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Theories of Emotion Regulation

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12
Theories of Emotion Regulation
Steven M. Gillespie and Anthony R. Beech
University of Birmingham, United Kingdom

Introduction

In this chapter, we examine theories of emotional regulation as they apply to the

understanding of the psychology of sexual offending. To begin, we provide a basic
overview of theories of emotion and the regulation of emotional states. Next, we out-
line the results of research investigating the breakdown in emotional regulation in
sexual offenders. We then discuss the corticolimbic neural circuitry that provides the
basis for emotion and the regulation of emotional states. Finally, we describe two med-
itational practices, mindfulness and the use of controlled breathing techniques, which
k have been shown to effect neural activity in these structures. We suggest that the use k
of such techniques will open up new directions for the treatment of self-regulation
problems among sexual offenders.

Emotion and Emotional Regulation

An emotion can be seen as a mental state that arises spontaneously rather than through
conscious effort and which is often accompanied by distinct physiological changes.
Affect can be defined as the conscious experience of such emotions. Ekman (2003)
suggested that ‘our emotions are often our best guides. Directing us to do and say
what is right for the situation’ (p. 52), but that is not always so for anyone, in that some
emotions can overwhelm the individual (such as anger or fear). Therefore, emotions
can obviously have massive effects upon the way one thinks and feels, in that they are
multifaceted and involve multisystem changes. Gross and Thompson (2007) noted
that emotional states can have a direct link to the goals of the individual, in order to
initiate changes in behaviour, through autonomic functioning or other physiological
changes.

The Wiley Handbook on the Theories, Assessment, & Treatment of Sexual Offending, First Edition.
Edited by Douglas P. Boer. Volume I: Theories, edited by Anthony Beech and Tony Ward.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.
ISBN: 9781118572655

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246 Single Factor Theories

The German philosopher Theodor Lipps in the nineteenth century was probably
one of the first to describe Einfühlung (emotion), literally meaning ‘feeling into’,
as a way of describing the relationship between an artwork and the observer in the
psychology of aesthetic experience. Darwin (1872) noted that emotions in man (sic)
and animals can include: suffering and weeping (the special expressions of man); the
‘low spirits’ of anxiety, grief, dejection and despair; and the ‘high spirits’ of joy, love,
tender feelings, and devotion. More recently, Ekman (1972) identified a list of basic
emotions (expressed through changes in facial muscles) that are biologically universal
to all humans. These basic emotions are anger, disgust, fear, happiness, sadness and
surprise. Ekman (1999) has since expanded this list of basic emotions to include a
range of positive and negative emotions (not all of which are encoded in facial mus-
cles), namely amusement, contempt, contentment, embarrassment, excitement, guilt,
pride in achievement, relief, satisfaction, sensory pleasure, and shame.
Emotions can be experienced as positive or negative, fleeting or more prolonged,
and at various levels of intensity, from the very weak to the very strong (which can
sometimes overwhelm the individual in terms of grief or fear). These qualities of emo-
tion make up what has been termed the modal model of emotion (Gross, 1998a), which
consists of four steps or events in emotional response generation: (1) situation, (2)
attention, (3) appraisal, and (4) response. According to the model, a psychologically
relevant (external or internal) situation attracts our attention and gives rise to a pro-
cess of situation appraisal. This appraisal can occur across a number of dimensions
(Ellsworth & Scherer, 2003). These dimensions include appraisals of the following:
k (i) the novelty of the situation, that is, the degree to which attention is attracted or k
oriented towards the change in the environment; (ii) the pleasantness or valence of
the situation, which can lead to approach or avoidance behaviours; and (iii) the moti-
vational relevance of the situation to the individual.
Following situation appraisal, an emotional response may be generated. This emo-
tional response can feed back in to, and cause a change in, the original situation. For
example, an angry response to our neighbour’s loud music may cause our neighbour
to reduce the volume (or turn it up!). Thus, our angry emotional response has caused
a change in the situation, and we must now respond to a new situation, a situation
in which our neighbour has (hopefully) reduced the volume of their music. This new
situation may warrant a different emotional response to that of anger, which may
again have an effect on the situation. Therefore, emotions are constantly moderating
the situation in which we find ourselves, causing us to reappraise and respond to the
situation as it develops (Gross & Thompson, 2007).
Gross (1998b) suggested that differing strategies for emotional regulation can
take place at five points along the chain of events constituting the modal model
of emotion. These strategies can be classified as antecedent focused or response
focused, dependent upon stage of the emotion generation process at which they are
employed. Antecedent-focused strategies have the greatest impact prior to emotional
response generation; response-focused strategies are of greatest use after emotional
response generation (Gross & Munoz, 1995). Of these five strategies, four represent
antecedent-focused strategies, termed situation selection, situation modification, atten-
tional deployment, and cognitive change, and one response-focused strategy has been
noted, namely response modulation. We now consider these strategies in more detail.

