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1. 2 The Adaptive Potential of Coping through Emotional Approach Annette L. Stanton, Ph.D., UCLA Sponsored by U.S. Army Medical Research and Materiel.

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Presentation on theme: "1. 2 The Adaptive Potential of Coping through Emotional Approach Annette L. Stanton, Ph.D., UCLA Sponsored by U.S. Army Medical Research and Materiel."— Presentation transcript:

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2 2 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

3 3 Collaborators Carissa Low Carissa Low Qian Lu Qian Lu Patricia Ganz Patricia Ganz David Creswell David Creswell Sharon Danoff-Burg Sharon Danoff-Burg Sarah Kirk Sarah Kirk Christine Cameron Christine Cameron Andrew Ellis Andrew Ellis Charlotte Collins Charlotte Collins Jennifer Austenfeld Jennifer Austenfeld Melissa Huggins Melissa Huggins James Berghuis James Berghuis Lisa Sworowski Lisa Sworowski Michelle Bishop Michelle Bishop Robert Twillman Robert Twillman Ann Branstetter Ann Branstetter Alicia Rodriguez-Hanley Alicia Rodriguez-Hanley David Amodio David Amodio Sarah Master Sarah Master Shelley Taylor Shelley Taylor

4 4 Plan Emotional processing and expression in the context of stress and coping research Emotional processing and expression in the context of stress and coping research Coping through emotional approach: development of the construct Coping through emotional approach: development of the construct Adaptive value of coping through emotional approach Adaptive value of coping through emotional approach Mechanisms for effects Mechanisms for effects

5 5 Coping Processes Cognitive, emotional, and behavioral efforts to manage demands that tax or exceed individuals resources Cognitive, emotional, and behavioral efforts to manage demands that tax or exceed individuals resources Traditional distinction = problem- focused and emotion-focused Traditional distinction = problem- focused and emotion-focused Oriented toward approaching or avoiding the stressor Oriented toward approaching or avoiding the stressor

6 6 The Bad Reputation of Emotion-Focused Coping Emotion-focused coping has consistently proven to be associated with negative adaptation (Kohn, 1996, p. 186) 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) Relation of emotion-focused coping and poor adjustment in 26 of 27 studies reviewed (Stanton, Parsa, & Austenfeld, 2002)

7 7 Problems in Conceptualization and Operationalization of Emotion- Focused Coping Aggregation of distinct strategies into umbrella construct 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 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 No existing unconfounded measures

8 8 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 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 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

9 9 Coping through Emotional Approach Efforts to manage perceived demands via: Efforts to manage perceived demands via: Emotional processing = active attempts to acknowledge, explore meanings of, and come to an understanding of ones emotions 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 Emotional expression = observable verbal and nonverbal behaviors that communicate or symbolize emotional experience –I take time to express my emotions

10 10 Development of Instruments to Assess Coping through Emotional Approach (Stanton et al., 2000, JPSP) Confirmatory factor analysis Confirmatory factor analysis Uncorrelated with social desirability Uncorrelated with social desirability Related to parents assessment of coping Related to parents assessment of coping Related to behavioral indicators of sadness in sadness induction Related to behavioral indicators of sadness in sadness induction Not just social support Not just social support

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12 12 The Adaptive Utility of Coping through Emotional Approach Longitudinal research with young adults, infertile couples, breast cancer patients Longitudinal research with young adults, infertile couples, breast cancer patients Experimental research on expressive disclosure Experimental research on expressive disclosure Reveals context-dependent effects Reveals context-dependent effects

13 13 Gender x Emotional Approach Interaction on Adjustment (Stanton et al., 1994, JPSP)

14 14 The Question of Gender Women use more emotional approach coping, but < 7% variance accounted for by gender Women use more emotional approach coping, but < 7% variance accounted for by gender Greater adaptiveness of emotional approach for young women Greater adaptiveness of emotional approach for young women BUT gender effects not consistent across studies BUT gender effects not consistent across studies

15 15 Predictive Utility for a Dyadic Stressor Berghuis & Stanton (2002, JCCP) Berghuis & Stanton (2002, JCCP) 43 infertile couples across an alternate insemination attempt 43 infertile couples across an alternate insemination attempt

16 16 Time 2 Depressive Symptoms Regressed on Emotionally Expressive Coping

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18 18 Emotional Approach in Breast Cancer Patients (Stanton et al., 2000; Stanton et al., 2002) Control for Initial Values on Dependent Variables Control for Initial Values on Dependent Variables > 80% Participation > 80% Participation Stage I and II Breast Cancer Stage I and II Breast Cancer Age50s (Range 21 – 76) Age50s (Range 21 – 76) Education> high school Education> high school White> 87% White> 87% Employed> 65% Employed> 65% Married78% Married78%

