Psychological Trauma: Theory, Research,

Practice, and Policy

Understanding the Relationship Between Social Support
and Posttraumatic Stress Disorder/Posttraumatic Growth
Among Adolescents After Ya’an Earthquake: The Role of
Emotion Regulation
Xiao Zhou, Xinchun Wu, and Rui Zhen
Online First Publication, October 13, 2016. http://dx.doi.org/10.1037/tra0000213

CITATION
Zhou, X., Wu, X., & Zhen, R. (2016, October 13). Understanding the Relationship Between Social
Support and Posttraumatic Stress Disorder/Posttraumatic Growth Among Adolescents After
Ya’an Earthquake: The Role of Emotion Regulation. Psychological Trauma: Theory, Research,
Practice, and Policy. Advance online publication. http://dx.doi.org/10.1037/tra0000213
 Psychological Trauma: Theory, Research, Practice, and Policy © 2016 American Psychological Association
2016, Vol. 8, No. 6, 000 1942-9681/16/$12.00 http://dx.doi.org/10.1037/tra0000213

Understanding the Relationship Between Social Support and Posttraumatic

Stress Disorder/Posttraumatic Growth Among Adolescents After Ya’an
Earthquake: The Role of Emotion Regulation

Xiao Zhou Xinchun Wu and Rui Zhen

Beijing Normal University and Tel Aviv University Beijing Normal University

Objective: Posttraumatic distress disorder (PTSD) and posttraumatic growth (PTG) may coexist in
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trauma survivors, but there are mixed relationships between PTSD and PTG. To elucidate their
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relationship and constructs, it is necessary to examine simultaneously predictive factors, and to compare
their determining factors. The aim of this study was to increasing our understanding the relationship
between PTSD and PTG by examining simultaneously the role of social support and emotion regulation
in PTSD and PTG among adolescents after the earthquake. Methods: Six months after the Ya’an
earthquake, 315 middle school students in Lushan county were assessed using measures of trauma
exposure, social support, and emotion regulation, as well as Child PTSD Symptom Scale and Posttrau-
matic Growth Inventory. Results: Social support had significant direct association with PTG but not with
PTSD, but social support had a negative indirect prediction on PTSD and a positive indirect prediction
on PTG through cognitive reappraisal. Social support, through expressive suppression, had a significant
and indirect prediction on PTSD, but a nonsignificant indirect prediction on PTG. Conclusions: This
study indicate that the predictive mechanism of PTSD and PTG were different and further suggest that
PTSD and PTG are separate, independent dimensions of psychological experiences following adversity.

Keywords: social support, cognitive reappraisal, expressive suppression, PTSD, PTG