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Theories of Emotion Regulation 247

Antecedent-Focused Strategies
Situation selection involves the avoidance or seeking out of situations, based on past
experience or forethought, which lead to the generation of a given emotional response.
Situation modification refers to attempts to modify a given external, physical situation
such that the outcome may become more, or less, desirable. For example, one may
avoid the boredom of driving in busy traffic by leaving the house earlier (selection).
Alternatively, one may modify the situation of sitting in traffic by listening to music
in an attempt to alleviate boredom (modification). Emotions can also be regulated
without the need to change or modify the physical situation. Under such circum-
stances, one can regulate one’s emotions through concentration or distraction, both
of which represent means of attentional deployment. It is noted that whereas concen-
tration involves directing attention towards the emotional features of the situation,
distraction involves the shifting of attention away from, or towards, a different aspect
of the situation (Gross & Thompson, 2007). Attentional deployment as a means
of emotional regulation may also include physical efforts to withdraw attention (for
example, withdrawing visual attention by covering our eyes), or the efforts of another
person to redirect our attention (for example, holding a cuddly toy in front of an
infant sitting nervously in the dentist’s chair). Cognitive change, the final strategy in
the antecedent-focused family, refers to the ability to change the ways in which we
appraise an emotional situation. As noted by Ochsner and Gross (2007), the reap-
praisal of an emotional situation, for example as threatening or rewarding, represents
one form of cognitive change. Through the use of reappraisal, emotional responses
k k
to the same situation may vary as a product of circumstance, goals, and motivations,
a process that is dependent upon the functioning of higher order cognitive processes
(Ochsner & Gross, 2005).

Response Modulation
The use of response modulation can be used to modulate or change our response
following emotional response generation. Gross and Thompson (2007) suggested
that response modulation involves direct influences on physiology, experience, or
behaviour. For example, the use of drugs, exercise, cigarettes, and alcohol may all act
to modulate particular aspects of our emotional response. Suppression represents one
common form of response modulation, whereby emotionally expressive behaviours
are inhibited while in a state of emotional arousal (Gross & Levenson, 1993).
Furthermore, the use of suppression has been linked with effects on expressive
behaviour and physiology while inhibiting negative and positive emotional states
(Gross, 1998b; Gross & Levenson, 1997).
According to Davidson et al. (2002), disturbed emotional regulation may repre-
sent an important component of disorders of emotion. Campbell-Sills and Barlow
(2007) suggested that ineffective and maladaptive emotion regulation, particularly a
tendency towards suppression in the regulation of negative emotions, may be of rele-
vance to anxiety and mood disorders. Furthermore, Campbell-Sills and Barlow (2007)
discussed the debilitating effects of ineffective situation selection strategies in relation
to phobic disorders and panic disorder. Additionally, a role of thought suppression has

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248 Single Factor Theories

also been noted in relation to Obsessive Compulsive Disorder in particular, whereby

the individual uses suppression in attempts to regulate intrusive and obsessive thoughts
(Tolin, Abramowitz, Przeworski, & Foa, 2002). In contrast, the use of concentra-
tion – the focusing of attention on the emotional aspects of a situation, a process
somewhat akin to rumination – has been found to intensify and maintain depressed
mood (Nolen-Hoeksema, Morrow, & Fredrickson, 1993). We now discuss research
findings regarding the role of emotional regulatory problems in sexual offending.

Emotion Regulation Problems in Sexual Offenders

It has been suggested that one of a number of precursors to a sexual offence is elevated
levels of negative affect (Smallbone & Dadds, 2000; Ward & Hudson, 2000). For
example, Ross and Fontao (2006) found that self-reported regulatory function was
poorer in sex offenders than non-sexual offenders. Specifically, the latter indicated that
they had better mood management and were less threatened by threatening and/or
stressful situations. Fisher, Beech, and Browne (1999) noted that child abusers often
reported an inability to handle negative emotions, as measured by high scores on a
measure of personal distress (i.e., an ability to handle negative emotions). Problematic
emotion regulation has also been noted among individuals convicted for rape who
tend to show high levels of angry affect (Groth, 1979; Ward & Hudson, 2000). These
findings are consistent with research suggestive of a relationship between negative
k emotional states and sexual offence recidivism (Pithers, Cashima, Cumming, Beal, & k
Buell, 1988). In that study, risk of recidivism was most strongly linked with feelings of
anxiety and depression among those with a paedophilic interest in children; and anger
among those convicted for rape.
Hanson and Morton-Bourgon (2005) conducted a meta-analytical review of the
literature on sex offence recidivism, and although not specific to the regulation of
emotional states, they identified a relationship between general self-regulation and
subsequent risk of reoffending. Differences in negative affect, including anger, dis-
tress, and psychiatric symptoms of any sort, have also been linked with an increased
risk of recidivism among sexual offenders (Hanson & Harris, 2000; Zamble & Quin-
sey, 2001). These self-management/general self-regulation problems were described
by Thornton (2002) as poor emotional control (i.e., a tendency to explosive outbursts
or other behavioural expression of emotional impulses) and, more recently (Thorn-
ton, 2012), as dysfunctional coping/social deviance, and by Hanson, Harris, Scott, &
Helmus (2007) as negative emotionality and hostility.
Creeden (2004) suggested that the genesis of such problems lies in the influence
of maladaptive early experience upon neurodevelopment, particularly the develop-
ment of those structures underlying emotion and emotion control. When considering
such effects upon brain development, it is important to note that different brain areas
mature at different stages (Anders & Zeanah, 1984). Thus, different ‘sensitive’ or
‘critical’ periods for development may be conferred upon different neural systems
(Greenough, Black, & Wallace, 1987). Vast synaptic growth occurs during early stages
of infancy, and the immediate environment will have a profound effect upon the neu-
rodevelopment of the individual (Haracz, 1985). Hence early family (attachment)

