Relationship between cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers: Exploring multiple mediation model

Author’s Accepted Manuscript Relationship between cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers: exploring multiple mediation model Wen-peng Cai, Yu Pan, Shui-miao Zhang, Cun Wei, Wei Dong, Guang-hui Deng www.elsevier.com/locate/psychres

PII: DOI: Reference:

S0165-1781(16)31639-0 http://dx.doi.org/10.1016/j.psychres.2017.06.018 PSY10565

To appear in: Psychiatry Research Received date: 27 September 2016 Revised date: 17 May 2017 Accepted date: 7 June 2017 Cite this article as: Wen-peng Cai, Yu Pan, Shui-miao Zhang, Cun Wei, Wei Dong and Guang-hui Deng, Relationship between cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers: exploring multiple mediation model, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2017.06.018 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Relationship between cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers: exploring multiple mediation model

Wen-peng Caia, Yu Panab, Shui-miao Zhangac, Cun Weia, Wei Donga*, Guang-hui Denga*

a

Faculty of Psychology and Mental Health, Second Military Medical University, 200433

Shanghai, China b

Department of Medical Psychology, General Hospital of PLA, 100853 Beijing, China;

c

Department of neurology, Jinan Military General Hospital of PLA, 250000 Jinan, China;

*, Address for correspondence: Professor Guang-hui Deng Faculty of Psychology and Mental Health Second Military Medical University Shanghai 200433, China Tel (Fax) & E-mail: +86-21-81871667, [email protected]

Associate Professor Wei Dong Faculty of Psychology and Mental Health Second Military Medical University Shanghai 200433, China Tel (Fax) & E-mail: +86-21-81871452, [email protected]

Running head: emotion regulation and acute stress Abstract The current study aimed to explore the association of cognitive emotion regulation, social support, 1

resilience and acute stress responses in Chinese soldiers and to understand the multiple mediation effects of social support and resilience on the relationship between cognitive emotion regulation and acute stress responses. A total of 1,477 male soldiers completed mental scales, including the cognitive emotion regulation questionnaire-Chinese version, the perceived social support scale, the Chinese version of the Connor-Davidson resilience scale, and the military acute stress scale. As hypothesized, physiological responses, psychological responses, and acute stress were associated with negative-focused cognitive emotion regulation, and negatively associated with positive-focused cognitive emotion regulation, social supports and resilience. Besides, positive-focused cognitive emotion regulation, social support, and resilience were significantly associated with one another, and negative-focused cognitive emotion regulation was negatively associated with social support. Regression analysis and bootstrap analysis showed that social support and resilience had partly mediating effects on negative strategies and acute stress, and fully mediating effects on positive strategies and acute stress. These results thus indicate that military acute stress is significantly associated with cognitive emotion regulation, social support, and resilience, and that social support and resilience have multiple mediation effects on the relationship between cognitive emotion regulation and acute stress responses. Keywords Military personnel; Coping; Psychological well-being; Positive refocusing; Blaming others; Bootstrapping techniques

1. Introduction Acute stress response (ASR), generally considered the fight-or-flight response, occurs under 2

psychologically or physically terrifying circumstances. Clinically, ASR refers to clusters of traumatic stress symptoms characterized by disassociation, avoidance, and arousal that occur in the first month after exposure to a traumatic event (Bryant et al., 2011). Although low to moderate levels of acute stress can be adaptive, the accumulated effects of chronic exposure to stress still lead to negative outcomes, including exhaustion, cognitive decline, poor health behaviors, depressive symptoms, avoidance behavior, and negative social relationships (Juster et al., 2010). Currently, the majority of soldiers are not engaged in wars or conflicts, but they have to face many other types of stressors, such as training exercises, heavy workloads, and family separation (Bartone et al., 1998; Castro et al., 1999). These inevitable stressors could give rise to anxiety, depression, posttraumatic stress disorder (Hoge et al., 2004;

