- Email: [email protected]
Unhealthy perfectionism, negative beliefs about emotions, emotional suppression, and depression in students: A mediational analysis
Personality and Individual Differences 110 (2017) 144–147
Contents lists available at ScienceDirect
Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
Short Communication
Unhealthy perfectionism, negative beliefs about emotions, emotional suppression, and depression in students: A mediational analysis Lisa Tran a,⁎, Katharine A. Rimes b a b
Guy's, King's and St Thomas' School of Medical Education, King's College London, Great Maze Pond, London SE1 9RT, UK King's College London, Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park, London SE5 8AF, UK
a r t i c l e
i n f o
Article history: Received 1 November 2016 Received in revised form 20 January 2017 Accepted 25 January 2017 Available online xxxx Keywords: Beliefs Emotion suppression Depression Perfectionism Students
a b s t r a c t Introduction: Literature suggests individuals who exhibit unhealthy perfectionist traits are more likely to be characterised by unhelpful emotion coping responses. The present study aims to explore negative beliefs about emotions as a mediator between unhealthy perfectionism and emotional suppression, and whether emotional suppression mediated the association between unhealthy perfectionism and depression. Method: A cross-sectional online self-report questionnaire was administered to students (n = 641), which assessed perfectionism, unhelpful beliefs about emotions, emotional suppression and depressive symptomatology. Results: Bootstrapping analyses suggested that beliefs about emotions mediated the relationship between unhealthy perfectionism and emotional suppression. Further analysis indicated that emotional suppression mediated the relationship between unhealthy perfectionism and symptoms of depression. Conclusion: It may be important for professionals treating people with depression or other psychological problems characterised by perfectionism, to ensure that therapy targets beliefs about emotions and emotional suppression. © 2017 Elsevier Ltd. All rights reserved.
1. Introduction Frost, Marten, Lahart, and Rosenblate (1990) suggested that perfectionism is a multidimensional trait incorporating five dimensions: setting high personal standards, concern over making mistakes, perceptions of parental expectations, perceptions of parental criticism, and the tendency to doubt the quality of one's performance. They found that the first of these dimensions (i.e. the setting of high personal standards) was associated with healthy experiences, or so-called ‘positive achievement striving’, which is line with Hamachek's (1978) description of ‘normal’ perfectionism. Frost et al. (1990) further suggested that the remaining dimensions of perfectionism reflected ‘maladaptive evaluation concerns’ and were associated with negative affect and unhealthy experiences, such as depression or anxiety. Throughout this study, the focus will be on the ‘unhealthy’ dimensions of perfectionism. Unhealthy perfectionism has been found to be associated with vulnerability towards psychological problems such as depression (Gross & John, 2003), anxiety (Flett, Hewitt, Blankstein, Solnik, & Brunschot, 1996) and eating disorders (Hewitt, Flett, & Ediger, 1995). One possibility for the link between perfectionism and such disorders may be that ⁎ Corresponding author. E-mail addresses: [email protected] (L. Tran), [email protected] (K.A. Rimes).
http://dx.doi.org/10.1016/j.paid.2017.01.042 0191-8869/© 2017 Elsevier Ltd. All rights reserved.
unhealthy perfectionists have certain coping tendencies when faced with emotionally arousing circumstances that put them at higher risk of developing these problems. Evidence has shown that perfectionism is associated with maladaptive cognitive emotion regulation tendencies, leading to greater levels of self-blame, rumination and lack of positive re-appraisal (Rudolph, Flett, & Hewitt, 2007). Aldea and Rice (2006) showed that emotional dysregulation played a meditational role between ‘maladaptive’ (unhealthy) perfectionism and psychological distress. More specifically, Dunkley, Blankstein, Halsall, Williams, and Winkworth (2000) suggest that unhealthy perfectionists exhibit dysfunctional and avoidant coping strategies, such as disengagement and denial, which exacerbate levels of stress. They found avoidance coping to be a unique mediator that explained the relationship between ‘evaluative concerns’ perfectionism and distress. Dunkley, Sanislow, Grilo, and McGlashan (2006) also showed that avoidant coping subsequently predicted depressive symptoms. Emotional avoidance or suppression has been previously identified as an unhelpful coping response, which may maintain distress and could have other adverse consequences (Richards & Gross, 1999). Furthermore, it is thought to be counterproductive as it can increase the frequency of distressing thoughts, and thus reaffirms the state of mind the individual had hoped to avoid (Trinder & Salkovskis, 1994). Cognitive behavioural approaches to the maintenance of distress suggest that coping responses such as emotional avoidance or suppression are
L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
influence by people's beliefs about emotions (Sydenham, Beardwood, & Rimes, 2017). For example, people may attempt to avoid or suppress negative emotions because they believe the experience of them to be unacceptable to themselves or others. There is evidence that unhealthy perfectionism is moderately correlated with beliefs about the unacceptability of negative emotions (Rimes & Chalder, 2010). Furthermore, Bergman, Nyland, and Burns (2007) reported that unhealthy perfectionism was found to correlate with emotional suppression as a coping mechanism. However no previous studies have investigated whether beliefs about the unacceptability of negative emotions mediate the relationship between unhealthy perfectionism and emotional suppression. There is some indirect evidence consistent with this suggestion. Individuals with anorexia nervosa show perfectionist traits, as well as the belief that negative emotions are unacceptable (Hewitt et al., 1995). One study showed that people with anorexia nervosa were more likely to suppress negative emotions, when compared with control groups (Geller, Cockell, Hewitt, Goldner, & Flett, 2000). This study explores three hypotheses associated with perfectionism and emotions: (1) Unhealthy perfectionism is associated with more emotion suppression, (2) the relationship between unhealthy perfectionism and emotion suppression is mediated by unhelpful beliefs about emotions and (3) Emotional suppression mediates the relationship between unhealthy perfectionism and symptoms of depression.
