Accepted Manuscript

Title: The conceptualization of emotion regulation difficulties,

and its association with posttraumatic stress symptoms in
traumatized refugees

Authors: Emma L. Doolan, Richard A. Bryant, Belinda J.

Liddell, Angela Nickerson

PII: S0887-6185(17)30185-8
DOI: http://dx.doi.org/doi:10.1016/j.janxdis.2017.04.005
Reference: ANXDIS 1938

To appear in: Journal of Anxiety Disorders

Received date: 26-5-2016

Revised date: 20-2-2017
Accepted date: 25-4-2017

Please cite this article as: Doolan, Emma L., Bryant, Richard A., Liddell, Belinda J.,
& Nickerson, Angela., The conceptualization of emotion regulation difficulties, and
its association with posttraumatic stress symptoms in traumatized refugees.Journal of
Anxiety Disorders http://dx.doi.org/10.1016/j.janxdis.2017.04.005

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 1

Highlights
We investigated the conceptualization of emotion regulation difficulties in refugees
We interviewed 147 resettled refugees from a variety of backgrounds.
Models of emotion regulation difficulties with 5 and 6 factors showed adequate fit
Factor correlations were significant for all subscales except awareness
Specific types of emotion dysregulation predicted posttraumatic stress symptom
severity
 2

The Conceptualization of Emotion Regulation Difficulties, and its Association with

Posttraumatic Stress Symptoms in Traumatized Refugees

Emma L. Doolan, Richard A. Bryant, Belinda J. Liddell & Angela Nickerson

School of Psychology, UNSW Australia

CORRESPONDANCE:
Angela Nickerson
School of Psychology
UNSW Australia
Sydney NSW 2052
Australia
Ph: +61 (0)2 9385 0538
Fax: +61 (0)2 9385 3641
a.nickerson@unsw.edu.au
 3

Abstract

This study investigated the conceptualization of emotion regulation difficulties in a sample of

refugees with varying levels of posttraumatic stress (PTS), and examined whether specific

emotion regulation difficulties were associated with PTS severity. Refugees were

administered an abbreviated version of the Difficulties in Emotion Regulation Scale, the

PTSD Symptom Scale Interview Version, and the Harvard Trauma Questionnaire.

Confirmatory Factor Analysis was used to examine model fit for the 6-factor model

originally proposed by the developers of the DERS and the more recently proposed 5-factor

model that excludes the awareness subscale. Both models displayed adequate fit. After

controlling for age, gender, time in Australia, and trauma exposure, the clarity and strategies

subscales were significantly associated with PTS severity. The association between impaired

emotional clarity and reduced agency related to accessing regulation strategies and PTS

severity in this refugee sample highlights the need for further research to assess interventions

that target these disruptions in refugees.

Keywords: Emotion regulation; refugees; trauma; posttraumatic stress disorder; torture;

traumatic stress.
 4

1. Introduction
At present, there are over 65 million refugees and forcibly displaced individuals

internationally (UNHCR, 2015). Refugees evidence significantly elevated rates of

posttraumatic stress disorder (PTSD) compared to population norms (Fazel, Wheeler, &

Danesh, 2005; Lillee, Thambiran, & Laugharne, 2015; Steel et al., 2009). A meta-analysis of

20 studies reported refugees based in western countries were approximately ten times more

likely to develop PTSD than an age-matched western population (Fazel et al., 2005). Existing

literature highlights the strong association between posttraumatic stress (PTS) and difficulties

in emotion regulation (Tull, Barrett, McMillan, & Roemer, 2007). Emotion regulation is the

mechanism by which an individual monitors, evaluates, and modulates his/her behavior

and/or emotional state in response to a given situation (Gratz & Roemer, 2004; Gross, 1998).

Individuals with PTSD evidence an impaired ability to regulate their emotions compared to

those without PTSD (Ehring & Quack, 2010; Tull et al., 2007; Weiss et al., 2012).

Furthermore, the inability to regulate emotions appropriately in response to a traumatic or

stressful life event has been implicated in the development and maintenance of prolonged

psychological distress (Bardeen, Kumpula, & Orcutt, 2013). Despite the fact that refugees are

typically exposed to multiple types of traumatic events and exhibit high levels of PTSD

symptoms, little research has examined emotion regulation in refugee groups.

Refugees may be especially likely to manifest emotion regulation difficulties as

research indicates that exposure to multiple traumatic events increases a persons

vulnerability to emotion regulation difficulties (Ehring & Quack, 2010; Tull et al., 2007;

Weiss et al., 2012). Further, prolonged, human-instigated trauma appears to have a

particularly strong impact on emotion regulation difficulties. For example, Walsh, Dilillo,

and Scalora (2011) found that victims of interpersonal and repeated traumas, such as

childhood sexual abuse, evidenced poorer emotion regulation skills compared to single-
 5

trauma survivors. Another study found that emotion regulation difficulties mediated the

relationship between childhood abuse experiences and PTS symptoms (Stevens et al., 2013).