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Theories of Emotion Regulation 249

Table 12.1 Different Attachment Styles Identified in Adults

Secure (autonomous) attachment is a style characterized by objective evaluations of

attachment-related experiences, whether these are good or bad. This pattern is associated
with sensitive and responsive parenting in childhood. Individuals with a secure attachment
style have been found to have high levels of self-esteem, view others as warm and accepting,
and report high levels of intimacy in close adult relationships.
Dismissive attachment is a style characterized by an emphasis on achievement and
self-reliance at the expense of emotional warmth towards others. This pattern is associated
with a rejecting or interfering parenting style, in that the parent has behaved in a remote,
cold, and controlling way. Hence if parents are emotionally unavailable the child will tend to
pull away from them and so develop a way of operating that minimizes reliance on others for
support. This form of experience for the individual results in an adult who is only ready to
express self-preservative behaviours, at the expense of any warm, interpersonal emotions and
interactions. Such a person is often self-absorbed, and is unwilling to approach others for
help and emotional support, in that they are not in touch with their emotions and not able
to establish emotional intimacy. If emotion is expressed it more likely to be anger/hostility.
Preoccupied/anxious attachment (resistant or ambivalent in childhood) is a style that is
characterized as the individual being enmeshed in past childhood) experiences. This style
has been found to be associated with an individual experiencing an inconsistent parenting
style in childhood, where the parent(s) behave in ways that interfere with the child’s
autonomy or exploration, leading the individual to be uncertain of the emotional quality of
relationships. Hence the person has a sense of confusion, especially when it comes to
relational issues, and they may become overly dependent on others and hence exhibit
clinginess (i.e., high levels of emotional expressiveness, worry, and impulsiveness, while
k craving emotional intimacy at all times). Although in extremis, this style can be associated k
with social withdrawal.
Disorganized/unresolved) attachment (disorganized/disoriented in childhood) is the
style most often associated with parental maltreatment, or where the primary caregivers
have experienced an unresolved loss or trauma of their own. Here, a parenting style that is
frightening (or frightened) leads to the situation where the child is caught in a conflict
where what should be their source of security becomes a source of fear. Individuals with this
style may not be actively hostile in their interactions with others, but may behave in a
passive–aggressive manner. Such individuals often feel compelled to leave the person who
deep down they love because something inside them ‘doesn’t feel right’, although they may
come up with other excuses for their behaviour because of their need to rationalize it. We
would also note that this attachment style is common in individuals with psychiatric
disorders.

Source: Ward et al. (1995).

experiences can have a major impact upon emotional processing and responding. Con-
sistently, early ‘attachment’ experiences have been found to play an important role
in the development of emotional regulatory strategies (Shaver & Mikulincer, 2007).
Table 12.1 provides a description of the relationship styles that are set down in child-
hood and provide a template for future social interactions throughout the individual’s
life span.
Ward, Hudson, Marshall, and Siegert (1995) noted that different types of sexual
offending behaviour appear be linked with particular styles of insecure attachment,

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250 Single Factor Theories

shown in Table 12.1. This model was tested by Ward, Hudson, and Marshall (1996),
who found that child abusers were likely to display either a fearful or preoccupied
attachment style, whereas rapists were found to be more likely to evidence a dismissive
style. Similarly, Stirpe, Abracen, Stermac, and Wilson (2006) and Abracen, Looman,
Di Fazio, Kelly, and Stirpe (2006) found that child molesters were significantly more
likely to be classified as preoccupied in comparison with violent offenders. Thus, these
different types of offender may be characterized by particular patterns of emotion
regulation. It is also worth adding that there appears to be an increased incidence
of anxiety disorders among sexual offenders. In particular, child abusers present with
elevated levels of social phobia (Baxter, Marshall, Barbaree, Davidson, & Malcolm,
1984; Hoyer, Kunst, & Schmidt, 2001; Raymond, Coleman, Ohlerking, Christen-
son, & Miner, 1999). Individuals with social phobia are characterized by fears of
negative evaluation (Carleton, Collimore, & Asmundson, 2007) and high levels of
anxiety and avoidance in response to social interactions and performance situations
(Liebowitz, 1987). We now examine the underlying neurobiology of emotion and
emotion regulation.