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the Cronbach's alpha indicates high internal consistency (α = 0.89) for the scale. 2.3.3. Affective Styles Questionnaire (ASQ) The ASQ (Hofmann & Kashdan, 2010) assesses the tendency to use three different strategies to regulate emotions: (1) adapting to the situation by re-adjusting one's emotions, (2) concealing or suppressing the emotion, and (3) tolerating and accepting emotions. In this study, the concealing subscale was used to measure emotional suppression. The ASQ has been shown to have good construct validity: the concealing subscale was largely correlated with the suppression subscale of the Emotion Regulation Questionnaire by Gross and John (2003), and the negative expressivity subscale of the Berkeley Expressivity Questionnaire (Gross, John, & Richards, 1995; Hofmann & Kashdan, 2010). The questionnaire has also been shown to have a good internal consistency (Hofmann & Kashdan, 2010). In the present study, Cronbach's alpha indicates high internal consistency (α = 0.871).
2. Method
2.3.4. Patient Health Questionnaire-9 (PHQ-9) The 9-item Patient Health Questionnaire (Kroenke & Spitzer, 2002) measures depression symptomatology. The measure has been shown to have a high level of reliability and validity as a brief measure of depression severity (Kroenke, Spitzer, & Williams, 2001). In the present study, the Cronbach's alpha (α = 0.89) indicates high internal consistency.
2.1. Design
2.4. Procedure
This is a cross-sectional, self-reported online study with a student population. The independent variable is the level of unhealthy perfectionism, and the dependent variable is emotional suppression. Beliefs about emotions are investigated as a possible mediator in the relationship between perfectionism and emotion suppression. In the second mediational analysis, emotional suppression is investigated as the mediator between unhealthy perfectionism and depression.
Data collection took place between December 2013 and February 2016. The questionnaire web link was distributed via different routes. The study was advertised online on social media sites (i.e. Facebook, Twitter), the Social Psychology Network, Psychological Research on the Net, and distributed via a research recruitment email at the authors' institution.
2.2. Participants A total of 641 participants took part (149 men and 492 women) (mean age = 21.87 years, SD = 6.52). The majority of the participants were located in the USA or Canada (n = 386, 60%). The remaining participants were from elsewhere including the United Kingdom, Singapore, Australia and Russia. Participants were studying a wide range of subjects, the most common being psychology (n = 200, 31%) and healthcare subjects (n = 72, 11%). 2.3. Materials 2.3.1. Frost Multidimensional Perfectionism Scale (FMPS) The FMPS (Frost et al., 1990) is a widely used 35-item questionnaire designed to assess different dimensions of perfectionism. This measure developed by Frost et al. was found to be highly correlated with an existing measure of perfectionism by Burns (1980) and therefore judged to have good construct validity (Hewitt & Flett, 1991). The concern over mistakes, parental criticism, parental expectations and doubts about actions subscales combined to constitute a superfactor of unhealthy perfectionism (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). In the present study, Cronbach's alpha for the unhealthy perfectionism dimension indicates high internal consistency (α = 0.921). 2.3.2. Beliefs about Emotions Scale (BES) The BES (Rimes & Chalder, 2010) assesses beliefs that it is unacceptable to experience or express negative emotions. It is a 12-item questionnaire that has been shown to have a good internal reliability and high level of validity (Rimes & Chalder, 2010). In the present study,