et al.,

), and even suicidal behaviors (Kuehn, 2009; Anglemyer et al., 2016), which

might seriously impair their functions in social and occupational areas, as well as other significant fields (Sharp et al., 2012). There is evidence that ASR is relatively frequent in military personnel (Huang et al., 2014; Speckhard, 2002), and exposure to acute stress for a long time can compromise an individual’s task effectiveness. Several protective factors (Israel-Cohen et al., 2016) and successful stress management strategies (Cruess et al., 2015) may be effective at reducing acute distress and also at buffering physiological response. In this instance, many researchers have examined military acute stress and potential related factors (Hu et al., 2012; Huang et al., 2014; Qi et al., 2014). Emerging research suggests that emotion regulation strategies are predictive of stress-related symptoms (Vanderhasselt et al., 2014). According to Garnefski et al(2001), the general concept of emotion regulation can be regarded as a cognitive style of managing the intake of emotionally arousing information, which encompasses a broad range of cognitive, behavioral, emotional, and physiological responses. This concept is assumed to be an understanding of the behavioral and emotional connection 3

between affective states and stress (Rudolph et al., 2007). Importantly, cognitive emotion regulation strategies are reported to affect the initial emotional response and its subsequent course when individuals confront stressful life events (Garnefski et al., 2006; Jinyao et al., 2012). Given the differential effects on mental health and behaviors, cognitive emotion regulation strategies are divided into adaptive and maladaptive strategies. Reappraisal, regarded as an adaptive strategy, involves altering how to think about an emotion by eliciting the situation to change its emotional impact. Suppression, considered a maladaptive strategy, involves inhibiting emotional expression in response to an emotion-eliciting event (Appleton et al.,2013). Adaptive cognitive emotion regulation strategies are of importance for well-being and successful functioning and are essential for the initiation, motivation, and task effectiveness, whereas maladaptive strategies might result in maladaptive behaviors, not favorable for individual rehabilitation (Wang et al., 2014; Garnefski et al., 2001). Several researchers suggested that emotion regulation is a critical factor for military performance (e.g., emotion/attention interactions, and motor task performance, etc., Janelle et al., 2008; Tenenbaum et al., 2008; et al.,

). Both military and non-military operations are stressful events for soldiers, but few studies

have explored the relationship between cognitive emotion regulation strategies and military acute stress, which is one of the current study’s objectives. Even though some people undergo negative physical and mental health effects following stressful life events, some others show high resilience to stress (Bartone, 2006). It’s on account of the potential effects on well-being, health, and quality of life that resilience becomes a fruitful focus of research (Friedli, 2009; Jr, 2011). Resilience is assumed to be an important factor that protects individuals from the negative impact of stress (Newman, 2005), increases the ability to cope with considerable challenges (Rutter, 1985) and to promptly pick up from negative emotional experiences (Tugade et al., 4

2004). Schaubroeck et al (2011) explored resilience to traumatic exposure among soldiers deployed in combat areas and suggested resilience might play a substantial role in differentiating those who prove to be more or less adaptive to extremely stressful environments. Then, several researchers demonstrated that resilience contributed to success at military academies (Bartone et al.,2013; Bezdjian et al., 2016; Maddi et al., 2012). Besides, emotion regulation processes prove to be the key to resilience and mental well-being (Gross et al., 2003; Hu et al., 2014; Kalisch et al., 2015). For example, Min et al (2013) showed that the cognitive emotion regulation strategies of refocus on planning, positive reappraisal, and less rumination contributed to resilience in patients with depression and anxiety disorders. It might provide potential targets for psychotherapeutic intervention to improve resilience in these patients. Therefore it is also important to help soldiers survive and thrive when dealing with negative events and to investigate the correlations among resilience, emotion regulation, and military acute stress. Another potential factor is social support, which is considered the perceived availability of support, affection, and instrumental aid from significant social partners, such as family members, intimate friends, and workmates (Larocca et al., 2015). Several studies have found that good social support is associated positive health effects (Berkman et al., 2000; Cohen, 2004), and poor social support leads to negative outcomes (Skarupski et al., 2015). Additionally, a longitudinal study successfully showed that entity theorists of emotion had lower emotion regulation and received less social support from new friends (Tamir et al., 2007). Due to strict management, family separations, and heavy workloads, social support turns out to be more important for soldiers’ mental health. On the one hand, social supports are able to promote soldiers’ combat motivation during deployment (Grant-Vallone et al., 2001; Greene et al., 2010; Kamphuis et al., 2012). On the other hand, a supportive family can provide service members 5