It is documented that both posttraumatic stress disorder (PTSD)
and posttraumatic growth (PTG) are common and representative
posttraumatic reactions (e.g., García Martinez, Reyes Reyes, &
Cova Solar, 2014; Pan et al., 2015; Ying, Wu, Lin, & Chen, 2013).
The former can be considered a pathological outcome of trauma
that involves intrusive symptoms, avoidance, and hyper-arousal
(e.g., Foa, Johnson, Feeny, & Treadwell, 2001), and the latter is
conceptualized as positive changes following trauma, including
perceived changes in the self, sense of relationship with others, and
life philosophy (Tedeschi & Calhoun, 1996). Importantly, PTSD
and PTG may coexist in trauma survivors (e.g., Tedeschi & Cal-
houn, 1996), which shed light on the discussion the relationship
between PTSD and PTG (e.g., Zhou, Wu, & Chen, 2015a).
Nevertheless, the relationship between PTSD and PTG remains
recently mixed (e.g., Shakespeare-Finch & Lurie-Beck, 2014); that
Xiao Zhou, Beijing Key Laboratory of Applied Experimental Psychol-
ogy, School of Psychology, Beijing Normal University and I-Core Re-
search Center for Mass Trauma, Bob Shapell School of Social Work, Tel
Aviv University; Xinchun Wu and Rui Zhen, Beijing Key Laboratory of
Applied Experimental Psychology, School of Psychology, Beijing Normal
University.
This study was supported by the Major Project of Beijing Social Science
Fund, China (grant: 15ZDA11). We sincerely appreciate the students and
teachers who voluntarily devoted time and interest to our research.
Correspondence concerning this article should be addressed to Xinchun
Wu, School of Psychology, Beijing Normal University, No. 19 Xinjiekou-
wai Street, Beijing 100875, China. E-mail: xcwu@bnu.edu.cn
is, some studies found a positive relation between the outcomes
(e.g., Wu, Xu, & Sui, 2016), meaning that individual with in-
creased PTSD reported increase PTG. Other studies indicated a
negative relationship between PTSD and PTG (e.g., Johnson et al.,
2007), which suggested that PTG and PTSD can be conceptualized
as two ends of the same continuum. Even some studies fail to find
a significant relation between these two posttraumatic reactions
(e.g., Salsman, Segerstrom, Brechting, Carlson, & Andrykowski,
2009), suggesting PTSD and PTG may be two independent con-
structs. These inconsistent findings disturbed the understanding of
constructs of PTSD and PTG. To elucidate their relationship and
constructs, Dekel, Mandl, and Solomon (2011) suggested that it is
necessary to examine simultaneously predictive factors and to
compare their determining factors (e.g., García, Cova, Rincón, &
Vázquez, 2015). The aim of this study was to examine simultane-
ously and compare possible factors and predictive mechanism of
PTSD and PTG among adolescents after the earthquake.
Social support is considered to be one of the most important
predictors of posttraumatic reactions (e.g., Ozer, Best, Lipsey, &
Weiss, 2003). Several theories have been proposed to explain the
role of social support in posttraumatic outcomes. One representa-
tive theory is the additive and direct model of social support, which
suggests that social support plays an independent role in alleviat-
ing stress reactions regardless of the effects of stressful events
(Cohen & Syme, 1985). For example, social support can directly
influence adjustment through changes in health-promoting behav-
ior. Based on this model, studies indicated that social support is a
protective factor for PTSD but promote PTG (e.g., Jia, Ying, Zhou,
Wu, & Lin, 2015; Yu et al., 2014). Nevertheless, the mechanism