Accordingly, refugees may be particularly vulnerable to emotion regulation difficulties as

they are highly likely to experience prolonged, repeated, and interpersonal trauma in the

context of persecution (Silove, 1999). Furthermore, research suggests that PTSD symptoms

are potentially exacerbated by stressful pre- and post-migration living difficulties, such as

ongoing deprivation, discrimination, uncertain visa-status, distance from loved ones and

unemployment, for refugees (Porter & Haslam, 2005; Silove, Sinnerbrink, Field,

Manicavasagar, & Steel, 1997). The only study examining emotion regulation difficulties in

refugees to date found that trauma exposure was associated with emotion regulation

difficulties in a community sample of resettled refugees (Nickerson et al., 2015). In

particular, difficulties in emotion regulation significantly mediated the relationship between

trauma exposure and PTSD symptoms (Nickerson et al., 2015). This research provides

preliminary evidence that emotion regulation difficulties may be prominent in trauma-

exposed refugees and underpin posttraumatic psychopathology, however there is a need for

further research elucidating the specific dynamics of this association.

Despite the abovementioned research, the extent to which current conceptualizations

of emotion regulation difficulties can be generalized to a refugee sample remains an

important empirical question. According to Gratz and Roemer (2004), emotion regulation

difficulties span across 6 factors comprising (a) non-acceptance of emotional responses; (b)

difficulties engaging in goal directed behavior; (c) impulse control difficulties; (d) lack of

emotional awareness; (e) limited access to emotion regulation strategies; and (f) lack of

emotional clarity (Gratz & Roemer, 2004). This 6-factor structure of emotion regulation

difficulties has shown consistency across various age (e.g., adolescents: Neumann, van Lier,

Gratz, & Koot, 2010; Perez, Venta, Garnaat, & Sharp, 2012; Sarta-Atalar, Genz, & zen,
 6

2015; young adults: Bardeen, Fergus, & Orcutt, 2012; Giromini, Velotti, De Campora,

Bonalume, & Cesare Zavattini, 2012; Gratz & Roemer, 2004; Ruganci & Genz, 2010; and

older adults: Fowler et al., 2014) and language groups (e.g., Italian: Giromini et al., 2012;

Dutch: Neumann et al., 2010; and Turkish: Ruganci & Genz, 2010; Sarta-Atalar et al.,

2015). While most of this research has been conducted with healthy samples, a study with

non-suicidal self-injury adolescent inpatients also supported the aforementioned 6-factor

conceptualization of emotion regulation difficulties (Perez et al., 2012). Recently, however, a

five-factor conceptualization has been proposed that excludes the lack of awareness factor. In

a study conducted by Bardeen and colleagues (2012), the authors argued that the awareness

factor made a significantly lower contribution to the emotion regulation construct compared

to the other five factors (Bardeen et al., 2012). Only one study has directly compared the 5-

and 6-factor conceptualizations of emotion regulation difficulties in a sample of adults with

severe mental illness, including major depressive disorder, anxiety, and substance abuse.

Results demonstrated equivalent model fit between the 6- and 5-factor models, leading the

authors to conclude that more research is necessary before disregarding the lack of awareness

factor (Fowler et al., 2014).

Considering the research conducted to date, there is a need to examine how emotion

regulation is conceptualized in a refugee sample. Accordingly, the current study first aimed to

examine the factor structure of emotion regulation difficulties in a sample of refugees with

varying levels of PTSD. Based on the prior research reviewed above, we hypothesized our

study would support a 6-factor structure. The second aim of this study was to examine which

aspects of emotion regulation difficulties were associated with PTS symptoms in a refugee

sample. Extant literature suggests that several of the DERS subscales in particular would be

associated with PTS symptoms (Tull et al., 2007). For instance, Alexithymia (i.e., difficulty

identifying and labelling experienced emotions, Taylor, Bagby, & Parker, 1991), which is
 7

conceptually similar to the lack of emotional clarity DERS subscale, has been shown to be

associated with PTS severity (Ntnen et al., 2002; Yehuda et al., 1997). Furthermore,

research suggests that an inability to accept negative emotions is also related to PTS severity.

In particular, there is evidence that PTS is related to an increased tendency to suppress

emotions (Moore, Zoellner, & Mollenholt, 2008), and engage in experiential avoidance (i.e.,

unwillingness to experience negative emotions; Plumb, Orsillo, & Luterek, 2004). Thus, we

expect that the current study will find a significant association between the two DERS

subscales, non-acceptance of emotional responses and lack of emotional clarity, and PTS

symptoms. As mentioned above, Nickerson et al. (2015) found that difficulties engaging in

goal-directed behaviour and lack of emotional clarity to be significantly associated with

PTSD symptoms in a refugee sample. Given the similarities between the current population

and that of Nickerson et al. (2015), we also predicted that we would find an association

between PTS symptoms and difficulties engaging in goal directed behavior.