with emotional resources, such as understanding and comfort, which enable individuals to perceive the experience as less threatening and to help them process through the situation (House et al., 1985; Schaefer et al., 1998). A recent research in otherwise healthy navy personnel suggested that greater resilience, greater post-deployment social support, and less stressful deployment environments could predict greater post-deployment adjustment (Cunningham et al., 2014). Also, adaptive emotion regulation skills and social relationships could have significant protective effects on the lives of recently returning combat veterans (Williston, 2013). In the current study, social support was expected to mediate the relationship between emotion regulation and acute stress response. The positive effects of social support might be especially beneficial for those military personnel with maladaptive emotion regulation strategies, because they used to experience more distress when exposed to the threat. Additionally, there is mounting evidence suggesting that social support interacts with interpersonal variables to confer resilience (Lee et al., 2011; Russell

et al., 2016), which is also one of the relationships this research aims to explore in

military personnel. Generally speaking, cognitive emotion regulation strategies, resilience, social support, and military acute stress are closely linked with one another. To our knowledge, the current study is the first report on a model examining the relationships among these four constructs in a large Chinese military sample. Specifically, we sought to (1) explore the associations among cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers; and (2) more importantly, understand the multiple mediation effects of social support and resilience on the relationship between cognitive emotion regulation and acute stress responses, supporting references for the improvement of acute stress responses in military personnel. 6

2. Methods 2.1. Participants Fifteen hundred forty-eight male soldiers of the Chinese People's Liberation Army from the same barracks were recruited for the current study. All the participants took part in the annual military examination, which was closely connected to their promotion and other incentives. They were informed in advance that participation was completely voluntary and that their command would not receive any respondent data. They also read the informed consent on the first page of the questionnaires. The whole self-report survey lasted approximately 30 min. All of the 1,548 questionnaires were collected, among which 71 were excluded because of obviously disordered answers or too much missing data on a scale, producing a questionnaire validity rate of 95.4%. A questionnaire with obviously disordered answers meant the respondent provided the same options for a whole scale or ABCD options repeatedly. A scale with more than 3 missing answers was also deemed invalid. The other missing data were replaced using Markov Chain Monte Carlo multiple imputation, which was reported to be a preferred technique for handling missing values because of several advantages over other approaches (Azur et al., 2011). Finally, a total of 1,477 participants consisting of soldiers (93.0%) and officers (7.0%) were included in this study (aged 17-38, M=21.34, SD=3.332; military service duration 1-20 years, M=3.02, SD=3.062). Other demographic variables can be seen in Table 1. 2.2. Measures Cognitive Emotion Regulation Questionnaire-Chinese Version (CERQ-C) The CERQ, developed by Dr. Nadia Garnefski and Dr. Vivian Kraaij, is a 36-item self-report 7

assessment of an individual’s cognitive emotion regulation strategies for stressful events in general (Garnefski et al., 2002; Garnefski et al., 2002). The 36-item CERQ is divided into 9 conceptually distinct subscales: 5 adaptive strategy subscales (acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting into perspective, e.g., ‘I think that I must learn to live with it’) and 4 maladaptive strategy subscales (self-blame, rumination, catastrophizing, and blaming others, e.g., ‘I feel that I am the one who is responsible for what has happened’). The adaptive strategy subscales are interpreted as “positively focused cognitive emotion regulation”, whereas the maladaptive strategy subscales are interpreted as “negatively focused cognitive emotion regulation” (Garnefski et al., 2001). Responders indicate their degree of agreement with a 5-point Likert scale ranging from 1 [(almost) never] to 5 [(almost) always]. Items are summed to obtain subscale scores between 4 and 20, with a higher subscale score denoting greater use of a specific cognitive strategy. The CERQ and CERQ-C both show good reliability and validity (Garnefski et al., 2005; Zhu et al., 2008; Yang et al., 2013). In the current sample, the CERQ-C positive subscale and negative subscale exhibited strong internal consistency (Cronbach’s alpha=0.826 and 0.806, respectively). Perceived Social Support Scale (PSSS) The PSSS, introduced by Blumenthal and designed by Zimet, is a multidimensional self-report questionnaire measuring perceived emotional support from friends, family and significant others (Blumenthal et al., 1987). According to the revisions by Jiang (2005), the 12-items PSSS contains two conceptually distinct subscales: family support and social support. The former is obtained by summing the scores for items 3, 4, 8 and 11 (e.g., ‘My family is willing to help me make decisions’), and the latter is obtained by combining the other items (e.g., ‘There is a special person who is around when I 8

