An emotional approach intervention for women living with advanced breast cancer

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The Adaptive Potential of Coping through
Emotional Approach

• Annette L. Stanton, Ph.D., UCLA
• Sponsored by U.S. Army Medical Research and
  Materiel Command
• National Cancer Institute
• California Breast Cancer Research Program

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Collaborators

• Carissa Low
• Qian Lu
• Patricia Ganz
• David Creswell
• Sharon Danoff-Burg
• Sarah Kirk
• Christine Cameron
• Andrew Ellis
• Charlotte Collins
• Jennifer Austenfeld
• Melissa Huggins

• James Berghuis
• Lisa Sworowski
• Michelle Bishop
• Robert Twillman
• Ann Branstetter
• Alicia Rodriguez-Hanley
• David Amodio
• Sarah Master
• Shelley Taylor

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Plan

• Emotional processing and expression in the
  context of stress and coping research
• Coping through emotional approach development of
  the construct
• Adaptive value of coping through emotional
  approach
• Mechanisms for effects

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Coping Processes

• Cognitive, emotional, and behavioral efforts to
  manage demands that tax or exceed individuals
  resources
• Traditional distinction problem-focused and
  emotion-focused
• Oriented toward approaching or avoiding the
  stressor

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The Bad Reputation of Emotion-Focused Coping

• Emotion-focused coping has consistently proven
  to be associated with negative adaptation (Kohn,
  1996, p. 186)
• Relation of emotion-focused coping and poor
  adjustment in 26 of 27 studies reviewed (Stanton,
  Parsa, Austenfeld, 2002)

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Problems in Conceptualization and
Operationalization of Emotion-Focused Coping

• Aggregation of distinct strategies into umbrella
  construct
• Tell myself that it is really not happening to
  me.
• Get angry.
• Self-report assessment contaminated with distress
  and self-deprecation
• I get upset and let my emotions out
• I become very tense
• I focus on my general inadequacies
• No existing unconfounded measures

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Are Published Emotion-Focused Coping Scales
Confounded with Distress? (Stanton et al., 1994,
JPSP)

• Clinical psychologists (n 194) judged majority
  of published emotion-focused coping items as
  reflecting symptoms of psychological disorder
• Longitudinal study of young adults (n 171)
  coping with self-nominated stressor
• Published emotion-focused scales weak predictors
  of adjustment when Time 1 DV controlled
• Unconfounded items predicted adjustment

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Coping through Emotional Approach

• Efforts to manage perceived demands via
• Emotional processing active attempts to
  acknowledge, explore meanings of, and come to an
  understanding of ones emotions
• I delve into my feelings to get a thorough
  understanding of them
• Emotional expression observable verbal and
  nonverbal behaviors that communicate or symbolize
  emotional experience
• I take time to express my emotions

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Development of Instruments to Assess Coping
through Emotional Approach (Stanton et al., 2000,
JPSP)

• Confirmatory factor analysis
• Uncorrelated with social desirability
• Related to parents assessment of coping
• Related to behavioral indicators of sadness in
  sadness induction
• Not just social support

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The Adaptive Utility of Coping through Emotional
Approach

• Longitudinal research with young adults,
  infertile couples, breast cancer patients
• Experimental research on expressive disclosure
• Reveals context-dependent effects

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Gender x Emotional Approach Interaction on
Adjustment (Stanton et al., 1994, JPSP)
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The Question of Gender

• Women use more emotional approach coping, but lt
  7 variance accounted for by gender
• Greater adaptiveness of emotional approach for
  young women
• BUT gender effects not consistent across studies

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Predictive Utility for a Dyadic Stressor

• Berghuis Stanton (2002, JCCP)
• 43 infertile couples across an alternate
  insemination attempt

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Time 2 Depressive Symptoms Regressed on
Emotionally Expressive Coping
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Emotional Approach in Breast Cancer Patients
(Stanton et al., 2000 Stanton et al., 2002)

• Control for Initial Values on Dependent Variables
• gt 80 Participation
• Stage I and II Breast Cancer
• Age 50s (Range 21 76)
• Education gt high school
• White gt 87
• Employed gt 65
• Married 78

