. Two studies evaluated the model using structural equation modeling procedures: one in a clinical sample and the other in a nonclinical sample. Support for the model was found in both studies, indicating its generalizability. These results provide further evidence for the notion that avoiding or inhibiting cognitive and emotional experience may be a particularly problematic coping style, which is more likely to be engaged in by emotionally intense individuals who are vulnerable to psychological distress.

Private experience (e.g., thought, sensation, emotion) is not always pleas- ant and, when aversive, most humans probably attempt to control their internal experience in some way. In fact, a variety of therapeutic interventions have been developed that are designed specifically to modify emotional or cognitive experience (e.g., cognitive-behavioral treatments that target irratio- nal beliefs and/or combat anxiety through relaxation). However, not all attempts at control are successful, and a growing body of empirical data suggests that attempts to control private experience through inhibition, suppression, or avoidance can be problematic (e.g., Gross & Levenson, 1997; Petrie, Booth, & Pennebaker, 1998; Wegner & Gold, 1995).

This work was supported in part by a grant from the National Alliance for Research on Schizophrenia and Depression to the first author. In addition, we wish to thank students who helped with data collection and data entry: Sarah Chase, Mai E1-Khoury, Britt Fox, Andrea Gonzalez, Dana Hosier, John Lasater, Angelina Mclntire, David Rak, Jessica Schlenoff.

Address correspondence to Thomas R. Lynch, Depamnent of Psychiatry and Behavioral Sci- ences, Duke University Medical Center, Box 3362, Durham, NC; e-mail: lynch011 @mc.duke.edu.

519 005 -7894/01/0519-053651.00/0 Copyright 2001 by Association for Advancement of Behavior Therapy

All rights for reproduction in any form reserved.

520 LYNCH ET AL.

The negative consequences of experiential avoidance or the unwillingness to experience certain thoughts, feelings, and/or related behavioral predisposi- tions have been described by Hayes, Wilson, Gifford, Follette, and Strosahl (1996) and Hayes, Strosahl, and Wilson (1999). For example, some private experiences are unresponsive to verbal control strategies because they are classically conditioned. Thus, if a painful emotion has been associated with a particular experience, purposeful control may be relatively ineffective because the underlying association is not amenable to cognitive or verbal control (Hayes et al., 1996). Avoidance of private experience also creates problems when the avoided emotion is an important natural reaction (e.g., grief at the loss of a relative) and/or may exacerbate problems associated with not mak- ing needed change in the behaviors or situations that prompt or elicit the emotion (Hayes et al., 1996). In addition, the process of deliberate control may often contradict the desired outcome, which typically is to feel better or have less of the unwanted experience (Hayes et al., 1999). For example, suppressing or avoiding private experience has been shown to be related to an increase in the severity of the experience, as has been documented for initial panic attacks (e.g., Craske, Miller, Rotunda, & Barlow, 1990).

For this paper, we investigated a mediational model in which emotion inhibition (i.e., chronic inhibition of thoughts and emotional experience/expression) was predicted to mediate the relationship between the trait of negative affect intensity and acute psychological distress in two separate studies: first, among a clinical sample to test the theoretical model; second, among a nonclinical sample to examine the generalizability of the model.

Affect Intensity Emotion inhibition likely is influenced by the degree of intensity with

which an individual typically experiences "negative" emotions. Affect intensity is considered a dimension of temperament and is reflected in individual differences in the activation and intensity of emotional responses (Goldsmith, 1993; Kagan & Snidman, 1991; Larsen, Diener, & Emmons, 1986; Strelau, 1991). Women report greater intensity of both positive and negative emotions and greater emotional reactivity to negative stimuli than men (Brody & Hall, 1993; Fujita, Diener, & Sandvik, 1991). In addition, certain diagnostic cate- gories may be associated with greater affect intensity. For example, Levine, Marziali, and Hood (1997) reported that adults with borderline personality disorder (BPD) reported significantly greater affect intensity compared to non-BPD controls on the Affect Intensity Measure (AIM; Larsen & Diener, 1987).