Current evidence suggests that those who have experienced a greater number of

traumas (Mollica, McInnes, Poole, & Tor, 1998), and spent less amount of time in their

resettlement environment are at greater risk of developing PTSD symptoms (Steel et al.,

2006). Demographic factors such as older age and female gender have also been associated

with increased PTSD symptoms in extant literature (Steel, et al., 2006). Therefore, we

controlled for participant age, gender, trauma exposure, and time in Australia in relevant

analyses.

2. Method

2.1. Participants and Procedure

Participants in this study were recruited via either referral from casework and

specialist counselling services in Sydney, Australia, or community advertisements. Inclusion

criteria for this study required that participants were (a) refugees or asylum-seekers, and (b)
 8

over 18 years of age. The final sample size was 147 participants. At the time of recruitment

participants were either permanent residents (N = 36, 24.5%), Australia citizens (N = 14,

9.5%), on a bridging visa (N = 80, 54.4%), or another type of visa (including community

detention or expired visa; N = 17, 11.6%). Participants were from a range of countries of

origin including Iraq (N = 19, 12.9%), Iran (N = 65, 44.2%), Afghanistan (N = 11, 7.5%), Sri

Lanka (N = 16, 10.9%), and other (including Bangladesh, Pakistan, Serbia, Myanmar,

Kuwait, Bhutan, Nigeria, and China; N = 36, 24.5%).

The study interviews were conducted at an outpatient hospital setting or specialist

counselling service in Sydney. Participants first provided informed consent in accordance

with approval from the Human Research and Ethics Committees at Northern Sydney Local

Health District and Western Sydney Local Health Districts. The measures were administered

by a clinical psychologist with masters or doctoral-level qualifications. Where necessary, an

accredited interpreter was used (n=109). All interpreters were trained in, and therefore

familiar with, working in a health-care setting. The psychologist directed all questions to the

participant, regardless of whether an interpreter was present. Participants were reimbursed

for costs associated with taking part in the research.

2.2. Measures

Difficulties in Emotion Regulation. The Difficulties in Emotion Regulation scale

(DERS; Gratz & Roemer, 2004) was used to measure participants difficulties in emotion

regulation. The DERS is a 36-item self-report questionnaire that assesses emotion

dysregulation across 6 domains: Goals (e.g., When Im upset, I have difficulty concentrating);

Non-acceptance (e.g., When Im upset, I become embarrassed for feeling that way); Impulse

(e.g., When Im upset, I become out of control); Strategies (e.g., When Im upset, I believe

that I will remain that way for a long time); Clarity (e.g., I have no idea how I am feeling);

and Awareness (e.g., I pay attention to how I feel). The DERS has demonstrated excellent
 9

internal consistency ( = .93), adequate test-restest reliability, and construct and predicative

validity (Gratz & Roemer, 2004).

The current study used an abbreviated version of the DERS, previously employed by

Nickerson et al. (2015). This abbreviated version was implemented to reduce assessment

burden on refugee participants, and included 18 of the original DERS items (3 from each

subscale; see Table 1). The items chosen for each subscale loaded the highest on each of their

respective primary factors as reported in Gratz and Roemer (2004), and demonstrated the

largest difference between their primary factor loading and the average of the loadings on

their non-primary factors. Response options ranged from 1 (almost never, 0 10%) to 5

(almost always, 91-100%). A higher score indicated greater emotion regulation difficulties,

with the exception of three items within the awareness subscale, which were reverse-scored.

A sum of specific items was produced to provide a score for each of the six emotion

dysregulation subscales. In the current study, each of these subscales demonstrated adequate

internal consistency (: Goals = .86; Non-acceptance = .85; Impulse = .92; Awareness = .74;

Strategies = .80; Clarity = .73).

Posttraumatic Stress Severity. PTS severity was measured using the PTSD Symptom

Scale Interview Version (PSSI; Foa et al., 1993). As this study commenced prior to the

revision of the PSSI for the DSM-5, we included four additional items to index DSM-5

symptoms of PTSD (American Psychiatric Association, 2013). In addition to the 16 DSM-IV

items (American Psychiatric Association, 1994), the following four symptoms were

measured: persistent negative emotional state; reckless /self-destructive behavior; blame of

self and/or others; and negative beliefs about the self, others, and the world. The 20 PSSI-I

items were administered via a semi-structured interview, and were measured via a four-point

Likert-type scale with responses options ranging from 0 (not at all) to 3 (5 or more times per

week/ very much). Overall PTS severity was calculated by summing all 20 PSSI-I items. A
 10

