The Relationship Between Emotional Suppression and Psychological Adjustment in Breast Cancer Patients
Table of Contents
|List of Abbreviations and Symbols||v|
|Table of Contents||viii|
|List of Tables|
|List of Appendices|
|Chapter I. Introduction||1|
|1.1 Breast Cancer||2|
|1.2 Emotional suppression||4|
|1.2.1 Emotion regulation||5|
|1.2.2 Suppression and repression||6|
|1.2.3 Consequences of emotional suppression||7|
|126.96.36.199 Affective consequences||7|
|188.8.131.52 Social consequences||8|
|184.108.40.206 Cognitive consequences||9|
|1.2.4 Emotional suppression and physical health||10|
|1.2.5 Suppression and psychological problems||10|
|1.2.6 Model of emotional suppression||12|
|1.3 Psychological Adjustment||12|
|1.3.1. Different perspectives of Psychological Adjustment||14|
|1.3.2. Factors Affecting Psychological Adjustment||15|
|1.3.3. Adjustment to Chronic Illness||16|
|1.3.4. Psychological Adjustment and Cancer||18|
|1.3.5. Theories of Psychological Adjustment||20|
|220.127.116.11. Coping theory||20|
|18.104.22.168. Theory of cognitive adaptation||21|
|1.4. Emotional Suppression, Psychological Adjustment and Cancer||22|
|1.4.1. Biopsychosocial Approach||24|
|1.4.2. Process Model of coping style and psychological, physiological hemoeostasis||25|
|Chapter II. Literature Review||26|
|2.1. Breast Cancer||26|
|2.2. Emotional Suppression||27|
|2.2.1. Effects of Emotional Suppression||28|
|2.2.2. Psychological Impact of Emotional Suppression||29|
|2.2.3. Emotional Suppression and Breast Cancer||31|
|2.3. Psychological Adjustment||31|
|2.3.1. Psychological Adjustment and Chronic Illness |
2.3.2. Psychological Adjustment and Cancer
|2.3.3. Psychological Adjustment and of Breast Cancer||36|
|2.4. Emotion Suppression and Psychological Adjustment||39|
|2.5. Emotional Suppression, Psychological Adjustment in Breast Cancer||39|
|2.6. Indigenous researches||42|
|2.6.1. Religious coping, mood and psychological adjustment in |
|2.6.2. Life satisfaction and quality of life in breast cancer patients||43|
|2.6.3. Psychological Wellbeing in Breast Cancer Patients and Caregivers||44|
|Chapter III. Method||48|
|3.1. Research Design||48|
|3.2.1. Inclusion criteria/ Exclusion Criteria||48|
|3.3. Operational definitions||52|
|3.3.1. Emotional Suppression||52|
|3.3.2. Psychological Adjustment||53|
|3.4. Assessment Measures||53|
|3.4.1. Demographic information form||53|
|3.4.2. Courtauld Emotional Control Scale (CECS)||53|
|3.4.3. Mini-Mental Adjustment to Cancer Scale (Mini-MAC)||54|
|3.5. Scale Translation||55|
|3.7. Ethical considerations||56|
|Chapter IV. Results||57|
|4.1 Descriptive Statistics of study variables||57|
|4.2 Relationship between emotional suppression and psychological adjustment||58|
|4.3 Prediction of Psychological Adjustment by Emotional Suppression||60|
|4.4. Difference in Psychological Adjustment due to Family System||61|
|4.5. Summary of the Findings||62|
|Chapter V. Discussion||64|
|5.1. Correlation between Emotional Suppression and Psychological |
|5.2. Relationship between Psychological Adjustment and Domains of |
|5.3. Relationship of Subscales of Emotional Suppression and |
|5.4. Prediction of Psychological Adjustment Domains by Emotional |
|Implications of Research Findings||70|
|Limitations for Future Research||70|
|Suggestions for Future Research||71|
List of Tables
|Table No.||Title||Page No.|
|3.1||Descriptive statistics of demographic variables||49|
|4.1||Descriptive statistics of study variables||57|
|4.2||Correlation among the subscales of emotional suppression and psychological adjustment||59|
|4.3||Prediction of psychological adjustment due to emotional suppression||61|
|4.4||Independent sample t test comparing study variables in nuclear and joint family system||62|
List of Appendices
|Appendix A||Permission letters from authors to use the scale||90|
|Appendix B||Permission Letters from authorities of hospitals||91|
|Appendix C||Consent form||92|
|Appendix D||Demographic form||93|
|Appendix E||Assessment measures||94|
LIST OF ABBREVIATIONS & SYMBOLS
|APA||American Psychiatric Association|
|DSM-IV-TR||Diagnostic and statistical Manual of Mental Disorder –Fourth Edition-Text Revised|
|GMC||General Medical Conditions|
|ICD-10||International Classification of Diseases-Tenth Edition)|
|R2||Multiple Regression Correlation Square|
|R||Multiple Regression Correlation Change|
|DCPR||Diagnostic Criteria for Psychosomatic Research|
|MAC||Mental Adjustment to Cancer Scale|
|Mini-MAC||Mini- Mental Adjustment to Cancer Scale|
|BMI||Body Mass Index|
|PANAS||Positive and Negative Affect Scales|
|DASS||Depression Anxiety Stress Scales|
|BDI-II||Beck Depression Inventory-II|
|ACS||Affective Control Scale|
|ERM||Emotion Rating Measure|
|ERS||Emotion Regulation Scale|
|LOH||Locus of Hope Scale|
|HADS||Hospital Anxiety and Depression Scale|
|UW-QOL||University of Washington Quality of Life Questionnaire|
|EORTC QLQ-C30||The European Organization for Research and Treatment of Cancer Questionnaire|
|MAC-Q||Mental Adjustment to Cancer Questionnaire|
|QoL||Quality of Life|
|PTSD||Post-Traumatic Stress Disorder|
|CECS||Courtauld Emotional Control Scale|
|POMS||Profile of Mood States|
|INMOL||Institute of Nuclear Medicine & Oncology, Lahore|
|FACT-B||Functional Assessment of Cancer Therapy-Breast Cancer|
The present study examined the relationship between emotional suppression and psychological adjustment in breast cancer patients. It was hypothesized that there is a relationship between emotional suppression and psychological adjustment in breast cancer patients. Moreover, emotional suppression and its domains are likely to predict psychological adjustment and its domains. Within group research design and purposive sampling technique was used to collect a sample of 100 breast cancer patients with age 25 years and above (M= 45.76 and S.D= 10.50) from governmental and private hospitals. Courtald Emotional Control Scale (CECS, Watson & Greer, 1983) and Mini-Mental Adjustment to Cancer Scale (Mini-MAC, Watson et al., 1994) were used to assess emotional Suppression and psychological adjustment respectively. Pearson product moment correlation and hierarchal regression were used for data analysis. Results showed that emotional suppression was significantly related to psychological adjustment. Anger, depression and anxiety were significantly correlated to hopelessness/helplessness and depression was significantly positively correlated to anxious preoccupation and fatalism. Moreover, anger negatively predicted fighting spirit and fatalism while depression positively predicted anxious preoccupation and fatalism. The study has important implications in psycho-oncology, counseling and health care of breast cancer patients. Future research suggestions are also discussed.
Keywords: Emotional suppression, anger, depression, anxiety, psychological adjustment, fighting spirit, cognitive avoidance, fatalism.
Man has some instincts which make him a special and indeed the most active member of society. These God-gifted traits create an influential impact on the life people spend. One such attribute is emotions which are natural impulses and need to be managed and regulated in the best possible way. If these emotions do not find a proper outflow people would not be able to fiddle with the environment on cognitive, behavioral, poignant and psychological level (Sheppes & Gross, 2011).
Managing emotions is an important concern. It has been an important area under consideration not only in social sciences but it has also remained the main focus of literature. Shakespeare’s Hamlet notably pondered that besieged by the assassination of his father, whether he should handle his feelings and emotions by engaging in the slings and arrows of outrageous fortune or by disengaging from his sea of troubles through sleep or fatality. It shows that the varying emotional situations of even quotidian trials and troubles necessitate people to opt which emotion-regulation approach to use. Hamlet understood instinctively what researchers now make out empirically i.e. people can adjust their feelings and emotions in various ways to ensemble their desires in a particular situation (Gross, 2007; Koole, 2009).
One crucial finding in the field of emotion regulation is that emotion-regulation strategies can have very different outcomes in different contexts (Cheng, 2001). Accordingly, several recent theoretical accounts have emphasized the importance of flexible choice among emotion-regulation strategies in the face of different situational demands (Cheang & Cooper, 1985; Gross, 2007; Kashdan & Rottenberg, 2010).
The study aims to discuss emotional suppression and psychological adjustment in breast cancer patients. It discusses the concepts of psycho oncology. The study describes emotions, emotional regulation and emotional suppression, repression and suppression, consequences of emotional suppression, effect of emotional suppression on physical and mental health. It also discusses the perspectives given to explain psychological adjustment, factors influencing psychological adjustment, psychological adjustment and chronic illness like cancer and specifically breast cancer. The effect of emotional suppression on psychological adjustment in breast cancer patients is the focus of the study.
1.1. Breast Cancer
Cancer is the anomalous and abnormal growth of cells. Cancer arises from an organ or body structure and consists of tiny cells that have lost the ability to impede their growth. It is known as a mass, growth, tumor, nodule, spot, lesion, lump or malignancy. In general the cancer must reach the size of 1 centimeter or may compose of one million cells before getting detected. It is a chronic disease. Cells become cancerous because of environmental factors (e.g. cigarette smoking or radiation exposure) or due to genetic predisposition called dump luck, which accounts for the majority of the cancers. Yet, other reasons are unknown. Cancer is a disease that has been feared beyond all others for centuries, in large part because neither its cause nor cure was known, indeed, it is a general belief that cancer equals death (Williams, Chambless, & Ahrens, 1997)
Breast cancer is type of solid tumors. Solid tumors are the ones not present in large numbers in body fluids. Breast cancer is an extremely complex disease, characterized by a progressive multistep process caused by interactions of both environmental and genetic factors. Psycho-oncology is the study of psychological factors and cancer. It carries important aspects of emotions, cognitions, mood and other processes in breast cancer patients (Bener, Ayoubi, Ali, Al-Kubaisi, & Al-Sulait, 2010).
- 1.1.1. Psycho-Oncology
Psycho-oncology, a small but emerging field of cancer, guides the psychological aspects of cancer, the training of staff in these areas, and provides expertise in psychological, social, and behavioral quality of life research. Collaboration with medical oncologists has been particularly fruitful because it has permitted identification of the most salient problems faced by patients and their doctors, as well as exploration of these questions in studies varying from response to the diagnosis, support through treatment, to palliative care and survivor-ship. Psycho-oncology, as a sub-specialty, addresses the two major psychological dimensions of cancer: the psychological responses of patients to cancer at all stages of the disease and that of their families and caretakers (onco-psychology); and the psychological, behavioral and social factors that may influence the disease process (psychosocial-oncology) (Dolbeault, Szporn, & Holland, 1999).