There has been a dearth of studies examining the relationship between emotion inhibition and affect intensity directly. Indirectly, research suggests that high affectively intense individuals seek out positively valenced emotional stimuli (e.g., happy stimuli) and avoid negative emotional stimuli when compared to low affectively intense individuals (Weed & Diener, 1986, unpub-

AFFECT INTENSITY A N D INHIBITION 521

lished study, as cited in Larsen & Diener, 1987). Flett, Blankstein, and Ober- tynski (1996) reported that high affectively intense individuals have negative expectancies about their ability to regulate their emotional states and conclude that their poor coping may be due to an inability and/or unwillingness to control negative emotions. While the link between affect intensity and emotion inhibition is not well understood, Linehan (1993) proposed a biosocial theory of personality functioning explicating a possible theoretical link. According to this theory, certain individuals are hypothesized to possess a biological predisposition for a heightened sensitivity and extreme affective reaction to emotional stimuli. In order to regulate these intense emotions, the individual may often engage in repeated inhibition or avoidance of negative emotional cues (i.e., negative-emotion-phobic: Linehan, 1993). Subsequent psychological distress occurs via the combination of affect intensity, chronic inhibition or avoidance of emotions (i.e., poor regulation of emotion), and an invalidating environment.

Inhibition of Emotional Expression Inhibiting or suppressing the expression of emotion has been found to be

problematic. As a culture, we are often ambivalent regarding the expression of emotion; emotional expression is commonly seen as both healthy and potentially dangerous. Support for the notion that emotional expression is advantageous comes from research that has demonstrated a relationship between the inhibition of emotional expression, increased auto- nomic arousal, and vulnerability to psychosomatic disease (e.g., Hokanson & Burgess, 1962; King & Emmons, 1990; Pennebaker, 1985; Petrie et al., 1998). However, recent work has found that conflict or ambivalence over emotional expression, rather than simply expressiveness itself, is associated with mental health outcomes (King & Emmons; Mongrain & Zuroff, 1994).

Ambivalence regarding emotional expression has been found to be positively correlated with measures of psychological distress such as depression, neuroticism, interpersonal sensitivity, obsessive/compulsive features, phobic anxiety, paranoid ideation, psychoticism, and guilt (Katz & Campbell, 1994; King & Emmons, 1990; Mongrain & Zuroff, 1994) and negatively correlated with measures of psychological well-being such as self-esteem and satisfac- tion with life (King & Emmons). In addition, feeling ambivalent about expressing emotions at a particular time has been reported to be associated with an increase in negative affect during that same time period (Katz & Campbell). Experimentally, Gross and Levenson (1997) found that subjects asked to suppress emotional expression during sad or amusing films had increased physiological arousal relative to no-suppression participants. It may be that when an individual experiences both an action urge to express an emotion and also a desire to withhold its expression, he or she experiences ruminations about the inhibited emotion or its associated action and/or psy-

522 LYNCH ET AL.

chological distress (Emmons & King, 1988; Gross & Levenson; Pennebaker & Hoover, 1986; Pennebaker, Hughes, & O'Heeron, 1987).

Thought Suppression The suppression of unwanted thoughts can also be conceptualized as a

method of avoiding emotional experience. Unwanted cognitions tend to be intimately intertwined with affective experiences, and attempts to avoid these thoughts often coincide with negative emotionality. For instance, both thought suppression and depression sensitivity (the degree to which an individual finds depressing thoughts disturbing, scary, or socially unacceptable) have been found to be related to mild depressive symptoms in a nonclinical sample, and thought suppression has been found to be associated with obses- sional thinking, depression, and anxiety in nonclinical samples (Wegner & Zanakos, 1994).