19 19 Dependent Variables Profile of Mood States (POMS) Profile of Mood States (POMS) Self-reported physical health/symptoms Self-reported physical health/symptoms Medical care utilization Medical care utilization –Cancer-related morbidities 88% - 92% concordance with medical records 88% - 92% concordance with medical records

20 20 Longitudinal Design - Stanton et al. (2000) 92 Breast Cancer Patients after Treatment Completion (M = 6 months post-diagnosis) 92 Breast Cancer Patients after Treatment Completion (M = 6 months post-diagnosis) Assessment at Treatment Completion and Three Months Assessment at Treatment Completion and Three Months

21 21 Hypotheses Coping through actively processing and expressing emotion will predict enhanced physical and psychological adjustment over time 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 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.

22 22 Regressions and Partial Correlations for 3-Month Outcomes

23 23 Medical Visits for Cancer- Related Morbidities

24 24 Expressive Coping x Hope Interaction on Medical Visits for Cancer-Related Morbidities at 3 Months

25 25 Emotional Disclosure Interventions (Pennebaker) Participants randomly assigned to write about deepest thoughts and feelings for 20 minutes on 3-4 occasions 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) 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 robust in clinical populations

26 26 Randomized, Controlled Trial of Written Emotional Expression and Benefit Finding (Stanton et al., JCO, 2002) Hypotheses Hypotheses Experimentally induced emotional disclosure and benefit finding will produce enhanced physical and psychological adjustment relative to a fact-control condition 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 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.

27 27 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) 60 breast cancer patients within 20 wks after completion of primary medical tx (M = 28 weeks post-diagnosis) Random Assignment to: 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 Four, 20-minute writing sessions over 3 weeks conducted in home, lab Three-Month Follow-Up Three-Month Follow-Up DV – Distress, Somatic Symptoms, Medical Appointments for Cancer-Related Morbidities DV – Distress, Somatic Symptoms, Medical Appointments for Cancer-Related Morbidities

28 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?

29 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 person…I 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 now…Ive 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.

30 30 Somatic Symptoms at Three-Month Follow-up F(2, 50) = 4.70, p =.014

31 31 Medical Appointments at Three-Month Follow-up F(2,51) = 6.04, p =.004

32 32 Condition x Avoidance Interaction on POMS Distress at Three-Month Follow-up

33 33 Medical Student Expressive Writing Trial (Austenfeld & Stanton, in press) 64 medical students in third-year clinical clerkships 64 medical students in third-year clinical clerkships Random assignment to: Random assignment to: –Deepest Thoughts and Feelings (EMO) –Best Possible Self (BPS) –Fact Control (CTL) Three, 25-minute writing sessions conducted in lab Three, 25-minute writing sessions conducted in lab Three-month follow-up Three-month follow-up

34 Emotional processing x condition interaction on prediction of depressive symptoms at 3-month follow-up

35 Emotional processing x condition interaction on prediction of health care visits at 3-month follow-up

36 36 Other Emotion Construct Moderators Norman et al. (2004, Psychosomatic Med) 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) Alexithymia (Lumley) –High difficulty identifying feelings – no benefit of emotional disclosure –High difficulty describing feelings – benefit of emotional disclosure

37 37 Mechanisms for the Effects of Emotional Approach

38 38 Mechanisms for the Utility of Approach-Oriented Coping Signaling Function Signaling Function Physiological Habituation/Regulation Physiological Habituation/Regulation Goal Clarification and Pursuit Goal Clarification and Pursuit Cognitive Reappraisal Cognitive Reappraisal Regulation of Social Environment Regulation of Social Environment

39 39 Stanton et al. (2000) Study 4 Experimental Disclosure Hypothesized adaptiveness of match between naturally elected and experimentally imposed emotionally expressive coping Hypothesized adaptiveness of match between naturally elected and experimentally imposed emotionally expressive coping 76 undergraduates whose parent had psychological or physical disorder 76 undergraduates whose parent had psychological or physical disorder Random assignment to discuss emotions or facts regarding disorder over two sessions 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 Dependent variables - PANAS-X negative affect (fear, hostility, guilt, sadness), heart rate, skin conductance

