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Contents lists available at ScienceDirect

Journal of Aective Disorders

journal homepage: www.elsevier.com/locate/jad

Acceptance alone is a better predictor of psychopathology and well-being 0$5.

than emotional competence, emotion regulation and mindfulness

Ilios Kotsoua, , Christophe Leysb, Pierre Fossionc
a
Faculty of Psychology, Universit Libre de Bruxelles, Brussels, Belgium & Chaire Mindfulness, Bien-Etre au travail et Paix conomique, Grenoble Ecole de Management,
France
b
Faculty of Psychology, Universit Libre de Bruxelles, Brussels, Belgium
c
Brugmann Hospital, Universit Libre de Bruxelles, Brussels, Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Emotional competence, emotion regulation, mindfulness and acceptance have all been strongly associated to
Anxiety emotional disorders and psychological well-being in multiple studies. However little research has compared the
Depression unique predictive ability of these dierent constructs. We hypothesised that they will all share a large proportion
Acceptance of common variance and that when compared to the broader constructs emotional competence, emotion reg-
Emotional competence
ulation and mindfulness, acceptance alone would predict a larger proportion of unique variance
Emotion regulation
Methods: 228 participants from a community sample completed anonymously measures of anxiety, depression,
Mindfulness
happiness, acceptance, mindfulness, emotional competence and emotion regulation. We then ran multiple re-
gressions to assess and compare the predictive ability of these dierent constructs.
Results: For measures of psychological distress, the acceptance measure uniquely accounted for between 4 and
30 times the variance that the emotional competence, emotion regulation and mindfulness measures did.
Limitations: These results are based on cross-sectional designs and non-clinical samples, longitudinal and ex-
perimental studies as clinical samples may be useful in order to assess the potential protective power of ac-
ceptance over time. Another limitation is the use of self-report questionnaires.
Conclusions: Results conrmed our hypothesis, supporting the research on the importance of acceptance as a
central factor in the understanding of the onset and maintenance of emotional disorders.

1. Introduction disorders. A well-established one is conceptualised as emotional com-

For after all, the best thing one can do when it is raining is let it
rain.
Longfellow (1906)
Psychological health is a central issue in our societies. According to
a recent systematic review and analysis encompassing data from 63
countries, one in ve respondents reported a disorder in the year pre-
ceding the assessment, and almost a third of the respondents have ex-
perienced a psychological health disorder some time in their life (Steel
et al., 2014). Lifetime prevalence of emotional disorders, such as an-
xiety or depression, is considered as high as 29%, for anxiety or 21% for
mood disorders (Kessler et al., 2005). In this paper, psychological
health is dened both by it pathological dimension (measured by three
indexes of emotional disorders: anxiety, depression and stress) and its
positive dimension, measured by happiness.
There are several empirically based predictors of emotional
petence (Petrides et al., 2016). Emotional competence (EC) refers to
individual dierences in the way individuals are able to identify, un-
derstand, regulate, and use their emotions (Mikolajczak, 2009). A high
level of emotional competence is related to improved psychological and
physical health (Martins et al., 2010).
Emotion regulation is one of the EC that has received extensive
attention (Gross, 2002) and there is strong evidence that anxiety, de-
pression and stress are multifactorial disorders that are at least partly
linked to maladaptive emotion regulation patterns (Cisler and Olatunji,
2012; Joormann and Gotlib, 2010). Acceptance and mindfulness are
two other well-studied predictors. Meta-analysis has shown that ac-
ceptance has a positive eect on various indicators such as anxiety,
depression or addiction (A-tjak et al., 2015). Conversely, a meta-ana-
lysis has shown that mindfulness-based therapy can be considered as an
eective intervention for treating anxiety and depression (Goyal et al.,
2014).
Because EC, emotion regulation, mindfulness and acceptance all

Correspondence to: Department of Psychology, Universit Libre de Bruxelles, Avenue F.D. Roosevelt 50, 1050 Bruxelles, Belgium.
E-mail address: ilios.kotsou@ulb.ac.be (I. Kotsou).