2.5. Data preparation and statistical analysis The data was analysed using SPSS. Only participants who had completed all of the survey items to be used for these analyses were included (n = 641). The Shapiro-Wilk test indicated that the unhealthy perfectionism variable was not normally distributed, so non-parametric correlational analyses were used. 2.6. Mediation analysis using bootstrapping The bootstrapping method was used to investigate mediation, as advocated by Preacher and Hayes (2004). Unlike some alternative methods, this does not require the assumption of normality of the sampling distribution. PROCESS for SPSS v2.15 by Andrew Hayes was used, (downloaded from http://www.afhayes.com/introduction-to-media tion-moderation-and-conditional-process-analysis.html) with 5000 bootstrapped samples and 95% confidence intervals. Indirect effects were considered significant when the bias corrected and accelerated confidence intervals did not include zero. 3. Results 3.1. Psychological characteristics and associations with gender and age The mean score for unhealthy perfectionism was 60.82 (SD = 17.44), beliefs about emotions was 48.65 (SD = 14.85) and emotion suppression was 25.41 (SD = 7.03). Independent t-tests were carried out to investigate whether there were gender differences for each of the three key variables. Results showed that there was no significant effect of gender on unhealthy perfectionism (t = −1.316, p = 0.329), beliefs about emotions (t = 0.084, p = 0.058) or emotion suppression
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L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
(t = 1.290, p = 0.080). Due to the restricted and non-normally distributed age of the sample (85% aged 16–25), associations between age and the key variables were not investigated. 3.2. Correlational findings Spearman's correlations showed that unhealthy perfectionism, unhelpful beliefs about emotions and emotional suppression were positively correlated with each other (Table 1). 3.3. Beliefs about emotions as mediator of the relationship between perfectionism and suppression The direct effect of unhealthy perfectionism on emotional suppression was not statistically significant (b = 0.3; CI = − 0.0055, 0.066). The effect of unhealthy perfectionism on beliefs about emotions was significant (b = 0.51, p b 0.0005), as was the effect of beliefs about emotions on emotional suppression (b = 0.17, p b 0.0005) (Fig. 1). The indirect effect of unhealthy perfectionism on emotional suppression was positive and statistically different from zero, as evidenced by a 95% bias-corrected bootstrap confidence interval that is entirely above zero (b = 0.09; CI = 0.065, 0.11). Therefore, this is consistent with the hypothesis that unhealthy perfectionism is associated with emotion suppression through beliefs about the unacceptability of negative emotions. The total of the direct and indirect effect of unhealthy perfectionism on emotional suppression was significant (b = 0.12, p b 0.0005). When unhealthy perfectionism and beliefs about emotions were entered into the model simultaneously, only beliefs about emotions (t = 8.17, p b 0.0005), and not unhealthy perfectionism (t = 1.66, p = 0.098), was significantly associated with emotion suppression (F(2641)= 66.2, p b 0.0005, R2 = 0.17). 3.4. Mediation of the relationship between perfectionism and depression Using PROCESS to investigate the mediation model, results showed that the indirect pathway between unhealthy perfectionism on depression, via emotional suppression was significant (b = 0.15; CI = 0.0071, 0.0263). 4. Discussion The results of this cross-sectional study suggest that beliefs about emotions mediate the relationship between unhealthy perfectionism and emotion suppression. When both unhealthy perfectionism and beliefs about emotions were entered simultaneously into the model, only beliefs about emotions was a significant predictor of emotional suppression. These results are consistent with the hypothesis that individuals with unhealthy perfectionist beliefs are more likely to have negative beliefs about emotions, leading to emotion suppression. Furthermore, the study also suggests that emotional suppression mediates the relationship between unhealthy perfectionism and depressive symptomatology. The findings that unhealthy perfectionism is associated with beliefs about the unacceptability of experiencing negative emotions replicates the previous finding by Rimes and Chalder (2010), but this time in a student sample. This is the first evidence showing that beliefs about the unacceptability of experiencing/expressing negative emotions may be a
Fig. 1. Mediation model for unhealthy perfectionism and emotional suppression showing unstandardised coefficients. ***p b 0.0005.
