The Adaptive Potential of Coping through Emotional Approach

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. 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 Collaborators

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

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)

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? (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

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

10. 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

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., 1994, JPSP)

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

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

18. 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%

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

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. 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.

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….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?”

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 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

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

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

42. Breast Cancer Patient Writing Study – Heart Rate

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

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. 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 -.01 -.15 .22 -.15 .02 Positive reappraisal -.21 -.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 Possible Neuroendocrine Mechanism?Relations of Coping Processes with Adjustment and Cortisol in Metastatic Breast Cancer Patients (n = 50)

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

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