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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Psychol Trauma. 2020 Oct 8;13(1):35–43. doi: 10.1037/tra0000974

Ethnic-Racial Identity and Posttraumatic Stress Disorder: The Role of Emotional Avoidance among Trauma-Exposed Community Individuals

Nicole H Weiss 1, Melissa R Schick 1, Miranda E Reyes 1, Emmanuel D Thomas 1, Allison Tobar-Santamaria 1, Ateka A Contractor 2
PMCID: PMC8443085  NIHMSID: NIHMS1738402  PMID: 33030936

Abstract

Objectives:

There are ethnic-racial differences in the prevalence of posttraumatic stress disorder (PTSD). However, the factors underlying these differences are not well studied or understood. The goal of this study was to explore the relation of strength of ethnic-racial identity to PTSD. Specifically, we examined whether strength of ethnic-racial identity was indirectly related to PTSD symptom severity through positive and negative emotional avoidance.

Method:

Participants were 401 trauma-exposed community individuals (Mage = 43.86 years; 70.1% female; 23.4% Asian, 23.7% Black, 25.1% Hispanic, 25.4% White).

Results:

Within the overall sample of ethnic-racial minorities, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathways of both positive and negative emotional avoidance was significant. However, these findings were not replicated within each of the specific racial-ethnic subsamples. Specifically, while strength of ethnic-racial identity was indirectly associated with PTSD symptom severity through both positive and negative emotional avoidance in the Black subsample, this indirect effect was only significant through the pathway of positive emotional avoidance in the Hispanic subsample, and was non-significant in the Asian and White subsamples.

Conclusions:

Results underscore ethnic-racial differences in the way in which strength of ethnic-racial identity impacts PTSD.

Keywords: Ethnic-racial identity, Positive emotional avoidance, Negative emotional avoidance, Posttraumatic stress disorder, Ethnic-racial differences

Global studies of the epidemiology of traumatic exposure indicate that between 29% to 85% of individuals experience a traumatic event in their lifetime, with estimates in most countries ranging from 61% to 76% (Benjet et al., 2016). Traumatic exposure has been linked to a wide range of mental health conditions (Smith, Goldstein, & Grant, 2016) – most notably posttraumatic stress disorder (PTSD; Kilpatrick et al., 2013). PTSD is a chronic and debilitating mental health condition associated with considerable disability and functional impairment (Bovin et al., 2016; Elhai et al., 2012; Kilpatrick et al., 2013), even amongst individuals who do not meet full criteria for the disorder (Hellmuth, Jaquier, Swan, & Sullivan, 2014). Notably, there is evidence for ethnic-racial differences in the prevalence of PTSD (for reviews, see Alcántara, Casement, & Lewis-Fernandez, 2013; Alim et al., 2006; Frueh, Brady, & de Arellano, 1998). For instance, a large (N = 34,653) epidemiological survey of the U.S. general population found a significantly higher lifetime prevalence rate of PTSD among Black individuals (8.7%) compared to White (7.4%) and Hispanic (7.0%) individuals (who had comparable prevalence rates), and Asian individuals (4.0%; who had a lower prevalence rate than all other ethnic-racial groups; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Further, risk of developing PTSD was higher among Black individuals (OR = 1.22) and lower among Asian individuals (OR = 0.67). Another study among natural disaster victims found that Hispanic individuals showed the highest rate of PTSD (38%), followed by Black (23%) and then White (15%) individuals (Perilla, Norris, & Lavizzo, 2002). Of note, heightened rates of PTSD among Black and Hispanic individuals persist after adjusting for differential exposure to trauma (Perilla et al., 2002; Roberts et al., 2011), and may develop or be maintained as a direct result of racism (e.g., hate crimes, implicit bias in medical decision-making; Carter, 2007; Dovidio, Gaertner, & Pearson, 2017). Given evidence for ethnic-racial differences in the prevalence of PTSD, additional research on the role of cultural phenomena that may underlie these differences is warranted. The findings of such investigations may inform culturally-sensitive interventions for addressing PTSD.