Research has also demonstrated that attempts to suppress unwanted thoughts may instead ironically increase their frequency of occurrence (e.g., Wegner & Erber, 1992; Wegner, Schneider, Carter, & White, 1987). In addition, studies of the effects of active suppression of emotional thoughts on emotions have found increases in psychophysiological responses (Wegner & Gold, 1995) and higher pain self-reports compared to controls (Cioffi & Holloway, 1993), even after suppression was discontinued. Initial suppression of anxious and depressing targets has been shown to lead to increases of directly related emotional statements over time, whereas initial expression led to subsequent decreases (Roemor & Borkovec, 1994). Wegner and Zanakos (1994) found that individuals who both avoid emotions and use thought suppression as a coping strategy evidence more depressive symptomatology than those who just avoid emotions. However, research on the "rebound" effects of suppression on thought frequency has been equivocal, particularly for thoughts about worry-related ruminations and phobic stimuli (see Purdon, 1999, for review). Purdon suggested that the degree an individual is motivated to inhibit thoughts may be influenced by the degree to which the thoughts are personally salient (i.e., unpleasant or distressing). For high negative affective intense individuals, the salience of any given negative emotional thought may at times be heightened simply because baseline arousal is higher. Consequently, the motivation to inhibit may be greater but the ease of regulation may be more difficult. Over time, chronic failed attempts at emotion regulation may lead to higher and higher levels of emotional distress, including hopelessness about one's ability to control the emotion and depression.

Hypotheses Considering this review, an overall theoretical model relating negative

affect intensity, emotion inhibition, and psychological distress was evaluated using structural equation modeling in two studies: one examining a clinical

AFFECT INTENSITY AND INHIBITION

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FIG. 1. Standardized parameters relating affect intensity, emotion inhibition, and psychological distress for patients. Note. Bolded estimates significant at p < .05.

psychiatric sample and the other a nonclinical student sample. We included the nonclinical sample to test the generalizability of the proposed model and did not a priori predict differences between the two samples with regard to model fit. The following hypotheses were evaluated: (a) negative affect intensity (operationalized as chronic intensity, emotionality, anxiety, and tense- ness) is associated with emotion inhibition (operationalized as ambivalence regarding emotional expression and thought suppression); (b) emotion inhibition is associated with psychological distress (operationalized as depressive symptomatology and hopelessness); and (c) emotion inhibition significantly mediates the relationship between negative affect intensity and psychological distress. This mediational model is depicted in Figure 1. In addition, this model was compared to an alternative model of only partial mediation in both studies.

STUDY 1 Method

Participants and Procedure The clinical sample (N = 89) consisted of psychiatric patients recruited

from two inpatient units and from the outpatient Behavior Research and Therapy Program and/or Mood Disorders Program at Duke University Medi- cal Center. Participants had a mean age of 35.3 years (±9.1), 83% (n = 73) were female, 44% (n = 39) were married or living with a partner, 3% (n = 3) reported a minority ethnic status, and 16% (n -- 14) declined to report minority status or had missing data. Sixty-six percent (n = 59) were acute inpatients (average length of stay was approximately 7 days) and 34% were out- patients (n -- 30). Up to three diagnoses on Axis I and/or II were made by several psychiatrists and psychologists based on clinical interviews with

524 LYNCH ET AL.

patients and collateral information. According to these chart diagnoses, 68% (n = 61) had a chart diagnosis of depression [major depressive disorder (n = 51), dysthymia (n = 4), and bipolar (n = 6)], 25% (n = 22) had an Axis I diagnosis in addition to or other than depression. Additional Axis I diagnoses included generalized anxiety disorder (1), panic disorder with agoraphobia (1), obsessive-compulsive disorder (2), posttraumatic stress disorder (5), cocaine dependence (3), other substance dependence (1), alcohol abuse (1), dissociative disorder NOS (2), dissociative identity disorder (1), anorexia nervosa (2), bulimia nervosa (1), eating disorder NOS (1), alcohol dependence (2), caffeine intoxication (1), impulse control disorder NOS (1), and attention-deficit/hyperactivity disorder (1). In addition, 48% (n = 43) had either a primary or secondary diagnosis of a personality disorder [borderline (n = 38), dependent (n = 1), NOS (n = 4)].

