Role of Emotion Regulation and Spirituality in Predicting the Psychological Well-being of the Elderlies

Maryam Safara , Mojtaba Salmabadi , Ali Tayaranirad 1 Assistant Professor, Department of Psychology, Women Research Center, AlZahra University, Tehran, Iran. 2 MA in Family Counseling, Department of Counseling, Allameh Tabataba'i University, Tehran, Iran. 3 MA in Family Counseling, Department of Educational Sciences, Farhangian University, Tehran, Iran. 4 PhD in Psychometrics, Department of Measurement, Allameh Tabataba'i University, Tehran, Iran.


Introduction
he 21st century has been called the elderly age due to the growing trend of the elderly population (1). Aging is a process that begins with the gradual erosion of physiological mechanisms and the inability to restore the capacity of vital organs and ends with death (2). Based on estimations, the world's elderly population will have increased from 9% to 16% and in Iran from 5.6% to 17.5% by 2030 (3).
Given the importance of psychological wellbeing during the aging period, it seems necessary to recognize more variables and factors affecting its maintenance and creation (4). Psychological well-being refers to the inner experience of positive emotions, feeling of vitality and emotional health, lack of mental helplessness experience, general satisfaction of life, and striving for perfection to realize individuals' potential abilities (5). It is a multidimensional concept that includes selfacceptance, positive relationships with others, autonomy, and self-development, as well as mastery of a purposeful living environment (6).
Elderly people with higher well-being experience more positive emotions and have a positive assessment of the past and the events and happenings around them; therefore, an individual is psychologically more equipped to prevent problems and deal with them. However, the elderlies with a low sense of well-being experience more depression and anxiety (7).
One of the influential elements on psychological well-being is emotion regulation (8), which is how an individual processes situations in confrontation with stressful and traumatic problems and events in life (9).
Emotion regulation is mainly examined in two important frameworks, the first of which is strategies activated before the creation of emotions, prevent the occurrence of intense emotions, and cause the interpretation of the situation. These strategies, which are called the reappraisal process, reduce the emotional response associated with that situation. The second framework consists of strategies that are activated after the emergence of emotions (these strategies cannot prevent the development of intense emotions) and are called the inhibition/suppression process (10).
Difficulty in regulating emotions is a predictor of future psychological trauma and a key and important factor in the development of problems (11). The results of studies have reported the role of emotion regulation in the psychological well-being of parents having children with cancer (12), that of students (13), and that of women with breast cancer (14). Religion and spirituality are social and psychological factors that can play a considerable role in the elderlies' health and well-being status and are among the key components investigated in studies on the elderlies (15). The reason for this importance is that the acquisition of spirituality can act as a protective shield and significantly prevent injuries to the elderlies (16). Spirituality is defined as a kind of identity that is related to purpose and meaning in life, connection with others, inner peace, and balance (17).
Spirituality is beyond religion and includes other concepts, such as spiritual well-being; peace originated from faith; spiritual conformity; one's experiences in a unique and dynamic process (reflecting faith in God with infinite power); connection to another person, nature, or God; and integrity of all human dimensions (18). Spirituality and religion have dramatic effects on the lives of people, especially adults (19,20). Spiritual practices provide meaning and emotional support for senior citizens (21). Such practices, through religious confrontation, serve as an important and buffering defense mechanism, plays an important role among elderlies in coping with stress and mental distress, anxiety, depression, and other psychological symptoms (22).
Nevertheless, since the increase in the elderly population has created many challenges for societies, addressing the challenges and adopting appropriate policies to promote psychological health and well-being of the senior citizens are considered necessities (23). To the best of our knowledge, few studies have been performed to investigate the role of emotion regulation and spirituality components in the psychological well-being of the elderlies . In the meantime, understanding the role of such factors as emotion regulation and spirituality in the psychological well-being of the senior citizens can facilitate a better understanding of the psychological state of this population, targeting, and designing appropriate intervene-tions to achieve this aim. Therefore, the present study aimed to investigate the role of emotion regulation and spirituality in predicting the psychological well-being of the elderlies, considering the available evidence and lack of direct study conducted on such a population, as well as the need to pay attention to the role of these components in the psychological wellbeing of the elderlies

Methods
This descriptive-correlation research was carried out on all elderlies (n=120) living in the nursing homes in Qazvin, Iran, in the summer of 2020. The samples (n=92) were selected from eligible cases willing to cooperate voluntarily using the Krejcie and Morgan (24) Table and availability sampling method. The inclusion criteria were having more than 60 years, having sufficient literacy and ability to answer the questions, lacking psychiatric disorders based on medical records, and willingness to participate in the study. On the other hand, the illiterate subjects who were unwilling to participate in the research and those who were unable to respond to the questions and had psychiatric disorders were excluded from the study. In this research, questionnaires were used as tools to collect the required data.