mediator in the relationship between unhealthy perfectionism and emotional suppression. The reason may be because unhealthy perfectionism is related to avoidance coping strategies, such as disengagement and denial, as discussed by Dunkley et al. (2000). Thus, it is possible unhealthy perfectionists are more likely to suppress distressing emotions as an avoidance coping strategy. Future therapy for depression or other conditions involving unhealthy perfectionism could be targeted at reappraising an individual's beliefs about their emotions. Cognitive behavioural therapy (CBT) addresses the thoughts and behaviours maintaining psychological disorders. Evidence suggests that CBT can be effective at treating unhealthy perfectionism (Egan et al., 2014). By understanding what mediates between unhealthy perfectionism and its consequences, i.e. emotion suppression, CBT can be utilised to even greater effect by targeting it at the negative beliefs about emotions that is thought mediate this relationship. It is important to note some study limitations. Firstly, the sample was a student population, and thus, results cannot be generalised to non-students or a clinical population who are seeking help for unhealthy perfectionism. Secondly, finding a statistically significant indirect effect that supports the mediation hypothesis does not necessarily prove the pattern of causation indicated in the figures. The data collected was cross-sectional and therefore it cannot be ruled out that other causal relationships between these variables are possible. Thirdly, a high proportion of the participants were medical students. The perfectionism profile amongst medical students is distinct from that of non-medical students (Enns, Cox, Sareen, & Freeman, 2001). The implications are that the data collected may be skewed towards the perfectionist traits specifically found in medical students. There were also a high proportion of psychology students, some of whom may be familiar with the study concepts. This study indicates that beliefs about the unacceptability of negative emotions only accounts for a moderate amount of the variance in emotional suppression. Other factors that could be affecting an individual's tendency to suppress their emotions were not investigated. Future research could explore other factors that may mediate the relationship between unhealthy perfectionism and emotion suppression.
Table 1 Bivariate correlation using Spearman's coefficient (r) between unhealthy perfectionism, beliefs about emotions, emotion suppression and depression. **Significant at the 0.01 level.
Unhealthy perfectionism Beliefs about emotions Emotional suppression Depression
Unhealthy perfectionism
Beliefs about emotions
Emotion suppression
Depression
1
0.56** 1
0.26** 0.38** 1
0.47** 0.45** 0.27** 1
L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
Despite its limitations, this study makes important contributions to the literature by confirming a link between unhealthy perfectionism and emotion suppression, via negative beliefs about emotions. It also shows that emotion suppression is a mediator in the relationship between unhealthy perfectionism and depression. The knowledge garnered from this study may be helpful when treating those with unhealthy perfectionism to ensure therapy is being targeted at these areas of emotional processing to reduce outcomes such as depression. By understanding the links between perfectionism, beliefs about emotions, emotion suppression and depression, researchers and clinicians can help to appreciate and recognise the reasons why perfectionists may suppress their emotions and help individuals address their emotional coping responses to prevent other potential psychological disorders. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical Statement Ethics approval was granted by the Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) within the Research Committee at King's College London (REF: PNM/13/14-39). Data was collected via ‘SurveyMonkey’, an online survey tool. An information sheet outlining the details of the study to participants, along with consent form was placed at the start of the survey. Acknowledgements There was no funding required for this study. We would like to thank all the participants for taking the time to complete the questionnaires for this study. References Aldea, M. A., & Rice, K. G. (2006). The role of emotional dysregulation in perfectionism and psychological distress. Journal of Counseling Psychology, 53(4), 498. Bergman, A. J., Nyland, J. E., & Burns, L. R. (2007). Correlates with perfectionism and the utility of a dual process model. Personality and Individual Differences, 43(2), 389–399. Burns, D. D. (1980). The perfectionist's script for self-defeat. Psychology Today, 14(6), 34–52. Dunkley, D. M., Blankstein, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000). The relation between perfectionism and distress: Hassles, coping, and perceived social support as mediators and moderators. Journal of Counseling Psychology, 47(4), 437.
