MLS PSYCHOLOGY RESEARCH www.mlsjournals.com/ Psychology-Research-Journal ISSN: 2605-5295

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Sánchez Alonso, J. (2021). Drogodependencia y desregulación emocional: una revisión sistemática. MLS Psychology Research 4 (1), 59-78. doi: 10.33000/mlspr.v4i1.597.

Javier Sánchez Alonso
Universidad Europea del Atlántico (Spain)
javier.sanchez1@alumnos.uneatlantico.es

Abstract. Introduction: Emotional regulation has been linked to a large number of mental disorders. Its definition has had some controversy and distinctions according to the author. Two explanatory models of emotional regulation are provided: the emotional regulation process model and the emotional regulation model based on emotional processing. Likewise, the relationship of this ability with the consumer population and the current state of consumption in Spain are explained. The objective of this study is to study the most recent scientific information, evaluate the usefulness of emotional regulation for prevention and intervention in drug addicts, and more specifically, identify and analyze the existing relationship, the evaluative techniques, and the sample used. Method: The selection of articles has been made from 2016 to 2020, these being related to emotional regulation and the drug dependent population. Searches were carried out in Scopus and Psycinfo, using the following terms: "emotional regulation" AND "drug addiction". Results: Of the total number of potential articles, 20 were selected that met the established inclusion and exclusion criteria. Numerous beneficial relationships between emotional regulation and drug addicts stand out, focusing the research found in adult populations. Likewise, a series of instruments used for the evaluation of the emotional regulation. Discussion: In this review it is concluded that emotional regulation has a great influence on the drug-dependent population, obtaining numerous benefits from its development, which are given at a level of both prevention and intervention.

Keywords: emotional regulation, emotional intelligence, drug dependence, addiction, systematic review.

Introduction

Emotional regulation (ER) is key in various disorders such as addictions, self-injurious behaviors, mood disorders, or anxiety disorders, being found in these dysfunctional regulation strategies (McNally, Palfai, Levine, & Moore, 2003; Gratz, 2003). In general, a person with less capacity to regulate his emotions will present difficulties in his daily life, appearing together with these psychological disorders; this is because emotions have an adaptive function to the environment, facilitating decision making and preparing the individual to act (Gross, 1999).

When analyzing the publications related to this topic, a marked increase can be seen in recent years. As can be observed in Figure 1, the published documents related to emotional regulation have a gradual increase in the last 20 years, indicative that there is a greater interest in what concerns this topic.

Figure 1. Documents by year published with the term "emotional regulation" in the area of psychology in the last 20 years. Copyright 2020 by Scopus.

In Figure 2, an increase in the interest of the ER related to substance addiction is observable, the increase in this case is not as marked as in the previous one, but it continues to show a tendency to grow.

Figure 2. Documents published by year with the terms "emotion regulation" and "drug addiction" in the area of psychology in the last 20 years. Copyright 2020 by Scopus.

Thompson (1994) and Gross (1999) agree that ER consists of the control or management of our emotions; such management can be functional or dysfunctional. In addition to the above, emotion regulation can be understood as the key process of emotional intelligence (E.I.) (Brenner & Salovey, 1997; Extremera, Durán, & Rey, 2005; Jiménez & López-Zafra, 2008; Pérez & Castejón, 2006), this aspect makes certain authors refer to both concepts as similar, although to be exact, ER should be included as a skill within EI. There are four levels of interaction between behavior and emotion, being factors of great importance when carrying out functional and adaptive behaviors:

• The perception, evaluation, and expression of emotion.
• The facilitating effect of emotions with respect to thinking.
• The understanding and analysis of emotions using emotional knowledge.
• Reflective regulation of emotions to promote intellectual and emotional growth.

There are several explanatory models of ER; in this review, two models stand out: the Process model of emotional regulation (Gross, 1999) and the Emotional regulation model based on emotional processing (Hervás, 2011). The selection of these two models, over others, is because they encompass the characteristics of ER, complementing each other.

The process model of emotional regulation (Gross, 1999)

This author differentiates several phases: Situation-Attention-Interpretation-Response. Emotional regulation strategies can be established according to the phase in which one finds oneself. Gross (1999), differentiates regulation focused on the antecedents of the emotion, and regulation focused on the emotional response.

In the first phase, people can choose or avoid different situations based on our previous experiences, preferably choosing situations that provoke positive emotions. In addition, within the situation itself, the person can choose the path he or she wishes to take.

Regarding attention, it has been seen that the attentional focus has a great relevance in the emotional response of the person. Research has corroborated that this attention can be trained and automated using very few cognitive resources (Wadlinger & Isaacowitz, 2011).

Interpretation is the phase on which most therapies have focused by working on emotional regulation, through cognitive reappraisal, demonstrating its influence on the subsequent emotional response.