Patients were asked to participate in the study if they had been referred for inpatient or outpatient treatment services of the Behavior Research and Ther- apy Program or the outpatient Mood Disorders Program at Duke University Medical Center. Inpatients were all assessed within the first several days of their admission to the unit. At the time of the interview, patients were given a packet of questionnaires to complete within the next 24 hours. Packets were collected the following day or at the next outpatient visit. Participants were not compensated.

Measures Affect Intensity Measure-Negative Intensity Scale (AIM-NI, Bryant, Yar-

nold,& Grimm, 1996; Larsen. 1984). To measure chronic tendencies toward intense negative emotions, we used one subscale (Negative Intensity) from a three-factor model created from the original 40-item AIM (Larsen, 1984) by Bryant et al. The Negative Intensity subscale (AIM-NI) includes 6 items that assess the characteristic strength of negative emotions when they are experienced, and each item is rated on a 6-point frequency scale. Items are designed to measure the typical intensity of experienced emotion and are not con- founded with the frequency of the emotion. Negative Intensity has been shown to be associated with greater personal distress (.38) and greater empathic fantasy (.32) on the Interpersonal Reactivity Index (IRI). Test-retest reliabilities for the total AIM at 1-, 2-, and 3-month intervals were .80, .81, and .81, respectively (Larsen), and scores correlated .75 (p < .01) with original AIM scores approximately 2 years later (Larsen & Diener, 1987).

Due to a word processing error, one item ("When I am nervous I get shaky all over") was inadvertently dropped from the Negative Affect Intensity scale. It is possible that this missing item resulted in a less than optimal Cronbach alpha for Negative Affect Intensity; Cronbach's alpha for this study of clinical participants was .61. A reliability analysis of the available five items indi- cated that the alpha would improve if one item ("When I feel guilty this emotion is quite strong") was removed. An examination of the face validity of the five items also suggested that this item may tap a different underlying factor;


it focuses on guilt while the remaining items describe a chronic negative intensity related to anxiety or emotionality. Therefore, the guilt item was dropped from analyses and a measurement model loading the four remaining items onto a latent factor of Negative Affect Intensity was used in the structural equation model, rather than the modified subscale. The four items, and the abbreviations for them that we use hereafter, are as follows: "My emotions tend to be more intense than those of most people" (Intensity); "My friends might say I'm emotional" (Emotional); "When I do feel anxiety it is normally very strong" (Anxiety); and "My friends would probably say I 'm a tense or 'high-strung' person" (Tense). The Cronbach's alpha was .63 for these four items in the clinical sample.

Ambivalence Over Emotional Expressiveness Questionnaire (AEQ; King & Emmons, 1990). This 28-item self-report questionnaire was one of two measures used to operationalize emotion inhibition. It measures active attempts to inhibit emotional experience and expression, as well as rumina- tion regarding the unwanted expression of emotion. An example of an item reads, "I try to control my jealousy concerning my boyfriend/girlfriend even though I want to let them know I'm hurting." Items are rated on a 5-point Likert-type scale. Test-retest reliability with a 6-week interval was .78 and the alpha reliability coefficient was .89. The AEQ has been shown to correlate slightly negatively with social desirability (Marlowe-Crowne Social Desir- ability Scale; r = -.20; King & Emmons). As a test of convergent validity, correlations between scores on the Raulin Intense Ambivalence Scale and the AEQ were positively correlated (r = .35; King & Emmons). For this study, the Cronbach alpha for the AEQ was .93 in the clinical sample.