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Dunkley, D. M., Sanislow, C. A., Grilo, C. M., & McGlashan, T. H. (2006). Perfectionism and depressive symptoms 3 years later: Negative social interactions, avoidant coping, and perceived social support as mediators. Comprehensive Psychiatry, 47(2), 106–115. Egan, S. J., van Noort, E., Chee, A., Kane, R. T., Hoiles, K. J., Shafran, R., & Wade, T. D. (2014). A randomised controlled trial of face to face versus pure online self-help cognitive behavioural treatment for perfectionism. Behaviour Research and Therapy, 63, 107–113. Enns, M. W., Cox, B. J., Sareen, J., & Freeman, P. (2001). Adaptive and maladaptive perfectionism in medical students: A longitudinal investigation. Medical Education, 35(11), 1034–1042. Flett, G. L., Hewitt, P. L., Blankstein, K. R., Solnik, M., & Brunschot, M. V. (1996). Perfectionism, social problem-solving ability and psychological distress. Journal of RationalEmotive & Cognitive-Behavior Therapy, 14(4). Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449–468. Frost, R. O., Heimberg, R. G., Holt, C. S., Mattia, J. I., & Neubauer, A. L. (1993). A comparison of two measures of perfectionism. Personality and Individual Differences, 14(1), 119–126. Geller, J., Cockell, S. J., Hewitt, P. L., Goldner, E. M., & Flett, G. L. (2000). Inhibited expression of negative emotions and interpersonal orientation in anorexia nervosa. International Journal of Eating Disorders, 28(1), 8–19. Gross, J. J., John, O. P., & Richards, J. (1995). Berkeley expressivity questionnaire. Edwin Mellen Press. Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology., 85, 348–362. Hamachek, D. E. (1978). Psychodynamics of normal and neurotic perfectionism. Psychology, 15, 27–33. Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60(3), 456–470. Hewitt, P. L., Flett, G. L., & Ediger, E. (1995). Perfectionism traits and perfectionistic selfpresentation in eating disorder attitudes, characteristics, and symptoms. International Journal of Eating Disorders, 18(4), 317–326. Hofmann, S. G., & Kashdan, T. B. (2010). The affective style questionnaire: Development and psychometric properties. Journal of Psychopathology and Behavioural Assessment, 32(2), 255–263. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9), 1–7. Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36(4), 717–731. Richards, J. M., & Gross, J. J. (1999). Composure at any cost? The cognitive consequences of emotion suppression. Personality and Social Psychology Bulletin, 25(8), 1033–1044. Rimes, K. A., & Chalder, T. (2010). The beliefs about emotions scale: Validity, reliability and sensitivity to change. Journal of Psychosomatic Research, 68(3), 285–292. Rudolph, S. G., Flett, G. L., & Hewitt, P. L. (2007). Perfectionism and deficits in cognitive emotion regulation. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 25(4), 343–357. Sydenham, M., Beardwood, J., & Rimes, K. A. (2017). Beliefs about emotions, depression, anxiety and fatigue: A mediational analysis. Behavioural and Cognitive Psychotherapy, 45(1), 73–78. Trinder, H., & Salkovskis, P. M. (1994). Personally relevant intrusions outside the laboratory: Long-term suppression increases intrusion. Behaviour Research and Therapy, 32(8), 833–842.
Contents lists available at ScienceDirect
Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
Short Communication
Unhealthy perfectionism, negative beliefs about emotions, emotional suppression, and depression in students: A mediational analysis Lisa Tran a,⁎, Katharine A. Rimes b a b
Guy's, King's and St Thomas' School of Medical Education, King's College London, Great Maze Pond, London SE1 9RT, UK King's College London, Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park, London SE5 8AF, UK
a r t i c l e
i n f o
Article history: Received 1 November 2016 Received in revised form 20 January 2017 Accepted 25 January 2017 Available online xxxx Keywords: Beliefs Emotion suppression Depression Perfectionism Students
a b s t r a c t Introduction: Literature suggests individuals who exhibit unhealthy perfectionist traits are more likely to be characterised by unhelpful emotion coping responses. The present study aims to explore negative beliefs about emotions as a mediator between unhealthy perfectionism and emotional suppression, and whether emotional suppression mediated the association between unhealthy perfectionism and depression. Method: A cross-sectional online self-report questionnaire was administered to students (n = 641), which assessed perfectionism, unhelpful beliefs about emotions, emotional suppression and depressive symptomatology. Results: Bootstrapping analyses suggested that beliefs about emotions mediated the relationship between unhealthy perfectionism and emotional suppression. Further analysis indicated that emotional suppression mediated the relationship between unhealthy perfectionism and symptoms of depression. Conclusion: It may be important for professionals treating people with depression or other psychological problems characterised by perfectionism, to ensure that therapy targets beliefs about emotions and emotional suppression. © 2017 Elsevier Ltd. All rights reserved.
1. Introduction Frost, Marten, Lahart, and Rosenblate (1990) suggested that perfectionism is a multidimensional trait incorporating five dimensions: setting high personal standards, concern over making mistakes, perceptions of parental expectations, perceptions of parental criticism, and the tendency to doubt the quality of one's performance. They found that the first of these dimensions (i.e. the setting of high personal standards) was associated with healthy experiences, or so-called ‘positive achievement striving’, which is line with Hamachek's (1978) description of ‘normal’ perfectionism. Frost et al. (1990) further suggested that the remaining dimensions of perfectionism reflected ‘maladaptive evaluation concerns’ and were associated with negative affect and unhealthy experiences, such as depression or anxiety. Throughout this study, the focus will be on the ‘unhealthy’ dimensions of perfectionism. Unhealthy perfectionism has been found to be associated with vulnerability towards psychological problems such as depression (Gross & John, 2003), anxiety (Flett, Hewitt, Blankstein, Solnik, & Brunschot, 1996) and eating disorders (Hewitt, Flett, & Ediger, 1995). One possibility for the link between perfectionism and such disorders may be that ⁎ Corresponding author. E-mail addresses: [email protected] (L. Tran), [email protected] (K.A. Rimes).
http://dx.doi.org/10.1016/j.paid.2017.01.042 0191-8869/© 2017 Elsevier Ltd. All rights reserved.