One important factor to study in relation to these ethnic-racial differences is the strength of ethnic-racial identity. Ethnic-racial identity is a multidimensional, psychological construct that is comprised of two factors: (1) content, which reflects beliefs and attitudes about ethnic-racial membership (one’s ethnic-racial group and its relations to other ethnic-racial groups), and (2) process, which reflects the mechanisms by which individuals explore, form, and maintain these beliefs and attitudes about ethnic-racial membership over time (Umaña-Taylor et al., 2014). While stronger ethnic-racial identity has generally been found to be associated with higher levels of self-esteem and well-being (for reviews, see Hughes, Kiecolt, Keith, & Demo, 2015; Smith & Silva, 2011), there is empirical evidence that the protective benefits of ethnic-racial identity may not directly extend to mental health conditions. For instance, one meta-analytic review found a substantially weaker effect size for the relation of strength of ethnic-racial identity to mental health symptoms (r = .04) versus self-esteem (r = .23) and well-being (r = .44; Smith & Silva, 2011). A similar pattern of findings has been detected for PTSD in particular, with existing empirical data indicating a non-significant association between strength of ethnic-racial identity and PTSD symptom severity among samples of maltreated youth (Kaur & Kearney, 2013) and college students (Khaylis, Waelde, & Bruce, 2007). These findings suggest that strength of ethnic-racial identity may not directly relate to PTSD severity.

One explanation for these results may be that strength of ethnic-racial identity is protective against PTSD through some third variable. Emotional avoidance is described as attempts to alter the form, frequency, or context of emotional experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), and has been associated with risk for developing PTSD following traumatic exposure (Orcutt, Pickett, & Pope, 2005; Plumb, Orsillo, & Luterek, 2004; Tull & Roemer, 2003). Emotional processing theory (Foa & Kozak, 1986) purports that emotional avoidance interferes with emotional processing (i.e., activation of the traumatic memory), and thus maintains feared consequences (i.e., new information that is incompatible with the fear structure underlying PTSD is not incorporated). Indeed, avoidance of trauma-related content (e.g., emotions) is a core feature of PTSD (American Psychiatric Association [APA], 2013). Notably, there is evidence that individuals with PTSD avoid a wide range of emotional experiences, including those that are not directly tied to their trauma. For example, experimental studies show that individuals with PTSD respond to both trauma- and non-trauma-related stimuli with greater negative emotionality (Wolf, Miller, & McKinney, 2009). Further, there is growing evidence that individuals with PTSD are non-accepting of both negative and positive emotional states, judging intense emotions – regardless of valence – to be undesirable (Weiss, Dixon-Gordon, Peasant, & Sullivan, 2018); thus, these individuals may be motivated to avoid any intense emotional state. Higher levels of emotional avoidance pre-trauma may increase vulnerability to trauma-related avoidance because it is highly reinforcing (Hayes et al., 1996). Alternatively, avoidance of trauma-related emotions may begin to generalize to other emotions not linked to the trauma over time (Roemer, Litz, Orsillo, & Wagner, 2001). Emotional avoidance may therefore be a key contextual factor to consider in determining risk for PTSD.

There is also evidence for the relevance of emotional avoidance to strength of ethnic-racial identity. Individuals with a strong ethnic-racial identity may be less likely to utilize emotional avoidance to manage stressors, instead employing a broad repertoire of strategies for approaching emotional experiences tied to their ethnic-racial status (Lee, 2003; Phinney, 2003). For instance, existing evidence suggests that individuals with a strong ethnic-racial identity exhibit greater awareness and clarity regarding the impact of their ethnic-racial status on their daily lives (e.g., ethnic-racial discrimination), and thus be more inclined to employ emotional approach (vs. avoidance) to manage stress stemming from such experiences (e.g., directly confronting versus minimizing or denying discrimination; Miller & Kaiser, 2001; Miller & Major, 2000). Further, individuals with a strong ethnic-racial identity have been shown to utilize social supports to provide comfort (Uba, 1994) and problem solving to exert control (Noh & Kasper, 2003) following discriminatory acts. Taken together, this literature suggests that ethnic-racial minorities with a strong ethnic-racial identity may be less likely to utilize emotional avoidance, which, in turn, may relate to less severe PTSD symptoms.

In summary, separate lines of research suggest associations between strength of ethnic-racial identity, emotional avoidance, and PTSD symptom severity. However, to our knowledge, no investigations have simultaneously explored the interactions among these variables. Further, research on ethnic-racial differences in emotional avoidance has almost exclusively compared Asian and White individuals, limiting knowledge in other ethnic-racial groups that are highly represented in the U.S. (Hispanic [17.8%] and Black [13.3%] individuals; U.S. Census Bureau, 2019). Finally, there is little understanding of the role of positive emotional avoidance in strength of ethnic-racial identity or PTSD symptom severity. Nonetheless, initial evidence suggests that the expression of some positive emotions (e.g., pride) may be more strongly regulated among some ethnic-racial groups (Parker et al., 2012). More, individuals with PTSD have been found to be less accepting of positive emotions (Weiss et al., 2018), thus they may avoid these emotions.

