Poor emotion regulation is associated with post-traumatic stress symptoms (PTSS). However, limited prospective research prevents any directional conclusions. No known studies have assessed emotion regulation with PTSS in American Indians, a high-risk population for poor mental health outcomes. The present prospective study explored whether emotion regulation strategies (cognitive reappraisal, expressive suppression) predicted later PTSS related to the COVID-19 global pandemic in a solely American Indian sample.
American Indian participants (N = 210; Mean (SD) age = 54.85(13.08) years, 58.7% female) completed the Emotion Regulation Questionnaire (ERQ) during Phase 1 (a few weeks before pandemic declaration) and the Impact of Event Scale-Revised (IES-R) with respect to the COVID-19 pandemic during Phase 2 (7–8 weeks after pandemic declaration). Bivariate correlations and hierarchical linear regression analyses were utilized.
ERQ reappraisal was negatively associated with IES-R total scores, such that higher reappraisal predicted lower PTSS. In contrast, ERQ suppression was positively associated with IES-R total scores, such that higher suppression predicted higher PTSS.
Greater suppression and lower reappraisal predicts PTSS in response to the COVID-19 pandemic in an entirely American Indian sample, providing critical information for future interventions in a population at high-risk for mental health disparities.
Psychological stress is a risk factor for poor mental and physical health outcomes . In the American Indian (AI) community, exposure to traumatic life events and other factors of psychological stress are disproportionately greater compared with the overall US population . High levels of exposure to psychological stress across the lifespan  likely contribute to the drastically increased rates of physical health disparities (e.g., heart disease, diabetes) [4, 5], as well as mental health disparities (i.e., suicide rates, mood disorders, substance abuse, and posttraumatic stress disorder [PTSD]) [6,7,8]. However, traumatic and stressful life events can impact individuals differently and more research is needed to identify possible risk factors that precipitate individual differences in psychopathology in the AI population .
Stressful events often induce a rise in negative emotions and how individuals regulate and respond to negative emotions can determine subsequent psychological and physiological changes . Difficulties with emotion regulation in adulthood are highly associated with psychopathology, such as greater rates of anxiety and mood disorders . In particular, a large portion of cross-sectional literature has established a robust relationship between emotion regulation difficulties and PTSD [12,13,14]. However, the majority of the previous work has examined these relationships in primarily White samples . That said, a cross-sectional study in an entirely African American sample reported that emotion dysregulation was significantly related to trauma exposure and probable PTSD . Limited prospective and longitudinal research has found emotion regulation to be predictive of later psychopathology, such as anxiety . One prospective study demonstrated that difficulties in emotion regulation predicted later posttraumatic stress symptoms (PTSS) following a mass school shooting and emotion dysregulation after the incident also hindered recovery from symptoms .
While research has identified a wide range of emotion regulation strategies , two of the most well-researched strategies are cognitive reappraisal and expressive suppression . Experimental studies demonstrate that reappraisal leads to decreased negative emotions and increased positive emotions, whereas suppression leads to decreased positive, but not negative, emotions . Research has found that greater use of suppression and lower use of reappraisal is related to greater PTSS [12, 21,22,23]. However, perceived benefits or consequences of emotion regulation strategies vary depending on context and cultural expectations [10, 20, 24, 25].
The outbreak of the novel coronavirus COVID-19 presented a unique opportunity to examine how emotion regulation strategies prospectively relate to reported distress while adjusting to the ongoing pandemic. COVID-19 was declared a global pandemic on March 11, 2020 , and a US national emergency on March 17, 2020 . COVID-19 has increased anxiety, depression, and stress in health care workers and general population [28, 29]. Recent evidence suggests racial and ethnic minorities are disproportionately affected by COVID-19 due to existing health disparities . This evidence includes AI communities; however, more research is needed to understand how AI populations are being affected by the pandemic and if any individual differences within members of this community predict higher levels of distress.