Three basic factors contribute to the psychological adaptation of a patient to cancer in context. The first factor is the disease itself: the site, type, and stage of the cancer, the available treatment, potential for rehabilitation, and the relationship to a supportive oncology team. The second factor that impacts adaptation is the person, himself or herself: the personality characteristics, coping skills, level of emotional maturity, and social surroundings (family, friends, community). The third contributing factor derives from the society and the culture in which the person lives: the society’s prevailing attitudes toward cancer (Davidson, 2000).
Cancer prevention and early detection depends largely on changing attitudes and behaviors that put people at greater risk. Oncologists better recognize psychological distress and psychiatric disorders such as anxiety, depression and delirium (in hospitalized patients) as frequent co morbid disorders. The development of valid assessment tools for the patients’ self-report has been important. Increasingly, outcome measures in controlled trials of new therapies include quality of life, and no longer look at survival alone (Eifert, & Heffner, 2003).
1.2. Emotional suppression
Emotions are a significant part of one’s personality. Emotions represent the wisdom of the ages (Lazarus, 1991). According to contemporary theories of emotion, emotions begin with an evaluation of internal or external cues that have particular relevance to an individual. When attended to and evaluated in certain ways, these emotion cues give rise to a coordinated set of response tendencies that involve experiential, behavioral, and physiological systems (Mauss, Levenson, McCarter, Wilhelm, & Gross, 2005).
Emotion suppression is the term used to define the unwillingness to experience negatively appraised feelings, corporal sensations, and thought (Hayes, Strosahl, & Wilson, 1999). It points out to the deliberate inhibition of behavioral cryptogram of emotion, while being emotionally roused (Gross and Levenson, 1993). Werman (2001) viewed the concept of suppression as the volitional abolition or diminution from consciousness, by any way, of disagreeable thoughts, feelings, or bodily ambiance.
Emotions must be necessarily regulated to maintain a proper emotional cycle. If remain unexpressed in hard times for a long period, they will lead to emotional suppression. Emotional suppression is a form of emotion regulation. The counterproductive effects of suppression have been documented across a variety of emotions including amusement, sadness, and disgust (Gross, 1998; Gross & Levenson, 1997).
Using habitual suppression was articulated as a type of response modulation which entails obstructing ongoing emotion-expressive behavior (Gross & John, 2003). Gross (2002) deduces that using emotional suppression in everyday life might really be related with greater negative emotion experience. When these characteristics are conceded, habitual suppression is considered under the title of anxious defensiveness.
Individuals possessing high levels of emotional suppression usually depend upon suppression, avoidance, and other control strategies to manage emotional experiences. It has recently been considered in juxtaposition with the concept of experiential avoidance (Stanton, Danoff-Burg, Cameron, Bishop, Collins, Kirk, Sworowski & Twillman , 2000). It has been found that experiential avoidance correlates with self-reported levels of anxiety and depression and considered to a noteworthy facet of emotional disorder (Hayes et al., 2004).
1.2.1. Emotion regulation
Emotional suppression is taken as a component of emotion regulation. Emotion regulation is defined as heterogeneous set of processes, which involve changes in the experiential, behavioral, and physiological response systems that comprise emotion (Gross, 1999). It also refers to methods by which one persuades which emotion one has, when he has them, and how he experiences and conveys those emotions (Gross, 1998). As emotions are multi-componential procedures that disclose over time, emotion regulation entails modifications in emotion dynamics or the latency, extent, rise time, degree, time period, and counterbalance of reaction in behavioral, pragmatic, or physiological spheres. Emotion regulation includes changes in how response mechanisms are interconnected as the emotions unfurl, such as increase in physiological reaction in the lack of explicit behavior (Thompson, 1991).
Emotion regulation processes are usually divided into two extensive categories, antecedent-focused and response-focused. As denoted by the names, antecedent-focused strategies involve attempts to modify the production of emotion before the emotion is generated. Thus, antecedent-focused strategies refer to things people do before the emotion response propensity have become fully triggered and have altered their behavior and peripheral physical responding. An example is a person taking a job interview as a chance to find out more about the company, instead of an acceptance-rejection test (Gross, 1998).
Opposite to the above strategy, response-focused strategy involves the attempts to alter emotional responding after it has been initiated. Thus, response-focused strategies involve things people do once an emotion is already in progress, after the response propensity has been produced. An example of response-focused regulation is keeping one’s anxiety from disclosing as one leaves a child at kindergarten for the first time. It takes the form of response modulation which refers to attempts to persuade emotion reaction tendencies once they have been already elicit. The widely spread response-focused strategy used is emotional suppression (Gross, 1998).
1.2.2. Suppression and repression
Suppression and repression are concepts usually taken as confusing ones. Although both are used as defense mechanisms however there is major dissimilarity between them. Emotional suppression includes conscious effort of inhibition of emotional expressive behavior while repression deals with an unconscious attempt of inhibiting expressive behavior (American Psychiatric Association, 1994).
Inhibition of emotional experiences is not assumed, as is the case in the definition of repression. Freud suggests that repression lays more stress than suppression upon the fact of attachment to the unconscious. At first, Freud treated all these inhibitions or distortions of reality as repression but by 1926, he felt compelled to simplify for fear of losing his original simple concept of repression (inhibition, suppression, etc.). And so he made a distinction between repression in the narrow (original) sense and repression in the widest sense (Campbell-Sills, Barlow, Brown & Hofmann, 2006). The oldest prototype was from the work of Ebbinghaus, who showed that intentional avoidance of memories results in their progressive forgetting over time (Erdelyi, 2006).
Suppressing emotions results into rebound effect. Rebound effect means that if one often struggles to push away and suppress thoughts and feelings, one will be making himself more troublesome. As a matter of fact, rebound effect itself creates a ferocious cycle in a way that when one has a painful emotion; he tries to thrust it away. It will show the way to more painful emotions which he again tries to push away and it continues this way thus producing no fruitful consequences (Gross, 2001).
1.2.3. Consequences of emotional suppression
Emotions are natural processes which need to be regulated. When suppressed, they may result into some consequences. On the basis of process model of emotions attempts to down-regulate sentiments through suppression alters the path of the whole emotional response, leading to lesser empirical, behavioral, and physiological responses (Gross, 2001). There are several consequences of emotional suppression which are listed below.
- 22.214.171.124. Affective Consequences. Emotional suppression lessens expressive behavior, but it does not decrease the experience one faced emotionally. It also increase the physiological responses due to the effort linked with inhibiting ongoing emotion-expressive behavior. Emotional suppression has different impacts on different types of emotional experiences (Lazarus & Opton, 1966). Suppressing negative emotion-expressive behavior has no perceptible impact on experience of negative emotion like disgust, sadness, and embarrassment. Contrary to this, inhibiting positive emotion-expressive behavior creates an impact on positive emotion experience, e.g., amusement (Gross, 2002).
- 126.96.36.199. Social Consequences. Expressing emotions does not only facilitate in personal life but it also has positive social consequences while suppressing feelings plays the opposite role. Since long, experts are agreeing upon the importance of expressing behaviors (Lazarus & Alfert, 1964) Theorists since Darwin’s era (1872-1998) have continued the notion that emotion expressive behavior plays an imperative role in aiding social relations and interactions. There is a greater significance of emotion-expressive behavior for social interaction and social functioning (Gross, 2002).
Emotional suppression appears as a direct instrument i.e. it decreases both positive and negative emotion-expressive behavior and in doing so it masks essential social signals that would otherwise be available to social interaction partners. While suppressing the emotions and expressions, individuals become conscious of them (Reiss, 1991). Monitoring one’s own facial expressions and vocal signals distracts the suppressing individual and make them less receptive to the emotional prompts of their partner and society. In the social domain, suppression comes into view having less advantageous and pleasing consequences (Brown, Nardo, Lehman, & Campbell, 2001).
Suppressing emotions leads individuals to share less of their positive and negative emotions, resulting in weakened social support, and even being less liked. So, suppression has negative social consequences in social conversation. This idea was supported by recent social functional analysis of emotions (Campos, Mumme, Kermoian, & Campos, 1994). Emotional suppression can also have positive affect depending upon the context and situation. Sometimes it is not advisable to express emotions as it is not the only way to down-regulate emotions in social context. Social gatherings sometimes demands individuals to streamline their emotions by controlling them (Davidson, Pizzagalli, Nitschke, & Putnam, 2002)
- 188.8.131.52. Cognitive Consequences.Emotions have a direct role in cognitive functioning and suppressing emotions will have cognitive consequences. Richards and Gross (2000) said that in many of the emotion-eliciting situations, an elevated level of cognitive performance is enviable. Emotions need to be synchronized in all situations as they affect an individual’s ability to perform well cognitively. Suppression is a form of emotion regulation that requires self-monitoring and self-corrective action throughout an emotional event. Such monitoring requires a continual expenditure of cognitive resources, dropping the resources available for processing events so that they can later be remembered. Therefore, this strategy usually requires continual self-regulatory effort during an emotional event. This would make costly self-regulation necessary, thus affecting memory (Bonanno, Keltner, Holen, & Horowitz, 1995).
Suppressing emotions affect memory but not all types of memories get affected by it. Moreover, the amount of emotions suppressed is not noteworthy. Suppression’s effect on verbal memory is as distinct for the low-emotion as for the high-emotion tasks, suggesting that it is the process of engaging in suppression that is cognitively precious, rather than the amount of emotion that is actually concealed (Richards & Gross, 2000). Where suppression alters verbal memory because individuals remain unable to pay attention to verbal tasks while suppressing their emotions, it is not true for nonverbal tasks too (Gross, 2002).
Emotional suppression had no reliable impact on nonverbal memory, signifying that the cognitive outlay of suppression are due to the verbal demands of self-instructions issued during the suppression (e.g., “I need to keep my face still”) (Taylor, 1953). On a verbal task, individuals scoring high in suppressing scales reported high worst memory than those who scored lower on suppression scales. Thus, suppression consumes cognitive resources, impairing memory (Cunningham, Dnarykowski, Wilson, McGrath, Sloan & Kenady, 1998).
1.2.4. Emotional suppression and Physical Health
Emotional suppression gives rise to increased sympathetic activation of the cardiovascular system that appears to be out of keeping with metabolic requirement. Each time emotion is suppressed, physiological responses are magnified, and thus there are acute physiological consequences of emotional suppression. Any one physiological response of increased intensity is unlikely to have deleterious consequences. But if such responses recur day after day after day, there might be adverse health consequences (Morrow & Nolen-Hoeksema, 1990).
Emotional suppression decreases all the behavioral response inclinations arising with a specific emotion in a given context. As heart rate usually follows body movement so it is also affected by suppression of emotions (Gross, 1998; Gross & Levenson, 1997). Prefrontal cortex of central nervous system is associated with suppression. Suppression also increases electro dermal response and blood pressure, and decreases finger temperature finger pulse amplitude, and pulse travel times. These latter changes can be expressed as increased sympathetic activation of the cardiovascular system (Davidson, 2003).
1.2.5. Emotional Suppression and Psychological Problems
Emotional suppression is a significant and necessary process of our lives. Emotions need an outlet to keep a harmonizing effect. If emotions are not regulated well, they lead to vital physical as well as psychological problems. According to Beck, most of the psychological problems are result of irrational and faulty thinking styles (Cole, 1986). When one gets struck in such problems, he may try to conceal it which gives way to suppression of emotions. Thus, this suppression leads to adverse negative consequences. Emotional suppression may result into different psychological problems like Borderline Personality Disorder (BPD), posttraumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD) because they struggle with so many painful thoughts and emotions. The negative emotions struck into one’s mind and create painful consequences (Cacioppo, 1994).