Neurobiology of Emotion Regulation

Various anatomical regions have been identified as crucial to emotion and emotion
k regulation, including the limbic system, a loosely defined collection of brain struc- k
tures, including the amygdala and the hippocampus, which are central to motivation,
behaviour, and emotion. Table 12.2 outlines some of the main structures involved
in the emotion regulatory process, including the orbital prefrontal cortex (OPFC),
the amygdala, and the anterior cingulate cortex (ACC). Table 12.2 also includes a
description of the basal ganglia and insula; these anatomical structures are central to
the generation of emotional expression (for example, both are involved in the gener-
ation of facial expressions of disgust).
It can be seen from Table 12.2 that the OPFC functions as a bridge between the cog-
nitive analysis of complex social events taking place within the cerebral cortex, with
emotional reactions mediated by the amygdala and the autonomic nervous system
(Hariri, Bookheimer, & Mazziotta, 2000; Mah, Arnold, & Grafman, 2004). It is sug-
gested that descending outputs to the amygdala from areas of the prefrontal cortex
(PFC) are involved in the attenuation of the amygdala’s emotional responses (Morgan,
Romanski, & LeDoux, 1993). This suggestion is consistent with extensive intercon-
nections of the PFC with cortical and sub-cortical regions, including the limbic system
and amygdala (Fuster, 1997). Such interconnections allow for an extensive role of the
PFC in the regulation of emotional states. Jackson et al. (2003) used electrophysi-
ological methods to assess the role of frontal neural territories in the regulation of
negative affective states, and the findings indicated that participants with greater left
anterior electroencephalogram (EEG) activity (see Table 12.3 for a description of this
and other techniques for assessing brain function) also showed faster recovery times
following an aversive event.

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Theories of Emotion Regulation 251

Table 12.2 The neurobiology of the emotional brain and emotional regulation

The amygdala is a set of interconnected nuclei (large clusters of neurons). Its functions are
related to arousal, the control of autonomic responses associated with fear, emotional
responses, emotional memory, and hormonal secretions. The amygdala can be split into two
major subdivisions: The basolateral complex exerts potent effects upon sexual behaviours.
These neural structures enable conditional associations to be made between neutral stimuli
and sexual reinforcers. The basal nuclei, in conjunction with the lateral nuclei, also play a
role in reinforcement more generally (Everett, Cador, & Robbins, 1989). The
centromedial complex is involved in (1) responding to fearful stimuli, (2) organizing sexual
behaviours, and (3) the visual system.
The orbital prefrontal cortex (OPFC) can be considered as the apex of the neural networks
of the social brain and is critical to the adaptation of behaviour in response to predicted
changes in reinforcement. It bridges the cognitive analysis of complex social events taking
place within the cerebral cortex, and emotional reactions mediated by the amygdala and the
autonomic nervous system. The OPFC therefore acts as a ‘convergence zone’ with its
connections to the hypothalamus allowing it to integrate internal and external information.
Its inhibitory role in autonomic functioning (via the amygdala and other subcortical
regions) means that it is critically involved in emotional regulation.
The anterior cingulate cortex (ACC) emotion activates the ACC in humans. The ACC also
becomes activated in response to the experience of pain or social stress in others, particularly
those who share a close emotional bond. Hence the ACC provides the basic circuitry for
communication, cooperation, and empathy and is involved in the simultaneous monitoring
of personal, environmental information, and it acts as a ‘lens’ to focus allocation of
attention to the most pertinent information in the environment at a particular moment in
k time. The ACC can be subdivided into an affective part and a cognitive part. k
The basal ganglia are associated with a variety of functions, including cognitive and
emotional functions, and lie over the top of the limbic system. Currently theory suggests
that the basal ganglia operate primarily in action selection (i.e., the decision as to which of
several possible behaviours to execute at a given time), and hence operate to provide
positive/negative emotional expression.
The insular cortex is situated between the temporal and frontal lobes. The insulae have
increasingly become the focus of attention for their role in body representation and
subjective emotional experience. The right anterior insula aids interoceptive awareness of
bodily states, such as the ability to time one’s own heartbeat. The greater right anterior
insular grey matter volume correlates with increased accuracy in subjectivity, and inversely
with negative emotional experience.

Source: Hariri et al. (2000); Mah et al. (2004); Morgan et al. (1993).

These findings have since been extended using advanced brain imaging methods,
which afford greater spatial resolution. In one of the earliest of these advanced func-
tional magnetic resonance imaging (fMRI) studies (see Table 12.3), Schaefer et al.
(2002) investigated the effects of conscious emotion regulation on neural activity
within the amygdala. Following presentation of a negative stimulus, the results showed
a more prolonged increase in amygdala activity among participants who were asked to
‘maintain’ their emotional response relative to those who were simply told to ‘passively
view’ the stimulus. These findings provided early evidence that conscious regulation
of emotion may be driven by alterations in amygdala response.