1
 2 ZHOU, WU, AND ZHEN
underlying the association between social support and PTSD/PTG
in the same study still was not evaluated. Thus, this study will
further examine simultaneously the underlying mechanism of so-
cial support to PTSD and PTG.
An assumption of the relationship between social support and
posttraumatic reactions argues that social support exerts a positive
effect in presence of stress by protecting people from the negative
effects of such stress (Cohen & Syme, 1985).For example, social
support can help people to redefine and reduce the potential for
harm posed by negative situations, or can bolster the ability to cope
with imposed demands, thereby changing negative appraisals of
stress. In this assumption, social support may have an effect on
stressful reactions by influencing others’ psychological processes
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(e.g., Schwarzer & Knoll, 2007). Emotion regulation is important
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among potential psychological processes underlying both PTSD
and PTG.
Emotion regulation is conceptualized as processes through
which individuals modulate their emotions consciously and non-
consciously to appropriately respond to environmental demands.
Social support can satisfy people’s relationship needs and help
people access more social resources, and thus social support can
exert a significant effect on emotion regulation strategies (e.g.,
Marroquín & Nolen-Hoeksema, 2015).
Specifically, social support can provide traumatized individuals
with a supportive environment (e.g., Carpenter, Fowler, Maxwell,
& Andersen, 2010), wherein individuals can experience the feel-
ings of safety and belongings (e.g., Zhou et al., 2014a), and in turn
encourage and activate traumatized individuals to disclose their
information, and share their emotions (e.g., Pietrzak, Johnson,
Goldstein, Malley, & Southwick, 2009). In addition, social support
can improve interpersonal relationship and increase interpersonal
intimacy (e.g., Marroquín, 2011), which will also increase the
likelihood of emotion sharing and cognitive disclosure (e.g., Rimé,
2009). Thus, some studies found that social support had a positive
effect on cognitive reappraisal (e.g., Valentiner, Holahan, & Moos,
1994), and a negative effect on expressive suppression (e.g., Sriv-
astava, Tamir, McGonigal, John, & Gross, 2009). Considering that
cognitive reappraisal and expressive suppression are two different
emotional strategies in the process model of emotion regulation
(Gross, 1998a), it is likely that social support can exert effects on
emotion regulation.
It is noteworthy that cognitive reappraisal, more specifically, is
a form of cognitive change that construes a potentially emotion-
eliciting situation in a way that changes its emotional impact (e.g.,
Lazarus & Alfert, 1964), one that involves making active efforts to
repair bad moods as well as generating benign or positive inter-
pretations or perspectives on a stressful situation (e.g., Gross,
1998b). These strategies can be helpful for traumatic survivors in
rebuilding their understanding of the world after trauma, reducing
distress, and fostering beneficial psychological changes post-
trauma. Thus, studies suggest that cognitive reappraisal protects
people from emotional disorders, decreases the severity of PTSD
(e.g., Boden, Bonn-Miller, Kashdan, Alvarez, & Gross, 2012), and
promotes PTG (e.g., Brans, Koval, Verduyn, Lim, & Kuppens,
2013).
In contrast, expressive suppression primarily modifies the be-
havioral aspects of emotion response tendency (e.g., Brans et al.,
2013), that is, the suppression of emotional expression, a risk
factor for negative psychological reactions (e.g., Gross, 2002).
Gross and John (2003) gave several potential explanations for this:
First, suppression can limit exposure to negative emotions, and
these emotions may thus continue to linger and accumulate unre-
solved. Second, using expressive suppression to regulate emotions
may consume too many cognitive resources, which will easily
cause burnout and result in further negative feelings. Third, sup-
pression creates in the individual a sense of incongruence, or
discrepancy, between inner experience and outer expression (e.g.,
Rogers, 1951), which may well lead to negative feelings about the
self. Therefore, it is proposed that expressive suppression may be
a risk factor for PTSD while discouraging PTG.
Although several theoretical predictions have been advanced to
describe the relationship between emotion regulation and negative
feelings and/or well-being, the predictive utility of these theories
focused on the relationship between emotion regulation and PTSD/
PTG has not been evaluated. In addition, prior studies investigat-
ing various emotion regulation strategies failed to control for the