am in need’). Responses to items are measured on a 7-point Likert scale ranging from 1 [strongly disagree] to 7 [strongly agree]. Items are summed to obtain scores between 12 and 84, with higher scores denoting greater support. A score below 32 indicates a severely dysfunctional social support system, and a score above 50 indicates a well-functioning one (Dai et al., 2016). The PSSS has shown good reliability and validity, and its subscale scores exhibited moderate and strong internal consistency (Cronbach’s alpha=0.757 and 0.879, respectively) in the current sample. Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) The Chinese version of the CD-RISC, revised by YU, is a multidimensional self-report questionnaire measuring resilience. The 25 items comprise 3 factors: strength (e.g., ‘One can achieve one’s goals’), tenacity (e.g., ‘Past success gives confidence for new challenge’) and optimism (e.g., ‘close and secure relationship’). The items were rated on a 5-point Likert scale from 0 (not true at all) to 4 (true nearly all the time). This Chinese version of the CD-RISC has demonstrated good reliability and validity (Yu et al., 2006; Xie et al., 2016). With the exception of optimism (Cronbach’s alpha=0.680), the other two factors showed good internal consistency (0.931, and 0.882) in the current sample. According to Malhotra et al (1998) and George et al (1999), a scale is reliable if Cronbach's alpha>0.6. Therefore, optimism was still included in the following analysis. Military Acute Stress Scale (MASS) The MASS, designed by Yan, is a widely used questionnaire measuring acute stress response scale for army men. The 37 items contain two factors: physiological responses (e.g., ‘Backache’, ‘Pallor’, ‘Diarrhea’) and psychological responses (e.g., ‘Self-accusation’, ‘Suicidal idea’, ‘Depression’). Participants exposed to stress needed to make a choice as to whether they had experienced these symptoms in the past month. It uses a two-level scoring system in which a ‘yes’ receives a 1 and a ‘no’ 9

receives a 2. Higher scores denote more serious stress-related symptoms. The correlation coefficients between subscales and the whole scale were 0.700 - 0.846. The scale was significantly related to the Chinese military psychosomatic health scale (r =0.338-0.962, p<0.01). The split-half correlation coefficients for the whole scale and subscales were 0.466-0.855. The test-retest correlation coefficients were 0.466-0.909 (Yan et al., 2012; Zhang et al., 2014). In the current sample, the consistency rates of physiological responses and psychological responses were 0.778 and 0.664, respectively. 2.3. Statistical approach Descriptive analyses, correlation analyses and regression analyses were performed using SPSS 22.0 software. The structural equation model and multiple mediation analysis were performed with Amos 17.0 software. The cognitive emotion regulation strategy was divided into positively focused one and negatively focused one. Family support and social support were included into perceived social support measurements. Likewise, strength, tenacity and optimism were included into resilience measurements, and physiological responses and psychological responses were included into military acute stress measurements. Several goodness-of-fit indices were used to evaluate the Structural Equation Modeling (SEM, Hu et al., 1998), and the multiple mediation analysis was evaluated using 1,000 bootstrap samples to calculate the 95% bias-corrected and accelerated bootstrap confidence intervals (CI), which are considered more statistically robust than traditional approaches (Preacher et al., 2008). 3. Results 3.1. Demographic variables Table 1 shows some demographic information for all participants in addition to descriptive statistics for study measures. 10

