Interpersonal emotion regulation as a mechanism of social support in depression

Abstract

Although social support is widely considered to be protective against depression, the mechanisms through which it acts on depressive psychopathology are not well known. This integrative review argues that emotion regulation serves as such a mechanism. First, the literature on the effects of social support on depression is reviewed, with an emphasis on open empirical questions regarding mechanisms linking support and depression. Then, the literature on emotion regulation is reviewed, highlighting its importance as a mechanism in the psychopathology of depression. Finally, potential interpersonal influences on depressive emotion regulation and dysregulation are suggested, drawing from theory and research on psychotherapy and on close relationships. The review suggests that emotion regulation is responsive to interpersonal influences, and that this responsiveness may account for the effects of social support on depression. Implications of an interpersonal perspective for basic and clinical research on depression, close relationships, and emotion regulation are discussed.

Introduction

Depression is one of the most prevalent psychiatric disorders, and in addition to being a profoundly disabling condition for individuals and families, its annual cost to societies is in the tens of billions of dollars (Judd et al., 2000, Kessler et al., 2005, Wang et al., 2003). The last several decades have seen historic improvement in therapies for major depression, due to advances in pharmacological science and clinical psychology. In many cases, however, depression remains an intractable problem, and efforts at prevention and treatment leave ample room for improvement (e.g., Dimidjian et al., 2006, Muñoz et al., 2010). Prevention and treatment of depression have been driven by cognitive and behavioral models of depressive psychopathology, and these models have tended not to emphasize the interpersonal context of the development, onset, and course of depression. Models that do emphasize interpersonal factors indicate that the individual-level pathology of depression interacts dynamically with the social environment in ways that sustain or exacerbate pathology (e.g., Hammen, 1991, Joiner et al., 1999). These approaches have highlighted maladaptive mechanisms, focusing less explicitly on adaptive interpersonal effects.

In contrast, a large body of work in epidemiology and in social and health psychology has examined the ways in which social relationships provide support in times of adversity, and there is now unambiguous evidence that relationships are positively related to both physical and mental health, including depression (Cohen, 2004, Cohen et al., 2000, House et al., 1988, Seeman, 1996). Despite the clear importance of social effects on health, however, the mechanisms through which the social world influences health are largely unclear. This gap in understanding is particularly large with respect to depression and other psychopathology. Although it is generally acknowledged that depression and other mental disorders exist within a social context, researchers and clinicians know more about intrapersonal mechanisms of pathology than they do about mechanisms that explain how social relationships “get under the skin” to influence individual pathology. In light of evidence that environmental factors – including social support – play important roles in the etiology, course, and treatment of depression, such mechanistic understanding is needed.

This review proposes that the often-neglected interpersonal aspects of emotion regulation represent such a mechanism of social support. In basic social psychology, research on the ways that people regulate their emotions has exploded in recent years. In clinical science, this work has motivated proposals that emotion dysregulation represents a core component of much psychopathology, including depression (Kring & Sloan, 2010). Both lines of work have recognized a social context, but there has been little empirical discussion of how social relationships influence intrapersonal emotion regulation in either healthy or depressed individuals. This neglect is inconsistent with the increasingly accepted view that interpersonal factors are indispensable components of understanding human psychology across mental domains (Reis & Collins, 2004). Examining interpersonal influences on emotion regulation has the potential to improve understanding of both the relational context of depression and the mechanisms through which social support acts on mental health at the individual level.

This paper reviews several mostly independent literatures, and suggests that they can profitably be integrated to elucidate social influences on depression and other psychopathology. First, I review the literature on social support and depression, focusing on the open questions of social support mechanisms. Second, I review the basic literature on emotion regulation as a system of response to the environment, emphasizing the emerging understanding of emotion dysregulation in depression. Third, I suggest that emotion regulation is subject to several interpersonal influences, and that these influences may account for the effects of social support on depression. Fourth, I examine whether these influences occur in close relationships, as would be expected if they represent important support mechanisms. Finally, I propose that by viewing emotion regulation (and dysregulation) within an interpersonal context, researchers can better understand both the interpersonal context of depression pathology and the fundamental mechanisms through which the social world influences mental health. Throughout this paper, it is acknowledged that the review of each specific literature is necessarily selective; each section thus includes direction toward more comprehensive reviews of its particular literature.