use of other strategies, which may exaggerate the probability of
making a Type I error because of co-occurrence of distinct emo-
tional strategies. More importantly, the transition through adoles-
cence is accompanied by physical, psychological, and social trans-
formations that elicit novel experiences of emotional arousal, and
perhaps greater susceptibility to traumatic events, and thus, ado-
lescence is an opportune time to explore processes and correlates
of emotion regulation (e.g., Silk, Steinberg, & Morris, 2003).
Given this backdrop, the present study examined how social
support and emotion regulation might be associated with both
PTSD and PTG in adolescent survivors of the Ya’an earthquake
and propose that emotion regulation (i.e., cognitive reappraisal and
expressive suppression) would mediate the relationship between
social support and both PTSD and PTG.
Method
Participants and Procedures
This study was conducted 6 months after the Ya’an earthquake
occurred on April 20, 2013. The area we focus on was Lushan
county in Sichuan province, which was most severely affected by
the earthquake. We first contacted the local education authority
and informed them of the aims and methods of investigation, and
indicated that we could provide psychological services if required.
With the approval of the local education authority, we chose two
middle schools in Lushan county. Under the help of the principals
and psychology teachers of the two schools, we randomly selected
three classes from Grade 1, and also three from Grade 2, respec-
tively, to participate (students in Grade 3 were not available due to
arduous academic burden). All students in selected classrooms
attended school on the assessment date. Three hundred fifteen
adolescent survivors were selected. The mean age of the adoles-
cents at the time of measurement was 14.62 (SD ⫽ 1.80) years, and
the range was 12.0 to 18.0 years. Of the 315 participants, 167
(53.0%) were female and 148 (47.0%) were male. Proportions of
missing data for six participants reached about 50% for all the
items of main measures in this study, such that these participants
were excluded from further analysis. Participants were thus 309 in
this study.
This study was approved by the Research Ethics Committee of
Beijing Normal University and was conducted according to the prin-
 SOCIAL SUPPORT, EMOTION REGULATION, PTSD/PTG
cipals of the participating schools. In the selected classes, everyone
who attended school on the date of the survey was recruited to
participate. There were no exclusion criteria. Compensation was not
provided. The purpose of the study and the voluntary nature of the
students’ participation were highlighted before the survey, and written
informed consent was obtained from school principals and classroom
teachers. In China, research projects that are approved by local edu-
cation authorities and the school administrators and that are deemed to
provide a service to the students do not require parental consent. The
researchers administered the questionnaire packets in a classroom
setting without the presence of the teachers. The participants were
initially asked to provide demographic information, including gender
and age. They were then asked to complete the remaining measures
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assessed traumatic exposure, social support, cognitive emotional reg-
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ulation, PTG, and PTSD. After the questionnaire packets were com-
pleted, the participants were told that school psychologists or teachers
were available to provide any psychological or counseling services
that they might need.
Measures
Trauma exposure. The trauma exposure questionnaire devel-
oped by Wu, Zhang, Lin, and Zang (2013) was adopted to measure
the severity of adolescent survivors’ traumatic experiences. This
questionnaire consists of 18 items and requires participants to
indicate whether they have directly seen or indirectly heard about
the death, injury or entrapment of parents, friends, teachers or
others. Each of the items is rated on a 3-point scale ranging from
1 (did not experience the situations above) to 3 (see myself). The
score range of this questionnaire was 18 –54. The questionnaire has
previously exhibited good reliability in adolescent survivors of the
Wenchuan earthquake (e.g., Wu et al., 2013). In this study, the
internal reliability of the questionnaire was again good (␣ ⫽ .72).
Social support. This questionnaire is a 20-item instrument
designed to measure the following forms of perceived social
support (Zou, 1999): Emotive support (i.e., Helping me to resolve
troubles), instrumental support (i.e., Giving me some suggestion
on solving problems), companion (i.e., Accompanying me to do