3.2. Correlation analysis of cognitive emotion regulation, social support, resilience and acute stress responses Table 2 shows descriptive statistics and Pearson correlations among the study variables. All the measuring instruments demonstrated acceptable internal consistency in the current sample. Physiological responses, psychological responses, and acute stress were positively associated with both positively focused cognitive emotion regulation and negatively focused cognitive emotion regulation (p<0.01), and negatively associated with social support and resilience (p<0.01). In addition, positively focused cognitive emotion regulation, social support, and resilience were significantly positively associated with one another (p<0.01), and negatively focused cognitive emotion regulation was negatively associated with social support (p<0.01). As negatively focused and positively focused cognitive emotion regulation strategies were interrelated, partial correlations between CERQ and MASS were also calculated. After controlling for the negatively focused cognitive emotion regulation, the positively focused cognitive emotion regulation was negatively associated (positive regulation & physiological responses Partial r=-0.086, p=0.001; positive regulation & psychological responses Partial r=-0.074, p=0.004). However, after controlling for positively focused cognitive emotion regulation, negatively focused cognitive emotion regulation still had a positive relationship with physiological responses (Partial r=0.343, p<0.001) and psychological responses (Partial r=0.289, p<0.001). These results implied that while the use of adaptive strategies was related to reporting lower physiological and psychological symptoms, the use of maladaptive strategies was related to reporting higher levels of these symptoms. 3.3. Mediation analysis

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Multiple hierarchical regression analysis was performed to determine the main contribution of antecedent variables (independent and mediator) to acute stress responses and their possible mediating effects. Independent variables (positively focused and negatively focused cognitive emotion regulation strategies) were included in step 1, and the mediators (social support and resilience) were included in step 2. As shown in table 3, positively focused and negatively focused cognitive emotion regulation strategies each made an independent and positive contribution to acute stress response. Furthermore, when social support and resilience were included in step 2, the contribution of positive and negative strategies changed, whereby the contribution of negatively focused cognitive emotion regulation strategies to acute stress response decreased, and the contribution of positively focused cognitive emotion regulation strategies was no longer significant. Therefore, social support and resilience partially mediated the relation between negative strategies and acute stress, and fully mediated the relation between positive strategies and acute stress. The above results provided preliminary support for the proposed structural equation model shown in Figure 1 (Model A). Maximum likelihood estimation was employed to calculate the goodness-of-fit indices,  /df=39.166/20=1.958 (p=0.006), RMSEA=0.025, CFI=0.997, GFI=0.994, 2

AGFI=0.987, NFI=0.994, RFI=0.986, IFI=0.997, TLI=0.993. According to Wu (2009), if AGFI > 0.900 and RMSEA <0.05, the model has a good fit. Therefore, the model fit was shown to be good. In addition, two alternative models were examined to test whether the suggested mediational model was preferred to two other models with different directional effects. In model B, social support and resilience were included as antecedents, and positive and negative strategies were included as 2

mediators ( /df=750.261/21=35.727, p<0.001, RMSEA=0.153, CFI=0.879, GFI=0.936, AGFI=0.856, NFI=0.877, RFI=0.736, IFI=0.880, TLI=0.741). Model C was a complete reversal model in which all 12

2

the paths in the proposed model were turned in the other direction ( /df=618.177/21=39.437, p<0.001, RMSEA=0.139, CFI=0.901, GFI=0.943, AGFI=0.872, NFI=0.898, RFI=0.782, IFI=0.902, TLI=0.788). Both Model B and C failed to obtain the best fit to the data, and several paths turned out to be non-significant (Model B: PSSS --> CERQ-C-Negative, CERQ-C-Positive --> MASS; Model C: PSSS --> CERQ-C-Negative). On this basis, bootstrapping techniques were used to evaluate multiple mediation. As shown in table 4, all the paths were explicitly significant (zero was not included in 95% CI), indicating that social support and resilience have mediating effects on cognitive emotion regulation and military acute stress. In this model, the direct effect of maladaptive strategies on military acute stress was 0.34, and the total mediation effect was 0.097 (0.064+0.020+0.013). Although there was no direct effect of adaptive strategies on military acute stress, the mediation effect turned out to be 0.139 (0.076+0.047+0.016). Social support and resilience partly mediate the relationship between maladaptive strategies and military acute stress, and fully mediated the relation between adaptive strategies and acute stress. Similarly, resilience partly mediated the relationship between social support and military acute stress. Integrating Figure 1 with Table 4, we can see a clearer association where social support and resilience exert multiple mediation effects on the relationship between maladaptive strategies and military acute stress. 4. Discussion The present study was undertaken to investigate the relationships among cognitive emotion regulation, social support, resilience and acute stress responses in Chinese soldiers. As hypothesized, military acute stress was significantly associated with cognitive emotion regulation, social support, and 13

