An Exploration of the Emotional Response to Breast Cancer:
An Irish Reflection
This research was an original piece of work, undertaken as part of my masters program in psychotherapy.
The information below is from the abstract and recommendations of the dissertation.
Breast cancer in women is a serious public health issue. It is the second most common type of cancer and the fifth most frequent cause of death in the world (Scor, 2016). When confronted with breast cancer diagnosis multiple adjustment challenges are experienced (Gonzalez et al., 2016). A qualitative study on breast cancer survivors, found that women viewed their cancer experience as a chronic illness that needed to be managed over the course of their lifetime, rather than an acute medical crisis that was resolved once treatment ended (Oxlad et al., 2008). The important role of emotion regulation and expression in adaptation to breast cancer is now widely recognized (Raque-Bogdan et al.,2015).Studies have shown that optimal emotion regulation strategies, including less constrained emotional expression are associated with better adaptation (Brandao et al.,2016). Due to the large number of strategies that can be invoked to regulate emotions and context is likely to influence the utility of these strategies, it is important to keep studying and exploring which responses can help women cope better with the challenges associated with breast cancer.
The following research explored the emotional response in breast cancer patients from an Irish perspective with a limited sample. The main objectives of this research were to critically assess the emotional response in the context of breast cancer, to identify factors that may impact on response, and make recommendations on how relevant services in Ireland could develop more psycho social supports to enable this demography cope better. The aim of this study was to explore a cohort of six previous breast cancer patients and seek greater understanding of their individual illness trajectory (diagnosis, treatment and recovery), through the use of semi-structured interviews held in the professional and confidential environment of a counselling agency.
Qualitative research on emotional response to breast cancer from an Irish survivor’s perspective is negligible. For the purposes of this research an exploratory study was chosen. The philosophical assumptions of a naturalistic paradigm guided this study to allow for greater understanding into the meaning of the participants individual experiences of emotional response. The research philosophy took an epistemological stance with an interpretive approach. Method of data collection and analysis were a qualitative approach with a mono-method of semi- structured interviews. Analysis was undertaken using thematic analysis, which included in-depth content analysis and coding to help achieve and fully understand the research findings. Semi-structured interviews were audio-recorded and transcribed using thematic content analysis within the meta-theme of emotional response.
Findings suggest consensus with previous research on existing emotional response to breast cancer, but also yielded new material and, therefore, the need for further research in this area. Two main categories within emotional response were dominant. Both emotional inhibition and emotional expression emerged as emotional responses to breast cancer. These were further subdivided into four emotional meta-themes; suppression, avoidance, distress and emotional resilience. This study demonstrated the complex interplay of challenges to suppress and avoid negative emotions, and the distress or emotional resilience engendered through the challenges of breast cancer. More importantly, the participants often discussed their tendency to avoid or suppress emotions and the experience of distress in the same fragment, indicating an interconnection between the two.
What became apparent from the interviews is that a chronological sequence of mutual emotional responses was obvious. It appears that the initial emotional response was suppression which engendered avoidant behaviour, cognitions and interpersonal relations and subsequently distress and resilience manifested. The research evidenced an emotional input response in terms of suppression and avoidance, emotional output in distress and reappraisal in emotional resilience. Established in the findings was both engagement and distancing from emotions; distancing in the form of suppression and avoidance and engagement in the form of distress and emotional resilience was descried. The study uncovered that this demography tended to escape or delay negative emotions as a means to deal with the immediacy of their diagnosis and later chose a positive emotional response to ameliorate their crises. The research illustrated that the emotional response was both conscious (suppression, avoidance, distress and resilience) and unconscious (repression).
The following recommendations have been put forth as the most significant areas for practice
from the research carried out. The recommendations have been described in order of
Psychotherapy and Counselling
Given that cancer–specific emotional inhibition in the research was both elevated and predictive of subsequent distress, it is likely a good target for intervention aimed at decreasing avoidance and suppression by promoting active coping skills (e.g seeking social supports, problem solving, behavioural activation, cognitive reappraisal) (Moreno et al.,2016). These have been shown to improve psychological adjustment in individuals with cancer (McClure, & Houts, 2003). Research about emotional regulation states that increasing expression of specific emotions over time in psychotherapy may improve quality of life and health outcomes (Kissane et al.,2004), especially for those who may not express strong negative emotions readily (Campbell & Muncer, 2008). Emotions can be released and reduced in intensity when one becomes conscious of them and share the feelings with another (Hawkins, 2009). Research shows that when patients talk for several utterances they are more likely to express an emotion. Showing concern (i.e., the expression of a condition or event that has an immediate and strong emotional component) is specified as affective communication (Brandes et al., 2017).