something interesting), affirmative evaluation (i.e., Respecting my
ideas), and intimacy (i.e., I always tell my secrets to this person).
All the items are rated on a 5-point Likert scale that ranges from
0 (completely disagree) to 4 (completely agree). The score range of
this questionnaire was 0 – 80. The questionnaire has previously
exhibited good reliability and validity in adolescent survivors of
the Wenchuan earthquake (e.g., Zhou et al., 2014a). In this study,
the internal reliability of the modified inventory was good (␣ ⫽
.94), and the fit indices from a confirmatory factor analysis based
on five dimensions were acceptable (␹2/df ⫽ 2.61, comparative fit
index [CFI] ⫽ 0.93, Tucker-Lewis index [TLI] ⫽ 0.91, root mean
square error of approximation [RMSEA] ⫽ 0.073).
Emotion regulation strategies. Emotion regulation strategies
were assessed using this questionnaire (Chinese revised version;
Wang, Liu, Li, & Du, 2007). This questionnaire was consisted of
10 items, wherein six items were designed to measure cognitive
reappraisal (score range was 6 – 42; i.e., When confronting with
negative emotions, I can change the way I think) and four were
designed to measure expressive suppression (score range was
4 –28; i.e., I did not disclose my emotions). All the items are rated
on a 7-point Likert scale that ranges from 1 (completely disagree)
3
to 7 (completely agree). The questionnaire has previously exhib-
ited good reliability and validity (Wang et al., 2007). In this study,
internal reliability of the modified inventory was good (␣ ⫽ .77),
and the fit indices from a confirmatory factor analysis based on
two dimensions were excellent (␹2/df ⫽ 2.06, CFI ⫽ 0.95, TLI ⫽
0.94, RMSEA ⫽ 0.040).
PTG. PTG was measured using a modified version of the
Posttraumatic Growth Inventory (Zhou et al., 2014a). The original
Posttraumatic Growth Inventory was developed by Tedeschi and
Calhoun (1996) and consists of the following five subscales:
personal strength, new possibilities, relating to others, appreciation
of life, and spiritual change. Each of the 21 items is scored on a
6-point scale that ranges from 0 (no change) to 5 (very great
degree of change). The PTGI has good internal consistency and
good construct, convergent, and discriminate validities. The re-
vised PTGI includes the following three subscales for a total of 22
items: Perceived changes in self, a changed sense of relationships
with others, and a changed philosophy of life. The modified
inventory exhibited good reliability and construct validity for a
sample of adolescent survivors of the Wenchuan earthquake (Zhou
et al., 2014a, 2015a). The score range of this questionnaire was
0 –110. In this study, the internal reliability of the modified inven-
tory was good (␣ ⫽ .93), and the fit indices from a confirmatory
factor analysis based on three subscales were acceptable (␹2/df ⫽
2.36, CFI ⫽ 0.91, TLI ⫽ 0.90, RMSEA ⫽ 0.067).
PTSD. PTSD symptom levels were assessed using the Child
PTSD Symptom Scale (Foa et al., 2001) as applied to the Chinese
population (Ying et al., 2013). This measure is a 17-item self-
report scale that was designed to assess the occurrence and fre-
quency of DSM–IV–TR PTSD symptoms in relation to the most
distressing event experienced by an individual. In the present
study, all of the items were translated into Chinese, and the
respondents rated the frequencies of the symptoms during the
previous 2 weeks on 4-point Likert scales that ranged from 0 (not
at all/only once) to 3 (almost always or more times a week). The
subscale scores range from 0 to 15 for intrusion symptoms, 0 to 21
for avoidance symptoms and 0 to 15 for hyper-arousal symptoms.
An overall severity score is generated by summing the scores for
the three symptom types. This scale exhibited good reliability and
construct validity for a sample of adolescent survivors of the
Wenchuan earthquake (e.g., Ying et al., 2013). The score range of
this scale was 0 –51. In this sample, the scale demonstrated good
internal consistency (␣ ⫽ .87), and the fit indices from a confir-
matory factor analysis based on three subscales were acceptable
(␹2/df ⫽ 2.26, CFI ⫽ 0.90, TLI ⫽ 0.89, RMSEA ⫽ 0.064).
Data Analysis Strategies
Descriptive analyses were conducted for all of the measures
administered. Pearson correlations were calculated to examine the
associations between the major variables.
The statistical analyses were conducted using Mplus 6.0 soft-
ware (Muthén & Muthén, 2010). We first conducted an analysis of
missing data in variables and found that missing data across all
items were less than 1.9%. To assess whether the missing data
pattern was random, we conducted analyses using Little’s missing
completely at random test. The analysis revealed that the data were
missing at random), ␹2(42) ⫽ 47.17, p ⫽ .269. We therefore
 4 ZHOU, WU, AND ZHEN