unhealthy perfectionists have certain coping tendencies when faced with emotionally arousing circumstances that put them at higher risk of developing these problems. Evidence has shown that perfectionism is associated with maladaptive cognitive emotion regulation tendencies, leading to greater levels of self-blame, rumination and lack of positive re-appraisal (Rudolph, Flett, & Hewitt, 2007). Aldea and Rice (2006) showed that emotional dysregulation played a meditational role between ‘maladaptive’ (unhealthy) perfectionism and psychological distress. More specifically, Dunkley, Blankstein, Halsall, Williams, and Winkworth (2000) suggest that unhealthy perfectionists exhibit dysfunctional and avoidant coping strategies, such as disengagement and denial, which exacerbate levels of stress. They found avoidance coping to be a unique mediator that explained the relationship between ‘evaluative concerns’ perfectionism and distress. Dunkley, Sanislow, Grilo, and McGlashan (2006) also showed that avoidant coping subsequently predicted depressive symptoms. Emotional avoidance or suppression has been previously identified as an unhelpful coping response, which may maintain distress and could have other adverse consequences (Richards & Gross, 1999). Furthermore, it is thought to be counterproductive as it can increase the frequency of distressing thoughts, and thus reaffirms the state of mind the individual had hoped to avoid (Trinder & Salkovskis, 1994). Cognitive behavioural approaches to the maintenance of distress suggest that coping responses such as emotional avoidance or suppression are
L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
influence by people's beliefs about emotions (Sydenham, Beardwood, & Rimes, 2017). For example, people may attempt to avoid or suppress negative emotions because they believe the experience of them to be unacceptable to themselves or others. There is evidence that unhealthy perfectionism is moderately correlated with beliefs about the unacceptability of negative emotions (Rimes & Chalder, 2010). Furthermore, Bergman, Nyland, and Burns (2007) reported that unhealthy perfectionism was found to correlate with emotional suppression as a coping mechanism. However no previous studies have investigated whether beliefs about the unacceptability of negative emotions mediate the relationship between unhealthy perfectionism and emotional suppression. There is some indirect evidence consistent with this suggestion. Individuals with anorexia nervosa show perfectionist traits, as well as the belief that negative emotions are unacceptable (Hewitt et al., 1995). One study showed that people with anorexia nervosa were more likely to suppress negative emotions, when compared with control groups (Geller, Cockell, Hewitt, Goldner, & Flett, 2000). This study explores three hypotheses associated with perfectionism and emotions: (1) Unhealthy perfectionism is associated with more emotion suppression, (2) the relationship between unhealthy perfectionism and emotion suppression is mediated by unhelpful beliefs about emotions and (3) Emotional suppression mediates the relationship between unhealthy perfectionism and symptoms of depression.
145
the Cronbach's alpha indicates high internal consistency (α = 0.89) for the scale. 2.3.3. Affective Styles Questionnaire (ASQ) The ASQ (Hofmann & Kashdan, 2010) assesses the tendency to use three different strategies to regulate emotions: (1) adapting to the situation by re-adjusting one's emotions, (2) concealing or suppressing the emotion, and (3) tolerating and accepting emotions. In this study, the concealing subscale was used to measure emotional suppression. The ASQ has been shown to have good construct validity: the concealing subscale was largely correlated with the suppression subscale of the Emotion Regulation Questionnaire by Gross and John (2003), and the negative expressivity subscale of the Berkeley Expressivity Questionnaire (Gross, John, & Richards, 1995; Hofmann & Kashdan, 2010). The questionnaire has also been shown to have a good internal consistency (Hofmann & Kashdan, 2010). In the present study, Cronbach's alpha indicates high internal consistency (α = 0.871).
2. Method
2.3.4. Patient Health Questionnaire-9 (PHQ-9) The 9-item Patient Health Questionnaire (Kroenke & Spitzer, 2002) measures depression symptomatology. The measure has been shown to have a high level of reliability and validity as a brief measure of depression severity (Kroenke, Spitzer, & Williams, 2001). In the present study, the Cronbach's alpha (α = 0.89) indicates high internal consistency.
2.1. Design
2.4. Procedure
This is a cross-sectional, self-reported online study with a student population. The independent variable is the level of unhealthy perfectionism, and the dependent variable is emotional suppression. Beliefs about emotions are investigated as a possible mediator in the relationship between perfectionism and emotion suppression. In the second mediational analysis, emotional suppression is investigated as the mediator between unhealthy perfectionism and depression.
Data collection took place between December 2013 and February 2016. The questionnaire web link was distributed via different routes. The study was advertised online on social media sites (i.e. Facebook, Twitter), the Social Psychology Network, Psychological Research on the Net, and distributed via a research recruitment email at the authors' institution.