resilience. Although the effect sizes were relatively small in the current results, the observed effects were obvious above and beyond the statistical variance accounted for by the covariates of concurrent cognitive emotion regulation, social support, and resilience. Cognitive coping processes have long been considered relevant to the experience and expression of physical and mental distress (Lazarus, 1993). Adaptive coping is implicated in the implementation of effective health behaviors (Lee Baggley et al., 2004), whereas maladaptive coping is observed in several mental health disorders (Bouchard et al., 2004). One vital aspect of emotion regulation was the individuals’ ability to use adaptive coping strategies in times of stress (Hien et al., 2003; Zimmer-Gembeck et al., 2014). Indeed, Kopp (1989) used emotion regulation almost synonymously with coping. Coping directed at regulating emotional experiences by altering an individuals’ response to a stress (Compas et al., 2014). According to Aldao et al. (2015), research on emotion regulation used to be rooted in the literature on coping, especially emotion-focused coping. Since its design, CERQ has been shown to predict depression, anxiety, anger, and stress (Martin et al., 2005; Mirzaee, 2016), which is consistent with the current result. Both soldiers and officers have to face various types of stressors in military camps. After controlling for the influence of the strategies, an interesting and very important shift became visible. Namely, the adaptive cognitive coping strategies yielded negative relationships with physiological and psychological symptoms, which suggested that acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting things into perspective contributed to positive acute stress adjustments. However, the relationship between maladaptive cognitive coping strategies and acute stress remained positive, which meant that individuals using maladaptive strategies, such as self-blame, rumination, catastrophizing, and blaming others, tended to experience greater stress. Therefore, adaptive cognitive coping strategies were

14

supposed to be adopted so that soldiers were able to carry out several effective emotion regulation strategies without situation selection or situation modification. It is interesting that social support and resilience partially mediated the relation between negative strategies and acute stress, and fully mediated the relation between positive strategies and acute stress. According to recent research, resilient soldiers will be better able to cope with the physical and mental demands of the military profession and over the long term will perform better while maintaining health and well-being (Szivak et al, 2015; Leners et al, 2014). What’s more, the role of resilience appears to have a greater impact on functional impairment in marines leaving military service, which suggests enhancing training programs and services intended to promote adjustment from military to civilian life (Hourani et al, 2012). Social support and coping with stress-related issues are badly needed in support of military personnel. Numerous studies suggest perceived social support plays an important role in their psychological well-being(Smith et al, 2013; Han et al, 2014; Russell et al, 2016). Although emotion regulation has little direct effect on acute stress response, an indirect effect by resilience and social support is found in the current study. On the other hand, the effect of maladaptive cognitive emotion regulation on military acute physiological and psychological responses could be explained by social support and resilience. Individuals using maladaptive strategies reported less social and family support, less resilience, and more acute stress responses, which helps us explore the psychological mechanisms of how cognitive emotion regulation impacts acute stress responses. Several studies analyzing students transitioning to college showed that frequent use of maladaptive emotion regulation strategies, such as behavioral suppression, led to less social support from friends and fewer close relationships with others (Srivastava et al., 2009; English et al., 2012). On the other hand, previous literature has also revealed the role of social support as a resilience factor (Cohen et al, 1985; Li et al., 15