adopted the robust maximum likelihood estimator (MLR) method survivor (Tedeschi & Calhoun, 1996). We also inserted emotion
are less biased and more reliable. regulation (i.e., cognitive reappraisal and expressive suppression)
In addition, we examine the distribution of scale scores and between social support and PTSD/PTG and added one related path
found that skewness and kurtosis are ⫺0.18 and 0.13 for expres- between cognitive reappraisal and expressive suppression to establish
sive suppression, ⫺0.31 and 0.45 for cognitive reappraisal, ⫺0.37 an indirect effects model. In addition, the traumatic exposure will be
and ⫺0.33 for social support, ⫺0.51 and 0.23 for PTG, and 0.76 controlled in this model (see Figure 1). Moreover, to test the signif-
and 0.47 for PTSD. Moreover, to examine the multivariate nor- icance of this indirect effect, we conducted bias-corrected bootstrap
mality of measures, Mardia’s multivariate normality tests were tests with a 95% confidence interval.
also conducted. The result showed that Mardia coefficient was
6.81 (CR ⫽ 7.16), which indicated that the data in this study did Results
not belong to multivariate normal distribution. Thus, we used
MLR in the model analysis according to Wang, Wang, and Jiang
Descriptive Statistics and Correlations Among
(2011) suggestion. To evaluate model fit, we used chi-square
Main Measures
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values, the CFI, the TLI, the RMSEA, and the standardized root
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mean residual (SRMR). A nonsignificant chi-square indicates Descriptive statistics and the correlations among the main measures
good model-data fit. The general cutoffs for accepting a model are are shown in Table 1. The mean levels of trauma exposure, social
equal to or greater than 0.90 for the CFI and TLI, and less than support, cognitive reappraisal, expressive suppression, PTSD, and
0.08 for the SRMR and RMSEA (e.g., Wen, Hau, & Marsh, 2004). PTG were 1.15, 2.40, 4.76, 3.84, 0.76, and 2.80, respectively. Pear-
We built structural equation models (SEM) to examine the roles son’s correlations were calculated. These analyses yielded significant
of social support and emotion regulation in PTSD and PTG. Here, correlations between all of main variables except for the relationship
the PTSD latent variable was evaluated according to CPSS sub- between social support and PTSD. More importantly, we obtained a
scale scores for intrusion, avoidance and hyper-arousal (Foa et al., nonsignificant relation between PTSD and PTG.
2001) whereas the PTG latent variable was evaluated in terms of
perceived changes in the self, a changed sense of relationships with
Analysis of the Indirect Effect
others, and a changed philosophy of life(Zhou et al., 2014a).
Next, we applied an SEM approach to assess structural paths from Correlation analysis found that social support was nonsignifi-
social support to PTSD and PTG, such that PTSD and PTG were cantly associated with PTSD, but according to Wen and Ye (2014),
assumed to be related because of their observed coexistence in trauma the indirect effect of social support on PTSD via a third variable