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Dependent Variables

• Profile of Mood States (POMS)
• Self-reported physical health/symptoms
• Medical care utilization
• Cancer-related morbidities
• 88 - 92 concordance with medical records

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Longitudinal Design - Stanton et al. (2000)

• 92 Breast Cancer Patients after Treatment
  Completion (M 6 months post-diagnosis)
• Assessment at Treatment Completion and Three
  Months

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Hypotheses

• Coping through actively processing and expressing
  emotion will predict enhanced physical and
  psychological adjustment over time
• Dispositional hope (Snyder et al., 1991) will
  moderate the relations of emotional approach
  coping with adaptive outcomes
• I meet the goals I set for myself.
• I can think of many ways to get the things in
  life that are most important to me.

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Regressions and Partial Correlations for 3-Month
Outcomes
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Medical Visits for Cancer-Related Morbidities
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Expressive Coping x Hope Interaction on Medical
Visits for Cancer-Related Morbidities at 3 Months
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Emotional Disclosure Interventions (Pennebaker)

• Participants randomly assigned to write about
  deepest thoughts and feelings for 20 minutes on
  3-4 occasions
• Demonstrates enhanced physical health and
  psychological well-being relative to control
  conditions (Smyth, 1998 Frisina, Borod,
  Lepore, 2004)
• Physical health benefits especially
• robust in clinical populations

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Randomized, Controlled Trial of Written Emotional
Expression and Benefit Finding (Stanton et al.,
JCO, 2002)

• Hypotheses
• Experimentally induced emotional disclosure and
  benefit finding will produce enhanced physical
  and psychological adjustment relative to a
  fact-control condition
• Condition x cancer-related avoidance interaction
• I try not to think about it.
• I turn to work or other activities to take my
  mind off things.

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Randomized, Controlled Trial of Expressive
Writing in Breast Cancer Patients

• 60 breast cancer patients within 20 wks after
  completion of primary medical tx (M 28 weeks
  post-diagnosis)
• Random Assignment to
• Deepest Thoughts and Feelings (EMO)
• Benefit Finding (BEN)
• Fact Control (CTL)
• Four, 20-minute writing sessions over 3 weeks
  conducted in home, lab
• Three-Month Follow-Up
• DV Distress, Somatic Symptoms, Medical
  Appointments for Cancer-Related Morbidities

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The past year has been a roller coaster
ride.Its hard to express these feelings of
frustration, sadness, anger, bitterness, and
disappointment. I worry about finances. Im
never feeling just right, with so many changes
going on in my body There is anger and real
fear. I must return to the real world. I have
to function, but I dont know how. I need to
move on, trust. Im realizing I dont have
control, and am experiencing real anger now.
Every twinge or pain brings fear. How fragile
life is. Why does it take this, to see that?
How do I move on?
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I feel so grateful each morning to wake up in my
bed and feel so good and alive and eager to face
another day. The inherent goodness of my family
and friends has been a really positive aspect.
They are all so supportive and make me feel like
such a loved and special personI feel like I
make more time for my friends and family. I also
do more things for myself and dont feel guilty
about it. I feel like this makes me a calmer,
happier woman. I talk to God on a much more
personal level nowIve learned to let go of
anger I had in the past. I feel more forgiving
and a lot less judgmental of other people and
their lives. When I think of the future, I
realize that it may not be as long as I had
thought, but having cancer makes me appreciate
this moment in my life.
 
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Somatic Symptoms at Three-Month Follow-up

• F(2, 50) 4.70, p .014

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Medical Appointments at Three-Month Follow-up

• F(2,51) 6.04, p .004

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Condition x Avoidance Interaction on POMS
Distress at Three-Month Follow-up
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Medical Student Expressive Writing Trial
(Austenfeld Stanton, in press)

• 64 medical students in third-year clinical
  clerkships
• Random assignment to
• Deepest Thoughts and Feelings (EMO)
• Best Possible Self (BPS)
• Fact Control (CTL)
• Three, 25-minute writing sessions conducted in
  lab
• Three-month follow-up