This study is unique in that it (1) extends prior cross-sectional research by using a prospective study design to examine how habitual emotion regulation strategies (reappraisal and suppression) relate to later reported PTSS during the COVID-19 pandemic, and (2) utilizes an entirely AI sample. Based on prior emotion regulation research, it was hypothesized that AI participants who engage in greater use of suppression as an emotion regulation strategy will be more likely to report greater PTSS in response to the pandemic, while those who engage in greater use of reappraisal as a strategy will be more likely to report fewer PTSS.
Participants and Procedures
Participants (N = 210; Mean (SD) [range] age = 54.85 (13.08) [30–99] years, 58.7% female; 100% AI, 8.5% lived on the reservation) were drawn from a larger cross-sectional study of 300 AI adults. This sample was recruited by Qualtrics using multiple managed research panels. Out of the 300 participants from the previous cross-sectional study, we had a sample of 210 interested AI adults who formed an online panel for longitudinal research. There were no statistically significant differences in age, income, or emotion regulation between those who chose to participate in this study and those who did not. Participants resided in 46 different states. Eligibility included self-identifying as AI and being over the age of 18. Surveys at Phase 1 included demographics, anxiety and depression symptomology, alcohol use, and emotion regulation strategies. Surveys at Phase 2 included anxiety and depression symptomology and COVID-19-related distress. Participants received $10 Amazon gift cards for their completion of each phase of the study. The study was approved by the university’s institutional review board, all participation was voluntary, participants provided informed consent, and participants had the right to withdraw at any point. Longitudinal data were stored on a password-protected computer.
Emotion regulation strategies were measured using the Emotion Regulation Questionnaire (ERQ) . The ERQ consists of 10 items separated into two subscales: six items for Cognitive Reappraisal and four items for Expressive Suppression. Participants responded on a seven-point Likert scale (1 = “strongly disagree” to 7 = “strongly agree”). Example items include “I control my emotions by changing the way I think about the situation I’m in” (i.e., reappraisal) and “When I am feeling negative emotions, I make sure not to express them” (i.e., suppression). Higher subscale scores indicate a greater use of that emotion regulation strategy. In the current sample, internal consistency was high for both reappraisal (Cronbach’s ⍺ = 0.98) and suppression (Cronbach’s ⍺ = 0.94) subscales.
COVID-19-Related Posttraumatic Stress Symptoms
The Impact of Event Scale-Revised (IES-R)  is used to measure subjective PTSS in reference to a specific, traumatic event (i.e., the COVID-19 pandemic). The IES-R consists of 22 items, with each item representing a potential difficulty that may arise after experiencing a stressful event. Participants were asked to rate how much they were distressed by each difficulty during the past 7 days with respect to the ongoing COVID-19 pandemic. Responses were given on a five-point Likert scale (0 = “not at all” to 4 = “extremely”), with a total score ranging from 0 to 88 (summing all items). In the current sample, the IES-R total score had excellent internal consistency (Cronbach’s ⍺ = 0.96).
Demographic covariates were determined a priori, including age, sex, income, and reservation status. Variables known to be risk factors for the development of PTSS as well as associated with emotion regulation were also controlled, including depression, anxiety [32,33,34], and alcohol use [35, 36]. The 14-item Hospital Anxiety and Depression Scale (HADS)  was used to measure symptoms of anxiety and depression at both Phase 1 and Phase 2. Internal consistency was good in the current sample (Cronbach’s ⍺ for anxiety Phase 1 = 0.88, anxiety Phase 2 = 0.89; depression Phase 1 = 0.86, depression Phase 2 = 0.88). Test-retest reliability for the anxiety and depression subscales was adequate between Phase 1 and Phase 2 (0.87 and 0.85, respectively). Alcohol use at Phase 1 was assessed using a 10-item screening instrument, the Alcohol Use Disorders Identification Test (AUDIT; Cronbach’s ⍺ for the AUDIT = 0.85).
Bivariate correlations were used to examine relationships between the main variables of interest. A series of hierarchical linear regressions were used to assess the separate associations between ERQ reappraisal and ERQ suppression scores at Phase 1 with COVID-19 related PTSS at Phase 2, while also adjusting for age, sex, income, reservation status, alcohol use, anxiety, and depression. In these models, covariates were entered into Step 1 and ERQ reappraisal or ERQ suppression was separately entered into Step 2. Results were reported as statistically significant if p values were ≤ 0.05 and SPSS version 27 (IBM Corp, USA) was used for analyses.