By merely expressing the feeling some of the energy behind it is reduced (Hawkins, 2012). Tamagawa et al., (2015) stated that emotional expression correlated with change in depression, which in turn was predictive of survival time (Giese-Davis., 2011). Furthermore, and in agreement with the research, Iwamitsu et al., (2005) suggested that disclosure of the diagnosis is a point of overwhelming stress and a critical time to intervene with treatment. In particular, patients who suppress emotions need to be encouraged to express their needs and feelings so that they do not develop patterns of depression and hopelessness/helplessness. Furthermore, Graves et al.,(2005) suggested that intrapersonal changes can be affected by the cancer patient’s interpersonal milieu and speculated that appropriate expressions of emotion from cancer patients, even negative emotions, are more likely to generate positive reactions from others. Furthermore, Tamagawa et al. (2013) observed that helping patients cultivate awareness and reduce/express deliberate emotional inhibition may be a useful focus for psycho-oncology interventions. Their paper strengthens the earlier theories of previous published papers and encourages further study in regards to how to promote more efficacious emotional styles in psycho-ontological intervention.
When the emotions has been reduced in its sheer quantity and intensity is a good time to start ‘letting go’ or ‘surrendering’ to aspects of the situation rather than the overall situation and its accompanying emotion ( Hawkins, 2012). Blanco et al. (2014) reasoned that the empowering approach of interpersonal psychotherapy could help to foster an active response to ongoing hardship and promote resilience, which could help this population. Their findings found the interpersonal psychotherapy is a powerful treatment for depression among women with breast cancer. Patients reported both symptomatic and functional improvement (Tamagawa et al. 2013). The research agrees with further studies that state, as one comes out of overwhelm or emotional crises it is important to note that any residual suppressed or evaded emotion can now be examined so as not to cause any unconscious harm (Hawkins, 2012). Going forward, the future of psychotherapy might bear this in mind, that it is important to handle an emotional crises on an emotional level rather that an intellectual level, this will shorten its duration dramatically There are numerous benefits to handling a life crises successfully. For one thing, the amount of suppressed or repressed emotion will be much less. There will be a greater feeling of self-esteem and confidence because there is the awareness that one can survive whatever life will bring (Hawkins, 2012).
Longitudinal data revealed that after the end of the intervention, the intensity of general distress and breast cancer-related emotions had decreased significantly (Fischer, 2013). Furthermore, Pauwels et al., (2013) study concluded that there are many unmet needs among breast cancer patients. The time preferred for receiving information and support was the period of breast cancer treatment and the most popular sources of information and support was consultation with a psychologist, information sessions and information websites (Fischer, 2013).
Research shows that people who communicate with others after an emotional event, positive or negative, show that emotional sharing offers intrapersonal and interpersonal benefits, as individuals feel inner satisfaction and relief after sharing, and social bonds are strengthened through the interaction (Rime, 2007). Health professionals and psychotherapists could use the present study’s findings to make appropriate recommendations for embracing positive life changes during the breast cancer trajectory as this study revealed specific characteristics, that are viewed a valuable aspect of the coping process. Brandao et al., (2016) evaluated the effects of psychosocial interventions on emotion regulation and emotional expression strategies for breast cancer patients. These intervention were designed to specifically target emotion processes (expression of emotion, mindfulness, and relaxation skills). Chan et al., (2006) found that an intervention emphasizing connections between mind and body significantly reduce emotional control. Targeted intervention aimed at reducing cancer-specific avoidance to decrease distressing intrusive thoughts and improve psychological wellbeing would be recommended by the research.
Previous studies have reported that psycho-oncological intervention are capable of modifying levels of emotional styles, including suppression of emotions (Cameron et al., 2007). While women who received emotion-focused interventions evidenced reduced emotional suppression, women who received only standard care showed enhanced emotional suppression during the year after their diagnosis (Tamagawa 2012). Schlatter &Cameron (2010) suggests that women high in suppression may be in greater need of support and intervention. Suppression tendencies can change in response to psychological interventions that provide training in emotional regulation techniques. Their findings provide new support for emotional regulation theories that suppression of negative emotions has physiological ramification that may affect physical health.
Acceptance and Commitment Therapy(ACT)
ACT aims to increase psychological health via acceptance of one’s minding, a focus on the present-moment living, and a commitment to value –driven life (Angiola & Bowen, 2012). This information may assist in the design of prevention and intervention programs, which should give patients the opportunity to discuss and help them develop effective coping strategies and encourage them to become more expressive in meeting their emotional needs.