Finally, there is the emotional response; in this case, we can work on various aspects such as emotional experience, behavioral expression/manifestation, or physiological activation. At the clinical level, the aim is to reduce the psychobiological level of the emotion.

Several limitations have been highlighted around this model, among them: nothing is said about emotional acceptance as an emotional regulation strategy, when it has widely demonstrated its positive effects (e.g., Alberts, Schneider, & Martijn, 2012; Liverant, Brown, Barlow, & Roemer, 2008). Second, the way in which Gross poses this model can lead to elaborate maladaptive behaviors, mostly focused on avoidance.

Emotional regulation model based on emotional processing (Hervás, 2011).

There are authors who defend that in order to regulate emotions, an active process of understanding and elaboration of the emotion is necessary (Hunt, 1998).

Stanton, Kirk, Cameron, and Danoff-Burg (2000), integrate emotional processing as a type of emotional coping, considering the latter as the ability to cope with a high intensity emotion. This study differentiates between emotional expression, considering it as the ability to recognize the emotion and express it through a corresponding behavior; and emotional processing, as the ability to know and understand the emotion.

This model argues that emotional processing is not only valid for high intensity emotions, but that it has positive effects for any situation, establishing six phases necessary for optimal emotional processing.

• Emotional openness. Ability to be aware of your emotions.
• Emotional attention. A range of attentional resources must be devoted to emotion (Gratz & Roemer, 2004; Salovey, Mayer, Goldman, Turvey & Palfai, 1995).
• The first two phases can be related to Gross's (1999) stage of attention.
• Emotional acceptance. Avoid making a negative judgment about the emotion (Gratz & Roemer, 2004).
• Emotional labeling. A person's ability to recognize what he or she feels and put a "name" to it (Gratz & Roemer, 2004; Salovey et al., 1995).
• Emotional analysis. A person's ability to understand what he or she is feeling and to reflect on it (Stanton, Kirk, Cameron & Danoff-Burg, 2000).

In this phase, there are a series of elements to be analyzed: first of all, the origin, that is, where the emotion comes from; then it is necessary to understand why it has appeared, that is, what it means. Many times emotions are activated through a series of mechanisms by mistake, it is necessary to observe if the emotion is coherent in the situation experienced; and, finally, if the emotion is coherent, it is necessary to learn from it.

6. Emotional modulation. Using various strategies to manage the emotion felt (Gratz & Roemer, 2004; Salovey et al., 1995).

Regarding its relationship with drug dependence, the study conducted by Fernández, Jorge & Bejar (2009) revealed that both substance abuse and consumption is used as an external self-regulation technique, i.e., as a way of relieving negative emotional states. This is also appreciable in the research carried out by Echeburúa & Corral (1999), in which it was found that a person who presents a dependence or addiction would tend to perform the behavior in question, in order to reduce the negative emotional states present.

Taking into account the aforementioned results, it can be inferred that addicts lack essential tools such as how to discriminate between emotions, how to express and regulate them, as well as how to guide their thinking and behavior; these tools would be very useful to this group in order to face their problematic consumption.

In Spain, one of the latest carried out surveys on alcohol and drugs (EDADES Study 2017-2018) identifies that the age of onset of consumption is less than 13 years, although the average age of consumption would be at 32 years. Likewise, there is an increase in legal drugs such as alcohol and tobacco, and with regard to non-legal drugs, it is worth highlighting the increase in cannabis consumption, especially in adolescents and young adults. All of this shows the importance of providing help for this problem, both in terms of prevention and intervention.

It is true that the study on the relationship between EI and substance addiction is still recent; however, there are studies that seem to indicate and affirm that such intelligence intervenes in a positive way in its relationship with addictions. Apart from the aforementioned studies, it is worth highlighting significant studies such as the following:

• The study on EI and alcohol conducted by Petterson, Malouff & Thorsteinsoon, (2011) in which significant type relationships were found between a low level of emotional intelligence and high consumption.
• The research on cocaine use conducted by Aranda, González, Salguero, Gualda & Herero (2009), it was concluded that EI acts as a direct protective factor against cocaine use.
• The article on legal drug use by Trinidad & Johnson (2002), in which it was observed that EI correlates negatively with substance use, adding also that adolescents with high EI are more able to resist peer pressure.

Con las conclusiones antes mencionadas, se puede ver la importancia que tiene la inteligencia emocional en las drogodependencias, así como el papel tan importante que llega a tener una regulación emocional adecuada.

Teniendo en cuenta todos los aspectos revisados en relación a la R.E. y las drogodependencias, este trabajo presenta los siguientes objetivos:

General objectives:

• Study the most recent scientific information on the subject in question, in order to provide a clear current view of addictions and the possible aspects that may be of help for this problem.
• Evaluate the usefulness of emotional regulation for both prevention and intervention with drug addicts.