Emotion dysregulation is a prominent feature of many forms of psychopathology (American Psychiatric Association, 1994). Indeed, by one count, over half of the non-substance related Axis I clinical disorders and all of the Axis II personality disorders involve some form of emotion dysregulation (Gross & Levenson, 1993). However links between affective science and clinical science are still in their early stages. This means that there is considerable uncertainty about how emotions are disrupted in different forms of psychopathology, and what clues such disruptions might provide to the nature of the emotion regulatory deficits. One important direction for future research is thus to extend laboratory research on emotion and emotion regulation to clinical populations (American Psychiatric Association, 1994) Individuals with Major Depressive Disorder have decreased emotional reactivity while viewing negative and positive emotional films (Rottenberg, Kasch, Gross & Gotlib, 2002).
The solution to the problem of suppressing emotion is to learn new, healthier ways to regulate your emotions. If one keeps on regulating emotions, he/she is less likely to rely on suppressing emotions all the time (Kirschbaum, & Hellhammer, 1994). Distracting oneself from an emotion by engaging in another activity may be a more effective way to regulate your emotions. Emotional suppression has played an important role in the research on psychosocial factors related to cancer. It has been argued to be an important psychological factor predicting worse psychosocial adjustment in people with cancer and it may mediate health outcomes (Davidson, 2000).
1.2.6. Model of Emotional Suppression
There are several models which explain the phenomenon of emotional suppression but one model clearly describes the process from where concept of emotional suppression forecasts its shadow. According to Gross’s (1998) process model of emotion regulation, strategies that act early in the emotion-generative process should have a different profile of consequences than strategies that act later on. This review focuses on two commonly used strategies for down-regulating emotion. The first, reappraisal, comes early in the emotion-generative process. It consists of changing the way a situation is construed so as to decrease its emotional impact. The second, suppression, comes later in the emotion generative process. It consists of inhibiting the outward signs of inner feelings. Experimental and individual-difference studies find reappraisal is often more effective than suppression. Reappraisal decreases emotion experience and behavioral expression, and has no impact on memory. By contrast, suppression decreases behavioral expression, but fails to decrease emotion experience, and actually impairs memory.
1.3. Psychological Adjustment
Hatchett, Friend, Symister & Wadhwa (1997) defined adjustment the process by which an organism or individual entity enters into a relationship of harmony and equilibrium with its environment and the condition of attaining such a relationship.
Psychological adjustment was defined in terms of depression or more global mood disturbance which is affected by personality factors, life changes, and social support. Both locus of control and extraversion have been linked to psychological well-being however an internal locus of control has been consistently associated with psychological adaptation (Stalker, Johnson & Cimma, 1990). Psychological adjustment is an important concept in clinical research within psychological oncology, as it is a major aspect in the study of chronic illness (Hatchett et al., 1997).
The stages of adjustment can be individual or varied. When patients get the diagnosis of illness and its subsequent propositions, it may result into a numbing effect and they initially show little emotional reaction. When they start considering themselves in the real situation, a sense of hopelessness, despondency, gloom, mourning for self, loss of role and function prevails around them. Such people also experience feelings of anger of depression. Bereavement is a natural response to loss and it permits time for reaction and restoration of emotional stability (Feldner, Zvolensky, Eifert, & Spira, 2003).
When individuals start facing their situation pragmatically, examine the changes that situation demands and adjust to the linked losses, they gradually start seeking adaptation and alternations to attain their integration into a broader level. The final upshot of adjustment is acceptance of the situation and the changes associated with it as well as a rational evaluation and implementation of vigor. Adjustment doesn’t point to the passivity and meekness regarding implications of the situation; conversely it means that the person is ready to move ahead in attaining finest execution capacity and psychological adjustment refers to the cognitive, behavioral and emotional processes involved to achieve it (Fobair, Hoppe, Bloom, Cox, Varghese & Spiegel, 1986).
Research also supports the concept that psychological stress resulting from poor adjustment has a strong effect on poor performance and job dissatisfaction (Stalker, Johnson & Cimma, 1990). On the other hand, good adjustment in a diverse context can lead to good mental health and satisfaction with life, good relationships with local people, compatibility with jobs, and a positive attitude toward new characteristics of jobs. Appropriate emotional expression can reduce psychological stress and poor adaptation (Cohen & Wills, 1985). Research also suggests that emotional stability and informational support can help reduce uncertainty and psychological distress in a cross-cultural setting (Manne, Taylor, Dougherty & Kemeny, 1997).
1.3.1. Different perspectives of Psychological Adjustment
The concept of adjustment originates from the Darwinian notion of adaptation which posits that those species most fitted to adapt to the dangers of the physical world are most likely to survive (Frank-Stromberg, Wright, Segalla & Diekmann, 1984). Watson, Greer, Blake and Shrapnell (1984) have defined adjustment to cancer as the cognitive and behavioral responses the patient makes to the diagnosis of cancer. This neutral but featureless definition of the term fails to include other important aspects, including the social and spiritual dimensions of adaptation, responses to stressful events following diagnosis such as treatment and discharge, and any indication of what constitutes a healthy or successful adjustment (Feldman, 1974).
However, an earlier more encompassing and satisfactory definition suggests that adjustment consists of the psychological processes by means of which the individual manages or copes with various demands or pressures though again this fails to locate these processes within a social context (Lazarus, 1969). The diagnosis of cancer and its aftermath undoubtedly lead to major life changes in a significant proportion of people (Lewin, 1935).
According to another view-point, rather than viewing adjustment as the attainment of a normatively-derived emotional state, it would be clearer to reserve the term to describe the processes of adaptation that occur over time as the individual manages, learns from and accommodates the multitude of changes which have been precipitated by changed circumstances in their lives. This definition emphasizes a more psychosocial and developmental approach and suggests processes which are broader than merely ‘coping’ with the demands brought about by the change (Markus & Kitayama, 1991) The crisis of a life event can be an opportunity for positive personal growth as well as distress (Hatchett, Friend, Symister &Wadhwa, 1997).
1.3.2. Factors Affecting Psychological Adjustment
According to Rosenberg (1965) the amount of time individuals take for adjusting psychologically with their disease depends upon personality, reactions of family, relatives and significant others. Other factors determining it are life circumstances, available resources and the kinds of challenges confronted by different individuals. When not favored by these factors, some individuals never acquire psychological adjustment. (Fobair et al., 1986). Non-acceptance of disease and absence of adjustment may be due to serenity, greater reliance, lingering bereavement time period and continued anger and antagonism as well as participation in detrimental and self-harming activities (Rosenberg, 1965). As coping strategies are imperative part of human nature that shields people from stress, reduce anxiety and facilitate adjustment that’s why overuse or negative use of coping strategies can postpone or inhibit psychological adjustment (Spiegel, 1987).
Factors within the person and factors that are feature of the environment i.e. both extrinsic and extrinsic factors are considered in terms of how they assist psychological adjustment or, in negative aspect, how they create hardships. According to Janoff-Bulman (1985), self-blame is adaptive if it brings about feelings of control and adjustment and the perception that one can act in a way which avoids similar misfortune in the future.
1.3.3. Adjustment to Chronic Illness
The populations of industrialized societies contain larger proportions of aging individuals and as acute diseases are increasingly well controlled, the impact of chronic illness grows (Fobair et al., 1986). Although the search for social-psychological causal factors in chronic illness is underway, the study of adjustment processes lag (Devesa, Silverman & Young, 1987). Salient issues in adjustment to chronic illness have been identified. First, chronic illnesses and disability require management of many elements over long time periods. Not only must the condition itself be contained by medications and therapies, but the patient’s lifestyle must be modified so that it becomes a regimen. Second, within the limits and requirements of diet, exercise, rest, stress management and environmental control, the patient often finds that social roles require correlative modification. Being chronically ill means living on a leash socially and emotionally as well as physically (Boring, Squires & Tong, 1994).There is temptation to adopt dependency as a way of life although one’s capacities are often only reduced rather than eliminated, and such adoption of the traditional sick role would be medically illegitimate (Fobair et al., 1986).
Miller Feuer and Hankey (1993) have discussed two distinct role expectations for people who have medical conditions. The sick role is a behavior pattern expected of those whose condition is serious and unpredictable; the impaired role is expected from those whose health is diminished but whose prognosis does not appear to be serious. In the sick role the appropriate behaviors are dependency and striving to recover, whereas in the impaired role, normal behavior is expected within the limits of the condition. If an individual is directed toward an inappropriate role response by physician or family, then necessary care and daily activities may not be acquired easily. Psychological adjustment is difficult because chronic illnesses tend to progress slowly and produce minimal reinforcement for management efforts. Another issue affecting psychological adjustment to chronic illness is the social devaluation of persons with long term illness and disability (Devesa, Shaw & Blot, 19997).
Adjustment to illness equates with adjustment to stigmatization so that disabled individuals often must acquire skills in deviance disavowal. Unlike the social role for acute illness, the social expectations for chronically impaired persons do not provide an avenue for returning to social acceptance (Davidson & Foa, 1991). There is no status-improving ‘getting-well’ phase for the chronically ill, so they remain deviant. At a more subjective level the patient may come to accept a devaluation of himself /herself by internalizing the negative evaluations of others who equate impairment with diminished personal and social levels at the same time that physical changes are occurring (Spiegel, 1987).
Several models of long-term adjustment were proposed. The idea of processes emphasizes the significance of the patient’s interpretation of the condition of his/her rearrangement of personal values. The process concept supports the contentions that long-term disabling conditions require acceptance of loss and substantial modification in self-concept. Spiegel (1987) stated that rehabilitation cannot begin in earnest until the patient accepts values which support medical intervention. The tendency for rehabilitation programs to overlook the social-psychological processes in favor of daily functioning skills oversimplifies the adjustment task for the patient is working within a web of physical, psychological and social constraints which may not dissolve under sheer motivation.
1.3.4. Psychological Adjustment and Cancer
It is generally accepted that the diagnose cancer and its treatment have a lot of psychological and social consequences, e.g. negative emotions, social isolation, psycho-sexual problems, loss of autonomy and control. These psychological problems may be temporarily or endure several years. Cancer as a life threatening disease often implies an existential crisis with long life consequences. An important question in the psycho-oncology is whether variations in the psychological adjustment are related to the progression of cancer. Another approach in studying the relationship between psychological adjustment and physical survival concerns the effects of participation in psycho-social support and counseling to cancer patients (Spiegel, 1987).