DSM-5 derived algorithm was used to determine rates of probable PTSD diagnoses

(American Psychiatric Association, 2013). Specifically, the number of symptoms endorsed (a

rating of 2 or greater) per symptom cluster was counted. If a participant endorsed at least one

intrusion symptom, one avoidance symptom, two changes in cognition and mood symptoms,

and two arousal and reactivity symptoms they were considered to have met diagnostic criteria

for probable PTSD. Symptom cluster scores were also calculated by averaging the

corresponding items for each cluster (i.e., re-experiencing, avoidance, changes in cognition

and mood, and arousal). The PSSI-I has demonstrated adequate inter-rater reliability and

convergent validity (Foa & Tolin, 2000). In the current study, the PSSI-I demonstrated

adequate internal consistency ( = .92).

Trauma Exposure. Trauma exposure was measured using the Harvard Trauma

Questionnaire (HTQ; Mollica et al., 1992). The HTQ consists of 16 items describing different

traumatic experiences typically experienced by refugees (e.g., lack of food or water, torture,

and rape or sexual abuse). Participants indicated whether they had experienced and/or

witnessed any of the traumatic events listed. Overall trauma exposure was calculated by

summing all HTQ items, whereby items that were witnessed or experienced were considered

to constitute exposure. The participants score on this item indicated the number of types of

traumas they had experienced, with the maximum possible score being 16. The HTQ is a

valid and reliable measure of trauma exposure and has been used by a number of studies

assessing refugee populations from various backgrounds (Nickerson et al., 2011, 2015;

Nickerson, Bryant, Steel, Silove, & Brooks, 2010; Shoeb, Weinstein, & Mollica, 2007; Steel

et al., 2009).

2.3 Data Analysis

First, descriptive statistics and bivariate correlations were calculated for the 6 DERS

subscales, HTQ, PSSI-I, and demographics. Second, confirmatory factor analysis was
 11

conducted using the originally-proposed 6-factor model (Gratz & Roemer, 2004) and the

more recently proposed 5-factor model of the DERS (Bardeen et al., 2012), using Mplus

version 7.3 (Muthn & Muthn, 19982010). As the DERS items are rated on an ordinal

scale, mean and variance-adjusted weighted least squares estimation was employed (Flora &

Curran, 2004; Wirth & Edwards, 2007). Model fit was assessed using the Comparative Fit

index (CFI), Root Mean Square Error of Approximation (RMSEA), and Tucker-Lewis index

(TLI). CFI and TLI values greater than or equal to 0.95 and a RMSEA score less than 0.06

indicate good model fit (Hu & Bentler, 1999). The 2 for both models are reported, however,

since the 2 statistic is heavily influenced by sample size, it was not used to assess model fit

(Schumaker & Lomax, 2004). As the 6- and 5-factor models of the DERS are not nested, a

chi-square difference test was not possible for model comparison. As such, visual inspection

of the fit indices for both models was conducted.

Next, regression analysis was conducted with PTS severity as the outcome variable,

and the DERS subscales as predictors. Age, gender, time in Australia, and trauma exposure

were entered in the first step of the regression, and the DERS subscales were entered in the

second step. This two-step procedure was implemented to investigate the relationship

between emotion regulation and PTSD symptoms over and above other important variables

that are likely to contribute to refugee mental health. Multicollinearity between predictors

was assessed using the variance inflation factor (VIF) and tolerance. A VIF value greater than

10 (Myers, 1990) and a tolerance value less than 0.1 (Menard, 1995) for individual predictors

was considered indicative of multicollinearity.

Finally, a series of zero-order partial correlations were conducted to examine the

associations between the DERS subscales and the PTS symptom clusters, controlling for age,

gender, time in Australia, and trauma exposure. A Bonferroni correction for multiple

comparisons was applied.

 12

3. Results

3.1. Demographic Characteristics

From the total sample of 147 respondents, 99 were male (67.3%), with a mean age of

36.49 years (SD = 10.96, range = 18 to 70). The average time in Australia was 3.68 years (SD

= 5.97) with a range of 0.2 to 36 years.

3.2. Trauma Exposure and PTS severity

The average number of types of traumatic events to which participants had been

exposed was 9.39 (SD = 3.48). The endorsement rate for individual types of traumatic events

(i.e., indication of having experienced or witnessed an event) ranged from 21% to 78% (see

Table 2). The mean PTS severity was 23.59 (SD = 14.52), and mean symptom cluster scores

ranged from 1.12 to 1.49 (re-experiencing: M=1.21, SD=0.91; avoidance: M=1.49, SD=1.10;

changes in cognition and mood: 1.12, SD=0.82; and arousal: 1.17, SD=0.80). The rate of

probable PTSD diagnosis in the sample was 34.7% (n = 51).