Specific objectives:

• Identify the relationship between emotional regulation and substance abuse.
• Know the different techniques for the evaluation of emotional regulation and analyze the most used ones.
• Analyze the groups of participants based on age and gender.

Method

Two databases, Psycinfo and Scopus, were used to search for articles with the following search terms: "emotional regulation" and "drug addiction." In this review, the following inclusion and exclusion criteria were applied in the selection of articles.

Criteria that had to be met in order to be included are:

• Published in the last 5 years, 2016-2020
• Original studies
• Academic publications
• Articles in English or Spanish
• An investigation in which emotional regulation was evaluated in order to look for a relationship with drug dependence.
  As exclusion criteria, it was established that articles would not be included:

  • Whose analyzed population was not that of drug-dependent patients.
  • That they were not finished.

Results

Considering Table 1, the total number of evaluated participants amounts to 6874, counting the smallest sample with only 10 participants (Sloan, Hall, Simpson, Youssef, Moulding, Mildred, & Staiger, 2018) and the largest sample with 2080 participants (Bakhshaie, Rogers, Kauffman, Tran, Buckner, Ditre & Zvolensky, 2019). Of the total there are 3755 females (54.64%) and 3118 males (45.36%). It is worth noting that there are both articles in which the sample is represented only by females (Hardy, Fani, Jovanovic, & Michopoulos, 2018), and studies only consisting of males (El-Rasheed, ElAttar, Elrassas, Mahmoud & Mohamed, 2017; Jalali, Hashemi, Hasani, & Fakoor Sharghi, 2017; Jauregui, Estevez, & Urbiola, 2016; Kumar, Kumar, Benegal, Roopesh, & Ravi, 2019; Zohreh & Ghazal, 2018).

In relation to age, three age groups were differentiated: adolescents (under 18 years), young adults (18-29 years) and adults (30-65 years). It was observed that most of the research is aimed at an adult population (60%), a smaller proportion at the young adult group (35%) and, finally, one study was presented with adolescents (5%) (Estevez, Jáuregui, Sanchez-Marcos, López-González, & Griffiths, 2017).

About the total number of instruments 22 were identified, almost all of them are specific to emotional regulation, except one of them where it is assessed indirectly (4.5%) through the "Toronto Alexithymia Scale-20" (TAS-20) (El-Rasheed, ElAttar, Elrassas, Mahmoud & Mohamed, 2017). Six instruments used are distinguished: "Difficulties in Emotion Regulation Scale" (DERS) (59.2%); "Emotion Regulation Questionnaire" (ERQ) (18.3%); "The Positive Affect Negative Affect Scale" (PANAS) (4.5%); "Regulatory Emotional Self-Efficacy scale" (RESE) (4.5%); "Cognitive Emotion Regulation Questionnaire" (CERQ) (4.5%); "Affect Regulation Checklist" (ARC) (4.5%).

Regarding the relationship observed, we studied consumer populations with addictions to various substances such as opioids, alcohol, cannabis, cocaine and non-substantial addictions such as Internet, video games or gambling. In all of them, an improvement in E.R. brought them benefits such as:

• An improvement during rehabilitation (such as in experienced well-being and a reduction in relapses).
• A lower frequency of subsequent consumption.
• Anxiety and stress reduction.
• Decrease in depression in the consumer population.
• Improvement of eating problems associated with consumption.
• Increased self-esteem and self-control.

In general, the ER has relevance and influence both at the beginning of consumption, as well as in the severity of addiction and subsequent progression; therefore, a preventive, rehabilitative, maintenance, and of intervention function is appreciated.

Discussion and conclusions

Taking into account the situation of the last few years of consumption in our country of both legal and non-legal drugs, there is a problem that is increasing, and that has increased even more due to the pandemic that we are experiencing, which has triggered consumption. Therefore, it is important to seek new ways to prevent and intervene in addictions and, of these, working with the ER is a key factor, since the consuming population stands out for having difficulties to control their emotions and uses drugs to make up for the shortcomings at this level.

Regarding the differences in the year 2020 in Figure 1 and Figure 2, in the introduction section, it should be noted that the number of articles in both graphs seems to drop significantly. This is understandable due to the pandemic experienced during this year that has caused, on the one hand, a reduction in the number of studies in general, and on the other hand, these studies are focused on consequences caused by confinement.