The area of psychological factors affecting cancer has been the object of research starting from the early 1950s and consolidating from the 1970s with the development of psycho oncology. A series of problems in the DSM-IV-TR and ICD systems, such as the difficult application of the criteria for psychiatric diagnoses (i.e. major depression, adjustment disorders) and the scarce space dedicated to the rubric of psychosocial implications of medical illness (i.e. Psychological Factors Affecting a Medical Condition under ‘Other Conditions That May Be a Focus of Clinical Attention in the DSM-IV represent a major challenge in psycho-oncology. The application of the Diagnostic Criteria for Psychosomatic Research (DCPR) has been shown to be useful in a more precise identification of several psychological domains in patients with cancer. The Diagnostic Criteria for Psychosomatic Research (DCPR) dimensions of health anxiety, demoralization and alexithymia have been shown to be quite frequent in cancer patient (37.7, 28.8 and 26%, respectively). The specific quality of the Diagnostic Criteria for Psychosomatic Research (DCPR) in characterizing psychosocial aspects secondary to cancer is also confirmed by the fact that some dimensions of coping (e.g. Mini-Mental Adjustment to Cancer sub-scale hopelessness) correlate with the Diagnostic Criteria for Psychosomatic Research (DCPR) dimension of demoralization. Psycho-social factors are significant in oncology (e.g. emotional repression and avoidance) (Taylor, 1983).
Consultation-liaison psychiatry and psycho-oncology studies reveal that a bulk of data showed that of 40-50% of cancer patients, in any phase of illness, can be diagnosed as having a psychiatric diagnosis according to DSM-iv or ICD-10 criteria, such as adjustment disorders, major depression and post-traumatic stress disorder. The largest area of emotional reactions, including distress, anger, denial and other psychological dimensions is extremely important in psycho oncology (Taylor, 1983).
Psychological adjustment is commonly used term in cancer and health psychology to indicate the dearth of psychological morbidity, and a return to normal functioning. People having Cancer have high incidence of psychological distress that’s why psycho-social adjustment is an important concept in oncology. In dealing with chronic illness and breast cancer, psychological and psycho social adjustment holds a standing position. Instead of claiming it as the absence of psychopathology or the end-point of coping with the comprehensive threat of cancer, adjustment refers to the psychological processes that occur over time as the individual, and those in their social world, manage, learn from and adapt to the massive amount of changes which have been precipitated by the illness and its treatment (Hatchett et al., 1997).
The term psychological adjustment suggests the completion of change from one state to another, yet research has often focused on adjustment as if it were merely the end-point of coping with the global threat of cancer, rather than the processes of cognitive and emotional change occurring within the individual. Poor adjustment is sometimes used to denote psychological morbidity, but without reference to its cause (Barbara & Tracey, 1984). The patient’s medical condition, especially the presence or absence of unpleasant symptoms like pain and the side effects of treatment, such as fatigue, nausea and vomiting as well as more advanced illness are highly associated with poor psychological functioning but it is questionable whether morbidity caused in this way should be equated with poor adjustment. Psychological adjustment varies when it is specified to cancer experience. One can get adjusted better or worse after chronic diseases. Positive meaning can be extracted from cancer experience (Taylor & Brown, 1988).
Among married women with cancer, partner support is viewed as the most crucial source of support which predicts lower level of depression anxiety making quality of life better. Two major types of support include emotional support e.g. listening empathetically, comforting while upset) and practical support e.g. helping him in performing chores, making his visits to hospital possible and easy. Both these supports are beneficial but emotional support is more valuable and worthy than the other one (Taylor, 1983). As a matter of fact, psychological support is consistently related to good psychological adjustment in cancer patients (Taylor & Brown, 1988) and predicts survival among breast cancer women (Taylor, 1983).
1.3.5. Theories of Psychological Adjustment
Psychological adjustment has been conceptualized in a number of ways.
184.108.40.206. Coping theory. Coping theorists have focused largely on the behavioral strategies that people employ both to negotiate the demands posed by the life event and to mitigate the negative emotions generated by the change or threat (Bell & Lee, 2003). According to coping theory (Lazarus and Folkman, 1984), coping is the process of managing internal and external demands which are appraised as taxing or exceeding the resources of the individual. It is an interaction between the individual and the environment in which each affects the other.
Coping research in cancer has largely examined relationships between coping responses and psychological outcomes (Gilbert, 1998). Lazarus (1993) has pointed out that, because of the diverse threats that people with cancer may be dealing with at any moment, research on the coping process must specify ‘the particular threats of immediate concern to the patient and to treat them separately rather than broadening the focus of attention to the overall illness’. He has also made a distinction between research focusing on a person’s coping style (a general propensity to deal with stress in a particular way) and that focusing on the utility of particular coping responses. Both approaches are evident in the psycho-oncology literature. The diagnosis, treatment and aftermath of cancer involves a long process of adaptation to multiple threats and novel experiences. How an individual characteristically appraises and responds to these threats and experiences is known as their coping style. The implicit assumption of the coping style approach is that coping will reflect a relatively enduring attitudinal: behavioural style, similar to a personality trait.
Watson has used the term mental adjustment to denote the coping style of individuals in the face of a diagnosis of cancer (Watson et al., 1988). Watson et al. (1988) developed the Mental Adjustment to Cancer (MAC) scale which identifies five behavioral styles of coping: denial: avoidance, fighting spirit, fatalism, helplessness: hopelessness, and anxious preoccupation.
The coping style approach is limited by the concept of coping leading to consistent behavioral responses by the individual, rather than as a situation-specific variable which may change over time in the light of different stresses. In cancer, the appraisal of threat is likely to vary according to the stage of the disease and its treatment. For example, anxious preoccupation may not characterize an individual while undergoing their treatment, though it may be a significant feature of their behavior prior to a subsequent hospital follow-up appointment (Schlatter & Cameron, 2010).
Parle, Jones & Maguire (1996) suggested that ‘adaptive coppers hold outcome expectancies and self-efficacy beliefs that are likely to facilitate their performance of coping responses’. If one regards a ‘full and enthusiastic return to the normal activities of life’ as being the hallmark of successful adaptation then coping theory and research has consistently demonstrated much of what is required of the individual and their careers. It strongly indicates that promoting increased self-efficacy through enabling people with cancer to take control of, and participate in their lives again, is likely to restore their confidence and self-esteem. Indeed, part of the popularity of complementary therapies may be due to their tendency to be patient-centered and stress the individual’s ability to act positively, while also addressing questions of meaning, purpose and direction in life (Gilbert, 1998).
220.127.116.11. Theory of cognitive adaptation. According to theory of cognitive adaptation to threatening events, it is argued that the adjustment process centers around 3 themes: A search for meaning in the experience, an attempt to regain mastery over the event in particular and over life more generally, and an effort to restore self-esteem through self-enhancing evaluations. These themes are discussed with reference to cancer patients’ coping efforts. It is maintained that successful adjustment depends, in a large part, on the ability to sustain and modify illusions that buffer not only against present threats but also against possible future setbacks (Taylor & Brown, 1988).
1.4. Emotional Suppression, Psychological Adjustment and Cancer
There are several factors which confirm the effects of psychological factors on cancer progression. Relevant factors include social support and non-expression of negative emotions. Conflicting or negative results concern studies on the influence of bereavement, helplessness, active coping and personality (Spiegel, 1997). Emotional suppression (the attempt to control expression of negative affect) has played an important role in psychosocial research on cancer patients. In fact, this construct has been increasingly considered as an important psychological variable that affects the psychosocial adjustment in people with cancer and it might mediate health outcomes (Horgan, Holcombe & Salmon, 2010). Emotional suppression is also outlined as an important variable in those studies dealing with the patient’s psychological adjustment when diagnosed and undergoing cancer treatment. Reynaud, Malhame, Blin, Khalfa (2012) reported that breast cancer patients with anxiety and total emotional suppression experienced more psychological distress than did patients with anxiety and total emotional expression after a breast cancer diagnosis. In addition, breast cancer patients with emotional suppression reportedly experienced more psychological distress than did those with emotional expression post-diagnosis and after surgery up to three months after discharge.
Although both the variables have a significant relationship as indicated by the current research, yet the type of affect both create on each other varies. It was found that expressing one’s emotions and acknowledging traumatic events had positive effects on physical and mental health. Patients who are diagnosed with a life-threatening illness (such as cancer) obviously undergo emotional distress. However, the extent of feelings of emotional distress varies in different patients. There are, however, interpersonal differences in the extent to which breast cancer patients are vulnerable to psychological distress (Iwamitsu, Shimoda, Abe, Tani, Okawa, 2001).
Some studies involved psychological interventions declaring that the facilitation of emotional expression is one intervention component. It provides evidence that these interventions can enhance psychological adjustment (Coan & Allen, 2002). Breast cancer patients with emotional expression exhibited higher levels of psychological adjustment and expressed more negative emotions than patients with emotional expression after receiving the diagnosis. Emotional expression can facilitate reduction of stress in three interrelated key mechanisms, expression can reduce distress about distress; expression can facilitate insight; and expression can affect interpersonal relationships in a desired way (Greer & Morris, 1975).
Identifying and attending to psychological distress in response to cancer is a worthwhile consideration. It is important not only for maintaining quality of life but also because psychological distress may itself be related to prospects for long term survival. During the first year following diagnosis, women show considerable psychological distress including shock including shock, emotional numbness, depression and anxiety. Many studies have found that younger women show more distress than older women. Research shows that cancer survivors may show cortisol and alterations in their HPA axis responses to cancer treatment; this may be due to fear of recurrence, stress associated with cancer or a combination (Somerfield, Stefanek, Smith & Padberg, 1999).
- 1.4.1. Bio-psycho social model
The model considers the kinds of biological mechanisms which link emotional suppression with cancer onset and progression. The model of cancer is a multi-stage one, in which the presence of a cell with unusual DNA, the oncogene is the first step. Researchers in psychosocial oncology suggest that homeostatic controls may influence the onset and development of cancer and the psychological factors may play some role in the homeostatic system (Greer & Watson, 1985). According to biopsychosocial approach, the consequences of cancer diagnosis and treatment are extremely significant. At the physical level, cancer can cause significant changes in the body and consequently the image the individual has of his body. The type of cancer which is visible like breast cancer or less visible cancer like leukemia, its stage, biological characteristics and treatment (e.g. physical mutilations, stomas, pain, nausea, vomiting and fatigue) are determining the emotional responses of patients, thus giving them a challenging situation. Functional activities, feeling of dependency from others, sexuality are examples of biological concomitants of cancer. From the psychological view-point, the loss of certainties, instability of one’s own emotional state (e.g. worries, anxiety, sadness, and fear), change of perspective in the future and threat of possible death are amongst some of the numerous experiences cancer patients have to deal with during path of life. Possible feelings of loneliness, abandonment, anomia, marginalization and stigmatization are the problems cancer patients deal with during trajectory of illness (as stated in Taylor & Brown, 1988).
4.2. Process Model of Coping Style and Psychological-Physiological Homeostasis
The model proposed by Temoshok is used to understand why Type C is associated with cancer outcome measures, and why the helplessness/hopelessness or emotional expression is related to outcome. According to Temoshok’s model, a personality style known as type C develops over time as means of coping and adjustment. Such style is characterized as cooperative and appeasing, unassertive, patient, unexpressive of negative emotions (particularly anger) and compliant with external authorities. This style appears adaptive initially as adaptive but later due to it psychological and biological needs are not satisfied. A person facing this situation is said to be chronically and unconsciously helpless or hopeless because he or she feels that his or her needs are not satisfied. When stresses mount up, including the extreme stressor of developing cancer, the individual’s type C coping style may either break down, revealing the previously hidden helplessness and hopelessness as depression, or it is replaced by a more satisfactory coping style as the individual learns to express his or her needs. It may also continue increasing strained by the demands placed on it by the accumulating stresses (Temoshok, 1987).