http://dx.doi.org/10.1016/j.jad.2017.09.047
Received 28 March 2017; Received in revised form 22 June 2017; Accepted 24 September 2017
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I. Kotsou et al. -RXUQDORI$IIHFWLYH'LVRUGHUV

seem to be eective but oer dierent perspectives on emotions and
psychological health, we wanted to compare their respective ability to
predict symptom severity (stress, anxiety, depression) and psycholo-
gical well-being (happiness). To our knowledge, no prior study has
examined this issue yet.
A growing body of research is now suggesting that acceptance is a
central trans-diagnostic process that explains a large proportion of
variance in diverse mood disorders (Kashdan et al., 2006). Following
Hayes and colleagues psychological exibility model, acceptance can
be seen as a trans-diagnostic process that is central in psychopathology
(Hayes et al., 2006). Therefore, we hypothesised that acceptance would
have a unique incremental predictive validity over the three other
predictors (mindfulness, emotional competence and emotional regula-
tion). We hypothesised that a) the four predictors combined will sig-
nicantly predict psychopathology and psychological well-being, b)
each of the four predictors will separately predict psychopathology and
psychological well-being, c) all 4 predictors will share important
common variance, but compared to the three other processes, accep-
tance will predict a larger proportion of unique variance.
Attention Awareness Scale (Jermann et al., 2009). The MAAS is a 15-
item ( = 87) instrument measuring the general tendency to pay at-
tention to present-moment experiences in daily life (which can be
considered to be one of the dimensions of the multidimensional con-
struct of mindfulness), using a 6- point Likert-type scale (almost always
to almost never).
Emotional competence (EC-T) was assessed with the Prole of
Emotional Competence (PEC; Brasseur et al., 2013). The PEC is a 50-
item ( = 91) tool that measures 10 facets of Emotional competence.
The scale can also be used with a single score.
Emotion regulation was measured with one of the PEC subscales,
Regulation of own emotions (ER), which consisted of 5 items ( =
75) As described in the introduction, this measure is supposed to be an
important predictor of psychopathology and well-being, and thus it was
of particular interest to us.
3. Results
3.1. Correlations