40 40 Study 4 Findings

41 Breast Cancer Writing Study - Effects of Condition on Heart Rate (HR) Indicators in Multilevel Models (Low, Stanton, & Danoff-Burg, in press) Potential MediatorEMO (n = 20) POS (n = 19) CTL (n = 16) F (df) P Baseline HR a a a (2, 52).95 HR Activation (writing HR controlling for baseline HR) a a a (2, 48).19 HR Habituation During Writing (Peak – End HR controlling for baseline HR) a b b (2, 50) <.001 HR Recovery (post-writing HR controlling for baseline HR) a ab b (2, 51).019

42 42 Breast Cancer Patient Writing Study – Heart Rate

43 Expressive interventionPhysical symptoms Within-session heart rate habituation r = -.41, F(1,48) = 9.4, p <.005 F(2,50) = 4.70 p =.01 MEDIATIONAL MODEL F(2,48) = 1.96, n.s.

44 44 Other Findings Greater negative emotion word use predicted reduction of physical symptoms 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 <.001) 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 <.001) Greater HR habituation predicted fewer medical appointments for cancer-related morbidities in EMO (r = -.30), but not a significant mediator Greater HR habituation predicted fewer medical appointments for cancer-related morbidities in EMO (r = -.30), but not a significant mediator

45 Possible Neuroendocrine Mechanism? Relations of Coping Processes with Adjustment and Cortisol in Metastatic Breast Cancer Patients (n = 50) CES-D Depressive symptoms POMS Negative mood POMS Positive mood Cortisol slope Mean cortisol Coping Processes Emotional approach-.41*-.40*.56*-.36*-.21 Seek social support Positive reappraisal * * Acceptance-.43*-.45*.32*-.51*.06 Problem-focused coping *.54*-.46*-.12 Avoidant coping.72*.76*-.50*

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47 Cortisol Slopes as a Function of Coping through Emotional Expression

48 48 Conclusions Adaptive Utility of Coping through Emotional Approach Depends on Context Adaptive Utility of Coping through Emotional Approach Depends on Context Intrapersonal Context Intrapersonal Context –Gender? –Hope Environmental Context Environmental Context –Stressor Characteristics – controllability –Social Receptivity Importance of Person-Environment Fit Importance of Person-Environment Fit –Manne intervention trial

49 49 Conclusions How Does Emotional Approach Work? How Does Emotional Approach Work? –Habituation and Competent Physiological Regulation –Motivates Goal Clarification and Pursuit –Cognitive Reappraisal –On-going Research

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51 Relations of Confounded Emotion-Focused Coping with Adjustment

52 Relations of Unconfounded Coping with Adjustment

53 Study 1 Factor Analysis

54 54 Study 3 Confirmatory Factor Analyses

55 Study 1 Correlations with Relevant Variables Emotional Processing Emotional Expression Social Desirability Emotional Expressiveness.26*.26*.44*.44* Family Expressiveness *.40* Problem-Focused Coping.47*.47*.24*.24* Seeking Social Support.44*.44*.56*.56*

56 56 Stanton et al. (2000) Study 1 Emotional Processing Gender Differences

57 57 September 11 Study Undergraduates (n = 131) Undergraduates (n = 131) hours after terrorist attacks hours after terrorist attacks 6-week follow-up 6-week follow-up DV = Days of illness-related activity restriction DV = Days of illness-related activity restriction

58 58 Neuroticism x Expressive Coping Interaction on Days of Illness-Related Activity Restriction at 6 Weeks after September 11

59 Baseline hostility x condition interaction on prediction of hostility at 3-month follow-up

60 Effects of Experimental Condition on Essay Word Variables and Self-Reported Mood During Writing Sessions in Multilevel Models (Stanton et al., in press) Potential MediatorEMO (n = 20) POS (n = 19) CTL (n = 16) Fp Positive Emotion Essay Words 2.91 b a c (2, 56).0001 Negative Emotion Essay Words 2.21 a b b (2, 56).0001 Cognitive Mechanism Words 9.44 a b b (2, 56).0001 Self-reported Negative Mood ab b a (2, 58).0194

61 Diurnal Cortisol Rhythm as a Predictor of Breast Cancer Survival (Sephton et al., 2000, JNCI)

62 62 Emotional Disclosure as a Buffer of Social Constraint Zakowski et al. (2004, HP) Zakowski et al. (2004, HP) 104 gyn and prostate cancer patients 104 gyn and prostate cancer patients 3 home-based sessions EMO vs CTL 3 home-based sessions EMO vs CTL 6 months – no main effects on psych outcomes, but moderated effects 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 EMO buffered negative effects of high social constraint in discussing cancer on general distress

63 63 Zakowski et al. (2004)

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