3.3. Confirmatory Factor Analysis of DERS

The final sample for the CFA analysis was 142. Five participants did not complete the

DERS, and so were excluded from analyses. The CFA testing the original 6-factor model of

the DERS demonstrated adequate fit according to the RMSEA = 0.05 (90% C.I. = 0.032

0.071), CFI = 0.96, and TLI = 0.96. As expected, the model produced a significant 2 statistic

(2 = 1475.75, p < .001). All factor loadings were greater than .50 (Table 1). Factor

correlations were found to be positive and significant for all subscales except for the

awareness subscale. The awareness subscale had a significant negative correlation with the

non-acceptance subscale (Table 3).

The CFA testing the 5-factor model of the DERS had adequate fit as evidenced by the

RMSEA = 0.06 (90% C.I. = 0.032 0.078), CFI = 0.97, and TLI = 0.96. The 5-factor model

also produced a significant 2 statistic (2 = 1310.62, p < .001). All factors were significantly
 13

positively correlated with each other (Table 3) and produced factor loadings greater than .50

(Table 1).

3.4. The Relationship Between DERS and PTS Symptoms

After controlling for age, gender, time in Australia, and trauma exposure (i.e., number

of types of traumas experienced and/or witnessed), the clarity and strategies subscales were

significantly associated with PTS severity (Table 4)1. There was a significant increase in R2

after the addition of the 6 DERS subscales as predictors in step 2 (R2 = .31, p < 0.01). There

was no significant multicollinearity between variables, with VIF ranging from 1.16 to 2.82

and tolerance from 0.36 to 0.86.

After controlling for age, gender, time in Australia, and trauma exposure, the goals,

impulse, strategies, and clarity subscales were significantly correlated with the changes in

cognition and mood, and arousal PTS symptom clusters. The strategies and clarity subscales

were also significantly associated with the re-experiencing PTS symptom cluster. The non-

acceptance and awareness subscales did not correlate with any PTS symptom clusters (Table

5).

4. Discussion

The first aim of the current study was to investigate the conceptualization of emotion

regulation difficulties in a sample of refugees with varying levels of PTSD. Emotion

regulation difficulties were measured using an abbreviated version of the DERS, and results

indicated both the 6-factor (Gratz & Roemer, 2004) and 5-factor models (Bardeen et al.,

2012) had adequate model fit. These findings are partially consistent with previous research,

insofar as previous studies have also found adequate model fit with 6 factors in adolescents

(Neumann et al., 2010; Sarta-Atalar et al., 2015) and undergraduates (Gratz & Roemer,

2004), and across various language groups (Giromini et al., 2012; Neumann et al., 2010;

1 A correlation table to supplement the regression analysis can be found in supplementary material.
 14

Sarta-Atalar et al., 2015). These findings also support outcomes from studies with non-

suicidal self-harm adolescents (Perez et al., 2012), and adult patients with severe mental

illness including depression, anxiety, and substance abuse (Fowler et al., 2014). This study is

the first to demonstrate that both the 6- and 5-factor models of emotion regulation difficulties

evidence good fit with a refugee sample.

The emotion regulation difficulties factor correlations in the 6 factor model were

found to be positive and significant for all subscales except for the lack of emotional

awareness subscale. A number of studies have noted weak correlations between this

awareness subscale and other emotion regulation difficulties subscales (e.g., Bardeen et al.,

2012; Neumann et al., 2010; Sarta-Atalar et al., 2015). Indeed, when developing the DERS,

Gratz and Roemer (2004) acknowledged modest correlations between the awareness subscale

and the other five DERS subscales. One potential reason for the current findings could be

that, unlike the other DERS subscales, each of the awareness items were reverse scored.

Reverse scoring of items can be a useful tool for identifying response bias, such as random

responding, in self-report measures (Paulhus, 1991). However, reverse-scored items can also

be misinterpreted, leading to systematic error and subsequent reduction in scale validity

(Conrad et al., 2004; Hinkin, 1995). The DERS was administered via face-to-face interviews

in the current study, reducing the likelihood of misinterpretation of the awareness items.

However, the change in direction of items may have still been confusing for participants from

a variety of backgrounds, many of whom were responding to items via an interpreter.

Interestingly, studies which have removed reverse-scored items from self-report measures

have evidenced enhanced psychometric properties (e.g., Conrad et al., 2004; Rodebaugh,

Woods, & Heimberg, 2007; Sonderen, Sanderman, & Coyne, 2013). In the current context,

all awareness items were reverse scored, meaning removal of these items would require

removing the entire subscale. Accordingly, future research could examine the psychometric
 15

properties of an adapted version of the DERS whereby the awareness items are re-worded in

a way that does not require reverse coding.