White Bear Suppression Inventory (WBSI). The WBSI (Wegner & Zana- kos, 1994) is a 15-item self-report questionnaire measuring people's general tendency to suppress unwanted thoughts and is the second measure used to operationalize emotion inhibition. An example of an item reads, "I always try to put problems out of mind?' Items are rated on a 5-point Likert-type scale. Reliability has been shown to be high, with Cronbach's alpha reported at .89 and a 12-week test-retest correlation of .80. The WBSI has been shown to correlate with measures of depression, OCD, repression, and anxiety (Weg- ner& Zanakos). It has also been found to be positively related to frequencies of intrusive thinking in thought suppression experiments (Muffs, Merckel- bach, & Horselenberg, 1996). The Cronbach alpha for this study was .89 for the clinical sample.

Beck Depression Inventory (BDI). The BDI (Beck, Rush, Shaw, & Emery, 1979) is a widely used self-report questionnaire employed to measure depressive symptomatology during the past week. Subjects rate the severity of 21 depressive symptoms on a 4-point scale ranging from 0 (not present) to 3 (very intense). Total scores range from 0 to 63. The BDI has been shown to have very good psychometric properties (Beck, Steer, & Garbin, 1988). The Cronbach alpha for this study was .85 for the clinical sample.

Beck Hopelessness Scale (BHS). The BHS (Beck, Weissman, Lester, &

526 LYNCH ET AL.

Trexler, 1974) is a 20-item true-false self-report questionnaire that assesses the degree to which a person holds negative expectations about the future. Psychometric properties have been very good, with reliability coefficients reported at .93. For this study, Cronbach alpha for the BHS was .92 for the clinical sample.

Results Data Analytic Strategy

Structural equation modeling (SEM) using AMOS (Arbuckle & Wothke, 1999) was employed to evaluate the proposed mediationai model as well as a competing model of partial mediation. As can be seen in Figure 1, the indicators used to measure the latent exogenous variable Affect Intensity (AI) were the four items we selected from the AIM-NI scale. For the latent mediator variable Emotion Inhibition (EI), two indicators were used: the AEQ total score and the WBSI total score. Finally, two indicators were used to measure the latent outcome variable Distress: the BDI total score and the BHS total score. Errors in the prediction of each of these measured variables were also estimated.

The structural paths relating the latent variables include a path from AI to EI, and a path from EI to Distress. In the first model evaluated (Model 1), the influence of AI on Distress was hypothesized to be indirect, through the mediator EI, and thus, was not estimated directly. However, a second model (Model 2) evaluated a competing hypothesis of partial mediation, and thus also estimated a direct path between AI and Distress. Errors in the prediction of the endogenous variables EI and Distress were also estimated.

Before evaluating the model using maximum likelihood estimation (ML), multivariate normality, an important distributional assumption of ML, was assessed. Very small multivariate kurtosis values (i.e., less than 1.00) are considered negligible, whereas values ranging from 1 to 10 often indicate moder- ate nonnormality, and values above 10 indicate extreme nonnormality. Assessment of multivariate normality in patients revealed a low and nonsignificant multivariate kurtosis value ( -2 .05 , p > .05). Thus, the usual ML X 2

statistic for overall model fit was used to evaluate the model, as well as the other practical fit indices that are not dependent on sample size, including the comparative fit index (CFI), the goodness-of-fit index, and the root mean square error of approximation (RMSEA). The CFI is a normed fit index that adjusts for the degrees of freedom. The GFI may be viewed as an absolute index of fit because it compares the hypothesized model to no model at all (see Hu & Bentler, 1995). The RMSEA takes into account the error of approximation in the population and evaluates how well "the model, with unknown but optimally chosen parameter values;' would fit the population covariance matrix (Browne & Cudeck, 1993, pp. 137-138). CFI and GFI values greater than .90 are considered good fit, whereas RMSEA values less than .10 are indicative of acceptable fit.