Hyper-arousal
Avoidance
Intrusion

0.78***
***
0.70 0.86***
CR
0.01 -0.17*
***
PTSD
0.22
TE *
0.14
0.22**
0.12*
0.12 *
0.25*** 0.07
0.32***
***
0.34
SS 0.18**
-0.14* PTG
ES 0.07
*** *** ***
0.91 0.84 0.71
0.91*** 0.80***
0.88*** 0.84*** 0.89***
Affirmative evaluation
Instrumental support

Philosophy changes
Emotive support

Relation changes
Companion

Self changes
Intimacy

Figure 1. Indirect effects model. Note: TE ⫽ Traumatic exposure; SS ⫽ Social support; CR ⫽ Cognitive
reappraisal; ES ⫽ Expressive suppression. ⴱ p ⬍ 0.05. ⴱⴱ p ⬍ 0.01. ⴱⴱⴱ p ⬍ 0.001.
 SOCIAL SUPPORT, EMOTION REGULATION, PTSD/PTG 5

Table 1
Means, Standard Deviations, and Correlations Between Traumatic Exposure Severity, Cognitive
Reappraisal, Expressive Suppression, PTSD, and PTG

M ⫾ SD 1 2 3 4 5 6

1. Traumatic exposure 1.15 ⫾ 0.19 1.00

2. Social support 2.40 ⫾ 0.78 0.05 1.00
3. Cognitive reappraisal 4.76 ⫾ 0.97 0.05 0.26ⴱⴱ 1.00
4. Experssive suppression 3.84 ⫾ 1.20 0.10† ⫺0.12ⴱ 0.20ⴱⴱ 1.00
5. PTSD 0.76 ⫾ 0.46 0.20ⴱⴱ ⫺0.01 ⫺0.11ⴱ 0.22ⴱⴱ 1.00
6. PTG 2.80 ⫾ 0.93 0.15ⴱⴱ 0.26ⴱⴱ 0.33ⴱⴱ 0.10† 0.07 1.00
ⴱ ⴱⴱ ⴱⴱⴱ
†
p ⬍ 0.086. p ⬍ 0.05. p ⬍ 0.01. p ⬍ 0.001.
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could be also examined as the “suppression effect” might exist. Salsman et al. (2009) studies, but not paralleled to others studies (e.g.,
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Suppression effect refers to a situation where the magnitude of the
relation between an independent variable and a dependent variable
becomes larger when a third variable is included (MacKinnon,
Krull, & Lockwood, 2000). Thus, we still examined the indirect
effect of social support on PTSD via emotion regulation in this
study (e.g., cognitive reappraisal and expressive suppression) to
assess the potential suppression effect of emotion regulation. In
addition, social support and PTG was significantly correlated, and
the roles of cognitive reappraisal and expressive suppression be-
tween social support and PTG were also examined. Taken to-
gether, we assumed that social support had indirect effect on both
PTSD and PTG via emotion regulation.
In addition, regarding for the coexistence of PTSD and PTG,
then a correlation path between PTSD and PTG was added. Fur-
thermore, we also controlled for the potential role of traumatic
exposure in structural equation model analyses, because of its
significant correlations with social support as well as PTSD/PTG.
However, the direct path from social support to PTSD was not
added because of the nonsignificant correlation between them. The
final indirect effects model was presented in Figure 1. The results
of model analysis found that this indirect effects model exhibited
acceptable fit indices, ␹2/df ⫽ 2.38, CFI ⫽ 0.95, TLI ⫽ 0.94,
RMSEA (90% CI) ⫽ 0.067 (0.054 –0.081), SRMR ⫽ 0.043. All
the paths were found significant except for the paths between
expressive suppression and PTG. PTSD and PTG were indepen-
dent.
Next, we conducted bias-corrected bootstrap tests with a 95%
confidence interval to assess the significance of observed indirect
effects. Table 2 illustrates the results of these tests, which revealed
that the findings in Figure 1 were accepted, and indicated that social
support had a positive and direct prediction on PTG. Moreover, social
support had a negative indirect prediction on PTSD and a positive
indirect prediction on PTG through cognitive reappraisal. Social sup-
port, through expressive suppression, had a significant and indirect
prediction on PTSD, but nonsignificant indirect prediction on PTG.
Johnson et al., 2007). A potential explanation might be attributed to
the difference of measuring instrument on PTSD and PTG, and
participants as well as their traumatic experiences. More importantly,
we found that the level of adolescent’s PTSD was relatively low in
this study. This may make it difficult to arouse traumatized individ-
uals’ motion to activate them to engage in cognitive thoughts on
traumatic clues (e.g., Meyerson, Grant, Carter, & Kilmer, 2011),
hence, it is hard for PTSD to promote growth. Therefore, we found a
nonsignificant relation between PTSD and PTG, although adolescents
had a high level of PTG.
In addition, consistent with previous studies (e.g., Jia et al., 2015;
Yu et al., 2014) and the direct model of social support (Cohen &
Syme, 1985), we found that social support had a positive and direct
prediction on PTG, Here, social support appeared to provide some
necessary emotional support for adolescent survivors, which can
enhance positive emotion, and in turn helps them to rethink self,
others and the world, and they then realize psychological growth (e.g.,
Zhou, Wu, Fu, & An, 2015b). In addition, social support can also
improve one’s interpersonal relationship with others, and in turn
increase the likelihood of emotion sharing and cognitive disclosure
(e.g., Rimé, 2009), and ultimately lead to the realization of PTG (e.g.,
García, Cova, Rincón, Vázquez, & Páez, 2016).
However, inconsistent with the assumptions of the direct social
support model, correlation analysis found a nonsignificant association
between social support and PTSD, which indicated that social support
did not play a direct and significant role in PTSD. A possible expla-
nation is that if constant social support from others is provided even
after 6 months since the Ya’an earthquake, the traumatized adoles-
Table 2
Bias-Corrected Bootstrap Tests of Mediating Effects
95% CI
Paths Standardized ␤ (SE) Low High