Bivariate correlations demonstrated a statistically significant negative association between ERQ reappraisal with IES-R total and a statistically significant positive association between ERQ suppression with IES-R total. Refer to Supplementary Table S1 for full correlation matrix and Table S2 for change in anxiety and depression scores from Phase 1 to Phase 2.
Hierarchical linear regression analyses adjusted for covariates in Step 1 (age, sex, income, reservation status, alcohol use, anxiety, and depression), while ERQ reappraisal or suppression were separately entered into Step 2. The covariates explained 31.2% of the variance in PTSS, F(9, 197) = 11.37, p < 0.001. The addition of ERQ reappraisal in Step 2 significantly explained an additional 3.2% of the variance in PTSS, F(10, 196) = 11.83, p < 0.001, such that higher reappraisal predicted lower reported PTSS. The separate inclusion of ERQ suppression in Step 2 significantly explained an additional 2.7% of the variance in PTSS, F(10, 196) = 11.57, p < 0.001, such that higher suppression predicted higher reported PTSS. Table 1 displays all coefficients and related regression statistics.
Using a prospective design, the current study examined whether emotion regulation strategies predicted PTSS in response to COVID-19 in an AI sample. Individuals who reported greater use of reappraisal as an emotion regulation strategy prior to the pandemic subsequently reported less PTSS in response to the pandemic. In contrast, those who reported greater use of suppression as a strategy reported greater PTSS in response to the pandemic. These associations were independent of age, sex, income, reservation status, alcohol use, anxiety, and depression.
The present study supports previous literature demonstrating different emotion regulation strategies lead to different consequential outcomes , with greater use of suppression and lower use of reappraisal related to greater PTSS [12, 21,22,23]. Reappraisal occurs early in emotional processing and allows for complete alteration of one’s emotional trajectory before the emotional response has been generated . Alternatively, suppression occurs later and reduces the behavioral expression of an emotion while leaving the experience of the emotion unaltered, creating a discrepancy between internal experience and external expression . As a result, suppression fails to mitigate the experience of negative emotions. Future research should aim to extend these finding by directly examining the consequential outcomes of suppression in order to identify what aspects of suppression pose the greatest risk for development of PTSS.
The current study supports previous cross-sectional findings indicating a relationship between poor emotion regulation and PTSS [12, 14, 16, 23] and prospective findings of poor emotion regulation predicting later PTSS directly following a traumatic incident . However, the present study extends previous findings by examining specific emotion regulation strategies (i.e., suppression, reappraisal), rather than global emotion regulation abilities (i.e., emotional clarity, acceptance). While both approaches assist in understanding emotion regulation, this study was able to identify a strategy (i.e., suppression) that may be a risk factor for ineffective coping with stress and trauma, providing a direction for future intervention research.
This research is not without limitations. First, while the current study consists of a prospective design, analyses are still correlational, and outcomes could be influenced by a third variable . That said, adjustment was made for possible confounders (i.e., age, sex, income, reservation status, alcohol use, anxiety, and depression). Second, the IES-R is not a diagnostic instrument for PTSD, and thus, no hard clinical conclusions may be drawn beyond self-reported distress. Lastly, this was an entirely AI sample and future researchers should be careful when considering the generalizability of results, as the outcomes may differ across racial and ethnic groups. Replication of this study using other populations is encouraged for comparison purposes.
In conclusion, this is the first prospective study using an AI sample to examine whether emotion regulation strategies predict later PTSS surrounding the onset of a traumatic event (i.e., global pandemic), with reappraisal related to less reported PTSS and suppression related to greater PTSS. The present findings extend the current literature by examining the predictive nature of emotion regulation in a population at high risk for mental health disparities, thus providing critical information for possible future interventions.
Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298:1685–7. https://doi.org/10.1001/jama.298.14.168.
Manson SM, Beals J, Klein SA, Croy CD. Social epidemiology of trauma among 2 American Indian reservation populations. Am J Public Health. 2005;95:851–9. https://doi.org/10.2105/ajph.2004.054171.