AFFECT INTENSITY AND INHIBITION 527

For all analyses, a cutoff criterion value for significance was set at p = .05. Correlations, means, and standard deviations o f all measured variables for patients can be found in Table 1.1

Model 1: Full Mediation

Overall modelfit. As evidenced by all o f the fit indices, this model yielded an excellent fit to the data for psychiatric patients (X2118/= 24.25, p = .15; CFI = .96, GFI = .94, R M S E A = .07).

Measurement and structural model. Standardized parameter estimates are shown in Figure 1. All factor loadings (paths f rom each latent factor to its measured variables) were significant (all p < .01), indicating well-defined latent constructs. In terms of structural relationships, the factor AI had a significant direct effect on the mediator EI (parameter estimate = .67, p < .01). In addition, EI had a significant direct effect on the outcome Distress (parameter estimate = .68, p < .01). Finally, the indirect effect o f AI on Distress was significant (parameter estimate = .46, p < .01).

Model 2: Partial Mediation

In Model 2, which added a direct path f rom AI to Distress, this path was nonsignificant (parameter estimate = 0.10, p > .05) and had no substantial effect on the practical fit indices (CFI = .95, GFI = .94, R M S E A = .08). In addition, the overall model fit (X2(17) = 24.08, p = .117) was not significantly improved from Model 1 (Ax211 / = .17). The full mediation model therefore accounts for the data as well as the model that also includes a nonmediated path, and is more parsimonious.

STUDY 2 Method

Participants and Procedure

The nonclinical sample consisted o f undergraduate students (N = 219) recruited through general advertisement and in undergraduate psychology classes. Participants had a mean age o f 19.2 years (__+ 1.1), 67% (n = 147) were female, 32% (n = 71) reported a minori ty ethnic status (n = 26 African American; n = 28 Asian; n = 7 Hispanic; n = 10 other), and 1 person ( < 1 % ) failed to report minori ty status. Marital status was not obtained f rom the student sample to avoid identifying data, as few undergraduate students at Duke University are married.

Although we did not have a priori hypotheses about gender differences in the structural equation model, t tests were run on each measured variable for both clinical and nonclinical samples. Using a Bonferroni adjusted alpha of .01, none of the five variables of interest (i.e., thought suppression, ambivalence, hopelessness, depressive symptomatology, and modified affect intensity measure) were found to be significant (all ps > .01). Thus, no further analyses by sex were conducted in the present studies.

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The nonclinical sample was recruited from undergraduate psychology students enrolled in courses requiring participation in research for course credit or student volunteers who were paid $10 for participation and recruited through campus advertisement. All participants signed informed consent forms and were each administered a packet of questionnaires that took approximately 30 to 40 minutes to complete.

Measures

The same measures were used as in Study 1. In this sample, the Cronbach's alpha on the AIM-NI subscale was .72. Due to the missing item, the low alpha, and the theoretical inconsistency of the guilt item, the same measurement model of AI was used in this study. The Cronbach's alpha was .76 for these four items in the nonclinical sample. For the nonclinical sample, the Cronbach's alpha was .92 for the AEQ, .89 for the WBSI, .83 for the BDI, and .80 for the BHS.

Results Data Analytic Strategy

The same initial model of full mediation that was specified for Study 1 was specified for this study, evaluated using SEM procedures in AMOS, and again compared with a competing model of partial mediation.

Multivariate kurtosis in students was 14.55 (p < .001), indicating a statistically significant degree of nonnormality. Considering the clinical relevance of several of the measures used in the study (i.e., BDI, BHS), such multivariate nonnormality in a nonclinical sample might be expected. We corrected for nonnormality using the Bollen-Stine (B-S) p-value instead of the usual maximum likelihood-based p-value to evaluate overall model fit (Academic Com- puting and Instructional Technology Services, 2000). The B-S p-value is obtained through bootstrapping procedures, and results from comparing the original model's obtained X 2 value with the mean X 2 value of the bootstrap samples, rather than with the usual critical value for the X 2 test (Bollen & Stine, 1993).