2015). Individuals making use of social support theoretically could adapt to and/or modify external stressors, thus promoting their adjustment, especially better psychosocial functioning. In the research by Lamond (Lamond et al., 2008), social support was shown to enhance resilience to stress in older adults. From a neurobiological perspective, researchers have clearly linked social support with psychological resilience (Ozbay, 2007). Extant clinical findings have demonstrated that low social support led to physiological and neuroendocrine indices of heightened stress reactivity, such as increased blood pressure (Uchino et al., 1996) and heart rate (Stansfeld et al., 1997), during which resilience was reduced by exaggerating cardiovascular and neuroendocrine responses to external stressors (Li et al., 2015). The current study combined these psychological variables organically in Chinese soldiers. Faced with rigorous training, heavy workloads, and family separation, it’s advised to modify soldiers’ cognitive emotion regulation strategies to control acute stress responses. Additionally, a harmonious social circle should be established so that soldiers are able to find trustworthy persons to discuss and solve troubles. Individuals with the above characteristics usually show strong resilience. They are expected not to use maladaptive strategies and find it easier to bounce back from adverse experiences, which is consistent with Carle and Chassin’s research (Carle et al., 2004). Internal strengths, great tenacity, and an optimistic mind help them fight against various military stresses and cope with psychological and physical problems, which has implications for training aimed to improve individual resilience. Prior studies found that resilience training may have an effect on supporting mental health and peer support in military personnel (Adler et al., 2015) and police (Arnetz et al., 2013). Therefore, a longitudinal study should be conducted to examine the effect of resilience training on acute stress.

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The above findings have some practical and theoretical implications for future work. The current study expands the role of cognitive coping strategies, from the only direct influence on stress responses to the potential indirect effect on stress responses via social support and resilience. However, there were still some limitations in the current study. Firstly, the participants were limited to male soldiers, because the barracks where we conducted the survey did not include female ones. It has been reported that gender differences exist in emotion regulation. Therefore, it remains to be verified whether female soldiers showed different cognitive regulation strategies in the face of military stress. Secondly, active-duty soldiers are more likely to have physiological and psychological responses when performing various military tasks, such as earthquake rescue, joint military maneuvers, and outside intensive training (Huang et al., 2014). We believe it to be of value to carry out more research to explore the effects of cognitive emotion regulation, social support, and resilience on acute stress responses in specific military tasks performed. Thirdly, although the current study is aimed to explore the influence factors on acute stress response, it’s advisable to include the PTSD measurement, which could be supported by existing researches. Last but not the least, given the causality assumptions of the mediation relationship, the cross-sectional survey used in the current study may not be rigorous enough to confirm how perceived social support may mediate the association between cognitive emotional regulation and acute stress responses rather than the reverse relationship. A longitudinal design should be used in future studies to address this concern, and more objective measurement techniques should be considered to improve upon self-report data and translation limitations. 5. Conclusions Above all, the current study is the first to simultaneously examine multiple mediation in one model to disentangle the complex mechanisms by which three key factors (cognitive emotion 17

regulation strategy, social support, and resilience) interact with one another to predict military acute stress responses among Chinese soldiers. These results suggest the potential great value of resilience training in reducing negative stress responses, but further research is needed to replicate the findings with longitudinal data in different populations. Conflict of Interest The authors declare that they have no conflict of interest. Acknowledgements We thank all the participants for volunteering in this study and give our sincere gratitude to Prof. Nadia Garnefski (Leiden University), Su Zhou & Xiuqin Zhang (Nanjing University of Chinese Medicine), Jun Gao (Shanghai Jiao Tong University) who gave us great help when we revised the article. This study was funded by the Major Program of the “12th Five-Year Plan” for Medical Development of PLA(14CXZ002), the General Program of the “12th Five-Year Plan” for Medical Development of PLA (CWS12J015), Second Military Medical University 2016 Annual PhD Innovative Research Fund (20152049), and the financial support from China Scholarship Council (201603170127).