Long CR, Curry MA. Living in two worlds: Native American women and prenatal care. Health Care Women Int. 1998;19:205–15. https://doi.org/10.1080/073993398246377.
Barnes PM, Adams PF, Powell-Griner E. Health characteristics of the American Indian or Alaska Native adult population: United States, 2004–2008. Natl Health Stat Report. 2010;1–22.
John-Henderson NA, Gruman HE, Counts CJ, Ginty AT. American Indian young adults display diminished cardiovascular and cortisol responses to acute psychological stress. Psychoneuroendocrinology. 2020;114:104583. https://doi.org/10.1016/j.psyneuen.2020.104583.
Beals J, Manson SM, Whitesell NR, Spicer P, Novins DK, Mitchell CM. Prevalence of DSM-IV disorders and attendant help-seeking in 2 American Indian reservation populations. Arch Gen Psychiatry. 2005;62:99–108. https://doi.org/10.1001/archpsyc.62.1.99.
May PA, Van Winkle NW, Williams MB, McFeeley PJ, DeBruyn LM, Serna P. Alcohol and suicide death among American Indians of New Mexico: 1980–1998. Suicide Life Threat Behav. 2002;32:240–55. https://doi.org/10.1521/suli.220.127.116.1172.
Pole N, Gone JP, Kulkarni M. Posttraumatic stress disorder among ethnoracial minorities in the United States. Clin Psychol (New York). 2008;15:35–61. https://doi.org/10.1111/j.1468-2850.2008.00109.x.
Jiang L, Beals J, Whitesell NR, Roubideaux Y, Manson SM. Stress burden and diabetes in two American Indian reservation communities. Diabetes Care. 2004;31:427–9. https://doi.org/10.2337/dc07-204.
Gross JJ. Emotion regulation: conceptual and empirical foundations. In: Gross JJ, editor. Handbook of emotion regulation. 2nd ed. New York, NY: Guilford Press; 2014. p. 3–20.
Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30:217–37. https://doi.org/10.1016/j.cpr.2009.11.004.
Ehring T, Quack D. Emotion regulation difficulties in trauma survivors: the role of trauma type and PTSD symptom severity. Behav Ther. 2010;41:587–98. https://doi.org/10.1016/j.beth.2010.04.004.
McLean CP, Foa EB. Emotions and emotion regulation in posttraumatic stress disorder. Curr Opin Psychol. 2017;14:72–7. https://doi.org/10.1016/j.copsyc.2016.10.006.
Weiss NH, Tull MT, Viana AG, Anestis MD, Gratz KL. Impulsive behaviors as an emotion regulation strategy: examining associations between PTSD, emotion dysregulation, and impulsive behaviors among substance dependent inpatients. J Anxiety Disord. 2012;26:453–8. https://doi.org/10.1016/j.janxdis.2012.01.007.
Seligowski AV, Lee DJ, Bardeen JR, Orcutt HK. Emotion regulation and posttraumatic stress symptoms: a meta-analysis. Cogn Behav Ther. 2015;44:87–102. https://doi.org/10.1080/16506073.2014.980753.
Weiss NH, Tull MT, Davis LT, Dehon EE, Fulton JJ, Gratz KL. Examining the association between emotion regulation difficulties and probable posttraumatic stress disorder within a sample of African Americans. Cogn Behav Ther. 2012;41:5–14. https://doi.org/10.1080/16506073.2011.621970.
Schneider RL, Arch JJ, Landy LN, Hankin BL. The longitudinal effect of emotion regulation strategies on anxiety levels in children and adolescents. J Clin Child Adolesc Psychol. 2018;47:978–91. https://doi.org/10.1080/15374416.2016.1157757.
Bardeen JR, Kumpula MJ, Orcutt HK. Emotion regulation difficulties as a prospective predictor of posttraumatic stress symptoms following a mass shooting. J Anxiety Disord. 2013;27:188–96. https://doi.org/10.1016/j.janxdis.2013.01.003.
Webb TL, Miles E, Sheeran P. Dealing with feeling: a meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychol Bull. 2012;138:775–808. https://doi.org/10.1037/a0027600.