Cancer is one of the most prevalent disease specifically breast cancer is the most common type of cancer in women of Pakistan. Many researches have been conducted to find out the causal factors, reasons and prevalence of cancer (Felton, Revenson, & Hinrichsen, 1984; Schlatter & Cameron, 2010).but little is known about the psychological impact of breast cancer in Pakistani population. The present study was conducted to explore the psychological factors related to this disease. Work has been done on patients of breast cancer to explore the role of emotions, emotional suppression and psychological aspects and domains.
2.1. Breast Cancer
In one survey of 200 cancer survivors, 30% had changed jobs and 23% had changed their living arrangements in the 2 years since their treatment (Eysenck, 1994). A research was conducted on 167 Qatari and other Arab expatriates women with breast cancer, with the aim of this study to examine the possible effect of consanguinity on the risk of breast cancer in a population with a high rate of consanguinity and find the associated risk-modifying factors. It was concluded that the lack of association between of breast cancer and the parental consanguinity in Arab women residing in Qatar. The family history of breast cancer and the body mass index (BMI) are highly associated with breast cancer (Jaber, Halpern, & Shohat, 1998).
A research was conducted in the field of Development of Diagnostic Criteria for Psychosomatic Research (DCPR). Sample consisted of 146 patients, who received a diagnosis of cancer within 18 months and a good performance status, which were evaluated by using DSM-IV-TR and DCPR. It was concluded that 44.5% subjects met the criteria for adjustment disorder and mood disorder. Interesting data was reported on examining the relation between DCPR and dimensions and coping styles as measured by mini-Mental Adjustment to Cancer Scale. The patients who were positive on health anxiety reported higher scores on mini-MAC anxious preoccupation subscale which indicated the presence of feelings of anxiety and tension concerning illness. Those meeting the demoralization had higher scores on mini-MAC hopelessness scale which reflects patient’s tendency to adopt a doomed to failure attitude towards his/her illness (Talley, Ellard, Jones, Tennant, & Piper, 1988).
2.2. Emotional Suppression
Emotional suppression has physiological effects as indicated in an experiment by Gross and Levenson (2003) in which 43 men and 42 women watched a short disgust-eliciting film while their behavioral, physiological, and subjective responses were recorded. It was concluded that suppression reduced expressive behavior and produced a mixed physiological state characterized by decreased somatic activity and decreased heart rate, along with increased blinking.
A study employed a prospective longitudinal design to test the real-life social consequences of suppression during the challenging transition to college. Suppression was assessed on two occasions: a pre-transition assessment during the summer while participants were still at home and an early transition assessment on campus right at the beginning of the fall term. This enabled to distinguish between two components of suppression: stable individual differences and dynamic changes across the transition to college. Data was collected from 278 students who had twice completed a measure of suppression. Suppression was measured using the suppression scale. To control for baseline levels of support, 12-item Interpersonal Support Evaluation List was used. Results indicated that both components of suppression predicted lower social support, less closeness to others, and lower social satisfaction. These findings were robustly corroborated across weekly experience reports, self-report, and peer reports and were consistent with a theoretical framework that defines emotion regulation as a dynamic process shaped by both stable person factors and environmental demands (Wong, 2003).
Myers, Vetere and Derakshan (2004) tested the idea that thought suppression creates a bond between the suppressed item and one’s mood state, such that the reactivation of one leads to the reinstatement of the other. In the first experiment, participants who were induced by music to experience positive or negative moods reported their thoughts while trying to think or not think about a white bear. When all participants were subsequently asked to think about a white bear, those who were in similar moods during thought suppression and a later expression period displayed a particularly strong rebound of the suppressed thought. In the second experiment, the investigators assessed participants’ moods following the expression of a previously suppressed or expressed thought. Mood reports showed that participants who had initially tried to suppress their thoughts experienced a reinstatement of the mood that existed during the initial period of suppression.
2.2.1. Effects of Emotional Suppression
A study compared the subjective and physiological effects of emotional suppression and acceptance in a sample of individuals with anxiety and mood disorders. Sixty participants diagnosed with anxiety and mood disorders were randomly assigned to one of two groups. One group listened to a rationale for suppressing emotions, and the other group listened to a rationale for accepting emotions. Participants then watched an emotion-provoking film and applied the instructions. Subjective distress, heart rate, skin conductance level, and respiratory sinus arrhythmia were measured before, during, and after the film. Positive and Negative Affect Scales: State Version (PANAS) and electroencephalogram (EEG) were used as measures. Although both groups reported similar levels of subjective distress during the film, the acceptance group displayed less negative affect during the post-film recovery period. In the above experiment, the suppression group showed increased heart rate and the acceptance group decreased heart rate in response to the film. There were no differences between the two groups in skin conductance or respiratory sinus arrhythmia (Mehlsen, Jensen, Christensen, Pedersen, Lassesen & Zachariae, 2009)
An experiment was conducted to note the paradoxical effects of emotional suppression. In a first experiment, subjects verbalizing the stream of consciousness for a 5-min period were asked to try not to think of a white bear, but to ring a bell in case they did. As indicated both by mentions and by bell rings, they were unable to suppress the thought as instructed. On being asked after this suppression task to think about the white bear for a 5-min period, these subjects showed significantly more tokens of thought about the bear than did subjects who were asked to think about a white bear from the outset. These observations suggest that attempted thought suppression has paradoxical effects as a self-control strategy, perhaps even producing the very obsession or preoccupation that it is directed against. A second experiment replicated these findings and showed that subjects given a specific thought to use as a distracter during suppression were less likely to exhibit later preoccupation with the thought to be suppressed (Wegner, Schneider, Carter & White, 1987).
2.2.2. Psychological Impact of Emotional Suppression
A study was conducted to examine the effects of emotional suppression and acceptance in a depressed sample. Sixty participants with diagnoses of unipolar depression completed a questionnaire packet and participated in an experiment. The experiment utilized two conditions to explore correlates of the spontaneous use of emotion regulation strategies and the effects of an experimental manipulation of acceptance and suppression. Self-report measures included initial questionnaire packet of Depression Anxiety Stress Scales (DASS-21), Beck Depression Inventory-II (BDI-II) and Affective Control Scale (ACS), Positive and Negative Affect Scales (PANAS), Emotion Rating Measure (ERM) and Emotion Regulation Scale (ERS). Results demonstrated that suppression produced short-term reductions in sadness. Notably, anxiety about the experience of depressed mood influenced the efficacy of emotional suppression with findings showing that suppression was no longer effective at moderate and higher levels of anxiety about the experience of depressed mood. Results suggest potential advantages for depressed individuals from the use of both emotional suppression and acceptance in the regulation of sadness (Mehlsen et al., 2009).
An experimental study aimed to investigate the causal effects of demands to suppress negative emotions, demands to express positive emotions, and their interaction in a simulated service interaction. In total, 101 participants were instructed to play the role of a service employee, who had to interact with a dissatisfied and uncivil customer. Participants were randomly given information that the organization expected them to (1) express genuinely felt emotions, (2) suppress negative emotions, (3) express positive emotions, or (4) suppress negative emotions and express positive emotions. Results indicated that emotional suppression can have positive as well as negative impact on well-being and adjustment. It was also found that demands to express positive emotions have more desirable associations with service providers’ well-being and service quality than demands to suppress negative emotions. Moreover, service quality was only increased if demands to express positive emotions were not supplemented by demands to suppress negative emotions. According to the research findings, demands to express positive emotions can reduce the cost/benefit ratio of emotional labor so organizations should avoid imposing demands to suppress negative emotions (Hopp, Rohrmann & Hodapp, 2012).
2.3. Emotional Suppression and Breast Cancer
In a research, thirty breast cancer patients and 27 healthy controls were compared for differences in personality, reported emotional state and autonomic responses occurring under conditions of acute experimental stress. The data indicated that breast cancer patients were more likely than a control group to report a tendency to control emotional reactions, particularly anger, and to respond to stress using a repressive coping style. Emotional state reported at different points throughout the procedure suggested that the breast cancer group experienced more anxiety and disturbance but were more inclined to inhibit their reaction. There were no differences between the groups on autonomic measures but within the breast cancer group increased electrodermal activity was significantly associated with a tendency to respond to stress using a repressive coping style. This research was carried out according to psychobiological models of cancer (Pettingale, Watson & Greer, 1984).
2.3. Psychological Adjustment
Frasure-Smith and Lespérance (2003) sought to assess the role of coping in the first few weeks after diagnosis for the later development of affective disorders. They prospectively studied 673 newly diagnosed cancer patients to assess the effects of their appraisals, coping responses and resolution of 14 specific concerns to do with their cancer (as measured using a semi-structured interview) on subsequent mental health (as measured by the Psychiatric Assessment Schedule). They found that neither the nature of the patients’ concerns, nor any specific coping response, predicted the development of an affective disorder. However, they did find that those who had high levels of generalized worry and multiple concerns were subsequently more likely to feel helpless and do nothing in response to these concerns.
Garnefski, Koopman, Kraaij, and Cate (2009) conducted a study of 59 early stage breast cancer patients. In the study, optimism was measured initially while coping and distress were assessed repeatedly, around the time of surgery and again up to 12 months post-surgery. The results indicated that optimism was inversely related to distress at each assessment point, but positively related to active coping efforts and acceptance of the reality of the disease. According to the research findings, optimism was supposed to be a personality trait which is associated with the use of certain coping behaviors and is likely to be highly related to fighting spirit (Frasure-Smith and Lespérance, 2003). This study reported denial correlated with higher distress, opposite to the early findings reported by Watson et al. (1984). The authors speculated that acceptance of the situation is important for adjusting to it especially when the situation, like cancer, has to be endured. This view is consistent with bereavement literature which indicates that denial is a temporary solution or defense which, if it persists, can lead to later maladaptive adjustment (Myers, Vetere, & Derakshan, 2004).
A research was conducted to analyze both the influence of social support and stressful life events on the psychological adjustment of intimate partner violence offenders and the relationship between offenders’ psychological adjustment and their victim-blaming attributions. The sample consists of 314 men convicted of intimate partner violence who were referred to a community-based intervention program. Results showed that social support and stressful life events were related to psychological adjustment. Psychological adjustment was also related to victim-blaming attributions among intimate partner violence offenders. A better understanding of the relationships between psychological adjustment of intimate partner violence offenders and its determinants, as well as its impact on victim blaming attributions, may provide support to new intervention strategies (Thomas, Moss-Morris, & Faquhar, 2006).
In a research conducted by Du and King (2012), it was examined how internal and external loci of hope could predict various indices of psychological adjustment. One hundred and ninety six Mainland Chinese university students participated in the study. There were 82 males 110 females and 4 students who failed to identify their gender. The average age was 20.54. To determine locus of hope, the 40-item Locus of Hope Scale (LOH) was used. Independent and interdependent self construal was measured using the 30-item Self-construal Scale while to measure psychological adjustment the 5-item Life Satisfaction Scale was included. Results revealed that all the loci of hope dimensions except for the external locus of hope-spirit were positively associated with the various indices of psychological adjustment (life satisfaction, personal self-esteem, and collective self-esteem).
