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The Adaptive Potential of Coping through Emotional Approach

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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 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

4 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

5 Coping Processes Cognitive, emotional, and behavioral efforts to manage demands that tax or exceed individual’s resources Traditional distinction = problem-focused and emotion-focused Oriented toward approaching or avoiding the stressor Emo not in original definition Used to be prb- vs emo-focused

6 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) Stanton et al emo and coping located studies that had rel with adj Contrasted with: Functionalist theories of emotion, Clinical literature on adjustment to adversity, Psychological intervention trials Emotional disclosure research

7 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

8 Are Published Emotion-Focused Coping Scales Confounded with Distress
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 19/35 EF coping items vs 0/11 author-constructed items

9 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 one’s 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 Dispositional and situational versions;

10 Confirmatory factor analysis Uncorrelated with social desirability
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 149 undergrads, 101 mothers, 83 fathers – Mo EP = .25, EE = .30; Child rate Mo EP = .10; EE = .32


12 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

13 Gender x Emotional Approach Interaction on Adjustment (Stanton et al
Gender x Emotional Approach Interaction on Adjustment (Stanton et al., 1994, JPSP) Sex x EAC interaction for depressive sx specific to interpersonal (not achievement) and low-control (not high-control situations)

14 The Question of Gender Women use more emotional approach coping, but < 7% variance accounted for by gender Greater adaptiveness of emotional approach for young women BUT gender effects not consistent across studies Some evidence for women more likely to find benefit than men, but no evidence that it works differently for women and men

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

16 Time 2 Depressive Symptoms Regressed on Emotionally Expressive Coping

17 Explain interaction So some evidence that EAC and BF of partner influences adjustment of other. What other characteristics of the environment are important? We’ve tested this through three experimental studies, all examining the basic hypothesis that the match between the individual’s naturally elected coping processes and the environmental demands will facilitate adjustment.

18 Emotional Approach in Breast Cancer Patients (Stanton et al
Emotional Approach in Breast Cancer Patients (Stanton et al., 2000; Stanton et al., 2002) Control for Initial Values on Dependent Variables > 80% Participation Stage I and II Breast Cancer Age 50s (Range 21 – 76) Education > high school White > 87% Employed > 65% Married 78% Age the only demo or ca-related variable related to adjustment, and controlled where relevant DV = Psychological variables = Distress, WB, QOL; Physical health = self-reported physical sx, Medical appts.

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

20 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

21 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.

22 Regressions and Partial Correlations for 3-Month Outcomes

23 Medical Visits for Cancer-Related Morbidities

24 Expressive Coping x Hope Interaction on Medical Visits for Cancer-Related Morbidities at 3 Months
Moderated relations on Medical Visits (same on POMS distress); EE also mediated rel of hope on perceived health and POMS vigor

25 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

26 Condition x cancer-related avoidance interaction
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. Originally hyp a condition by EAC interaction, but little variability in EAC Avoidance = mental/behav disengagement; IES avoidance

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) 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

28 “The past year has been a roller coaster ride…
“The past year has been a roller coaster ride….It’s hard to express these feelings of frustration, sadness, anger, bitterness, and disappointment. I worry about finances. I’m 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 don’t know how. I need to move on, trust. I’m realizing I don’t 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?” Written by woman who had just completed treatment for breast cancer

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 don’t 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…I’ve 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 Somatic Symptoms at Three-Month Follow-up
Main Effects on Physical Health Outcomes F(2, 50) = 4.70, p = .014

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

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

33 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 Med students in their 3rd year clinical clerkships – first real responsibility for patient care BPS = future as if all personal/professional goals achieved, overcome at least one major obstacle

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 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