Gross JJ, John OP. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J Pers Soc Psychol. 2003;85:348–62. https://doi.org/10.1037/0022-3518.104.22.1688.
Boden MT, Westermann S, McRae K, et al. Emotion regulation and posttraumatic stress disorder: a prospective investigation. J Soc Clin Psychol. 2013;32:296–314. https://doi.org/10.1521/jscp.2013.32.3.296.
Eftekhari A, Zoellner LA, Vigil SA. Patterns of emotion regulation and psychopathology. Anxiety Stress Coping. 2009;22:571–86. https://doi.org/10.1080/10615800802179860.
Moore SA, Zoellner LA, Mollenholt N. Are expressive suppression and cognitive reappraisal associated with stress-related symptoms? Behav Res Ther. 2008;46:993–1000. https://doi.org/10.1016/j.brat.2008.05.001.
Mesquita B, De Leersnyder J, Albert D. The cultural regulation of emotions. In: Gross JJ, editor. Handbook of emotion regulation. 2nd ed. New York, NY: Guilford Press; 2014. p. 284–301.
Nagulendran A, Jobson L. Exploring cultural differences in the use of emotion regulation strategies in posttraumatic stress disorder. Eur J Psychotraumatol. 2020;11:1729033. https://doi.org/10.1080/20008198.2020.1729033.
World Health Organization. “Coronavirus disease (COVID-2019) situation reports.” https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports Accessed 22 July 2020.
Centers for Disease Control and Prevention. “Coronavirus disease 2019: Cases in the US.” https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html Accessed 22 July 2020.
Rajkumar RP. COVID-19 and mental health: a review of the existing literature. Asian J Psychiatr. 2020;52:102066. https://doi.org/10.1016/j.ajp.2020.102066.
Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, Ng CH. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiat. 2020;7:228–9. https://doi.org/10.1016/s2215-0366(20)30046-8.
van Dorn A, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet. 2020;395:1243–4. https://doi.org/10.1016/s0140-6736(20)30893-x.
Weiss DS, Marmar CR. The impact of event scale- revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford Press; 1997. p. 339–441.
Ginzburg K, Ein-Dor T, Solomon Z. Comorbidity of posttraumatic stress disorder, anxiety and depression: a 20-year longitudinal study of war veterans. J Affect Disord. 2010;123:249–57. https://doi.org/10.1016/j.jad.2009.08.006.
Campbell-Sills L, Ellard KK, Barlow DH. Emotion regulation in anxiety disorders. In: Gross JJ, editor. Handbook of emotion regulation. 2nd ed. New York, NY: Guilford Press; 2014. p. 393–412.
Joormann J, Stanton CH. Examining emotion regulation in depression: a review and future directions. Behav Res Ther. 2016;86:35–49. https://doi.org/10.1016/j.brat.2016.07.007.
Kober H. Emotion regulation in substance use disorders. In: Gross JJ, editor. Handbook of emotion regulation. 2nd ed. New York, NY: Guilford Press; 2014. p. 428–46.
Emerson MA, Moore RS, Caetano R. Association between lifetime posttraumatic stress disorder and past year alcohol use disorder among American Indians/Alaska Natives and Non‐Hispanic Whites. Alcohol Clin Exp Res. 2017;41(1):576–84. https://doi.org/10.1111/acer.13322.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–70. https://doi.org/10.1111/j.1600-0447.1983.tb09716.
Christenfeld NJS, Sloan RP, Carroll D, Greenland S. Risk factors, confounding, and the illusion of statistical control. Psychosom Med. 2004;66:868–75. https://doi.org/10.1097/01.psy.0000140008.70959.41.
Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number U54GM115371 and P20GM103474. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Conflict of Interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Below is the link to the electronic supplementary material.
About this article
Cite this article
Tyra, A.T., Ginty, A.T. & John-Henderson, N.A. Emotion Regulation Strategies Predict PTSS During the COVID-19 Pandemic in an American Indian Population. Int.J. Behav. Med. (2021). https://doi.org/10.1007/s12529-021-09964-2
- Emotional regulation
- Posttraumatic stress
- American indians
- Prospective studies