Family and Social Supports
The research recommends that optimal supports are paramount for one to overcome emotional inhibition. Social supports have been repeatedly indicated as a positive predictor of old survivors work related quality of life and return to work (Mujahid et al., 2010). Speaking about breast cancer can also draw a great deal of valued support and tangible help (Robinson et al., 2015). Social support in general have been associated with better sense of control and other health benefits (Uchino, 2006). Furthermore, Robinson et al., (2015) found that co-workers play an important role in communication and support over the cancer life-cycle.
Casellas-Grau et al., (2016) concluded that chemotherapy has many unpleasant side effects, both physical and psychosocial, which negatively disturb the patient’s emotional balance. These long term physical effects require significant social and family support which can in turn promote greater cohesion and interpersonal closeness. Survivors of breast cancer may still need social supports even when they are no longer undergoing treatment. Thus the moment immediately after the primary oncological treatment may be a suitable time to evaluate further psychosocial supports. The research revealed the concrete social support received from patient’s partners also has a stress absorbing role for patients by buffering the negative effects of stress and increasing positivity. It is not uncommon for cultural minority populations to lack large social networks support systems capable of offering tangible assistance or resources in times of need and illness (Gonzalez et al., 2016). Some women noted the benefits of support from community support groups.
Tamagawa et al., (2015) stated storytelling with friends and family may make it easier for others to hear and respond to their distress. This could represent an emotional-regulation skill in which women are able to convey distress without overburdening others. Storytelling increases cognitive rather than emotional processing. When people tell stories, their current and not fully conscious concerns can become apparent, allowing patients to express emotions that they find difficult to express directly. Transforming hostile and defensive expressions to more productive primary negative affect expression is a possible mediator of health benefits. Storytelling engenders reordering life priorities, finding meaning, and improving communication with friends and family and physician (Tamagawa et al., 2015).
Iskandarsyah et al., (2014) identified that several modifiable psycho social and culture related barriers to seeking medical help and adherence were evident in breast cancer patients. The research argues that not only financial support is needed but also extensive information provision through media campaigns. Women undergoing breast cancer treatment seem to be burdened by severe side effects of treatment suggesting that education for cancer professionals may be needed. Several programs could be introduced to improve breast cancer awareness and knowledge that may contribute to lowering the number of delay in seeking medical help. The use of media campaigns, such as public service announcements on TV, radio and newspapers have found to be an effective way to improve breast cancer knowledge to teach women how to conduct breast self-examination and to increase best health practices (Sun et al., 2007).
Health Care Professionals
Health care professionals are in a unique positions to encourage positive coping strategies that could assist breast cancer patients cope with their diagnoses and transition to survivorship (Gonzalez et al., 2016). Tailored cancer support intervention has the potential in reducing psychosocial health disparities. Brandes et al., (2017) theorised when a patient expresses emotions, providers may also be able to adequately reduce this emotion with an instrumental reaction rather than an emotional reaction. These responses could lead to both types of coping behaviours (problem orientated and emotional coping). A daily diary study may help health professionals understand the dynamic of cancer specific avoidance and emotional approach across time (i.e., the extent to which these coping processes coexist or oscillate over the course of hours, days, weeks) (Moreno et al., 2016).
Tamagawa et al., (2012) proved individual’s tendency to be mindful in daily life was associated with low levels of aversive mood and stress symptoms, while individuals with suppressive traits were associated with high levels of health complaints. The link between high levels of trait mindfulness and less likelihood of developing psychopathological symptoms is proven (Berstein et al., 2011). These findings suggest that trait mindfulness may be an important health protective factor for cancer patients. Several studies empirically demonstrated increased levels of trait mindfulness following mindfulness based stress reduction (MBSR) and this change mediated positive effects among cancer patients (Branstrom et al., 2010). Considering many patients potentially go through multiple challenges associated with medical treatment and living with cancer fostering mindfulness through a mindfulness-based program such as MBSR or MBCT (mindfulness based cognitive therapy) may be beneficial for improving self-reported mood and stress symptoms. Brandao et al., (2016) and Henderson et al (2013) found that a mindfulness –based stress reduction intervention decreased emotional inhibition. In addition focus on the three emotional channels (experiential, behavioural and physiological) mindfulness can offer regulatory efforts on choosing or modifying one’s situation , altering one’s attentional focus or changing one’s understanding of the situation (Schulz & Lazarus, 2012).
The research recommends the benefits of psychological interventions, such as emotion-focused group therapy, mindfulness and MBSR. They may work well because through these programs, individuals are able to acknowledge potentially maladaptive emotional tendencies and learn an alternative way to deal with difficult emotions (Tamagawa et al., 2012).