Addressing these critical gap in the extant research, we explored the potential underlying roles of positive and negative emotional avoidance in the relation between strength of ethnic-racial identity and PTSD symptom severity in a community sample of Asian, Black, Hispanic, and White trauma-exposed individuals. We expected that strength of ethnic-racial identity would be indirectly associated with PTSD symptom severity through emotional avoidance, such that a weaker ethnic-racial identity would be related to higher levels of emotional avoidance, which in turn would be related to more severe PTSD symptoms. Notably, we focused on the examination of PTSD symptom severity (vs. diagnosis) in the current study for these reasons: (a) most individuals who have been exposed to a trauma experience some PTSD symptoms (Schnurr, 2014), (b) PTSD symptoms can produce clinically significant impairment in functioning, and (c) PTSD symptoms are linked to deleterious health outcomes even when not meeting criteria for full diagnosis (e.g., suicidality, physical and psychological comorbidity; Marshall et al., 2001).

Methods

Participants and Procedures

Participants were recruited from Qualtrics Panels, an internet-based crowdsourcing platform. Qualtrics Panels recruits participants via several methods such as member referrals, social media, and permission-based networks (Soucy & Hadjistavropoulos, 2017). Participants recruited via Qualtrics Panels have been shown to be demographically diverse and representative of the general population (Boas, Christenson, & Glick, 2020); Qualtrics Panels has been shown to be a viable platform to examine health symptoms (Prather et al., 2017; Soucy & Hadjistavropoulos, 2017). Participants self-selected into the study. Inclusionary criteria included: (1) ages 18 years or older, (2) having a working knowledge of the English language, (3) residing in the United States, and (4) Asian, Black, Hispanic, or White ethnic-racial background. Recruitment was stratified by ethnicity and race to assure equal representation of individuals from these four ethnic-racial groups. Eligible participants who provided informed consent and completed the survey without failing validity checks (see Exclusions and Missing Data) received compensation. All procedures were approved by the University of Rhode Island Institutional Review Board.

Exclusions and Missing Data

A total of 1,160 participants initiated the survey. Participants were excluded for one or more of the following reasons: being under 18 years of age (n = 121); no working knowledge of the English language (n = 27); not residing in the United States (n = 303); identifying as an ethnicity and race other than Asian, Black, Hispanic, or White (n = 76); failing validity checks inserted to ensure attention and comprehension (n = 380; Meade & Craig, 2012; Oppenheimer, Meyvis, & Davidenko, 2009; Thomas & Clifford, 2017); or attempting to take the survey more than once (n = 24). An additional 33 participants were excluded who did not endorse at least one traumatic event on the Life Event Checklist for DSM-5 (LEC-5; Weathers, Blake, et al., 2013)

The final sample included 401 participants. Average age was 43.86 years (SD = 15.07), and 281 were female (70.1%). Of the sample, 94 individuals identified as Asian (23.4%), 95 identified as Black (23.7%), 102 identified as Hispanic (25.4%), and 110 identified as White.

Measures

The LEC-5 (Weathers, Blake, et al., 2013) is a 17-item self-report measure designed to screen for traumatic events in a respondent’s lifetime. It assesses exposure to 16 traumatic events, with a final item assessing for any other stressful event not captured in the first 16 items. For each event, the respondent is asked to indicate if: a) it happened to them, b) they witnessed it, c) they learned about it, d) they experienced it as part of their job, e) they aren’t sure if they experienced it, or f) they didn’t experience it. Either of the first four response options indicated a positive Criterion A traumatic event endorsement (APA, 2013). The LEC has convergent validity with measures assessing traumatic exposure (Gray, Litz, Hsu, & Lombardo, 2004).