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252 Single Factor Theories

Table 12.3 Techniques used to examine the functional/structural aspects of the brain

Electroencephalogram (EEG). In an EEG, the subject has electrodes placed in specific

points over the scalp. These electrodes detect the brain’s electrical impulses, which are then
recorded and analysed by a computer. The frequency and amplitude of the resultant signals
can then be interpreted. Increasing frequency is associated with increasing arousal, and
lower frequency is associated with lower arousal.
Event-related potential (ERP). This is a measure of the magnitude of change in brain
activity after the presentation of specific stimuli. The change, or deflection, may be positive
or negative in direction, and occurs within milliseconds of the onset of the stimulus.
Typically, an ERP is measured several times, and the average of all the trials is taken. The
P300 is a positive waveform typically occurring approximately 300 ms after the presentation
of a stimulus. It reflects processes involved in stimulus evaluation or categorization (i.e., it is
related to the engagement of attention).
Magnetic resonance imaging (MRI). MRI scans are created by using powerful magnetic
fields to orient all of the hydrogen atoms (primarily found in water molecules) in the brain
in the same direction. A radiofrequency electromagnetic field is introduced which produces
a signal that is detected by the MRI scanner’s receiver. These signals are then assembled into
high-resolution images that can distinguish the grey from the white matter of the brain.
MRI scans do not use radiation and produce more detailed pictures than do CAT scans, but
they also take much longer to obtain and are much more expensive. However, both of these
procedures produce images of brain structures that can then be measured and studied.
Functional magnetic resonance imaging (fMRI). This measures change in blood oxygen
levels in regions of interest in the brain while cognitive tasks are undertaken. These blood
oxygen level-dependent (BOLD) signals are used as a proxy for how active a region of the
k brain is. By comparing regions of interest with matched controls, activation patterns can be k
studied to learn how the functioning of various brain regions relates to the condition in
question.
Photon emission tomography (PET). This technique relies on injecting subjects with a
radioactively labelled substance, such as glucose. Images can then be obtained that depict
areas of radioactive signal due to glucose metabolism, with increased glucose metabolism
indicative of greater neural activity.
Single photon emission tomography (SPECT). This form of imaging also involves the
injection of a radioactive tracer. The camera detects the amount of radiation coming from
different parts of the brain. These differences are due to differences in regional cerebral
blood flow (rCBF) and reflect different levels of activity in various parts of the brain.
Diffusion tensor imaging (DTI). This is a relatively recent technique, allowing images to
be taken of the structural integrity of the white matter tracts connecting various parts of
the brain.

Source: Schaefer et al. (2002).

In other work, Ochsner, Bunge, Gross, and Gabrieli (2002) found that the reap-
praisal of a negative emotional response was associated with reductions in negative
affect and increased activation of regions of the PFC coupled with reduced amygdala
activity. Furthermore, it was found that activation of the ventrolateral PFC was cor-
related with reduced activity within the amygdala. Thus, increased prefrontal control
over the amygdala response may underlie reduced negative affect following cognitive
reappraisal. Furthermore, differences in neural activity during upward and downward

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Theories of Emotion Regulation 253

emotional regulation have also been explored (Ochsner et al., 2004). As expected,
the results revealed that the direction of the amygdala response is consistent with the
direction of emotional regulation, with increased neural activity within the amygdala
during the upregulation of a negative emotional response.
Researchers have also examined the relationship of activity in the ventromedial PFC
and amygdaloid circuitry with diurnal patterns of salivary cortisol secretion (Urry
et al., 2006). Analyses of fMRI data revealed that increasing negative affect was associ-
ated with altered activation in regions of the PFC and amygdala. Although decreasing
negative affect did not produce the expected pattern of increased PFC activity overall,
participants who demonstrated increased ventromedial PFC and reduced amygdala
responding during the suppression of negative affect also showed steeper declines in
cortisol levels through the course of the day (Urry et al., 2006). These results sug-
gest an association between the adaptive hypothalamic–pituitary–adrenal (HPA) axis
functioning, a system involved in the release of hypothalamic and adrenocortical hor-
mones, including cortisol, and effective regulation of emotional states.
The association of emotion regulation with anxiety and mood disorders is also evi-
dent in neuroimaging research involving participants with anxiety-related disorders of
emotion. For example, activation levels in a neural circuit comprising the OPFC and
amygdala has been linked with an increased propensity to experience anxiety (David-
son, 2002). Also, Hahn et al. (2011) observed disconnection between areas of the
PFC and amygdala in patients presenting with social anxiety disorder, and reduced
recruitment of PFC and a failure to attenuate amygdala outputs has also been noted
k as a possible prelude to violence (Davidson, Putnam, & Larson, 2000). k
In contrast to research examining the neural systems underlying the regulation of
negative affective states, relatively little research has been conducted into the regula-
tion of positive affect. However, Beauregard, Levesque, and Bourgouin (2001) used
fMRI to investigate conscious regulation of positive emotion in response to sexually
arousing video clips. They instructed participants either to attempt to inhibit their
sexual arousal in response to erotic film excerpts or to respond in a normal man-
ner. The results revealed that the viewing of sexually arousing stimuli was associated
with increased activity in the limbic and paralimbic regions, including the amygdala.
By contrast, in the attempted inhibition condition, no activity was observed in limbic
structures. However, significant regions of activation were identified in frontal regions,
including the dorsolateral PFC, in addition to reduced loci of activity in the amygdala,
hypothalamus, and anterior temporal pole (Beauregard et al., 2001). It was concluded
that prefrontal attenuation of the amygdala response, and resulting attenuation of
outputs to the hypothalamus and temporal pole involved in endocrine and autonomic
responding during sexual arousal, may underlie the regulation or attempted inhibition
of sexual arousal.
Therefore, taken together, these results suggest that ‘resilience’ depends upon the
ability of the PFC to regulate activation of the amygdala. In the final section of this
chapter, we examine mindfulness and controlled breathing techniques, including the
use of biofeedback. The application of such techniques may represent a useful adjunct
in treating emotion dysregulation among sexual offenders. The use of such techniques
has been found to affect the functioning of those neural regions outlined above which

