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Cognitive behavioral therapy (CBT) of depression is hypothesized to achieve its effects by correcting negative biases. However, little research has tested how biases change over the course of CBT. We focus on biases in interpersonal judgments and examine whether changes in biases occur in CBT and are associated with symptom improvements. A sample of 126 adults (60% women, mean age 31.7, 83% White) participated in CBT of depression. Observers provided ratings of patients participating in two interpersonal tasks on three occasions. Patients were asked to predict observers’ ratings. In a thin slice (TS) task, observers evaluated how patients came across in a brief segment in which patients talked about themselves. In a Standard Interaction Task (SIT), observers rated the social skills patients displayed in challenging role plays. The difference between patient predictions and observer ratings provided measures of bias in these interpersonal judgments. TS and SIT bias became significantly less pessimistic and more realistic over the course of CBT. Improvements in TS bias were associated with a faster reduction in symptoms, whereas there was a non-significant trend for improvement in SIT bias being associated with faster symptom reduction. Consistent with the CBT model, negative interpersonal biases became more realistic throughout a course of CBT for depression and at least some of the changes in bias were related to therapeutic outcomes. We encourage future researchers to continue examining for whom and under which conditions correcting such biases produces the greatest benefits.

Recent research has highlighted the importance of testing interactions between adaptive and maladaptive emotion regulation strategies when examining their associations with mental health. However, there has been little work on the interaction between adaptive strategies such as cognitive reappraisal and two forms of repetitive negative thinking (RNT)—worry and rumination. Furthermore, prior research has exclusively relied on self-report measures to assess mental health as the primary outcome and more research is needed to understand the psychophysiological correlates of emotion regulation. To address these limitations, we tested the interaction between cognitive reappraisal and RNT when predicting resting respiratory sinus arrhythmia, which measures heart rate variability across the respiratory cycle and is conceptualized as a transdiagnostic biomarker for psychopathology and emotion regulation capacities. We also predicted depression symptoms as a secondary outcome in an attempt to replicate prior research. In a sample of 233 undergraduates, we found that RNT had a negative association with resting respiratory sinus arrhythmia, but only among participants who reported low levels of cognitive reappraisal use. The effect of RNT on depressive symptoms was not moderated by cognitive reappraisal use. Overall, these results suggest that worry and rumination might have the most detrimental links with physiological functioning when people do not frequently use cognitive reappraisal to regulate affect. This study also underscores the necessity of utilizing psychophysiological measures when modeling interactions between regulatory strategies.

Rumination (negative thinking about the past) and worry (anxious apprehension) are two forms of repetitive thinking associated with psychopathology. Prior research indicates that rumination and worry have both distinct and overlapping features, but the extent to which there are separable groups of individuals who engage in rumination, worry, or both has yet to be examined. We used latent profile analysis, a person-centered statistical technique, to examine profiles of repetitive thinkers in two samples ( ns = 635 and 755). In both studies, profiles emerged of individuals who rarely ruminate or worry ( low repetitive thinkers), individuals who primarily ruminate ( ruminators), individuals who primarily worry ( worriers), and individuals who frequently ruminate and worry ( high repetitive thinkers). In Study 2, a fifth profile of average repetitive thinkers also emerged. Across both samples, high repetitive thinkers showed the highest levels of depression and anxiety symptoms, followed by worriers and ruminators, and then by low repetitive thinkers. In Study 2, the average repetitive thinkers fell below the ruminators and worriers but above the low repetitive thinkers. Thus, there are distinct groups of ruminators and worriers, but individuals who engage in both rumination and worry exhibit the worst outcomes. As such, these findings support adopting a person-centered approach to better understand repetitive thinking styles.

Recent research has emphasized the importance of studying the interaction between adaptive and maladaptive emotion regulation strategies in predicting mental health. In this respect, putatively maladaptive strategies (e.g., avoidance) have been found to moderate the link between putatively adaptive strategies (e.g., reappraisal) and psychopathology symptoms (e.g., Aldao and Nolen-Hoeksema in J Abnorm Psychol 121(1):276–281, 2012; Aldao et al. in J Anxiety Disord 28(4):382–389, 2014). Moreover, this line of work suggests that the direction of this moderation might vary as a function of symptom severity. However, research has yet to: (1) simultaneously examine how this interaction differs between clinical and non-clinical groups, and (2) test the interaction between specific emotion regulation strategies rather than composite scores of adaptive and maladaptive strategies. Doing so is essential in order to develop a more sophisticated understanding of the disturbances in the use of emotion regulation strategies in psychopathology. To that end, we investigated the interaction between reappraisal and emotional nonacceptance in participants diagnosed with generalized anxiety disorder (GAD) and non-anxious controls. In the GAD group, there was a negative association between reappraisal and disability only when the use of nonacceptance was low, suggesting that the use of maladaptive strategies might interfere with the benefits typically associated with utilizing adaptive strategies. In the non-anxious group, there was a negative association between reappraisal and disability and depression symptoms, only when the use of nonacceptance was high, likely reflecting a compensatory and flexible use of regulation strategies. These findings highlight the importance of modeling interactions between specific emotion regulation strategies when seeking to understand their relationship to psychological functioning in GAD.

When cognitive-behavioral therapy (CBT) was first developed approximately 50 years ago, it revolutionized the field of clinical psychology and psychiatry. Since then, modern conceptualizations of psychopathology have increasingly emphasized the role of emotion dysregulation in the onset, maintenance, and exacerbation of psychological disorders. Thus, contemporary versions of CBT have begun to adopt an emotion regulation framework in treatment. Numerous randomized controlled trials (RCTs) have provided considerable empirical support for these newer, emotion-focused interventions. Additionally, laboratory-based experimental studies have begun to examine the specific emotion regulation mechanisms underlying the effects of CBT. However, one barrier preventing the field from advancing further and improving our cognitive-behavioral treatments is the apparent chasm between treatment outcome studies and laboratory-based experimental studies. This is a noteworthy limitation given that these methodologies are complementary and have their greatest potential when used in combination with each other. In this chapter, we first review treatment outcome studies (i.e., RCTs) that test the efficacy of cognitive-behavioral interventions that highlight the importance of emotion regulation as a key principle of treatment. We then discuss the utility of laboratory-based experimental studies to identify emotion regulation mechanisms underlying treatment efficacy. Lastly, we call for the integration of these two approaches in order to enhance our understanding of psychopathology and further elucidate the role of emotion regulation in cognitive-behavioral approaches to treating psychological disorders.