Direct paths
Discussion SS - PTG 0.18 (0.07)ⴱⴱ 0.07 0.29
To our knowledge, this is the first study to date to simultaneously Indirect paths
SS - CR - PTSD ⫺0.05 (0.02)ⴱ ⫺0.09 ⫺0.02
examine the roles of social support and emotion regulation in influ- SS - CR - PTG 0.11 (0.03)ⴱⴱⴱ 0.06 0.15
encing PTSD and PTG, and to elucidate the relationship between SS - ES - PTSD ⫺0.03 (0.02)ⴱ ⫺0.06 ⫺0.001
PTSD and PTG by examining their differences in terms of influencing SS - ES - PTG ⫺0.01 (0.01) ⫺0.03 0.01
factors, after controlled traumatic exposure. The findings indicated a Note. SS ⫽ Social support; CR ⫽ Cognitive reappraisal; ES ⫽ Expres-
nonsignificant relation between PTSD and PTG in correlation analy- sive suppression.
ⴱ
sis and model analysis, which was consistent with the results from p ⬍ 0.05. ⴱⴱ p ⬍ 0.01. ⴱⴱⴱ p ⬍ 0.001.
 6 ZHOU, WU, AND ZHEN
cents in the environment that always protects traumatized adolescents
by others’ social support have few chances to learn to cope on their
own, and this will further damage their self-efficacy and enthusiasm
in coping with trauma (e.g., Zhou, Wu, An, & Chen, 2014b), and
thereby it is difficult for traumatized adolescents to relieve negative
psychological results, such as PTSD.
Another potential explanation for the nonsignificant effect of social
support on PTSD is that “suppression effect” existed between them.
Specifically, the present study found that social support had an indi-
rect and significant negative prediction on PTSD by increasing cog-
nitive reappraisal. A previous study suggested that perceived high
social support can increase adolescents’ feelings of safety and belong-
ing and can help adolescents to share their traumatic experiences
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
freely with supporters (e.g., Zhou et al., 2014a), which can increase
This document is copyrighted by the American Psychological Association or one of its allied publishers.
the probability of cognitive reappraisal on trauma and emotion. Fur-
thermore, cognitive reappraisal represents a more effortful, deliberate
cognitive process, and this process can serve as an adaptive coping
strategy (e.g., Salsman et al., 2009), which helps to relieve the severity
of PTSD. In addition, cognitive reappraisal provides an opportunity
for producing the thoughts that concern the positive implications of a
traumatic experience (e.g.,Cann, Calhoun, Tedeschi, & Solomon,
2010), and hence relieves the level of PTSD. Thereby, social support
could buffer the severity of PTSD via increasing traumatized adoles-
cents’ cognitive reappraisal.
An interesting finding of this study is that expressive suppression
also had a “suppression effect” between social support and PTSD.
Specifically, the finding found that social support also could relieve
indirectly the severity of PTSD through decreasing expressive sup-
pression. Here, in a setting with high social support, people are more
likely to expose their emotions to others and to vent negative feelings,
and in turn the probability of expressive suppression is reduced.
Generally, expressive suppression can lead to increased sympathetic
nervous system arousal (e.g., Harris, 2001) and impaired memory
(e.g., Richards, Butler, & Gross, 2003), which will elicit greater
depression and social anxiety, and more negative emotions in re-
sponse to negative affective stimuli (e.g., Sperberg & Stabb, 1998).
Thus, social support has an indirect predictive role in PTSD by
reducing expressive suppression.
Nevertheless, our findings indicated that cognitive reappraisal,
but not expressive suppression, mediated the relationship between
social support and PTG. Specifically, social support has indirect
and positive effect on PTG via increasing cognitive reappraisal but
has nonsignificant indirect effect on PTG via decreasing emotion
suppression. Previous studies indicated that PTG could be acti-
vated by people’s cognitive activities, such as positive reappraisal
(e.g., Stockton, Hunt, & Joseph, 2011). Here, cognitive reappraisal
can distract traumatized adolescents’ attention from negative as-
pects of traumatic clues and keep their focus on the positive side
of posttraumatic world (e.g., Zhou, Wu, Fu, & An, 2015b). This
will then increase the likelihood for traumatized adolescents to
restructure their understanding on self, interpersonal relationship,
and the world following trauma, which promotes them to find the
meanings of posttraumatic world, and in turn their PTG realized
(e.g., Zhou et al., 2015b). Thus, when cognitive reappraisal and
expressive suppression were inserted in the relation between social
support and PTG simultaneously, the role of emotional process in
PTG was obscured by such cognitive process.
Several design and measurement limitations must be acknowl-
edged. First, because of the aim of our study and the characteristics
of participants, our sample may be somewhat selective, which can
entail the risk of a reporting bias. Second, the study was conducted
with a sample of adolescent survivors after the Ya’an earthquake
in China, and generalizations to people with other traumatic ex-
periences must be made with caution. Moreover, the study was a
cross-sectional study, and generalization of the results to other
studies should be made with caution, future studies should further
examine these main measures from longitudinal perspective.
Despite these limitations, this study contributes new knowledge to
previous theoretical and empirical studies on the relationships be-
tween social support, emotion regulation, and PTSD/PTG. In partic-
ular, this study further supports the assumption that pathways to
PTSD and PTG are different (e.g., Chan, Ho, Tedeschi, & Leung,
2011) and has demonstrated that PTSD and PTG have different
predictive factors as well as indirectly predictive process. In fact,
Dekel et al. (2011) proposed that the existence of unique predictors of
PTSD and PTG would suggest that they were separate constructs.
From this perspective, these results indicated that PTSD and PTG are
separate, independent dimensions of psychological experiences fol-
lowing adversity (e.g., Linley & Joseph, 2004).
From an intervention and health-enhancement perspective, this
study also highlights important implications for adolescent survivors
of the Ya’an earthquake. The assessment for adaptation to the ado-
lescents with traumatic experience should incorporate both positive
and negative indices of adjustment. Clinical efforts should focus on
the improvement of cognitive reappraisal. For example, school psy-
chologists or parents can encourage adolescents to think of the posi-
tive aspect of posttraumatic world, and look positively on self, inter-
personal relationship, and the world after trauma. By this, adolescents
can positively reframe the trauma reminders, and also disclosing their
negative emotions to others will mitigate negative posttraumatic ef-
fects and instead contribute to positive posttraumatic growth.
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Received June 1, 2016
Revision received August 2, 2016
Accepted September 17, 2016 䡲