An alternative explanation for the current findings is that the lack of emotional

awareness subscale is less relevant to the emotion regulation construct in a refugee sample.

Indeed, there is conflicting evidence regarding whether emotional awareness is associated

with adaptive emotion regulation. For example, emotional awareness can be beneficial in

enabling an individual to decide whether they need to alter their affective state in a given

situation (i.e., maintain their emotional state or take action to improve it; Lischetzke & Eid,

2003). Research suggests self-awareness that is reflective (as opposed to ruminative) evokes

self-regulatory processes which lead to adaptive behaviors such as problem solving, in order

to improve ones affective state (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008).

Contrastingly, emotional awareness can also be construed as rumination when one focuses on

his/her distress symptoms in a manner that is repetitive and passive. People who ruminate

often fail to actively change their emotional state, and instead remain fixated on their

negative affect (Nolen-Hoeksema et al., 2008). Rumination is associated with exacerbated

and prolonged distress and has been shown to predict both depression and anxiety symptoms

(Nolen-Hoeksema et al., 2008; Nolen-Hoeksema, 2000). As suggested by Tull et al. (2007), it

is plausible that the awareness subscale fails to discriminate between adaptive and

maladaptive self-awareness, and consequently does not strongly associate with the other

emotion regulation subscales. A measure that distinguishes between adaptive and

maladaptive emotional awareness may reconcile the conflicting literature on whether

awareness is an underlying dimension of the overall emotion regulation construct. This

distinction may be particularly relevant to refugee samples, who evidence high rates of PTS

and other psychopathologies associated with rumination and rigid cognitions.

 16

The second aim of this study was to examine which components of emotion

regulation difficulties were specifically associated with PTS symptoms in a refugee sample.

We found that two subscales, lack of access to emotion regulation strategies (indexed by

items such as When Im upset, I believe I will remain that way for a long time, and When

Im upset, I believe that Ill end up feeling very depressed) and lack of emotional clarity

(indexed by items such as I have difficulty making sense out of my feelings and I have no

idea how Im feeling), were significantly associated with PTS severity. These findings

extend those of Tull et al. (2007) who found that PTS symptom severity significantly

correlated with all DERS subscales except for lack of emotional awareness. The current

findings are partly consistent with the findings of Nickerson et al. (2015), who found that the

lack of emotional clarity and difficulties engaging in goal directed behavior subscales

predicted PTS severity in a different sample of traumatized refugees. The association

between the lack of emotional clarity subscale and PTS severity is not surprising given the

similarity between the clarity subscale and alexithymia (i.e., difficulty identifying and

labelling ones emotion; Taylor et al.,1991), and research linking alexithymia to PTSD

(Ntnen et al., 2002; Yehuda et al., 1997). In terms of the findings regarding the limited

access to emotion regulation strategies subscale, Perez et al. (2012) argues that this subscale

is not targeting ones lack of ability to use emotion regulation strategies but rather ones

beliefs about his/her own emotion regulation abilities and their effectiveness. Accordingly,

the current results may suggest there is a link between poor beliefs regarding emotion

regulation capacity and increased PTS severity in this refugee sample. Previous research

conducted in non-refugee groups has suggested that reduced beliefs in self-efficacy is

associated with poor coping with stress, leading to increased anxiety (Benight & Bandura,

2004). Given that refugees face significant ongoing stress in their resettlement environment

(Porter & Haslam, 2005), attention to this particular emotion regulation disruption in refugee
 17

groups may be beneficial to assisting refugees to better manage their emotional reactions to

intense stressors. More research is required to determine whether PTS severity is heightened

because of these initial beliefs, or whether these beliefs are a result of the traumatic

experience and, in turn, are exacerbating PTS symptoms. Our results provide preliminary

evidence to suggest that targeting beliefs about emotion regulatory abilities in refugees with

PTSD, as well as their ability to appropriately identify their emotions, may be of benefit.

Accordingly, treatment targeting emotion regulation has been demonstrated to reduce PTS

severity in refugees (Hinton, Hofmann, Pollack, & Otto, 2009).

Similar to Tull et al. (2007) significant correlations were found between several of the