Evaluation of the individual parameter p-values was based upon two bootstrap procedures that control for multivariate nonnormality, including the 95% confidence interval (95CI) percentile method and 95CI bias corrected percentile method. For all analyses, a cutoff criterion value for significance was set at p = .05. Correlations, means, and standard deviations of all measured variables for students can be found in Table 2.

Model 1: Full Mediation

Overall modelfit. The value of X2/Is) was 69.21, B-S p = .004, which suggests a less than adequate fit to the data. However, with a relatively large sample such as this, even small deviations between model and data will pro- duce a significant X 2. We therefore relied primarily on fit indices that are less

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FI6. 2. Standardized parameters relating affect intensity, emotion inhibition, and psychological distress for students. Note. Bolded estimates significant at p < .05.

dependent on sample size. The GFI suggested that this mediational model fit the student data well (GFI = .92), but the RMSEA was just above the recom- mended cutoff (RMSEA = .11). Examination of the modification indices of this model identified a large correlated error between the AI items anxiety and tense. Given the substantive reasonableness of this parameter, a final model was specified in which this correlated error was freely estimated. This slightly improved the goodness-of-fit indices (X21~7) = 56.57, B-S p = .004, GFI = .94, RMSEA = .10) and the difference in fit from the initial model was statistically significant (Ax2(~) = 12.64,p < .05).

Measurement and structural model. Standardized parameter estimates for the final full mediation model are shown in Figure 2. All factor loadings (paths from each latent factor to its measured variables) were significant using the usual ML-based values (all p < .001), the 95CI percentile method values (all p < .01), or the 95CI bias corrected percentile method values (all p < .05). These findings indicate well-defined latent constructs. In terms of structural relationships, the factor AI had a significant direct effect on the mediator El (parameter estimate = .51, p < .05). In addition, E1 had a significant direct effect on the outcome Distress (parameter estimate = .84, p < .05). Finally, the indirect effect of AI on Distress was significant (parameter estimate = .42, p < .05).

Model 2: Partial Mediation

In Model 2, which added a direct path from AI to Distress, this path was nonsignificant (parameter estimate = -0 .06 , p > .05) and had no substantial effect on the practical fit indices (GFI - .94, RMSEA = .1 I). In addition, the overall model fit (X2(16} = 56.23, B-S p = .000) was not significantly

532 LYNCH ET AL.

improved from Model 1 (Ax2fj I -- 0.33), providing support for the more parsimonious model of full mediation.

Discussion The results of the current studies provide support for a mediational model

in which emotion inhibition, operationalized as ambivalence over emotion expression and thought suppression, mediates the relationship between the trait of negative affect intensity and acute psychological distress, operationalized as depressive symptomatology and hopelessness. The two studies presented here extend previous research in that they examined specific mecha- nisms by which negative affect intensity may be related to psychological distress in both a clinical and nonclinical sample.

In support of the first part of the model, the trait of negative affect intensity was found to be significantly associated with avoiding expressions of emotion and with attempts to suppress unwanted thoughts in both the clinical and nonclinical samples. This finding supports the hypothesis that emotion inhibition is more likely to be used by individuals who describe themselves as more intense than their peers, emotional, and "high strung." Indeed, inhibitory strategies may be intermittently reinforced by temporary reductions in arousal. However, when overused, inhibition may paradoxically increase negative arousal, exacerbating baseline affect intensity. This latter directionality has been supported by previous research reporting that thought suppression and emotional avoidance often exacerbate arousal (Cioffi & Holloway, 1993; Craske et al., 1990; Gross & Levenson, 1997: Wegner & Gold, 1995), and may reduce opportunities to habituate to emotional stimuli (Foa & Kozak, 1986; Roemer & Borkovec, 1994). Unfortunately, the correlational nature of our data makes it impossible to determine causality. However, we would suggest that the relationship between affect intensity and emotion inhibition most likely works in both directions, reflecting a cycle of increasing affect intensity and more frequent attempts at controlling related private experience.