A study was conducted to assess parent-child relationship, ethnic pride, and psychological adjustment of children who were inter-country adopted in a sample of 241 Korean-born adolescent adoptees. Parental support of ethnic background and positive parent-child relationship, and collective self-esteem and psychological adjustment were constructed as independent and dependent variables for the study. The findings show that a more positive parent-child relationship; in which the parents support their children’s ethnic identity development and share ethnic socialization experiences; predicted better psychological adjustment of the adopted children (Verma, & Khan, 2007).
2.3.1. Psychological Adjustment and Chronic Illness
Longitudinal data on the coping strategies used by 151, 41–89 years old middle-aged and older adults faced with 1 of 4 chronic illnesses were used to evaluate the role of coping in the explanation of psychological adjustment. During the research, illnesses that offer few opportunities for control (rheumatoid arthritis and cancer) and those more responsive to individual and medical efforts at control (hypertension and diabetes) was distinguished and the emotional consequences of 2 coping strategies were evaluated . Two types of coping strategies, information seeking and wish-fulfilling fantasy are expected to play different roles in adjustment. Results show that information seeking had salubrious effects on adjustment and that wish-fulfilling fantasy had deleterious consequences; contrary to expectation, neither strategy’s effects were modified by illness controllability. Analyses of the direction of causation between coping and adjustment suggest that wish-fulfilling fantasy is linked to poor adjustment in a mutually reinforcing causal cycle. (Felton & Revenson, 1984).
A study employs a longitudinal design to analyze the adjustment process of 103 people diagnosed with multiple sclerosis and in the middle and later stages of their illness careers. The mean age of the sample was 52 years, and mean duration since diagnosis was 17 years. A highly reliable self concept measure was used as the indicator of adjustment and changes in adjustment. Four sets of variables are analyzed in their relationship to adjustment: (I) socio-demographic; (2) disease-related; (3) medical; and (4) social-psychological. Females were more likely than males to show positive adjustment (improving self concepts). Hours of employment and living arrangement were also related to the adjustment process. The vast majority of respondents show only slight decline in mobility but among the disease related variables, number of episodes (exacerbations) in past seven years, which is the strongest predictor of changes in adjustment. Subjects with an internal locus of control have more positive adjustment scores. Those who say they cope through acceptance of the disease show improvements in self concept while those reporting religion or family as major coping strategies have decreasing self concepts. Results indicated that the majority make satisfactory adjustment as indicated by maintenance of positive self concepts over the 7 year period, although the disease was chronic and progressive (Brooks & Matson, 1982).
2.3.2. Psychological Adjustment and Cancer
A series of studies have shown that. Vermetten and Bremner (2002) conducted a research and noticed that psychological and social factors have a noteworthy role in negatively influencing patient’s adjustment, quality of life, their interpersonal relationships, behavioral dimensions like adherence to treatment, maladaptive coping and maintenance of at risk behavior and possibly prognosis and survival. The study showed that, among cancer patients, a series of attitudes and perceptions of health status subsumed under the concept of normal illness behavior, e.g. affective inhibition, disease conviction in spite of medical support, frictions in interpersonal relationships, are related to depressive states. Furthermore, maladaptive coping and adjustment styles, such as hopelessness/helplessness have been related to other psychosocial dimensions such as poor social support and personality variables. The dimensions of demoralization, as a clinical syndrome apart from the depression have been shown to be remarkably common and noteworthy in cancer settings.
A study investigated the psychological outcome and its relationship with functional status and coping mechanisms following treatment of oral cancer patients. Sixty-eight patients were evaluated 6 months to 6 years after treatment (from October 1992 to October 1997) for oral cancer. The Hospital Anxiety and Depression Scale (HADS) were used for psychological evaluation, the University of Washington Quality of Life Questionnaire (UW-QOL) and The European Organization for Research and Treatment of Cancer Questionnaire (EORTC QLQ-C30) for evaluating the head and neck specific and general functional status, respectively. Finally, the Mental Adjustment to Cancer Questionnaire (MAC-Q) was used for evaluation of coping mechanisms. The results indicated that the incidence of anxiety and/or depression was 25% and the socio-demographic and medical characteristics showed poor correlation with the psychological outcome in this study. The results indicated that there was a strong association between psychological outcome and head and neck specific and general quality-of-life (QOL) domains, and style of coping. It was concluded that deteriorated functional status and ineffective coping strategies were strongly associated with poor psychological outcome in patients with cancer (Hassanein, Musgrove, Bradbury, 2002).
A study described cancer patients’ characteristics and social support factors as predictors of the patients’ responses to having cancer. Patients’ responses to having cancer were measured using the Japanese version of the Mental Adjustment to Cancer (MAC) scale. The MAC scale is a self-rating scale developed in the United Kingdom (Watson et al, 1988). A total of 455 ambulatory cancer patients completed the Mental Adjustment to Cancer (MAC) scale and participated in a structured interview about their characteristics and social support. The results suggested that size of household, performance status, support from physicians and satisfaction with support were predictive of patients’ fighting spirit, whereas age, education, size of household, performance status and satisfaction with support were predictive of helplessness/ hopelessness (Akechil, Okamura, Yamawaki, & Uchitomi, 1998).
2.3.3. Psychological Adjustment and of Breast Cancer
A study was conducted to determine psychological and psychosocial aspects of breast cancer. The study involved the literature search during the period 1989-1992. The following research areas were studied: the relationship between psychological characteristics and breast cancer, and between psychosocial interventions and breast cancer; quality of life after breast cancer surgery and treatment; and the relationship between social support and breast cancer. The results showed that the medical community is divided into believers and nonbelievers with respect to whether or not psychosocial factors influence breast cancer outcomes. One of the best predictors of a woman’s post cancer adjustment is her psychological state before the breast cancer. The results also showed that the difference in psychological outcome between mastectomy and breast-con-serving surgery was small and non-significant. Another finding was that the social context and social support from partner, family, friends, relatives and medical professions are important for survival (Pettingale, Watson & Greer, 1984).
A study assessed long-term psychological effects in survivors of breast cancer. Thirty-nine long-term female survivors of breast cancer were compared with 39 matched women who had not been exposed to any chronic disease regarding post-traumatic stress disorder (PTSD), quality of life (QoL), emotional distress and coping styles. Survivors revealed significantly higher rates of full and partial Post Traumatic Stress Disorder (PTSD), participants also scored significantly higher on emotional distress, scored significantly lower on physical and psychological QoL and exhibited coping styles significantly different from those of the control group. PTSD was associated with the coping style of suppression. It was concluded that chemotherapy and disease stage, as well as the interaction between chemotherapy and disease stage, were significant predictors of hyper arousal. The findings show that post-traumatic symptoms are a common sequel after recovery from cancer (Amir & Ramati, 2002).
A significant proportion of breast cancer patients experiences psychiatric morbidity in the first year after a breast cancer diagnosis and/or beginning of treatment. A consecutive series of 87 patients, aged 40–75 years, were assessed prior to diagnosis of breast cancer and followed-up approximately 8 weeks after beginning of cancer treatment and again 9 months after first follow-up. Assessments included measures of psychiatric morbidity using the General Health Questionnaire (GHQ-12), coping style using the Mental Adjustment to Cancer (MAC) Scale, symptom attribution, beliefs about breast cancer, social support, socio-demographic and clinical variables. Results indicated that a total of 85.1% of patients completed assessments, especially in women who had thought they had cancer. It was concluded that psychiatric morbidity is higher prior to, than following, a definitive diagnosis of breast cancer. Early reactions of this kind are predictive of post-treatment adjustment. However, only the presence of social support seems to be associated with successful adjustment in the first year following a breast cancer diagnosis. Women at increased risk of psychological morbidity after a breast cancer diagnosis may be thus identifiable and targeted therapeutically (Nosarti, Roberts, Crayford, McKenzie & David, 2002).
A research recognizes that many individuals experience positive psychological changes following a diagnosis of cancer. Such positive change is related to well-being, and some psychological interventions have promoted such change in women with breast cancer. The research explored the grounded theory and explored the process whereby positive emotional changes arose in 20 women (mean age 53 years) diagnosed with breast cancer. Results indicated that most women experienced several positive changes as a result of their breast cancer. Analyses suggested that changed priorities in life and increased empathy for others emerged from the patients’ reflections upon the suffering they endured during their illness. By contrast, increased self-confidence appeared to emerge from reflecting on how they managed their illness, and from concluding that they had been courageous in doing so. Factors promoting reflections included acceptance of breast cancer, ending treatments, and communication from others that emphasized rather than minimized the personal significance of cancer (Horgan, Holcombe & Salmon, 2010).
2.4. Emotion Suppression and Psychological Adjustment
A research reports differences across 23 countries on 2 processes of emotion regulation––reappraisal and suppression. Cultural dimensions were correlated with country means on both and the relationship between them. Measures include Diener’s measure of subjective well-being, the World Values Survey happiness index (World Values Survey Group), Inglehart’s measure of subjective well-being, Bradburn’s Positive and Negative Affect Scale, Veenhoven’s measure of subjective appreciation of life, and Veenhoven’s World Database of Happiness. Cultures that emphasized the maintenance of social order––that is, those that were long-term oriented and valued embeddedness and hierarchy––tended to have higher scores on suppression, and reappraisal and suppression tended to be positively correlated. Affective autonomy and egalitarianism tended to have lower scores on suppression, and reappraisal. Moreover, country-level emotion regulation was significantly correlated with country-level indices of both positive and negative adjustment (Reynaud, El-Khoury-Malhame, Blin, & Khalfa, 2012).
2.5. Emotional Suppression, Psychological Adjustment in Breast Cancer
A study was conducted with the aim to determine whether psychological adjustment to advanced breast cancer was positively associated with expressing emotion and adopting a fighting spirit and negatively associated with denial and fatalism. The sample included 101 women with a diagnosis of metastatic or recurrent breast cancer. Fighting spirit and emotional expressiveness were found to be associated with better adjustment (Watson & Greer, 1983).
A research was conducted to determine whether psychological adjustment to advanced breast cancer was positively associated with expressing emotion and adopting a fighting spirit and negatively associated with denial and fatalism. Total mood disturbance on the Profile of Mood States was used as the measure of psychological adjustment. The Courtauld Emotional Control Scale measured emotional expression, and the Mental Adjustment to Cancer measured fighting spirit, denial, and fatalism. The sample included 101 women with a diagnosis of metastatic or recurrent breast cancer. Fighting spirit and emotional expressiveness were found to be associated with better adjustment. No association was found between mood disturbance and denial or fatalism. From the study, no conclusions regarding a causal relationship between adjustment and emotional expressiveness or adjustment and fighting spirit were obtained (Catherine, Cheryl, Karyn & David, 1996).
A study determines the interpersonal consequences of suppression. In the study, unacquainted pairs of participants were allowed to watch a documentary of the bombing of Hiroshima and Nagasaki together and then discuss their reactions. Sample consisted of 72 women. One partner was instructed (unbeknownst to the other) to suppress her emotional expressions during the discussion. Interacting with a partner who suppressed was more stressful than interacting with a partner who acted naturally, as indexed by increases in blood pressure. These findings suggest that by disrupting the give and take of emotional communication, suppression has the potential to undermine social functioning to a significant degree (Reynaud et al., 2012).