The Ethnic Identity Scale-Brief Form (EIS-B; Douglass & Umaña-Taylor, 2015) is a 9-item self-report measure modified from the original 17-item EIS (Umaña-Taylor et al., 2014). The EIS-B assesses ethnic-racial identity exploration (i.e., seeking information and experiences related to one’s racial/ethnic identity), affirmation (i.e., positive feelings about one’s racial/ethnic group), and resolution (i.e., clarity about what one’s race/ethnicity means to them). Participants rate each item using a 4-point Likert-type scale (1 = does not describe me at all, 4 = describes me very well). A composite score was created by summing all of the items, with higher scores indicating stronger ethnic-racial identity. The EIS-B has good psychometrics across ethnic-racial groups (Douglass & Umaña-Taylor, 2015). Internal consistency was good (α = .81).

The Emotional Avoidance Questionnaire (EAQ; Taylor, Laposa, & Alden, 2004) is a 10-item self-report measure that assesses avoidance of positive (EAQ-Positive) and negative (EAQ-Negative) emotions. Items are rated on a 5-point scale (1 = not true of me, 5 = very true of me). A composite score is created for each subscale, with higher values indicating greater emotional avoidance. The EAQ has adequate psychometric properties. Internal consistency in the current sample for the positive (α = .90) and negative (α = .92) subscales was good.

The PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz, et al., 2013) is a 20-item self-report measure that assesses past 30-day PTSD symptoms. In completing the PCL-5, participants are asked to reference the traumatic event identified as most distressing on the LEC-5. Items are rated on a five-point Likert-type scale (0 = not at all, 4 = extremely). A total score was calculated by summing all the items, with higher scores indicating greater PTSD symptom severity. A score of 31 or higher is indicative of a probable PTSD diagnosis (Blevins, Weathers, Davis, Witte, & Domino, 2015). The PCL-5 has excellent psychometric properties (Bovin et al., 2016; Wortmann et al., 2016). Internal consistency in the current sample was excellent (α = .97).

Analytic Plan

Analyses were conducted using IBM SPSS Statistics Version 24.0 (IBM Corporation, 2016). As recommended by Tabachnick and Fidell (2014), all study variables were assessed for the assumption of normality. Next, Pearson product-moment correlations were calculated to explore the bivariate associations among strength of ethnic-racial identity, positive and negative emotional avoidance, and PTSD symptom severity in the overall sample of ethnic and racial minorities in the United States (i.e., Asian, Black, and Hispanic) as well as among each of the ethnic and racial subgroups. Then, to examine whether positive and negative emotional avoidance explained the relation between strength of ethnic-racial identity and PTSD symptom severity, analyses were conducted with the PROCESS SPSS macro, as recommended by Hayes (2013). The PROCESS procedures use ordinary least squares regression and bootstrapping methodology, which confers more statistical power than do standard approaches to statistical inference and does not rely on distributional assumptions. Bootstrapping was done with 5,000 random samples generated from the observed covariance matrix to estimate the standard errors of parameter estimates and the bias-corrected confidence intervals of the indirect effects (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002; Preacher & Hayes, 2004). The effect is significant if the 95% confidence interval does not contain zero (Preacher & Hayes, 2004). Finally, as exploratory analyses, we examined whether positive and negative emotional avoidance explained the relation between strength of ethnic-racial identity and PTSD symptom severity in Asian, Black, Hispanic, and White subsamples.

Results

Approximately one-third of participants reported symptom severity consistent with a probable PTSD diagnosis (n = 151, 34.8%). See Table 1 for descriptive data and bivariate correlations. Means for the primary variables within ethnic-racial subsamples are graphically depicted in Figure 1. In the overall sample of ethnic-racial minorities (Asian, Black, Hispanic), strength of ethnic-racial identity was negatively related to both positive and negative emotional avoidance. Further, both positive and negative emotional avoidance were positively related to PTSD symptom severity. Positive relations were identified between both negative and positive emotional avoidance and PTSD symptom severity among the ethnic-racial subsamples. Among the Black subsample, strength of ethnic-racial identity was negatively related to both positive and negative emotional avoidance; among the Hispanic subsample, strength of ethnic-racial identity was negatively related to positive emotional avoidance only. No relations were found among strength of ethnic-racial identity and emotional avoidance in the Asian and White subsamples.

Table 1.