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254 Single Factor Theories

are crucial to emotion regulation in terms of an increase in coping/resilience, yet are

inaccessible by talking therapies such as Cognitive Behavioural Therapy (CBT).

Clinical Utility of Self-Regulation Techniques in the

Treatment of Sexual Offenders

We have recently argued that mindfulness self-regulation and the development of

controlled breathing techniques, both of which have been linked with effective emo-
tion control, may represent useful techniques in the treatment of sexual offenders
(Gillespie, Mitchell, Fisher, & Beech, 2012). We now briefly examine these approaches
and the ways in which they affect the functioning of specific neural systems, particularly
the corticolimbic circuitry.

Mindfulness
Howells (2010) suggested that mindfulness may represent a therapeutic adjunct to
traditional CBT interventions for offenders. A meditative practice with its roots in
Buddhist philosophical traditions, mindfulness was defined by Bishop et al. (2004) as
a two-component model. The first component involves the self-regulation of atten-
tion in the present moment, and the second refers to orientation of experience, with
the maintenance of a curious attitude of openness and acceptance towards thoughts,
k feelings, and emotional experiences, as and when they arise (Bishop et al., 2004). k
Mindful individuals are therefore less reactive and more accepting in coping with emo-
tional experience (Shapiro, Carlson, Astin, & Freedman, 2006). Teasdale, Segal, and
Williams (2003) suggested that such a focus on acceptance may lead to a reduced
tendency towards rumination and rehearsal of negative thoughts and experience. For
example, individuals scoring higher on a measure of mindfulness tend to show lower
scores on a measure of ruminative thinking (Borders, Earleywine, & Jajodia, 2010).
This may be particularly important with sex offenders evidencing grievance thinking,
a thinking style characterized by feelings of hostility, rumination, and vengefulness, as
reported by Wakeling and Barnett (2010).
A state of mindfulness may be achieved through the practice of meditation on the
breath (Crane, 2009). This practice involves an intense focus on the experience of
breathing in the here and now, taking note of various sensations associated with res-
piration as and when they occur. When the mind wanders, the individual is instructed
to return slowly to the present moment, maintaining focus on the sensation of breath-
ing. Evidence for the beneficial effects of meditation on the breath was presented by
Arch and Craske (2006). Relative to participants in a worry induction group, partici-
pants in the focused breathing group were willing to view negative emotional slides for
longer and reported lower levels of emotional instability (Arch & Craske, 2006). The
authors suggested that these results may represent adaptive responding and acceptance
of negative emotional experience.
Although mindfulness practice involves the focusing of attention on the present
moment without conscious manipulation of one’s breathing pattern, it has been

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Theories of Emotion Regulation 255

argued that mindfulness may nonetheless exert some effects on cardiophysiological

mechanisms. For example, Roemer and Orsillo (2003) argued that the measurement
of the inter-beat interval of the heart may represent a promising dependent variable
in mindfulness research. Evidence for this was presented by Ditto, Eclache, and
Goldman (2006), who found that participants showed significant increases in the
respiratory sinus arrhythmia (RSA) following two sessions of mindfulness meditation.
The RSA refers to a reduction in heart rate during expiration (Bernardi, Porta,
Gabutti, Spicuzza, & Sleight, 2001), thought to be the product of increased activity
of the vagus nerve (Levy, 1990). This slowing of the heart can lead to fluctuations in
the inter-beat interval of the heart, known as heart rate variability (HRV) (Thayer &
Brosschot, 2005).