2.2. Participants A total of 641 participants took part (149 men and 492 women) (mean age = 21.87 years, SD = 6.52). The majority of the participants were located in the USA or Canada (n = 386, 60%). The remaining participants were from elsewhere including the United Kingdom, Singapore, Australia and Russia. Participants were studying a wide range of subjects, the most common being psychology (n = 200, 31%) and healthcare subjects (n = 72, 11%). 2.3. Materials 2.3.1. Frost Multidimensional Perfectionism Scale (FMPS) The FMPS (Frost et al., 1990) is a widely used 35-item questionnaire designed to assess different dimensions of perfectionism. This measure developed by Frost et al. was found to be highly correlated with an existing measure of perfectionism by Burns (1980) and therefore judged to have good construct validity (Hewitt & Flett, 1991). The concern over mistakes, parental criticism, parental expectations and doubts about actions subscales combined to constitute a superfactor of unhealthy perfectionism (Frost, Heimberg, Holt, Mattia, & Neubauer, 1993). In the present study, Cronbach's alpha for the unhealthy perfectionism dimension indicates high internal consistency (α = 0.921). 2.3.2. Beliefs about Emotions Scale (BES) The BES (Rimes & Chalder, 2010) assesses beliefs that it is unacceptable to experience or express negative emotions. It is a 12-item questionnaire that has been shown to have a good internal reliability and high level of validity (Rimes & Chalder, 2010). In the present study,
2.5. Data preparation and statistical analysis The data was analysed using SPSS. Only participants who had completed all of the survey items to be used for these analyses were included (n = 641). The Shapiro-Wilk test indicated that the unhealthy perfectionism variable was not normally distributed, so non-parametric correlational analyses were used. 2.6. Mediation analysis using bootstrapping The bootstrapping method was used to investigate mediation, as advocated by Preacher and Hayes (2004). Unlike some alternative methods, this does not require the assumption of normality of the sampling distribution. PROCESS for SPSS v2.15 by Andrew Hayes was used, (downloaded from http://www.afhayes.com/introduction-to-media tion-moderation-and-conditional-process-analysis.html) with 5000 bootstrapped samples and 95% confidence intervals. Indirect effects were considered significant when the bias corrected and accelerated confidence intervals did not include zero. 3. Results 3.1. Psychological characteristics and associations with gender and age The mean score for unhealthy perfectionism was 60.82 (SD = 17.44), beliefs about emotions was 48.65 (SD = 14.85) and emotion suppression was 25.41 (SD = 7.03). Independent t-tests were carried out to investigate whether there were gender differences for each of the three key variables. Results showed that there was no significant effect of gender on unhealthy perfectionism (t = −1.316, p = 0.329), beliefs about emotions (t = 0.084, p = 0.058) or emotion suppression
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L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
(t = 1.290, p = 0.080). Due to the restricted and non-normally distributed age of the sample (85% aged 16–25), associations between age and the key variables were not investigated. 3.2. Correlational findings Spearman's correlations showed that unhealthy perfectionism, unhelpful beliefs about emotions and emotional suppression were positively correlated with each other (Table 1). 3.3. Beliefs about emotions as mediator of the relationship between perfectionism and suppression The direct effect of unhealthy perfectionism on emotional suppression was not statistically significant (b = 0.3; CI = − 0.0055, 0.066). The effect of unhealthy perfectionism on beliefs about emotions was significant (b = 0.51, p b 0.0005), as was the effect of beliefs about emotions on emotional suppression (b = 0.17, p b 0.0005) (Fig. 1). The indirect effect of unhealthy perfectionism on emotional suppression was positive and statistically different from zero, as evidenced by a 95% bias-corrected bootstrap confidence interval that is entirely above zero (b = 0.09; CI = 0.065, 0.11). Therefore, this is consistent with the hypothesis that unhealthy perfectionism is associated with emotion suppression through beliefs about the unacceptability of negative emotions. The total of the direct and indirect effect of unhealthy perfectionism on emotional suppression was significant (b = 0.12, p b 0.0005). When unhealthy perfectionism and beliefs about emotions were entered into the model simultaneously, only beliefs about emotions (t = 8.17, p b 0.0005), and not unhealthy perfectionism (t = 1.66, p = 0.098), was significantly associated with emotion suppression (F(2641)= 66.2, p b 0.0005, R2 = 0.17). 3.4. Mediation of the relationship between perfectionism and depression Using PROCESS to investigate the mediation model, results showed that the indirect pathway between unhealthy perfectionism on depression, via emotional suppression was significant (b = 0.15; CI = 0.0071, 0.0263). 4. Discussion The results of this cross-sectional study suggest that beliefs about emotions mediate the relationship between unhealthy perfectionism and emotion suppression. When both unhealthy perfectionism and beliefs about emotions were entered simultaneously into the model, only beliefs about emotions was a significant predictor of emotional suppression. These results are consistent with the hypothesis that individuals with unhealthy perfectionist beliefs are more likely to have negative beliefs about emotions, leading to emotion suppression. Furthermore, the study also suggests that emotional suppression mediates the relationship between unhealthy perfectionism and depressive symptomatology. The findings that unhealthy perfectionism is associated with beliefs about the unacceptability of experiencing negative emotions replicates the previous finding by Rimes and Chalder (2010), but this time in a student sample. This is the first evidence showing that beliefs about the unacceptability of experiencing/expressing negative emotions may be a
Fig. 1. Mediation model for unhealthy perfectionism and emotional suppression showing unstandardised coefficients. ***p b 0.0005.