2. Method Descriptive statistics are provided in Table 0 in Supplemental ma-

terials. Pearson's Correlations are reported in Table 1. We used SPSS 24
2.1. Participants for all analysis. As predicted, all four predictors correlate signicantly
with psychopathology namely anxiety, depression and stress - and
Participants were recruited by an internet announcement posted by positively with happiness, and each association was in the predicted
a non for prot organization that organizes mindfulness interventions. direction.
The sample consisted of 228 participants (175 women, 53 men) from a
French-speaking community sample. The participants were 2569 years 3.2. Multiple regression analysis
of age (mean age = 43.70 years, SD = 10.04). 67% were living with a
partner, 33% were single. 63% had a high level of education (master or We then ran multiple regressions to assess the total variance (R2)
higher). that could be attributed individually to the four centered predictors. In
accordance with our hypothesis, we then separately compared AAQ
2.2. Procedure with each of the three others predictors, the total EC-T, ER and MAAS
with HADS-A, HADS-D, PSS and SHS as dependent variables. We
Ethical standards related to privacy, anonymity and informed con- wanted to assess the overlap in prediction between the variables (the
sent, in accordance with the ethics code of American Psychological common variance) and the unique contribution in variance that can be
Association, were respected. The questionnaires were completed in attributed to each construct, above and beyond the other factors (sr2).
French anonymously online and the participants were given no re- When introduced individually in regression analysis, MAAS and
tribution for participation in order to avoid the risk of undue induce- HADS-A, R2=.15 [.07;.23]; MAAS and HADS-D, R2=.07 [.01;.13];
ment. Participants were voluntary, they were aware they were parti- MAAS and PSS, R2=.22 [.13;.31]; and MAAS and SHS, R2=.07
cipating in a study and could withdraw from the questionnaire at any [.01;.13]. We did the same analysis for EC-T and HADS-A, R2=.08
time. The study received the authorisation of the ethical committee of [.01;.15]; EC-T and HADS-D, R2=.07 [.01;.13]; EC-T and PSS, R2=.15
the university. [.07;.23]; and EC-T and SHS, R2=.12 [.04;.20]. Then we computed the
regression for ER and HADS-A, R2=.17 [.08;.26]; ER and HADS-D,
2.3. Materials R2=.10 [.03;.17]; ER and PSS, R2=.25 [.15;.35]; and ER and SHS,
R2=.21 [.12;.30]. Lastly we computed regression between AAQ and
Anxiety and depression. Anxiety and depression were measured HADS-A, R2=.31 [.21;.41]; AAQ and HADS-D, R2=.24 [.14;.34]; AAQ
with the HADS, Hospital Anxiety and Depression Scale (Bocran and and PSS, R2=.39 [.29;.49]; and AAQ and SHS, R2=.44 [.34;.54].
Dupret, 2014). The HADS comprises fourteen items: seven items ( = We then systematically compared AAQ to the total score of EC-T,
77) assessing anxiety (HADS-A) and seven items ( = 79) measuring
depression (HADS-D). Each item is coded from 0 to 3, giving a score Table 1
varying between 0 and 21 for each scale. Variable characteristics.
Stress. Perceived stress was evaluated via the Perceived Stress Scale
Variables n M SD Skewness Kurtosis
(PSS; Cohen et al., 1983). The PSS is a 10-item scale ( = 87) designed
to measure the degree to which individuals appraise their life as HAD-A 228 1.43 .56 .77 .11 .54
stressful. HAD-D 228 .78 .49 .79 .77 .29
Happiness. Happiness was assessed using the SHS, the French ver- PSS 228 2.06 .62 .87 .08 .42
SHS 228 4.33 1.24 .89 .29 .51
sion of the Subjective Happiness Scale (Kotsou and Leys, 2017). The
AAQ 228 3.87 1.18 .90 .05 .25
measure is composed of 4 items ( = 89) scored on a 7-point Likert- MAAS 228 3.34 .74 .87 .13 .66
type scale and provides a general assessment of whether one is a happy EC-T 228 3.31 .45 .91 .05 .03
or an unhappy person. ER 228 2.59 .74 .75 .20 .38
Acceptance. The Acceptance and Action Questionnaire (AAQ-II) was
HADS-A = Hospital Anxiety and Depression Anxiety Subscale, HADS-D = Hospital
used to asses acceptance (Bond et al., 2011). It is a 7-item ( = 90)
Anxiety and Depression Subscale, PSS = Perceived Stress Scale, SHS = Subjective
measure scored on a 7-point scale (1 = strongly agree, 7 = strongly Happiness Scale, AAQ = Acceptance and Action Questionnaire, MAAS = Mindful
disagree). A high score on the AAQ means a low level of acceptance. Attention Awareness Scale, EC-T = Emotional Competence Total Score, ER = Regulation
Mindfulness. Mindfulness was assessed with the MAAS, the Mindful of Own Emotions Subscale.