DERS subscales, including difficulties engaging in goal-directed behaviour, impulse control

difficulties, limited access to emotion regulation strategies, and lack of emotional clarity; and

the PTSD symptoms clusters changes in cognition and mood, and arousal. Furthermore,

limited access to emotion regulation strategies, and lack of emotional clarity were associated

with re-experiencing symptoms. Indeed, there are similarities between the items that make up

the DERS subscales and the DSM-5 (American Psychiatric Association, 2013) criterion for

each of the PTSD symptoms clusters. For instance, difficulty concentrating and controlling

ones behaviour when upset, as measured by the difficulties engaging in goal-directed

behaviour, and impulse control difficulties subscales respectively, both correspond to the

arousal PTSD symptom cluster (i.e., problems with concentration, irritable behaviour and

angry outbursts). Furthermore, the lack of emotion regulation strategies subscale reflects

catastrophic thinking (When Im upset, I believe that I will remain this was for a long time),

and depressive thoughts (When Im upset, I believe that wallowing in it is all I can do),

which have been linked to PTSD re-experiencing and changes in cognition and mood

symptoms (Ehlers & Clark, 2000; Friedman et al., 2011; Mollica et al., 1998). Contrary to

previous findings (Moore et al., 2008; Plumb et al., 2004; Tull et al., 2007), the current study
 18

did not find any association between emotional non-acceptance and any of the PTSD

symptom clusters. The current study investigated emotion regulation in a sample of

individuals from culturally diverse backgrounds. In contrast, the majority of previous studies

have investigated these constructs in western samples. Individuals from western backgrounds

are more likely to identify with an individualist orientation, valuing factors such as

independence and autonomy (Markus & Kitayama, 1991). Higher levels of individualism

have been shown to be associated with greater willingness to express emotion (Matsumoto,

1990; Soto, Levenson, & Ebling, 2005). In western samples, attempts to suppress emotional

responses have been associated with adverse consequences, such as negative psychological

functioning (Soto et al., 2011), increased arousal of the sympathetic nervous system (Gross &

Levenson, 1993), and disrupted interpersonal interactions and affiliation (Butler et al., 2003).

In contrast, when individuals from collectivist cultures suppress their emotions, the negative

emotional consequences may be attenuated or non-existent (Butler, Less, & Gross, 2007,

Soto et al., 2011). It has been argued that, within collectivist cultures, emotional suppression

may be enacted in order to maintain group harmony (Butler et al., 2007). This argument

suggests that emotional acceptance and expression may be considered of greater value in

individualist than collectivist cultures (Kim & Sherman, 2007). Participants in the current

sample were from non-western backgrounds and likely identified with collectivist cultures. It

may be the case that participants did not experience the negative consequences of emotional

suppression and non-acceptance, and thus non-acceptance of emotional responses scores

failed to correlate with any of the PTSD symptom clusters. Further research is needed to

more specifically examine the causal, rather than associative, relationship between emotion

regulation difficulties and PTSD symptoms.

The current study had several limitations. Given the linguistically diverse nature of

the sample, an interpreter was employed for non-English speaking participants. Whilst this
 19

method may have reduced standardization among participants, it allowed for generalization

of results across various ethnic and cultural backgrounds. Further, mental health stigma is

common amongst mental health sufferers, and may limit how much a client is willing to

disclose. In the current context, it is plausible that participants were reluctant to disclose their

trauma experiences and relevant symptoms due to the presence of the interpreter. Second,

participants were not excluded if they exhibited comorbid psychological diagnoses. While

this enhances generalizability of the results to comorbid PTSD diagnoses, it is not possible to

determine the extent to which the current findings are specific to PTSD. Third, it is not clear

the extent to which the HTQ meets DSM criteria A for PTSD. However, given that the

participants had been exposed to, on average, nine different types of traumas, it is evident the

current sample reflected a highly traumatized population. Fourth, employing an abbreviated

version of the DERS may have altered the validity of the scale. Finally, the current study

employed a cross-sectional design meaning conclusions regarding causality cannot be made.

Future research employing a longitudinal design would be beneficial for examining the

direction of the relationship between emotion regulation difficulties and PTSD symptoms in

refugees.

This study is the first to assess the factor structure of emotion regulation difficulties in

a sample of refugees with variable levels of PTSD. The results provide evidence supporting

the proposed factor structure for emotion regulation difficulties in trauma-exposed refugees.

Further, findings indicate that certain types of emotion regulation difficulties are associated

with PTS symptoms in this group, namely disruptions to clarity around affective states and

activating emotion regulation strategies as needed. Further research should be conducted

elucidating emotion regulation difficulties in refugees, given their association with PTS

reactions, and their clinical importance.

 20

Acknowledgments

We gratefully acknowledge the contributions of the participants in this study, as well as

Benjamin Garber, Dr. Ola Ahmed, Dr. Jessica Cheung, Ly Huynh, and Dr. Rosanna Pajak.

Angela Nickerson was supported by a National Health and Medical Research Council

Clinical Early Career Fellowship and Project Grant.

The funding source had no role in study design; in the collection, analysis and interpretation

of data; in the writing of the report; or in the decision to submit the article for publication

The authors disclose no conflicts of interest.