mediator in the relationship between unhealthy perfectionism and emotional suppression. The reason may be because unhealthy perfectionism is related to avoidance coping strategies, such as disengagement and denial, as discussed by Dunkley et al. (2000). Thus, it is possible unhealthy perfectionists are more likely to suppress distressing emotions as an avoidance coping strategy. Future therapy for depression or other conditions involving unhealthy perfectionism could be targeted at reappraising an individual's beliefs about their emotions. Cognitive behavioural therapy (CBT) addresses the thoughts and behaviours maintaining psychological disorders. Evidence suggests that CBT can be effective at treating unhealthy perfectionism (Egan et al., 2014). By understanding what mediates between unhealthy perfectionism and its consequences, i.e. emotion suppression, CBT can be utilised to even greater effect by targeting it at the negative beliefs about emotions that is thought mediate this relationship. It is important to note some study limitations. Firstly, the sample was a student population, and thus, results cannot be generalised to non-students or a clinical population who are seeking help for unhealthy perfectionism. Secondly, finding a statistically significant indirect effect that supports the mediation hypothesis does not necessarily prove the pattern of causation indicated in the figures. The data collected was cross-sectional and therefore it cannot be ruled out that other causal relationships between these variables are possible. Thirdly, a high proportion of the participants were medical students. The perfectionism profile amongst medical students is distinct from that of non-medical students (Enns, Cox, Sareen, & Freeman, 2001). The implications are that the data collected may be skewed towards the perfectionist traits specifically found in medical students. There were also a high proportion of psychology students, some of whom may be familiar with the study concepts. This study indicates that beliefs about the unacceptability of negative emotions only accounts for a moderate amount of the variance in emotional suppression. Other factors that could be affecting an individual's tendency to suppress their emotions were not investigated. Future research could explore other factors that may mediate the relationship between unhealthy perfectionism and emotion suppression.
Table 1 Bivariate correlation using Spearman's coefficient (r) between unhealthy perfectionism, beliefs about emotions, emotion suppression and depression. **Significant at the 0.01 level.
Unhealthy perfectionism Beliefs about emotions Emotional suppression Depression
Unhealthy perfectionism
Beliefs about emotions
Emotion suppression
Depression
1
0.56** 1
0.26** 0.38** 1
0.47** 0.45** 0.27** 1
L. Tran, K.A. RimesPersonality and Individual Differences 110 (2017) 144–147
Despite its limitations, this study makes important contributions to the literature by confirming a link between unhealthy perfectionism and emotion suppression, via negative beliefs about emotions. It also shows that emotion suppression is a mediator in the relationship between unhealthy perfectionism and depression. The knowledge garnered from this study may be helpful when treating those with unhealthy perfectionism to ensure therapy is being targeted at these areas of emotional processing to reduce outcomes such as depression. By understanding the links between perfectionism, beliefs about emotions, emotion suppression and depression, researchers and clinicians can help to appreciate and recognise the reasons why perfectionists may suppress their emotions and help individuals address their emotional coping responses to prevent other potential psychological disorders. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical Statement Ethics approval was granted by the Psychiatry, Nursing & Midwifery Research Ethics Subcommittee (PNM RESC) within the Research Committee at King's College London (REF: PNM/13/14-39). Data was collected via ‘SurveyMonkey’, an online survey tool. An information sheet outlining the details of the study to participants, along with consent form was placed at the start of the survey. Acknowledgements There was no funding required for this study. We would like to thank all the participants for taking the time to complete the questionnaires for this study. References Aldea, M. A., & Rice, K. G. (2006). The role of emotional dysregulation in perfectionism and psychological distress. Journal of Counseling Psychology, 53(4), 498. Bergman, A. J., Nyland, J. E., & Burns, L. R. (2007). Correlates with perfectionism and the utility of a dual process model. Personality and Individual Differences, 43(2), 389–399. Burns, D. D. (1980). The perfectionist's script for self-defeat. Psychology Today, 14(6), 34–52. Dunkley, D. M., Blankstein, K. R., Halsall, J., Williams, M., & Winkworth, G. (2000). The relation between perfectionism and distress: Hassles, coping, and perceived social support as mediators and moderators. Journal of Counseling Psychology, 47(4), 437.
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