Emotion regulation questionnaire
This 10-item questionnaire, developed by Gross and John (2003), consists of two subscales evaluating the cognitive reappraisal (items 1, 3, 5, 7, 8, and 10) and expressive suppression (items 2, 4, 6, and 9). The items are rated on a 7-point Likert scale (1=from strongly disagree to 7=strongly agree), rendering for the total score range of 10-70, with low scores indicating low emotional regulation and vice versa (25). Gross and John reported a Cronbach's alpha coefficient of 0.79 and 0.73 for cognitive reappraisal and expressive suppression, respectively, and the test-retest reliability of the entire scale was obtained at 0.69 after 3 months (25). In a study performed by Mashhadi et al. (2013), the internal consistency of the scale, calculated by Cronbach's alpha coefficient, was estimated at a range of 0.60 to 0.81, and the validity of the questionnaire was confirmed through the principal component analysis with Varimax rotation, the correlation between the two subscales (r=0.13), and the desired criterion validity (26).

Spiritual Attitude Scale
This 43-item questionnaire, designed by Shahidi and Farajnia (2012), measures two subscales of spiritual attitude (items=24) and spiritual ability (items=19). The replies are scored on a 5-point Likert scale (from 0=strongly disagree to 5=strongly agree), with a total score range of 0-215, in which higher scores indicate higher spirituality and vice versa (27). The face and content validity of the items were examined and confirmed through a survey of 19 experts and its reliability was obtained at 0.61 by performing test-retest on 40 students within a 5-week interval. Then the questionnaire was administered to 235 students of Shahid Beheshti University, Tehran, Iran, and 2 factors with a specific value of  5 were identified using factor analysis with the Varimax rotation method. Moreover, the internal consistency of this instrument was calculated using the Cronbach alpha coefficient (α=0.91) (27).

Psychological Well-being Scale
The short-form of Psychological Well-being Scale, designed by Ryff (1989), was used in this research. This 18-item questionnaire includes 6 subscales, namely autonomy (items 9, 12, and 18), environmental mastery (items 1, 4, and 6), personal growth (items 7, 15, and 17), positive relations with others (items 5, 14, and 16), purpose in life (items 3, 11, and 13), and self-acceptance (items 2, 8, and 10). The items 1, 4, 5, 8, 15, 16, 17, and 18 are reversed scored. The replies are rated on a 6-point Likert scale (from 1=strongly disagree to 6=strongly agree), resulting in the total score range of 18-108, with higher scores indicating better psychological well-being (28). The correlation of the 84-item scale of this questionnaire was reported to be from 0.70-0.89 and the internal consistency of the 3-item scale was obtained at 0.56 (28). In Iran, Khanjani et al. used the Cronbach alpha coefficient to measure the internal consistency of this instrument and reported 0.51, 0.76, 0.75, 0.53, 0.73, and 0.72 for self-acceptance, environmental mastery, positive relationship with others, purpose in life, personal growth, and autonomy, respectively. The reliability of the whole scale was determined by the Cronbach alpha coefficient (α=0.71), and it was revealed that all factors had a good fit using the confirmatory factor analysis method (29).
Regarding the ethical considerations, the participants were assured of the confidentiality of their information and were informed of the possibility of study withdrawal at any research stage. Moreover, informed consent was obtained from all the subjects. The collected data were analyzed in SPSS software (version 24) using the mean and standard deviation, as well as the Pearson correlation coefficient and multiple regression test after examining the statistical presuppositions (i.e., uniformity of residual scatter, linear relationship between variables, error normality) of In this study, the significance level was determined at 0.05 .
Based on the results of Table 1, the highest and lowest mean scores were obtained for spirituality and suppression at 136.3815.463 and 17.744.071, respectively. Furthermore, the calculated correlation coefficients of emotion regulation and spirituality with psychological well-being were positive and significant (P<0.01). Therefore, psychological well-being had a direct relationship with emotion regulation and spirituality.
Multiple regression test was used to predict the psychological well-being of the elderlies through emotion regulation and spirituality variables. Accordingly, the Durbin-Watson statistic was used to examine the independence of the residues, which rendered the value of 1.839, indicating the observance of the presumption of residues independence. The normal distribution of scores was examined using the Kolmogorov-Smirnov test, which due to the lack of significance of the obtained values, the assumption of the normal distribution of the scores was accepted (P<0.05).
To investigate the existence of multicollinearity between the predictor variables, tolerance indices and variance inflation factor were used, which according to the obtained results, no deviation was observed from the assumption of multicollinearity. The F-value obtained from the investigation of the regression model was 11.625, which was significant regarding a p-value of  0.01, indicating that emotion regulation and spirituality variables could explain the changes related to psychological well-being and showing the appropriateness of the proposed regression model.
According to the results of Table 2, the multiple correlation coefficient between the independent variables and the dependent variable was obtained at 0.597. Additionally, the value of the adjusted R 2 was estimated at