The psychological responses were examined in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which were lower. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data was interpreted in terms of a process model of psychological responses which suggested that emotional control (an important component of the Type C behavior pattern) fatalism, helplessness and psychological morbidity were linked. It was found that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis (Wong, 2003).
As the psychological impact of the breast cancer include adjustment disorders, depression, and anxiety and may generate feelings of fear, anger, guilt, and emotional repression so a study was conducted to explore the efficacy of a complementary creative arts therapy intervention to enhance emotional expression, spirituality, and psychological well-being in newly diagnosed breast cancer patients. Thirty-nine women with Stage I and Stage II breast cancer were randomly assigned to an experimental group who received individual creative arts therapy interventions or a control group of delayed treatment. Results indicated the intervention was not effective in enhancing the emotional approach coping style of emotional expression or level of spirituality of subjects in the sample. However, participation in the creative arts therapy intervention enhanced psychological well-being by decreasing negative emotional states and enhancing positive ones of experimental group subjects.
In a cross-sectional study, it was tested that whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account. A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS). Results were consistent with hypotheses indicating that lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance. It was concluded that expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups (Curtis, Groarke, Coughlan & Gsel, 2005).
2.6. Indigenous researches
Work has been done in Pakistan related to cancer and its types including breast cancer. Psychological aspects of cancer are also analyzed and reviewed in researches.
A research was conducted and descriptive statistics were analyzed and evaluated for the clinicopathologic profile of local breast cancer patients. Among 28,740 cancer patients, 6,718 were registered as breast cancer. The female to male ratio was 100:2. Breast cancer accounted for 23% of all and 41% of female cancers. Research findings showed the results that the mean age of females with breast cancer was 47±12 years and the age ranged from 18 to 90 years. The median age was 45 years and mode was 40 years. Peak age of incidence was 40-44 years followed by 45-49 years. (Khokher, Qureshi, Riaz, Akhtar, Saleem, 2002).
- 2.6.1. Religious coping, mood and psychological adjustment in cancer patients
A study was carried out to investigate the relationship between mood and resilience after onset of cancer. The sample consisted of 50 patients taken from Institute of Nuclear Medicine & Oncology, Lahore (INMOL). State-Trait Resilience Scale and Positive Affect Negative Affect Scale were used for the assessment. Findings revealed that that there was a relationship between positive mood and high resilience (Jabeen, 2009).
A research was conducted to examine posttraumatic growth and religious tendency after cancer onset. The data was collected from 40 patients taken from Institute of Nuclear and Medical Oncology, Lahore (INMOL). A self-prepared questionnaire and Posttraumatic growth inventory was used. It was found that there were more changes related to people than related to rituals and God in cancer patients (Sherman, Simonton, Latif, Spohn & Tricot, 2005). Majority of the people become religious and develop posttraumatic growth after the diagnosis of cancer. A large number of cancer patients show positive changes, spiritual changes and appreciation of life than others. It was also found that if cancer patients are more religious after onset of disease than there is posttraumatic growth in them (Rasool, 2008).
- 2.6.2. Life satisfaction and quality of life in breast cancer patients
A research was conducted to explore relationship between quality of life and life satisfaction in breast cancer patients. The sample was taken from institute of Nuclear Medicine and Oncology Lahore (INMOL). The sample included 60 female patients across INMOL hospital setting. The assessment scales included Functional Assessment of Cancer Therapy-Breast Cancer FACT-B (Version 4) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire EORTC QLQ-C30 (Version 3). The results showed that there was a significant positive correlation between quality of life and life satisfaction (Javed, 2008). Jaben (2009) conducted a research to find the relationship between quality of life and emotional well-being in breast cancer patients. The findings of the research was based on the response of 60 breast cancer women of age range 20-60 and it was concluded that there is a strong relationship between quality of life and emotional well-being.
A research was conducted to find out differences in post-traumatic growth and life satisfaction among women diagnosed with breast cancer and three other types of cancer’s namely leukemia, cervix and ovary cancer. A sample of 60 women diagnosed with cancer was recruited. Data was collected from two major hospitals of Lahore, city. Posttraumatic growth inventory and Life Satisfaction developed were used to measure the study variables. Results indicated that there were significant differences on life satisfaction between women diagnosed with breast cancer and other three types of cancer namely leukemia, cervix and ovary cancer (Javaid, 2011).
- 2.6.3. Psychological Well being in Breast Cancer Patients and Caregivers
A study was aimed to investigate the relationship between psychological wellbeing and social support among middle aged and young aged breast cancer patients. Research included 100 participants (50 middle aged and 50 young aged breast cancer patients). Sample was collected from the oncology departments of Sir Ganga Ram Hospital, Mayo Hospital and INMOL Hospital. Demographic Information Questionnaire, Psychological Well-Being scale for cancer patients and Social Support Questionnaire were used to measure psychological wellbeing and social support of the participants respectively. Results indicated strong positive correlation among psychological well-being and social support among young and middle aged breast cancer patients. Psychological well- being and social support among middle aged breast cancer patient was higher than that of young aged breast cancer patients. These findings suggest that there is a need to improve the psychological wellbeing of young aged breast cancer patients as well as to counsel the family and caregivers of the patients to improve the communication and support which can help to improve their mental health (Tariq, 2010).
Not only the patients but also their relatives suffer from the effects of cancer. A research investigated manifestation of depression in caregiver-spouses of hospitalized cancer patients. A sample of 80 caregiver-spouses of cancer patients was selected by contacting the oncology units of six hospitals of Lahore, Rawalpindi and Islamabad. The age range of caregiver-spouses was 17-68 years. Beck Depression Inventory (BDI- Urdu version) was administered to determine the degree of depression expressed by the caregiver-spouses of cancer patient. An interview schedule was devised by the researcher to determine the psychosocial and economic problems like household problems, financial problems, degree of hopelessness/helplessness, faith in spiritual healing and their interpersonal relationships. The results indicate that female caregiver spouses manifested more depression when their male partner is the victim than the male caregiver-spouses. Moreover, there is significant difference between the male and the female caregiver-spouses on degree of hopelessness/helplessness and faith in spiritual healing which indicates that female caregiver-spouses would feel more hopeless/ helpless when their male partners are afflicted with cancer and more inclined to seek for spiritual help (Akbar & Farooqi, 2001).
A study aimed to explore the level of anxiety and depression among caregivers of leukemia and breast cancer patients. The sample consisted of 50 caregivers of leukemia and 50 caregivers of breast cancer patients, which included 47 males and 53 females. Age range of the sample was 16 to 64 years. Measures used in the study included two subscales of Symptom Checklist-R i.e. depression and anxiety. The result findings suggested that there was gender difference between anxiety and depression among caregivers of leukemia and breast cancer patients. There was no difference between the level of anxiety and depression among caregivers of leukemia and breast cancer patients (Basharat, 2010).
The above literature is linked to the theoretical framework. Suppressing one’s emotions will definitely result into some change in patient’s psychological well-being and adjustment because both are psychological components affected by the chronic diseases. Breast cancer is a chronic disease affecting the psychological health and emotional expression of patients. The literature supports the notion that emotional suppression is somehow linked to psychological adjustment.
The primary purpose of conducting this current research is to explore the effect on psychological adjustment due to suppression of emotions in Pakistani society, where people are used to an environment; in which social groups mostly share intimate relationship; and are ready to stand beside one another through thick and thin. Patients need to have emotional support and outflow of emotions so they can have better psychological adjustment. Previous researches (Gross & Leveson, 1993; Davidson, 2000) claim that emotions play an imperative role in psychological adaptation but it will also be important to look into the consequences/role of emotional suppression on psychological adjustment. It is intended that through these research findings an impactful message based on research evidence will be put forward in seminars and awareness programs of Pink Ribbon. Suggestion of appointing counselors in hospitals and strengthening family/social support can be made so patients can be facilitate with emotional expression for betterment of their psychological adjustment and factors associated with it.
It can also be judged through research basis that understanding this adjustment process is a primary goal of psychologists and health care providers who conduct psychosocial interventions with cancer patients. By examining natural processes and predictors of adjustment in cancer patients, one can find clues to designing effective interventions (Lepore, 2012)
The aims of this study are:
- To explore the relationship between emotional suppression and psychological adjustment in breast cancer patients.
- To investigate the relationship between different domains of emotional suppression and psychological adjustment.
- To determine the consequences one faces psychologically when he/she suppresses his/her feelings and emotions.
- To find out the effect of demographic variables on psychological adjustment and its domains.
- There would be a significant relationship between emotional suppression and psychological adjustment in breast cancer patients.
- There would be a significant relationship between domains of emotional adjustment and psychological adjustment in patients with breast cancer.
- The domains of emotional suppression are likely to predict domains of psychological adjustment in breast cancer patients.
3.1. Research Design
Within group research design was used to access the impact of emotional suppression on psychological adjustment in breast cancer patients.
In present research the purposive sampling technique was used. The sample consisted of a total number of 100 breast cancer patients. It was taken from the different hospitals of Lahore including governmental and private hospital i.e. Jinnah hospital and Institute of Nuclear and Medical Oncology, Lahore (INMOL). Age range of participants was 25 to 76 years with the mean and standard deviation of 45.76 and 10.50 respectively.
3.2.1. Inclusion criteria/ Exclusion Criteria
Following was the inclusion criteria of the study
- The age of the participants was 25 years and more. This age range was taken because in Pakistan there is more prevalence of breast cancer in this age group as according to research of Gillani, Akhter and Kamal (2003), the maximum number of cases is falling in the age group 40-50. The mean age of females with breast cancer was 40±12 years Peak age of incidence was 40-44 years followed by 45-49 years (Khokhar, Qureshi, Niaz, Naseem, Akhtar & Saleem, 2012).
- Patients currently with only breast cancer and no co morbid disease were included to avoid confounding.
- Only females were included because research states that males are in very few numbers as compared to females i.e. 2:100 (Gillani, Akhter and Kamal, 2003).
- Stage 3 and 4 patients were included. This is because a high proportion of breast cancer patients, 71% of the cases at INMOL and 63% at SKMCH have reported at stage III and IV. Such late presentation of the disease is an important aspect of this study. It points to the alarming situation due to the rising trend of breast cancer incidence in Pakistan (Gillani, Akhter & Kamal, 2003).
Following was the exclusion criteria of the study
- Males were excluded because a vast majority of breast cancer patients in hospitals are females (Gillani, Akhter and Kamal, 2003).
- Patients whose were unable to understand Urdu were not taken to avoid language barrier and confounding.
Descriptive Statistics of Demographic Variables
|Duration of Feeding||14.82 (10.68)|
|Duration of Diagnosis||16.73 (18.07)|
|Puberty age||13.80 (1.70)|
Table 3.1 (continued)
Descriptive Statistics of Demographic Variables
|Source of income|
Table 3.1 (continued)
Descriptive Statistics of Demographic Variables
|FA/ FSc.||7 (7)|
|BA/ BSc.||7 (7)|
|MA/ MSc.||4 (4)|
|Severity of Disease|
|Very severe||37 (37)|
|Moderately Severe||44 (44)|
|Less Severe||19 (19)|
|Disease in family|
|Only using Medication|
|Satisfaction with treatment|
|Table 3.1 (continued)Descriptive Statistics of Demographic Variables|
|Manupause due to illness|
|Any psychological problem|
3.3. Operational definitions
- 3.3.1. Emotional Suppression
Emotional suppression is the extent of the suppression or control of anger, depression, anxiety, and total negative emotion in daily life (Watson & Greer, 1983). This will be measured by Courtald Emotional Control Scale (CECS).