The neural and physiological underpinnings of mindfulness. Through the use of

advanced brain imaging methods, researchers have attempted to assess the underlying
structural and functional correlates of mindfulness meditation. For example, Hölzel
et al. (2010) observed reductions in perceived stress accompanied by decreased right
basolateral amygdala grey matter density following an 8-week mindfulness meditation
programme. Additionally, Lazar et al. (2005) demonstrated that mindfulness is
associated with increased thickness of the PFC and anterior insula (involved in the
processing of high-level visceral information). Differences in neural function have also
been noted among those who practice mindfulness meditation relative to controls.
One of the earliest studies to assess the functional correlates of mindfulness was
k conducted by Davidson et al. (2003), who observed increased left-sided anterior k
activation among trained meditators relative to non-meditators. It was noted that a
similar pattern of anterior activation is linked with feelings of positive affect.
Frewen et al. (2010) observed an association between mindfulness traits, dorso-
medial prefrontal activity, and responsivity of the left amygdala. Similarly, Modinos,
Ormel, and Aleman (2010) showed that participants’ degree of mindfulness was posi-
tively correlated with activity in the PFC. Activity in this region was inversely correlated
with amygdala responsivity during the reappraisal of negative emotional stimuli. These
results provide evidence for an influence of mindfulness on activity in the frontolim-
bic circuits known to interact in the cognitive reappraisal of emotions (Ochsner &
Gross, 2005). Creswell, Way, Eisenberger, and Lieberman (2007) noted a relation-
ship of dispositional mindfulness with increased prefrontal activity and a reduction in
the amygdala response bilaterally during an affect labelling task. However, this mech-
anism of mindfulness may be true for beginner meditators only. Results suggest that
more experienced meditators show a pattern of activity more in keeping with increased
acceptance of emotional states and greater present-moment awareness (Taylor et al.,
2011).

Mindfulness with sex offenders. Although mindfulness remains to be implemented on

a large scale for the treatment of sexual offenders, some studies have sought to assess
the benefits of mindfulness in a forensic therapeutic context. Samuelson, Carmody,
Kabat-Zinn, and Bratt (2007) assessed hostility, self-esteem, and mood disturbance
following a prison-based mindfulness programme and noted benefits among both
male and female participants. Benefits of mindfulness practice have also been observed

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256 Single Factor Theories

among aggressive psychiatric inpatients, with reductions in both verbal and physical
aggression reported alongside increased levels of self-control (Singh, Wahler, Adkins,
& Myers, 2003; Singh et al., 2007a,b). In addition, Singh et al. (2010) observed
improved regulation of deviant sexual arousal among three learning disabled adult
sexual offenders following a programme of mindfulness meditation. However, per-
haps most promisingly, mindfulness modules have been successfully incorporated into
Dialectical Behaviour Therapy (DBT) (Linehan, 1993), a commonly used interven-
tion for treating extreme levels of emotional dyscontrol in patients with a diagnosis
of Borderline Personality Disorder (DSM-IV-TR; American Psychiatric Association,
2000) (Hogue, Jones, Talkes, & Tennant, 2007; Nee & Farman, 2005).

Controlled Breathing Techniques

Practitioners have aimed to aid clients to control their breathing pattern with the
aim of achieving gains in heart rate variability (HRV). Lower levels of HRV have
frequently been observed among patients with disorders of mood and anxiety, sug-
gesting a relationship of HRV with the ability to regulate affective states (Garakani
et al., 2009; Hofmann, Schulz, Heering, Muench, and Bufka, 2010; Thayer, Fried-
man, & Borkovec, 1996). Bernardi et al. (2001) suggested that a breathing pattern
of 0.1 Hz, or six breaths per minute, may be optimal for HRV gains. Consistent
with this observation, Lehrer, Vaschillo, and Vaschillo (2000) developed a biofeed-
back system that could help practitioners to induce in their clients a pattern of slow
k and controlled breathing. Ultimately, the aims of biofeedback are to aid clients to k
achieve higher levels of HRV and associated improvements in emotional regulatory
abilities. Such biofeedback techniques have also been integrated into the treatment
of various mood and anxiety disorders (Hassett et al., 2007; Karavidas et al., 2007;
Reiner, 2008; Siepman, Aykac, Unterdörfer, Petrowski, & Mueck-Weymann, 2008;
Tan, Dao, Farmer, Sutherland, & Gevirtz, 2011). In a review of the literature in this
area, Wheat and Larkin (2010) concluded that biofeedback does confer some degree
of therapeutic utility for (i) improving levels of HRV and related physiology and (ii)
improving clinical outcomes.

The neural and physiological underpinnings of controlled breathing. Lehrer et al. (2003)
suggested that biofeedback may exert therapeutic benefits via effects on those mech-
anisms which modulate cardiac activity. These mechanisms include the baroreflex, a
negative feedback mechanism whereby stretch receptors detect changes in blood pres-
sure and modulate vagal nerve activity accordingly, and peak expiratory flow, a person’s
maximum speed of expiration. Furthermore, benefits following biofeedback training
may result from effects of autonomic activity on those neural circuits underlying emo-
tional regulation. For example, a model of ‘neurovisceral integration’ outlined by
Thayer and Lane (2009) suggests that patterns of neural activity in the brain, including
the PFC and amygdala, may be affected by changes in cardiophysiology. Evidence for
this model was presented by Napadow et al. (2008), who combined advanced fMRI
techniques and HRV measurements to study the neural correlates of autonomic mod-
ulation among healthy participants. The results revealed relationships of HRV levels