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Table1 Demographic variables for all participants Only child in family

Educational level Junior

Yes

No

498(3

979(6

3.7%)

high

Household

Senior

high

or

secondary

College and

Countr

above

City

279(1

6.3%)

925(62.6%)

273(18.5%)

2.7%)

Mar

y

336(2

8.9%)

Marital status

Single 1141(7

ried

1390(9

7.3%)

4.1%)

Divorce Widowhood

83( 5.6%)

4(0.3%)

Table 2 Descriptive statistics and Pearson correlations among the study variables Mean±S Variable

D

CERQ-C-positi ve

65.34±1

CERQ-C-negat 244

support

support CD-RISC-stren gth

739

471

31.20±1

131

**

215

**

4

5

6

0

(0. 806)

355

**

-0. 080

**

129

**

0.

0 -52

**

0.

8 -56

21.53±6.

0.

4 -28

337

3

(0

1

40.37±8.

2

.826)

6-70

0.929 CD-RISC-tenac

0-96

21.07±4.

PSSS-social

1 2

42.27±8.

PSSS-family

1

ange

0.123

ive

R

757)

-0.

0.

0.

(0.

0. 558

**

262

**

-0. 016 -0.

(0. 879)

0.

0. 356

0.

**

0.

30

(0. 931) 0.

(0.

7

8

9

0

ity

688 CD-RISC-opti

mism

8.74±3.2 42

0 -16

4.90±4.0 MASS-phy

06

-21

43

MASS

-16

53

291

073

**

092

**

012

290

345

**

089

276

101

**

149

**

**

343

**

366

205

**

267

**

134

**

724

137

**

185

**

254

747

163

**

202

**

680) -0. 120

**

184

**

-0.

-0. 173

(0.

-0.

-0.

-0. **

0. **

-0.

-0.

-0.

882)

0. **

-0.

-0.

0.

868**

0. **

-0.

0.

0.

366**

0. **

0. **

0.

0 -37

-0.

0.

0

8.92±6.9

265**

041

0. **

0

4.02±3.5 MASS-psy

340**

-33

196

**

.778)

-0.

-0.

**

(0

0. 696

-0. 163

**

**

(0 .664)

0. 931

**

0. 910

**

(0 .831)

*p<0.05, **p<0.01 (Two-tailed) Cronbach’s alpha values listed on the diagonal. Table 3 Hierarchical regression analysis predicting military acute stress β

SE

R2

Adj R2

CERQ-C-positive -0.064**

0.019

0.127

0.127**

0.330**

0.024

CERQ-C-positive

0.014

0.021

0.173

0.036**

CERQ-C-negative

0.266**

0.024

**

0.016

-0.047*

0.010

Step1

CERQ-C-negative Step2

PSSS -0.090 CD-RISC

Table 4 Indirect effects (and 95% confidence intervals) of emotion strategies for military acute stress via social support and resilience and social support on military acute stress via resilience Path

Estimate

SE

Lower 95% CI

Upper 95% CI

Negative→PSSS→MASS

0.064

0.011

0.042

0.086

Negative→CD-RISC→MASS

0.020

0.006

0.007

0.032

Negative→PSSS→CD-RISC→MASS

0.013

0.004

0.006

0.021

Positive →PSSS→MASS

-0.076

0.013

-0.098

-0.052

Positive →CD-RISC→MASS

-0.047

0.014

-0.060

-0.034

Positive →PSSS→CD-RISC→MASS

-0.016

0.005

-0.023

-0.009

PSSS→CD-RISC→MASS

0.042

0.008

0.027

0.049

Fig. 1 CERQ-negative: negatively focused cognitive emotion regulation; CERQ-positive: positively focused cognitive emotion regulation; PSSS(Family/Social): Perceived Social Support Scale (family support and social support); CD-RISC: Chinese version of the Connor-Davidson Resilience Scale; MASS(PSY/PHY): Military Acute Stress Scale (psychological responses/ physiological 31

responses). Standardized paths (β’s) are displayed.

Highlights 

This study explored the association of cognitive emotion regulation, social support, resilience and acute stress responses among 1477 Chinese male soldiers.



Social support and resilience partially mediated the relation between negative strategies and acute stress, and fully mediated the relation between positive strategies and acute stress.



Military acute stress was significantly associated with cognitive emotion regulation, social support, and resilience and social support and resilience have multiple mediation effects on the relationship between cognitive emotion regulation and acute stress responses.

32