Descriptive data and bivariate correlations among variables of interest

Construct 1 2 3 4 M (SD) Range
Sample of Ethnic-Racial Minorities
 1. Ethnic-Racial Identity -- −.22** −.17** −.05 31.35 (5.44) 3-39
 2. Positive Emotional Avoidance -- .53*** .34*** 10.70 (5.52) 4-25
 3. Negative Emotional Avoidance -- .48*** 44.22 (14.27) 9-75
 4. PTSD Symptom Severity -- 24.79 (22.05) 0-80
Asian Subsample
 1. Ethnic-Racial Identity -- −.001 −.04 −.02 30.53 (5.87) 3-39
 2. Positive Emotional Avoidance -- .54*** .47*** 11.90 (5.54) 4-25
 3. Negative Emotional Avoidance -- .52*** 46.33 (14.22) 15-75
 4. PTSD Symptom Severity -- 21.77 (22.09) 0-80
Black Subsample
 1. Ethnic-Racial Identity -- −.40*** −.29** −.27** 32.12 (5.19) 11-39
 2. Positive Emotional Avoidance -- .61*** .38*** 11.19 (6.15) 5-25
 3. Negative Emotional Avoidance -- .46*** 41.81 (14.25) 9-75
 4. PTSD Symptom Severity -- 22.59 (21.19) 0-80
Hispanic Subsample
 1. Ethnic-Racial Identity -- −.29** −.15 .10 31.38 (5.21) 8-39
 2. Positive Emotional Avoidance -- .46*** .32** 9.14 (4.45) 5-21
 3. Negative Emotional Avoidance -- .46*** 44.51 (14.12) 15-66
 4. PTSD Symptom Severity -- 29.64 (22.21) 0-77
White Subsample
 1. Ethnic-Racial Identity -- −.05 .02 −.16 26.84 (7.41) 3-39
 2. Positive Emotional Avoidance -- .64*** .45*** 11.59 (6.00) 5-25
 3. Negative Emotional Avoidance -- .53*** 42.85 (14.59) 15-75
 4. PTSD Symptom Severity -- 22.82 (23.99) 0-72
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Note: PTSD = posttraumatic stress disorder

*

p<.05

**

p<.01

***

p<.001

Figure 1.

Figure 1.

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Means of Primary Study Variables of Interest among Ethnic-Racial Subsamples

Models were first conducted to examine whether positive and negative emotional avoidance explained the relation between strength of ethnic-racial identity and PTSD symptom severity in the ethnic-racial minority subsample (Asian, Black, Hispanic; see Table 2). The model testing the role of positive emotional avoidance is shown in Figure 2. The association between strength of ethnic-racial identity and positive emotional avoidance was significant, b = −.23, SE = .06, t = 3.94, p < .001, as was the association between positive emotional avoidance and PTSD symptom severity, b = 1.38, SE = .23, t = 6.05, p < .001. Further, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of positive emotional avoidance was significant, b = −.32, SE = .12, p <.05, 95% CI (−.57, −.12). The model explicating the role of negative emotional avoidance in the relation between strength of ethnic-racial identity and PTSD symptom severity is shown in Figure 2. The association between strength of ethnic-racial identity and negative emotional avoidance was significant, b = −.48, SE = .15, t = 3.13, p = .002, as was the association between negative emotional avoidance and PTSD symptom severity, b = .75, SE = .08, t = 9.10, p < .001. Furthermore, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of negative emotional avoidance was also significant, b = −.36, SE = .12, p <.05, 95% CI (−.62, −.13).

Table 2.

Summary of mediation analyses examining the role of positive and negative emotional avoidance in the relation between ethnic-racial identity and PTSD symptom severity (5,000 bootstrap samples)

Mediating Variable (MV) Effect of Ethnic-
Racial Identity on MV		 Effect of MV
on PTSD		 Indirect effect Total effect
(a) (b) (a x b) 95% CI (c) R 2
Sample of Ethnic-Racial Minorities
 Positive Emotional Avoidance −.23 (.06)*** 1.38 (.23)*** −.32 (.12)* −.57, −.12 −.21 (.24) .12***
 Negative Emotional Avoidance −.48 (.15)** .75 (.08)*** −.36 (.12)* −.62, −.13 .23***
Asian Subsample
 Positive Emotional Avoidance .01 (.10) 1.85 (.37)*** .01 (.21) −.46, .38 −.07 (.40) .22***
 Negative Emotional Avoidance −.10 (.26) .81 (.14)*** −.08 (.19) −.51, .25 .28***
Black Subsample
 Positive Emotional Avoidance −.47 (.11)** 1.12 (.36)** −.53 (.23)* −1.02, −.12 −1.12 .16**
 Negative Emotional Avoidance −.80 (.27)** .62 (.14)*** −.50 (.21)* −.94, −.12 (.41)** .24***
Hispanic Subsample
 Positive Emotional Avoidance −.27 (.08)** 1.91 (.49)*** −.51 (.19)* −.90, −.16 .43 (.43) .14**
 Negative Emotional Avoidance −.51 (.27) .80 (.14)*** −.42 (.23) −.90, .02 .25***
White Subsample
 Positive Emotional Avoidance −.04 (.08) 1.76 (.34)*** −.07 (.16) −.38, .26 −.54 (.32) .22***
 Negative Emotional Avoidance .05 (.20) .88 (.13)*** .04 (.18) −.27, .45 .32***
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Note: PTSD = posttraumatic stress disorder