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Theories of Emotion Regulation 257

with activity in various neural regions, including the hypothalamus, limbic structures
including the amygdala and hippocampus, and regions of the PFC.
We have earlier noted that the benefits of mindfulness among untrained medita-
tors may be due to improved prefrontal control over emotion. Similarly, studies have
revealed a relationship between cortical activity, heart rate, and HRV. For example,
Ahern et al. (2001) observed increases in heart rate and reductions in vagally mediated
HRV following inactivation of each hemisphere using intracarotid sodium amobarbi-
tal injection. Further research using neuroimaging procedures has shown that vagal
activity is associated with activity of the PFC, with emotion-specific regional cerebral
blood flow (rCBF) in the medial PFC associated with emotion-specific increases in
HRV (Lane et al., 2009). Further, inverse correlations of emotional arousal with levels
of both HRV and prefrontal rCBF were also noted. Additionally, increased vagal activ-
ity and prefrontal functioning have also been linked with improvements in executive
functioning (Hansen, Johnsen, Sollers, Stenvik, & Thayer, 2004).
Taken together, the above results provide support for a model of neurovisceral inte-
gration whereby prefrontal cortical activity tonically inhibits those circuits responsible
for accelerations in heart rate (see Thayer, Hansen, Saus-Rose, & Johnsen, 2009).
Thus, it is argued by Thayer and Sternberg (2006) and Thayer et al. (2009) that
reduced vagally mediated HRV is associated with a reduction in prefrontal inhibitory
control over subcortical threat circuits, including the amygdala. Hence this mecha-
nism may account for an association of vagal function and HRV with improvements
in emotional regulation.
k k

Conclusions

Research has consistently pointed towards deficits in emotional regulation among sex-
ual offenders. Therefore, targeting emotional regulation during treatment may lead
not only to better regulation of emotional states, but also to an associated decline in
symptoms of anxiety and mood disorder. In addition, improving emotional regula-
tion among sexual offenders may have implications beyond the domain of emotional
regulation, with benefits perhaps expected in the ability to manage deviant sexual
arousal and fantasy, which have been linked with negative emotional states. Further-
more, intense emotional states have also been noted in the days preceding an offence.
Therefore, when considering these issues together, improving emotional regulation
among sexual offenders would be expected to lead to a reduction in recidivism rates.
As we move into a new era in the treatment of sexual offenders, with a particular
focus on a biopsychosocial model of change, there is a drive towards the development
of interventions that are both evidence based and informed by scientific theory (Mann,
2011). We would argue that the use of mindfulness and controlled breathing/HRV
biofeedback techniques is in keeping with the aims of this model of change. In addition
to a growing literature on the therapeutic benefits of mindfulness in both clinical and
non-clinical participants, early research also indicates potential benefits of mindfulness
in a forensic therapeutic context. Furthermore, the use of neuroimaging in the study
of mindfulness has highlighted a likely mechanism of action, involving the OPFC and
amygdala. Notably, the results of these studies are consistent with the results of various

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258 Single Factor Theories

neuropsychological studies that indicate reduced prefrontal inhibition of threat-related

neural circuits, including the amygdala, in emotion dysregulation.
A similar mechanism of action may also underlie the therapeutic benefits of HRV
biofeedback training. Although the therapeutic benefits of HRV biofeedback with
sexual offenders are yet to be tested, we would argue that there is a considerable liter-
ature to suggest that the use of such techniques will have a positive impact on emotion
regulatory abilities. Again, this suggestion is supported by the results of therapeutic
interventions with clinical patients and the results of pharmacological and neuroimag-
ing based studies of vagally mediated HRV.

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Please note that the abstract and keywords will not be included in the printed
book, but are required for the online presentation of this book which will be
published on Wiley’s own online publishing platform.
If the abstract and keywords are not present below, please take this opportunity
to add them now.
The abstract should be a short paragraph upto 200 words in length and key-
words between 5 to 10 words.

ABSTRACT
Emotions refer to mental states that are spontaneously generated, can be positive or
negative, fleeting or more prolonged, and can be experienced at varying levels of
intensity. Emotions are also under cognitive control, whereby strategies for emotion
regulation mean that they may be experienced more or less intensely. A failure to reg-
ulate emotional states adequately has been linked with antisocial behaviour and sexual
offending in particular. This chapter discusses the evidence for emotion regulation
difficulties in sexual offenders and describes the ways in which mindfulness meditation
and biofeedback techniques may be used to enhance the ability for emotion regula-
tion in the treatment of sexual offenders. The use of these techniques has been shown
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to affect the functioning of the prefrontal cortex and the amygdala, the critical struc-
tures involved in emotion regulation, and have been linked with improved regulation
of affective states in clinical studies.
KEYWORDS
sexual offender; emotion regulation; treatment; mindfulness; heart rate variability;
heart rate variability biofeedback

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