After the analysis of the 20 selected articles, it is observed that, by working emotional regulation in the addictions collective, such people obtain a series of benefits. These benefits seem to be of great importance, improving both the intervention and subsequent rehabilitation (Dingle, Neves, Alhadad & Hides, 2018). All this is related to the fact that people who present an addiction, whether substantial or non-substantial, tend to use consumption as a way to regulate their emotions, mainly in particularly stressful moments in their lives (Estevez, Jáuregui, Sanchez-Marcos, López-González, & Griffiths, 2017). Because of this, ER would allow increasing the number of tools of this group and would promote regulation skills that would replace consumption, avoiding the subsequent development of addiction and the related consequences.

The benefits found include self-control, reduction of stress, depression, and anxiety and as a result of the above, a lower frequency of consumption as indicated by the results (El-Rasheed, ElAttar, Elrassas, Mahmoud & Mohamed, 2017; García, Luque, B., Ruiz, & Tabernero, 2017; Jalali, Hashemi, Hasani, & Fakoor Sharghi, 2017; Kumar, Kumar, Benegal, Roopesh, & Ravi, 2019). These benefits are particularly important in the early stages of the problem, leading to greater control over the addiction and a reduction in the severity of subsequent damage; and in the intervention, being related to an increase in the effectiveness of the intervention (although this should continue to be studied in future research). It should be noted that only in the research by Decker, Morie, Hunkele, Babuscio, & Carroll (2016), a relevant influence of emotional regulation in cocaine addicts was not found. In the same article, it is mentioned that more research is needed, but that it seemed to indicate that emotional regulation was not as relevant as in other addictions, for example, opioids, alcohol, gambling disorders, among others.

In this review, a wide range of instruments to assess emotional regulation has been observed, but of all of them the most employed were the DERS and the ERQ. A brief description of the two tests mentioned will be given below:

• DERS (Gratz & Roemer, 2004). It is a 36-item questionnaire, whose purpose is the evaluation of the global capacity that the person presents to respond adaptively to distressing emotions in life. It focuses on six domains: (a) lack of emotion acceptance; (b) inability to perform certain behaviors in the face of negative emotions; (c) impulsive behaviors in the face of negative emotions; (d) limited access to effective emotional regulation strategies; (e) lack of emotional awareness; and (f) lack of emotional clarity. The DERS has been shown to be sensitive to change over time (Gratz & Gunderson, 2006), exhibiting good test-retest reliability, (Gratz & Tull, 2010) and exhibited high internal consistency (α = .951), in research by Fisher, Atzil-Slonim, Bar-Kalifa, Rafaeli, & Peri, (2019).
• ERQ (Gross & John, 2003). Questionnaire consisting of 10 items, it aims to measure two emotional regulation strategies, suppression (4 items) and reappraisal (6 items) on a 7-point Likert-type scale. Adequate validity and reliability of the test has been observed in reviews (Sánchez, González & Adánez, 2020).

After the exposed characteristics, it is understandable that they tend to be the most used, being adequate instruments for the evaluation of ER (Sánchez-Teruel & Robles-Bello, 2018; Guzmán-González, Trabucco, Urzúa, Garrido & Leiva, 2014).

The limitations found in this study are mentioned below. Firstly, the studies found do not focus on the elderly, and there is only one study on adolescents; therefore, part of the general population is not reflected in this review. This is because many of the studies found did not work with this type of sample and others, despite having a sample of this type, it did not work on ER directly but acted as a secondary factor, which is why it was not included in this review.

Likewise, this review has focused on articles written in English or Spanish. Research written in other languages may yield new information on the topic addressed.

In general, emotional regulation is an essential mechanism to maintain a functional and adaptive behavior, especially for problems such as addictions, whose central axis are emotions and their mismanagement, mainly derived from a lack of tools or strategies to manage them properly, reaching, for example, the use of drugs as a mechanism to reduce negative emotions.

This review concludes that emotional regulation has a great influence on the drug-dependent population, obtaining from its development numerous benefits, which occur at a level of both prevention and intervention, so that working with this skill is essential to reduce both the incidence and collateral damage of this problem. In addition to this, when analyzing the evaluative techniques used, it can be appreciated that these have a correct scientific support, allowing an adequate and professional analysis of the ER in the sample.

Regarding future lines of research, it is recommended to use samples with both adolescent and elderly populations to observe whether the same problems occur and whether emotional regulation plays a greater role. Similarly, they should focus on the use of ER in aspects of primary prevention, and how the promotion of these abilities can help to avoid later addictions.

Another aspect to highlight is that articles strictly pertaining to psychology have been used. Articles from other areas of interest should be taken into consideration, which may shed new light on this topic, such as those pertaining to neurosciences, in which case future reviews/research should be carried out to observe the involvement of emotional regulation in the brain, both in the population with and without addiction.

Finally, it is considered necessary to improve drug dependence intervention programs focused on improving emotional regulation skills, which would allow the implementation of more complete and effective interventions to address this problem.

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