 21

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Table 1. Standardized factor loadings in the 6-factor and 5-factor models of the DERS

Factor Item Factor Loadings

Model 1 Model 2

Goals When Im upset, I have difficulty getting work .72 .72

done

When Im upset, I have difficulty focusing on .88 .87

other things

When Im upset, I have difficulty concentrating .88 .88

Non-acceptance When Im upset, I become embarrassed for .77 .77

feeling that way

When Im upset, I feel ashamed with myself for .93 .93

feeling that way

When Im upset, I feel guilty for feeling that way .75 .75

Impulse When Im upset, I become out of control .83 .82

When Im upset, I have difficulty controlling my .92 .92

behaviors

When Im upset, I lose control over my behaviors .92 .92

Strategies When Im upset, I believe that I will remain that .72 .72
way for a long time

When Im upset, I believe that Ill end up feeling .83 .83

very depressed

When Im upset, I believe that wallowing in it is .73 .74

all I can do

Clarity I have no idea how I am feeling. .56 .55

I have difficulty making sense out of my feelings .73 .74

I am confused about how I feel .78 .78

Awareness I pay attention to how I feelR .74 -

I am attentive to my feelings R .78 -

When Im upset, I acknowledge my emotions R .58 -

Note: Model 1 = 6-factor model. Model 2 = 5-factor model.

R
Reverse scored
Table 2. Frequency of endorsed items on the Harvard Trauma Questionnaire (HTQ)
Experienced Witnessed Experienced and

N (%) (N %) Witnessed N (%)

Being close to death 35 (23.8) 20 (13.6) 62 (42.2)

Lack of food or water 33 (22.4) 13 (8.8) 69 (46.9)

Serious Injury 19 (12.9) 41 (27.9) 54 (36.7)

Ill health without access to medical care 34 (23.1) 35 (23.8) 43 (29.3)

Combat situation 27 (18.4) 31 (21.1) 46 (31.3)

Lack of shelter 22 (15.0) 27 (18.4) 40 (27.2)

Unnatural death of family or friend 58 (39.5) 13 (8.8) 17 (11.6)

Murder of family or friend 49 (33.3) 6 (4.1) 28 (19.0)

Forced separation from family members 51 (34.7) 5 (3.4) 26 (17.7)

Imprisonment 17(11.6) 22 (15.0) 40 (27.2)

Murder of stranger or strangers 22 (15.0) 26 (17.7) 30 (20.4)

Torture 20 (13.6) 13 (8.8) 32 (21.8)

Forced isolation from others 44 (29.9) 3 (2.0) 11 (7.5)

Brain washing 22 (15.0) 2 (1.4) 30 (20.4)

Lost or kidnapped 21 (14.3) 10 (6.8) 8 (5.4)

Rape or sexual abuse 21 (14.3) 4 (2.7) 6 (4.1)

Other 36 (24.5) - 18 (12.2)

Table 3. Factor correlations for 6-factor and 5-factor models of the DERS

Correlation Goals Non-acceptance Impulse Strategies Clarity Awareness

Goals 1 .44*** .51*** .79*** .50*** -.03

Non-acceptance .45*** 1 .35*** .46*** .47*** -.24*

Impulse .52*** .35*** 1 .69*** .48*** -.19

Strategies .79*** .46*** .69*** 1 .71*** -.06

Clarity .51*** .48*** .48*** .70*** 1 .13

Awareness - - - - - 1

Note: Values above the diagonal in bold are factor correlations for the 6-factor model. Values
below the diagonal are factor correlations for the 5-factor model. ***p < .001. *p < .05
Table 4. Regression analysis examining DERS subscales as predictors of PTS symptom
severity, controlling for age, gender, years in Australia, and trauma exposure

B SE B 95% CI p

Step 1:

Age -0.01 0.11 -0.23 0.21 .94

Gender 3.99 2.45 -0.85 8.83 .11

Years in Australia -0.32 0.21 -0.74 0.09 .13

Trauma exposure 1.92 0.35 1.23 2.61 < .01**

Step 2:

Goals -0.32 0.34 -0.99 0.35 .35

Non-acceptance -0.09 0.30 0.67 0.50 .78

Impulse 0.05 0.33 - 0.61 0.70 .89

Strategies 1.87 0.42 1.03 2.70 < .01**

Clarity 1.02 0.38 0.27 1.77 .01*

Awareness 0.24 0.34 -0.43 0.92 .48

Note: R2 = .19 for step 1, R2 = .30 for step 2 (p < .001). *p<.05 **p<.001
Table 5. Correlations between the DERS subscales and posttraumatic stress symptom
clusters (controlling for age, gender, time in Australia, and trauma exposure).
Re-experiencing Avoidance Cognition Arousal
and Mood
Goals .15 .08 .41* .36*

Non-acceptance .11 .16 .24 .25

Impulse .22 .10 .39* .37*

Strategies .37* .13 .60* .58*

Clarity .33* .19 .49* .39*

Awareness .08 .09 .01 .06

Note: *significant after Bonferroni correction for multiple comparisons was applied.