*

p<.05

**

p<.01

***

p<.001

Figure 2.

Figure 2.

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Summary of Analyses Explicating the Role of Negative and Positive Emotional Avoidance in the Relation between Ethnic-Racial Identity and PTSD Symptom Severity

Next, separate models were conducted within the ethnic-racial subsamples (see Table 2).

Asian subsample.

The association between positive emotional avoidance and PTSD symptom severity was significant, b = 1.85, SE = .37, t = 4.99, p < .001. However, the association between strength of ethnic-racial identity and positive emotional avoidance was not significant, b = .01, SE = .10, t = .05, p = .96, nor was the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of positive emotional avoidance, b = .01, SE = .21, 95% CI (−.46, .38). Similarly, the association between negative emotional avoidance and PTSD symptom severity was significant, b = .81, SE = .14, t = 5.84, p < .001. However, the association between strength of ethnic-racial identity and negative emotional avoidance was not significant, b = −.10, SE = .26, t = 0.38, p = .71, nor was the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of negative emotional avoidance, b = −.08, SE = .19, 95% CI (−.51, .25). These findings suggest that neither positive nor negative emotional avoidance explain the relation between strength of ethnic-racial identity and PTSD symptom severity for Asian individuals.

Black subsample.

The association between strength of ethnic-racial identity and positive emotional avoidance was significant, b = −.47, SE = .11, t = 4.20, p < .001, as was the association between positive emotional avoidance and PTSD symptom severity, b = 1.12, SE = .36, t = 3.12, p = .002. Furthermore, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of positive emotional avoidance was also significant, b = −.53, SE = .23, p <.05, 95% CI (−1.02, −.12). The association between strength of ethnic-racial identity and negative emotional avoidance significant, b = −.80, SE = .27, t = 2.94, p = .004, as was the association between negative emotional avoidance and PTSD symptom severity, b = .62, SE = .14, t = 4.41, p < .001. Furthermore, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of negative emotional avoidance was significant, b = −.50, SE = .21, 95% CI (−.94, −.12). These findings suggest that both positive and negative emotional avoidance explain the association between strength of ethnic-racial identity and PTSD symptom severity for Black individuals.

Hispanic subsample.

The association between strength of ethnic-racial identity and positive emotional avoidance was significant, b = −.27, SE = .08, t = 3.20, p = .002, as was the association between positive emotional avoidance and PTSD symptom severity, b = 1.91, SE = .49, t = 3.91, p < .001. Furthermore, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of positive emotional avoidance was also significant, b = −.51, SE = .19, p <.05, 95% CI (−.90, −.16). The association between negative emotional avoidance and PTSD symptom severity was significant, b = .80, SE = .14, t = 5.61, p < .001. However, the association between strength of ethnic-racial identity and negative emotional avoidance was not significant, b = −.53, SE = .27, t = 1.96, p = .05, nor was the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of negative emotional avoidance, b = −.42, SE = .23, 95% CI (−.90, .02). These findings suggest that positive but not negative emotional avoidance explains the relation between strength of ethnic-racial identity and PTSD symptom severity for Hispanic individuals.

White subsample.

