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Anxiety Stress Coping. Author manuscript; available in PMC 2022 July 01.
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Anxiety Stress Coping. 2021 July ; 34(4): 479–485. doi:10.1080/10615806.2021.1929934.

The Impact of Emotion Regulation Therapy on Emotion

Differentiation in Psychologically Distressed Caregivers of
Cancer Patients
Mai B. Mikkelsen1, Emma Elkjær1, Douglas S. Mennin2, David M. Fresco3, Robert
Zachariae1,4, Allison Applebaum5, Mia S. O’Toole1
1Dept. of Psychology and Behavioural Sciences, Aarhus University, Denmark
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2Dept. of Psychology, Teachers College, Columbia University, New York, NY, USA
3Department of Psychiatry & Institute for Social Research, University of Michigan, Ann Arbor, MI,
USA
4Dept. of Oncology, Aarhus University Hospital, Aarhus, Denmark
5Dept.of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York,
NY, USA

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

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

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

Corresponding author: Mai B. Mikkelsen, Bartholin’s Allé 11, DK8000 Aarhus, Denmark. mai@psy.au.dk. Telephone: +45 87 16 62
41.
Emma Elkjær, Bartholin’s Allé 11, DK8000 Aarhus, Denmark
Douglas S. Mennin, 525 West 120th Street, New York, NY 10027, USA.
David M. Fresco, 2559 Rachel Upjohn Building 4250 Plymouth Road Ann Arbor, MI 48109-2435, USA
Robert Zachariae, Bartholin’s Allé 11, DK8000 Aarhus, Denmark.
Allison Applebaum, 1275 York Avenue, New York, NY 10065, USA.
Mia S. O’Toole: Bartholin’s Allé 11, DK8000 Aarhus, Denmark.
Disclosure of interest: The authors report no conflicts of interest.
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Conclusions: The results suggest that negative emotion differentiation can improve as a result of
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psychotherapy. Further research is needed to clarify how improvements in emotion differentiation

following therapeutic interventions relate to treatment outcomes such as distress.

Keywords
Emotion; emotion differentiation; caregiver; cancer; emotion regulation therapy

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

Emotion regulation therapy (ERT) is an intervention developed to target perseverative

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

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

Pointing to the potential malleability of emotion differentiation, Van der Gucht and
colleagues (2019) reported improved emotion differentiation as a result of a mindfulness­
based intervention in a sample of individuals experiencing varying levels of distress. To
further assess the malleability of emotion differentiation and its role in the effects of ERT,
the present study aimed to investigate the effect of ERT on emotion differentiation in a

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sample of distressed caregivers of cancer patients, and to examine whether improvements

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in emotion differentiation were associated with reduced distress. The present study involves
a secondary analysis of data obtained from a randomized controlled trial assessing the
efficacy of ERT tailored to distressed caregivers of cancer patients (ERT-C; O’Toole et al.,
2019). This trial reported that distressed caregivers who received ERT-C, as compared to a
waitlist condition, experienced significant reductions in symptoms of psychological distress
(gs = .55–.96; O’Toole et al., 2019). For the present study, we hypothesized: 1) ERT-C
leads to significant improvements in emotion differentiation in distressed caregivers of
cancer patients, and 2) Improvements in emotion differentiation are associated with reduced
distress.

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

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

Emotion Regulation Therapy for Cancer Caregivers (ERT-C)

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

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doctoral students, who received weekly supervision. Adherence to the treatment protocol
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was high (see O’Toole et al., 2019 for elaboration).

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

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

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

Independent t-tests were applied to compare baseline differences in emotion differentiation

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

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

Results
Eighty-one caregivers were randomized. Emotion differentiation for at least one time point
could be calculated for 54 (66.7 %) caregivers (26 in the ERT-C condition; 28 in the waitlist
condition). The mean age of the 54 caregivers was 45.15 (SD = 15.77). Most caregivers

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were women (74.1 %) caring for male patients (63.4 %). Twelve caregivers (22.2 %)
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dropped out. Dropouts did not differ from completers in age (p = .321), gender (p = .934),
or pre-treatment worry (p = .717). Completers reported more pre-treatment perseverative
negative thinking than dropouts (completers: M = 13.29, SD = 3.41; dropouts: M = 10.83,
SD = 2.52; t(52)=2.31, d = 0.76, p = .025).

Treatment Effects on Emotion Differentiation

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

Short-term Associations between Emotion Differentiation and Outcomes

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

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

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

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sampling, memory tasks are less burdensome, making it a valuable method for future
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research on emotion differentiation in distressed populations.

Concerning our second hypothesis, that improvements in emotion differentiation would be

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

Hence, future research may employ study designs that allow for testing potential mediators.

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

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

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

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

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

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

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Table 1.

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

Negative emotion differentiation

Variable ERT-C Waitlist Acute treatment effects
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Time × Group
Pre-treatment Post-treatment Pre-waitlist Pre-treatment F p η2
Mean differentiation (SD) 0.25 (0.21) 0.31 (0.23) 0.30 (0.20) 0.25 (0.20) 7.17 .012 0.21

Positive emotion differentiation

Variable ERT-C Waitlist Acute treatment effects
Time × Group

Pre-treatment Post-treatment Pre-waitlist Pre-treatment F p η2

Mean differentiation (SD) 0.10 (0.06) 0.10 (0.07) 0.12 (0.11) 0.12 (0.12) <0.01 .973 <0.01

Note: Mean emotion differentiation scores reflect intra-class correlation coefficients subtracted from 1; higher scores indicate better emotion differentiation. Results from analyses of acute treatment effects
were based on z-transformed emotion differentiation scores.

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Table 2.

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

Total sample mean scores 1 1

Short-term effects, correlation with NED Long-term effects, correlation with NED
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Outcome, M (SD) Pre-treatment Post-treatment 6-month follow-up r p r p

Caregiver burden 35.24 (11.46) 29.72 (13.40) 31.68 (17.88) −.14 .492 −.08 .733

Distress 18.56 (6.78) 11.71 (7.91) 13.55 (9.05) .07 .725 .12 .603

Worry 51.62 (8.94) 42.27 (8.40) 47.09 (10.70) .30 .127 −.06 .781

Note: NED = Change in negative emotion differentiation from pre-treatment to post-treatment.

1
Analyses were conducted with residualized gain scores based on z-transformed emotion differentiation scores, and residualized gain scores for change in outcomes from pre-treatment to post-treatment
(short-term effects) and pre-treatment to six-month follow-up (long-term effects).

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