I. Kotsou et al. -RXUQDORI$IIHFWLYH'LVRUGHUV

Table 2 of overlap between the dierent predictors. Given that AAQ, MAAS, EC-
Common and unique contribution of AAQ, EC-T, ER and MAAS as predictors of psycho- T and ER are all constructs related to the way we deal with our emo-
pathology and happiness.
tions, we expected that they would share a large proportion of common
Acceptance and emotional competence single score variance. Yet, results revealed that the AAQ combined with any other
predictor (the MAAS, EC-T or ER) shared barely a sixth to less than a
AAQ+EC-T Common EC-T (sr2) AAQ (sr2) half of common variance.
R2[IC] variance
Altogether, these results show that acceptance, as measured with
Psychopathology:
HADS-A .32** [.22;.42] .07** .01 .24** the AAQ, is a robust predictor of psychological health such as anxiety,
HADS-D .25** [.15;.35] .06** .01 .18** depression, stress and happiness. These results are consistent with a
PSS .41** [.31;.51] .11** .03** .27** growing body of evidence suggesting that emotional avoidance (or its
Well-being: reversed form, emotional acceptance) is a key process in aective dis-
SHS .45** [.36;.54] .12** .01* .32**
orders (Kashdan et al., 2006) that uniquely predicts several positive
Acceptance and emotion regulation
therapeutic outcomes (Kashdan and Rottenberg, 2010). We believe the
AAQ + ER (R2) Common ER (sr2) AAQ (sr2)
current investigation supports models suggesting that emotional
variance
Psychopathology avoidance is a central and common factor in psychopathology that is
HADS-A .34** [.24;.44] .14** .03* .17** involved in the onset and maintenance of aective disorders (Barlow
HADS-D .26** [.16;.36] .10** .01 .17** et al., 2004). Emotional avoidance can therefore be seen as a main
PSS .44** [.34;.54] .20** .05** .19** factor of psychological vulnerability and emotional acceptance as a
Well-being
SHS .45** [.36;.54] .18** .02* .25**
factor of emotional resiliency, leading individuals to be less prone to
Acceptance and mindfulness develop emotional disturbances.
AAQ + MAAS Common MAAS (sr2) AAQ (sr2)
(R2) variance 5. Limitations and future directions
Psychopathology
HADS-A .34** [.24;.44] .14** .2* .18** Related to limitations, rst, this study is based on nonclinical sam-
HADS-D .24** [.14;.34] .7** .00 .17**
ples. Further studies may assess the same hypothesis with clinical
PSS .43** [.33;.53] .17** .05** .21**
Well-being
samples. Second, these results are based on cross-sectional designs,
SHS .43** [.33;.53] .7** .00 .36** longitudinal and experimental studies may be useful in order to assess
the potential protective power of acceptance over time. As an example,
R2 = adjusted R2, proportion of outcome variables variance explained by predictors; sr2 it would be interesting to measure the evolution of acceptance before
= semi-partial r2 (proportion of variance attributable only to a specic predictor). and after interventions related to mindfulness or emotional competence
** p < .001.
to conrm its relevance. Third, to measure mindfulness, we used the
* p < .05.
MAAS that only evaluates one dimension of mindfulness, attention to
the present moment. We may have dierent results using other mea-
the total score of ER and the total score of MAAS. These combined total
sures of mindfulness comprising multiple dimensions, some being more
scores signicantly predicted all scores for anxiety, depression, stress
related to emotions. Lastly, we only used self-reported measures, and
and happiness. The AAQ uniquely predicted more variance then the
thus further research should replicate these results with behavioral or
three other predictors for all outcomes. Table 2 presents the part of the
biological outcomes.
variance predicted by the combined predictors (column 2), common to
Notwithstanding these limitations, we believe that this research
the two predictors (column 3) and the part of variance that is unique to
advances our understanding of the processes involved in emotional
each of them (columns 4 & 5). In a nutshell, the results show that the
psychopathology and that some theoretical and applied conclusions can
AAQ predicted signicantly more unique variance than the other pre-
be drawn. At the theoretical level, our results suggest that many current
dictors for each of the outcomes.
theoretical approaches could very well boil down to a main common
process, the ability to accept one's emotions in order to enhance one's
4. Discussion psychological exibility. At a clinical level, our results suggest that
regardless of the type of intervention, it is important to bolster the
The aim of this study was to compare emotional acceptance with acceptance abilities of patients with psychopathology.
emotional competence, emotion regulation and mindfulness, in their
ability to predict psychological distress (stress, anxiety, depression) and Acknowledgements
psychological well-being (happiness). As expected, when introduced
individually these predictors all displayed signicant relationships with We thank Betty Chang for her help in order to correct the paper
each outcome. For the AAQ, these relations (except for one that was
moderate) were large in size, although the relations were small to Appendix A. Supporting information
moderate in the case of MAAS and EC-T, and moderate in the case of
ER. MAAS accounted for between 7 to 22% of the variance for the Supplementary data associated with this article can be found in the
dierent outcomes, ER for between 10 to 25%, EC-T for between 7 to online version at http://dx.doi.org/10.1016/j.jad.2017.09.047.
15% while AAQ accounted for 2444% of the variance, showing the
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