Discussion
This study aimed to determine the role of emotion regulation and spirituality in predicting the psychological well-being of the elderlies. The results showed that emotion regulation and its components (reappraisal and suppression) had a direct relationship with psychological well-being. Moreover, these components could positively predict the psychological well-being of senior citizens. Regarding this, an increase in emotional regulation led to an increase in the psychological well-being of this population.
To the best of our knowledge, no similar study has been conducted directly on the elderly community. However, the results of the current research are indirectly consistent with those of studies carried out in this domain. For instance, Besharat et al. showed that harm avoidance and psychological well-being were related to the cognitive emotion regulation strategies among parents of children with cancer (12). The results of a study conducted by Farmani on students showed that there was a positive and significant relationship between psychological well-being and emotion regul-ation. In other words, an increase in emotion regulation led to an increase in psychological well-being (13).
Salajegheh et al. investigated women with breast cancer and reported that the relationship between emotion regulation strategies and psychological well-being was direct and significant. To illustrate this result, it can be said that individuals who use positive evaluation to reduce their negative emotions in confrontation with negative events are reported to reveal fewer symptoms of anxiety and depression.
The employment of effective cognitive strategies, such as positive reappraisal, helps individuals to interpret stressful situations in a new and positive way (30), which reduces confusion and other negative psychological consequences among the elderlies. In addition, emotion regulation contributes to individuals to flexibly respond to changing situations and existing needs that lead to the formation of new emotions; this flexibility is correlated with psychological well-being (31). However, due to the fact that suppression is one of the psychological defense mechanisms that works similar to other such mechanisms if it does not exceed the normal level, it is natural and is effective in relieving anxiety and creating calm. On the other hand, since the use of psychological mechanisms is inversely related to the mental strength of individuals, a higher mental strength leads to less use of psychological defense mechanisms.
The employment of this defense mechanism by the senior citizens against annoying thoughts and their unfulfilled desires helps them to relieve anxiety and promotes their psychological well-being in this period of life, especially because they are facing the crisis of aging and reduced mental and physical strength, as well as the power of confronting the facts. In addition, due to the nature of the primary and normal role of psychological defense mechanisms in reducing anxiety, it can be said that although in the field of emotion control, suppression is among negative strategies and the goal is desirable in resolving conflicts, its effect in reducing anxiety, and therefore, psychological well-being is not denial.
Another finding of this research was indicative of the existence of a direct relationship between spirituality and psychological well-being. Moreover, the components of spirituality, namely spiritual attitude and spiritual ability, could positively predict the psychological well-being of the elderlies. Accordingly, an increase in spirituality causes an increase in the psychological well-being of this population. The obtained result is in line with those of previous studies performed in this domain. For example, the findings of a study conducted by Bagheri Sheikhangfsheh and Shabahang revealed that spirituality, social support, and optimism had a positive correlation with the psychological well-being of senior citizens (19).
In their study, Sadoughi and Hesampour found that increased spirituality, gratitude to God, and perceived social support, especially from the family, boosted psychological wellbeing among the elderlies (20). Koushaie et al. showed that spirituality had a close and significant relationship with life satisfaction and psychological well-being of the senior citizens, leading to their better understanding of life events and positive evaluation of them (21).
Spirituality plays an important role in coping with stress and mental distress among the elderlies, and the application of religious beliefs, especially when accompanied by group activities, can prevent loneliness and reduce depression, anxiety, and other psychological symptoms and improve the elderlies' psychological status (22). Regarding this, it can be said that spiritual beliefs and practices cause humans to alleviate their daily mental worries and anxieties and experience high status of psychological well-being. This applied particularly to the last years of life when an individual reviews one's past constantly and explores his/her favorable and unfavorable happenings.
The performance of spiritual practices can make the elderlies approach inner peace and contentment and be hopeful and optimistic about the future and afterlife .In addition, spirituality plays a significant role in the physical and mental health of individuals, meaning that spiritual beliefs and practices considerably influence an individual's selfdevelopment, purpose in life, self-knowledge, and effective and positive communication with others. It is noteworthy that with aging, a person proceeds toward disability and is often involved in various problems, such as depression, anxiety, and reduced life expec-tancy. Furthermore, the feeling of worthless-sness, growing old, and losing strength among the elderlies are significant obstacles to have a satisfying life that can reduce psychological well-being in an individual (32).
One of the limitations of the present study was related to its research design, which since it was correlational, inferring causal relationships was not possible. The other limitation was associated with the samples, who were selected from the elderlies, and therefore, limiting the generalizability of the results. It is recommended to perform further longitudinal and interventional research studies in this domain among normal and clinical groups. It is also suggested that comparative studies be conducted in other cultures and nations to increase the possibility of generalizing the results. Additionally, the training of emotion regulation and spiritual therapy should be accomplished in the form of workshops in the daily activities of the elderlies.

Conclusion
The results of the present study showed that emotion regulation and spirituality could predict 32.6% of the psychological well-being of the elderlies. Based on the findings, there was a direct and significant correlation between predictor and criterion variables, indicating that an increase in emotional regulation and spirituality led to an increase in psychological well-being and vice versa. Based on the findings of the present study emphasized the role of emotion regulation and spirituality as one of the most important issues in the psychological well-being status of the elderlies .

Conflict of interest
The authors declare that there is no conflict of interest.