The association between positive emotional avoidance and PTSD symptom severity was significant, b = 1.76, SE = .34, t = 5.10, p < .001. However, the association between strength of ethnic-racial identity and positive emotional avoidance was not significant, b = −.04, SE = .08, t = 0.51, p = .61, nor was the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathway of positive emotional avoidance, b = −.07, SE = .16, 95% CI (−.38, .26). Similarly, the association between negative emotional avoidance and PTSD symptom severity was significant, b = .88, SE = .13, t = 6.69, p < .001. However, the association between strength of ethnic-racial identity and negative emotional avoidance was not significant, b = .05, SE = .20, t = 0.23, p = .82, nor was the indirect effect of ethnic-racial identity on PTSD symptom severity through the pathway of negative emotional avoidance, b = .04, SE = .18, 95% CI (−.27, .45). These findings suggest that neither positive nor negative emotional avoidance explain the relation between strength of ethnic-racial identity and PTSD symptom severity for White individuals.1

Discussion

Ethnic-racial differences in the severity of PTSD have been well-documented in the extant research (Perilla et al., 2002; Roberts et al., 2011). The goal of the current study was to explore the role of strength of ethnic-racial identity in PTSD symptom severity in an ethnically and racially diverse sample of trauma-exposed individuals in the community. Specifically, we examined the potential underlying roles of positive and negative emotional avoidance in the association of strength of ethnic-racial identity to PTSD symptom severity. Within the overall sample of ethnic-racial minorities in the United States, the indirect effect of strength of ethnic-racial identity on PTSD symptom severity through the pathways of both positive and negative emotional avoidance was significant. However, these findings were mixed across the specific ethnic-racial subsamples. Specifically, whereas positive and negative emotional avoidance explained the relation between strength of ethnic-racial identity and PTSD symptom severity for the Black subsample, only positive emotional avoidance was significant for the Hispanic subsample, and neither positive nor negative emotional avoidance was significant for the Asian and White subsamples. The results of this study point to important distinctions in the way that strength of ethnic-racial identity influences PTSD symptom severity across ethnic-racial groups.

Extending existing research, the findings of the current study indicate that individuals with a weaker ethnic-racial identity were more likely to avoid positive and negative emotions, which in turn was associated with more severe PTSD symptoms. Ethnic-racial identity involves awareness and clarity regarding the meaning and consequences of membership in one’s ethnic-racial group (Phinney & Ong, 2007). This occurs through both intrapersonal and interpersonal processes: exploration of the meaning of one’s ethnic-racial group membership enhances self-knowledge and the development of attachments with the larger collective results in a sense of belonging and shared identification with members of one’s ethnic-racial group. Researchers have speculated that a strong ethnic-racial identity may counter the negative effects of minority stress on health outcomes (Phinney & Ong, 2007). Our findings suggest that this may occur through the strategies that one employs to modulate distress. In line with extant findings (Miller & Kaiser, 2001; Miller & Major, 2000), individuals with a weaker ethnic-racial identity were more likely to utilize emotional avoidance. Extending this work, we found that lower levels of emotional avoidance explained the negative relation between ethnic-racial identity and PTSD symptom severity. This finding suggests that emotional avoidance may be an important factor in understanding risk for PTSD in relation to ethnic-racial identity. Future research is needed to identify the contexts in which these relations may be stronger (e.g., in the presence of individuals of the same versus different ethnic-racial group). Further, studies are needed to explore the role of other clinically relevant cultural constructs (e.g., acculturation) on emotional avoidance and PTSD, as well as the impact of emotional avoidance on other health outcomes (e.g., depression).

Notably, findings from the larger subsample of ethnic-racial minorities in the United States were not replicated within each of the specific racial-ethnic groups. Specifically, while strength of ethnic-racial identity was indirectly associated with PTSD symptom severity through both positive and negative emotional avoidance in the Black subsample, this indirect effect was only significant through the pathway of positive emotional avoidance in the Hispanic subsample, and was non-significant in the Asian and White subsamples. Examination of zero-order correlations suggests that these divergent findings may result from the differential influence of strength of ethnic-racial identity on positive and negative emotional avoidance across the ethnic-racial subgroups. While the results for the Black and White subsamples were consistent with our expectations, those for the Asian and Hispanic subsamples were inconsistent with the literature in this area. Notably, this research is limited in its focus on ethnic-racial group membership versus strength of ethnic-racial identity per se (Gross & John, 2003). Thus, one explanation for these findings is that emotional avoidance may be more strongly related to other, perhaps more specific, cultural values (e.g., independence versus interdependence, strong versus weak uncertainty avoidance, indulgence versus restraint; Schwartz, 2004) among Asian and Hispanic individuals. Alternatively, the national origins of Asian, Black, and Hispanic individuals in the current study are unclear. Although usually classified as a single ethnic group by researchers, Asian, Black, and Hispanic individuals comprise heterogeneous ethnic and racial groups, representing various national origins that each have their own culture (González Burchard et al., 2005; Wong et al., 2012). Thus, it is possible that strength of ethnic-racial identity may have been related to emotional avoidance for subgroups of Asian and Hispanic individuals. Regardless of the reason why, these findings underscore the issue of aggregating across ethnicity-race, indicating that such research may obscure relations and advocate for inappropriate treatment.