37 Mechanisms for the Effects of Emotional Approach

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

39 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

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 Mediator EMO (n = 20) POS (n = 19) CTL (n = 16) F (df) P Baseline HR 81.68a 2.46 81.46a 2.52 82.58a 2.74 0.05 (2, 52) .95 HR Activation (writing HR controlling for baseline HR) 87.43a 1.03 84.76a 1.02 85.89a 1.11 1.70 (2, 48) .19 HR Habituation During Writing (Peak – End HR controlling for baseline HR) 16.78a 1.52 10.27b 1.54 6.52b 1.67 10.74 (2, 50) <.001 HR Recovery (post-writing HR controlling for baseline HR) 77.35a 1.06 79.90ab 1.08 81.95b 1.17 4.29 (2, 51) .019 For all participants, heart rate and SCL were assessed continuously throughout writing. SCL analyses were not significant, so for the rest of the talk, autonomic habituation will refer to the HR data. In the EMO condition, where we expected stronger negative emotional and physiological arousal initially, we expected that repeated or prolongned exposure to these emotions would result in habituation, or decreased heart rate over time as patients are desensitized to emotion and thoughts associated with cancer. However, because we did not anticipate strong negative arousal in the POS or CTL group, we did not hypothesize autonomic habituation as a mediator for these groups. In other words, women who wrote about their deepest thoughts and feelings whose autonomic arousal decreased over time within or across sessions would report fewer medical visits In the POS group, we thought that the positive emotional content expressed in the essays may be related to the health effect. This hypothesis was based on Barbara Fredrickson’s “physical undoing” theory of positive emotion – activation of positive emotion speeds physical recovery from negative emotional arousal. Thus, women who were instructed to write about positive thoughts and feelings and conveyed more positive emotion in their essays would report fewer medical visits. However, we did not anticipate much expression of positive feelings in the emotional expression group, so we did not expect to see positive essay content related to health effects in that condition. We also expected that the degree of cognitive processing conveyed in the essays might correlate with health changes, as increasing cognitive processing and insight regarding the experience may reflect that the experience of cancer is assimilated into participants’ life stories coherently, decreasing stress and arousal.

42 Breast Cancer Patient Writing Study – Heart Rate

43 MEDIATIONAL MODEL Expressive intervention Physical 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 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 < .001) Greater HR habituation predicted fewer medical appointments for cancer-related morbidities in EMO (r = -.30), but not a significant mediator

45 Possible Neuroendocrine Mechanism
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 Positive Cortisol slope Mean cortisol Coping Processes Emotional approach -.41* -.40* .56* -.36* -.21 Seek social support -.01 -.15 .22 .02 Positive reappraisal -.24 .31* -.32 -.44* Acceptance -.43* -.45* .32* -.51* .06 Problem-focused coping -.26 -.42* .54* -.46* -.12 Avoidant coping .72* .76* -.50* .19 -.13

46 Lutgendorf (2002, J Urology) – less pain and urgency when higher morning cort in interstitial cystitis pts;

47 Cortisol Slopes as a Function of Coping through Emotional Expression

48 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 Consideration of Context Provides Richer Portrait of the Influence of Coping Processes on Adaptive Outcomes under Adverse Circumstances Carries Implications for Intervention – e.g., avoidant people do not benefit from straight Pennebaker paradigm; Manne cancer couples group – high EE predicted better outcomes Lischetzke & Eid (2003, Emotion) for indivs with high self-efficacy in regulating mood, greater attention to feelings predicted better WB, but if low mood regul, then attention predicted poor WB

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


51 Relations of Confounded Emotion-Focused Coping with Adjustment

52 Relations of Unconfounded Coping with Adjustment

53 Study 1 Factor Analysis

54 Study 3 Confirmatory Factor Analyses

55 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 .56*

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

57 September 11 Study Undergraduates (n = 131)
36-60 hours after terrorist attacks 6-week follow-up DV = Days of illness-related activity restriction

58 Neuroticism x Expressive Coping Interaction on Days of Illness-Related Activity Restriction at 6 Weeks after September 11 No interaction of benefit-finding with hope or neo in these studies, BUT

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

60 Positive Emotion Essay Words 2.91b 0.24 4.72a 1.41c 0.26 41.96 (2, 56)
Effects of Experimental Condition on Essay Word Variables and Self-Reported Mood During Writing Sessions in Multilevel Models (Stanton et al., in press) Potential Mediator EMO (n = 20) POS (n = 19) CTL (n = 16) F p Positive Emotion Essay Words 2.91b 0.24 4.72a 1.41c 0.26 41.96 (2, 56) .0001 Negative Emotion Essay Words 2.21a 0.12 1.15b 0.13 1.03b 0.14 26.09 Cognitive Mechanism Words 9.44a 0.28 6.48b 6.37b 0.31 37.91 Self-reported Negative Mood 13.87ab 1.13 10.14b 14.48a 1.22 4.22 (2, 58) .0194

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

62 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

63 Zakowski et al. (2004)



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