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Emotional processing x condition interaction on
prediction of depressive symptoms at 3-month
follow-up
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Emotional processing x condition interaction on
prediction of health care visits at 3-month
follow-up
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Other Emotion Construct Moderators

• Norman et al. (2004, Psychosomatic Med)
• High ambivalence over emotional expression? less
  disability at 2 months in chronic pelvic pain
  patients in EMO vs CTL
• Alexithymia (Lumley)
• High difficulty identifying feelings no benefit
  of emotional disclosure
• High difficulty describing feelings benefit of
  emotional disclosure

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Mechanisms for the Effects of Emotional Approach
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Mechanisms for the Utility of Approach-Oriented
Coping

• Signaling Function
• Physiological Habituation/Regulation
• Goal Clarification and Pursuit
• Cognitive Reappraisal
• Regulation of Social Environment

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Stanton et al. (2000) Study 4 Experimental
Disclosure

• Hypothesized adaptiveness of match between
  naturally elected and experimentally imposed
  emotionally expressive coping
• 76 undergraduates whose parent had psychological
  or physical disorder
• Random assignment to discuss emotions or facts
  regarding disorder over two sessions
• Dependent variables - PANAS-X negative affect
  (fear, hostility, guilt, sadness), heart rate,
  skin conductance

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Study 4 Findings
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Breast Cancer Writing Study - Effects of
Condition on Heart Rate (HR) Indicators in
Multilevel Models (Low, Stanton, Danoff-Burg,
in press)
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Breast Cancer Patient Writing Study Heart Rate
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Other Findings

• Greater negative emotion word use predicted
  reduction of physical symptoms
• Greater use of cognitive mechanism words was
  associated with greater HR habituation (r .43,
  p .001) and more use of negative emotion words
  (r .52, p lt .001)
• Greater HR habituation predicted fewer medical
  appointments for cancer-related morbidities in
  EMO (r -.30), but not a significant mediator

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Possible Neuroendocrine Mechanism?Relations of
Coping Processes with Adjustment and Cortisol in
Metastatic Breast Cancer Patients (n 50)
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Cortisol Slopes as a Function of Coping through
Emotional Expression
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Conclusions

• Adaptive Utility of Coping through Emotional
  Approach Depends on Context
• Intrapersonal Context
• Gender?
• Hope
• Environmental Context
• Stressor Characteristics controllability
• Social Receptivity
• Importance of Person-Environment Fit
• Manne intervention trial

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Conclusions

• How Does Emotional Approach Work?
• Habituation and Competent Physiological
  Regulation
• Motivates Goal Clarification and Pursuit
• Cognitive Reappraisal
• On-going Research

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Relations of Confounded Emotion-Focused Coping
with Adjustment
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Relations of Unconfounded Coping with Adjustment
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Study 1 Factor Analysis
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Study 3 Confirmatory Factor Analyses
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Study 1 Correlations with Relevant Variables
Emotional Processing Emotional Expression
Social Desirability .08 .06
Emotional Expressiveness .26 .44
Family Expressiveness .17 .40
Problem-Focused Coping .47 .24
Seeking Social Support .44 .56
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Stanton et al. (2000) Study 1 Emotional
Processing Gender Differences
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September 11 Study

• Undergraduates (n 131)
• 36-60 hours after terrorist attacks
• 6-week follow-up
• DV Days of illness-related activity restriction

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Neuroticism x Expressive Coping Interaction on
Days of Illness-Related Activity Restriction at 6
Weeks after September 11
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Baseline hostility x condition interaction on
prediction of hostility at 3-month follow-up
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Effects of Experimental Condition on Essay Word
Variables and Self-Reported Mood During Writing
Sessions in Multilevel Models (Stanton et al., in
press)
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Diurnal Cortisol Rhythm as a Predictor of Breast
Cancer Survival (Sephton et al., 2000, JNCI)
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Emotional Disclosure as a Buffer of Social
Constraint

• Zakowski et al. (2004, HP)
• 104 gyn and prostate cancer patients
• 3 home-based sessions EMO vs CTL
• 6 months no main effects on psych outcomes, but
  moderated effects
• EMO buffered negative effects of high social
  constraint in discussing cancer on general
  distress

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Zakowski et al. (2004)
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