Evidence was also found in support of the second part of the model for both samples. That is, both inhibition of emotional expression and suppression of unwanted thoughts were associated with depressive symptomatology and hopelessness. Results regarding the relationship between avoidance and depressive symptomatology in the clinical sample extend previous work in nonclinical samples (Katz & Campbell, 1994; King & Emmons, 1990; Mort- grain & Zuroff, 1994; Wegner & Zanakos, 1994). Our finding that both ambivalence and thought suppression significantly predicted hopelessness also extends previous work by examining hopelessness as a dependent variable. Although in our primary analyses, depression and hopelessness are combined as a latent variable, the correlation coefficients in Tables 1 and 2 show that each is significantly related to thought suppression and inhibition of emotion expression. Our results suggest that hopelessness may more often result from failed attempts to control emotion than from intense negative emotion itself.


What are the clinical implications of these findings? It may be that at higher levels of negative affect intensity, individuals begin to rely more on avoidance techniques to escape, albeit temporarily, noxious arousal. High levels of chronic avoidance or inhibition may also set up conditions such that the change effort itself becomes a form of behavior contradictory to the goal of the change effort (Hayes et al., 1999). For example, running from aversive emotions may reinforce notions that emotions are truly scary and reduce feelings of mastery and self-efficacy. In addition, although private experience is at best only partially controllable, as a culture we often act as if emotions and thoughts can be controlled in the same fashion as external objects. Repeated failure at this type of internal control may only exacerbate feelings that there is "something wrong with me" and trigger additional unwanted emotional experience (e.g., shame). Indeed, when the paradoxical effects of inhibition and avoidance occur, increased depressive symptomatology and hopelessness may result.

These findings also suggest that it may be useful for therapeutic interventions to target emotional inhibition and avoidance, as well as conditions that set up negative arousal. This focus may be especially important for chroni- cally intense individuals who may be predisposed to negative emotional arousal and ineffective avoidance. Further development of therapeutic interventions designed to enhance emotional acceptance and nonavoidance, such as graduated exposure to relevant cues and mindfulness practice (Robins, in press; Teasdale et al., 2000), may reduce psychopathology in clinical populations.

However, although purposeful inhibition or avoidance is hypothesized as a maladaptive emotion-regulation strategy, we are not suggesting that noninhi- bition or nonavoidance should become the primary goal of treatment. Instead, inhibition may best be considered within a context of discrimination train- ing--learning to recognize when purposeful inhibition of private experience may be useful and when it may insteadexacerbate distress or lead to secondary negative emotions such as shame. For example, inhibiting or avoiding private experience may be useful when the goal is to elicit another emotion (e.g., focusing outside the body on a pleasurable activity) or as a way to temporarily attend to other important tasks that require immediate attention. Problem inhibition may occur when the individual is unwilling to experience the emotion or thought regardless of the consequences of doing so.

Several factors limit the generalizability of the results of the present study and suggest directions for future research. The cross-sectional design of the study does not allow us to conclude anything about the causal relations among the variables studied, except that the hypothesized causal model is not contradicted by the data. Prospective and experimental studies are necessary to determine whether or not trait affect intensity indeed leads to increased emotion inhibition, and in turn to increased psychopathology. A second limi- tation is the nature of the nonclinical sample, which was used to examine model generalizability but consisted solely of university students. Replication in a community sample reflecting wider age and educational ranges would be

534 LYNCH ET AL.

useful. Finally, the data for these studies were entirely from self-report questionnaires. Future studies could include a combination of self-report, behavioral observation, and psychophysiological measures.

In summary, this study found support for a mediational model relating trait negative affect intensity, emotion inhibition, and psychological distress in the form of depressive symptoms and hopelessness. Results provide further evidence for the notion that avoiding or inhibiting private experience is a particularly problematic coping style and that emotionally intense individuals may be vulnerable to psychological distress.

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A mediational model relating affect intensity, emotion inhibition, and psychological distress

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