While preliminary in nature, the results of the present study may help to inform cultural adaptations for PTSD interventions. Consistent with the study findings, evidence suggests that emotional avoidance may be adaptive for Black and Hispanic individuals in some contexts (Markus & Kitayama, 1991; Matsumoto, 1990; Tsai & Levenson, 1997). Emotional masking (concealing/hiding emotions) is one survival strategy that confers benefits for ethnic-racial minorities (Rodriquez, 2006). Emotional masking is transmitted intergenerationally and serves to minimize the negative impacts of racism. Indeed, cultural norms and values around emotional restriction may protect Black and Hispanic individuals from acts of race-related discrimination (Nelson et al., 2012). Thus, future clinical intervention research in these populations may explore treatment approaches that facilitate flexibility in one’s responses to emotional experiences (Bonanno, Papa, Lalande, Westphal, & Coifman, 2004), such as emotional avoidance in the presence of threat (e.g., stressors related to ethnic-racial identity) and emotional expression when experiencing PTSD symptoms in safe settings. This approach is in line with evidence that emotional avoidance confers benefits in some contexts (Aldao, 2013), such as those that involve threat (Roth & Cohen, 1986) or are uncontrollable (Valentiner, Holahan, & Moos, 1994); these situations may be particularly salient to ethnic-racial identity. Relatedly, a therapeutic focus on avoidance of positive emotions (versus negative emotions alone) may be important, in particular, for Black and Hispanic individuals presenting with PTSD symptoms, particularly considering that few PTSD interventions target positive emotion processes (Contractor et al., 2020).

Although findings of the present study add to research on the role of strength of ethnic-racial identity in PTSD symptom severity, limitations are noteworthy. First, the cross-sectional and correlational nature of the data precludes determination of the precise nature and direction of the relations of interest. Future studies should address this concern through prospective, longitudinal investigations. Second, while the online recruitment platform we used is a notable strength of our study, collecting data via the internet has disadvantages that may limit generalizability of results, such as sample biases (e.g., self-selection). Research that integrates other data collection methods is warranted. Third, while significant efforts were made to ensure a diverse sample, research is needed to examine the relations examined here in ethnic-racial groups not represented here (American Indians/Alaska Natives). Fourth, Asian, Black, and Hispanic individuals were classified as ethnic-racial minorities based on United States representation; Studies in other geographic regions may classify ethnic-racial minorities differently. Lastly, whereas use of a sample of trauma-exposed individuals is a strength of the current study, our findings require replication across more diverse samples of trauma-exposed individuals, including clinical populations of individuals (e.g., treatment-seeking) diagnosed with PTSD.

Despite these limitations, findings of the current study improve our understanding of the associations among strength of ethnic-racial identity, emotional avoidance, and PTSD symptom severity in an ethnically and racially diverse trauma-exposed community sample. Specifically, our results provided support for an indirect relation between strength of ethnic-racial identity and PTSD symptom severity through negative and positive emotional avoidance. Moreover, they suggested that this pattern of findings varied as a function of ethnic-racial group membership, such that emotional avoidance was relevant to the ethnic-racial identity-PTSD symptom severity link for Black and Hispanic (but not Asian and White) individuals. Our findings may be used to inform culturally-sensitive practices for PTSD that are tailored to the unique needs of Asian, Black, Hispanic, and White trauma-exposed individuals.

Clinical Impact Statement:

There are ethnic-racial differences in the prevalence of posttraumatic stress disorder (PTSD). Our findings suggest that individuals with a weaker ethnic-racial identity are more likely to avoid emotions, which in turn is associated with greater severity of PTSD symptoms. The strength of these associations varied by ethnic-racial group.

Acknowledgments

Work on this paper by the first author (NHW) was supported by National Institutes of Health grants K23DA039327 and P20GM125507.

Footnotes

1

Results remained the same in strength and direction when probable PTSD diagnosis was the dependent variable

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