- 3.3.2. Psychological Adjustment
Psychological adjustment is the measure of the cognitive and behavioral responses to cancer (Watson, Greer, Young, Inayat, Burgess, & Robertson, 1988). It will be measured by Mini-Mental Adjustment to Cancer Scale (mini-MAC).
3.4. Assessment Measures
3.4.1. Demographic information form
A self prepared demographic form will be used to get information about age, qualification, marital status, family system, monthly household income, no. of children, breast feed and its duration, age of menstruation, treatment-induced menstruation, duration of illness, time since diagnosis, primary or metastatic, age of diagnosis, nutrition, exercise, social support, satisfaction with treatment, doctor’s and patient’s view about disease (Appendix D).
3.4.2. Courtauld Emotional Control Scale (CECS)
The Courtauld Emotional Control Scale (Watson & Greer, 1983) is a 21-item questionnaire developed to assess suppression of anger, anxiety and depressed mood. It is separated into three subscales. The subscales include anger, anxiety and depressed mood. Each subscale consists of 7 items. Test-retest reliability is good: anger (.86), anxiety (.84), and depressed mood subscales (.89), and total CECS score (.95).
It has 21 items, ranging from 1 = almost never to 4 = almost always for the extent to which they attempt to control expression of anger, anxiety, and depression. Items consist of an emotion stem (e.g. “When I feel unhappy’’) and responses to be rated (e.g., ‘‘I refuse to say anything about it’’ or ‘‘I keep quiet’’ or ‘‘I bottle it up’’) (Watson & Greer, 1983). The reliability of scale and subscales in current study is very high i.e. .91 of total scale while .82 of anger, .74 of depression and .86 of anxiety.
3.4.3. Mini-Mental Adjustment to Cancer Scale (Mini-MAC)
The Mini-Mental Adjustment to Cancer Scale (Mini-MAC) (Watson et al., 1988) was developed to measure cancer patients’ cognitive and behavioral responses to diagnosis and treatment. The 29-item Mini-MAC yields five subscales: Fighting Spirit, Helpless/Hopeless, Anxious Preoccupation, Cognitive Avoidance and Fatalism. Items in the subscales are 8, 8, 4, 4 and 5 respectively. The mini-MAC has demonstrated reliability with Cronbach’s alpha coefficients for each domain ranging from 0.62–0.88. It has rating scale from 1 to 4 whereas 1 refers to never and 4 refers to always. The mini-MAC does not distinguish between state and trait-like coping responses (Zucca et al, 2012). The reliability of scale in current study was .78. It has following subscales
Helplessness or Hopelessness
It is characterized by feelings of giving up and engulfment by knowledge of the diagnosis and a pessimistic attitude. E.g., I feel like giving up (Watson et al, 1988). Its reliability in current study is .84.
It is characterized by constant preoccupation with cancer and feelings of devastation, anxiety, fear and apprehension. E.g., It is a devastating feeling (Watson et al, 1988). Its reliability in the present study is .79.
It is characterized by a determination to fight the illness and the adoption of an optimistic attitude. E.g., I see my illness as a challenge (Watson et al, 1988). In the current study its reliability is .52.
It is where the patient distracts herself and avoids thinking about the illness. E.g., I deliberately push all thoughts of cancer out of my mind (Watson et al, 1988). It shows reliability value of .73 in the present study.
Fatalism is where the patient puts herself in the hands of God, while she takes one day at
a time. It is an attitude of optimism in the face of a realistic appraisal of the illness. E.g., I’ve put myself in the hands of God (Watson et al, 1988). Its reliability in the current study is .20.
3.6. Scale Translation
The scale was translated into Urdu according to internationally accepted translation methodology of MAPI guidelines and following the instructions of author. Linguistic validation process was to obtain a translation of an original instrument in a target language that is both conceptually equivalent to the original and easily understood by the people to whom the translated questionnaire is administered. The original scale was translated into Urdu by two language experts (Forward translation) and retranslated into English by one language expert. It was then pilot tested on 5 patients. A translated word was replaced by another word because patients were unable to understand that word easily.
Permission to use and translate the scale was obtained from the author via e-mail. For data collection, a permission letter was signed by the Director of Institute of Applied Psychology and supervisor of the study. Permission was sought from the heads of the respective hospitals and Cancer ward. Information about the type of patients was given to doctors so they can facilitate in finding the desired sample. After introducing and briefly describing the purpose, consent form was given to patient to sign. They were assured about the confidentiality of the information and anonymity of their Identity. Then the data was collected from the patients using questionnaire. After that the data was analyzed through statistical procedure and discussed.
- Study was carried out after obtaining the permission from the authors for using and translating the tools (Appendix A).
- Permission letter was signed by the supervisor and head of department in order to collect the data (Appendix B).
- Permission was taken from the ethical committee, heads and cancer ward of the Institute of Nuclear and Medical Oncology Lahore and Jinnah Hospital (Appendix B).
- Informed consent was taken from the participants and they were assured that the information obtained from them will be kept confidential (Appendix C).
- Data was collected at the feasibility and ease of patients without creating a hindrance in their rest.
- Anonymity and discretion of the patients was maintained (Appendix C).
The research aimed to investigate the emotional suppression and psychological adjustment of breast cancer patients. In this chapter, results are presented according to research hypotheses. The data analysis involved performing; (i) Descriptive statistics for study variables (ii) Pearson product moment correlation to find out relationship between study variables (iii) Hierarchal regression to determine whether there is a prediction between variables (iv) Independent samples t-test to find out difference in psychological adjustment due to joint and nuclear family.
Descriptive analysis was performed to examine the mean, standard deviation, minimum-maximum score and reliability of the study variables. The scores of the subscales were transformed into standard scores because the number of items in each subscale of one scale was not equal so items were made comparable. The formulae used for standard score was ((total score / number of items) / response options) * 10
4.1 Descriptive Statistics of study variables
Descriptive Statistics of the Study Variables (N=100)
|Variables||K||M||SD||Min Scores||Max Scores||α|
Note.k= Number of Items in the Subscale, M= Mean, SD= Standard Deviation, Min Score= Minimum Score, Max Score= Maximum Score, α= Reliability Co-efficient
The results indicated that he Cronbach alpha reliability of emotional suppression, psychological adjustment and its subscales is high except for one subscale i.e. fatalism.
4.2 Relationship between emotional suppression and psychological adjustment
It was hypothesized that there is likely to be a significant relationship between emotional suppression and psychological adjustment and its subscales.
Results revealed that emotional suppression was significantly positively related to psychological adjustment while negatively correlated to hopelessness/helplessness and anxious preoccupation. According to hypothesis of the study emotional suppression would significantly correlate with psychological adjustment and its subscales. Anger was only significantly positively correlated to hopelessness/helplessness. Depression was positively correlated to psychological adjustment while negatively correlated to hopelessness/helplessness and anxious preoccupation. Anxiety was positively correlated to psychological adjustment, hopelessness/helplessness and anxious preoccupation. Fatalism was positively correlated to depression. Hypothesis was approved as there was a significant relationship between emotional suppression, psychological adjustment and its domains.
Correlation among the Subscales of Emotional Suppression and Psychological adjustment (N=100)
|Note. *p<.05, **p<.01, **p<.001|
4.3 Prediction of Psychological Adjustment by Emotional Suppression
It was hypothesized that emotional suppression is likely to predict psychological adjustment in patients with breast cancer. Hierarchal regression analysis was run to test the hypothesis.
Multiple hierarchical regression analysis was performed to estimate the extent to which emotional suppression (depression, anxiety and anger) was predicting the psychological adjustment of women having breast cancer after controlling other demographic variables. Control variables were entered in step 1, none of them were significantly predicting women’s psychological adjustment. In second step, emotional suppression (depression, anxiety and anger) was entered, the overall for Hopelessness Helplessness explained 15% variance with F (19, 79 ) =1.67, p =.60 all of them were found to be non-significant predictors. Whereas the overall model for Anxious Preoccupation explained 24% of the variance with F (19, 79) = 1.99, p = .02. Only depression was found to be significant positive predictor of anxious preoccupation. Moreover the overall model for the Fighting Spirit explained 25% of the variance with F (19, 79) = 1.36, p = 1.70. Only anger was predicting significantly and negatively to fighting spirit. Furthermore the overall model for Cognitive Avoidance was fond non-significant, explaining only 2% of the variance with F (19, 79) = 1.18, p = .29. Finally the overall model for Fatalism explained 27% of the variance with F (18, 80) = 1.62, p = .08. Anger was significantly and negatively, while depression was significantly and positively predicting fatalism.
Prediction of Psychological Adjustment due to Emotional Suppression
Note.a: HH stands for Hopelessness/Helplessness, AP stands for Anxious Preoccupation, FS stands for Fighting Spirit, CA stand for Cognitive Avoidance, FA stands for Fatalism. Control variables included age, marital status, number of siblings, number of children, breast fed, duration of feeding, income, education, duration of diagnosis, cancer type, illness duration, severity of disease, disease in family, satisfaction with treatment, menopause, menopause due to illness and social support.
***p< .001, **p<.01, *p< .05.
4.4. Difference in Psychological Adjustment due to Family System
It was hypothesized that there is likely to be greater psychological adjustment in breast cancerpatients having joint family sytem as compared to those having nuclear family system. T-test was carried to see difference of nuclear and joint family system on pscyhological adjustment.
Independent samples t-test comparing Study Variables in Nuclear and Joint Family System (N=100)
(n = 62)
(n = 38)
|95% CI||Cohen’s d|
Note. CI = Confidence Interval; LL= Lower Limit; UL = Upper Limit.
The results revealed that there was no significant difference between the hopelessness/helplessness, anxious preoccupation, fighting spirit, cognitive avoidance and fatalism in patients due to family system.
4.5. Summary of the Findings
- It was found that emotional suppression has a significant correlation with psychological adjustment.
- It was also found that emotional suppression of anger, depression and anxiety were significantly positively correlated with hopelessness/helplessness; depression and anxiety were positively correlated to anxious preoccupation while depression was significantly positively correlated to fatalism.
- Suppression of anger negatively predicted the fighting spirit and fatalism while suppression of depression was positively correlated to anxious preoccupation and fatalism in patients with breast cancer. Anxiety did not significantly predict the subscales of psychological adjustment.
- No significant differences were found in psychological adjustment between nuclear and joint family systems.
Health psychology is an emerging field in Pakistan. As theories show a clear interlink of biological and psychological aspects, so was the study conducted to know about psychological states and problems of patients suffering from cancer. Psycho oncology deals with the psychological problems in cancer patients. The present study was conducted in that domain. In Pakistan, not a great deal of work had been done to know about the psychological adjustment in patients suffering from an advance state of breast cancer. The research was conducted to check whether and how significant role emotions play in overall adjustment so the study was conducted to check the association between emotional suppression and psychological adjustment due to it (Horgan, Holcombe & Salmon, 2010).
5.1. Correlation between Emotional Suppression and Psychological Adjustment
Results indicated that there was a significantly positive relationship between emotional suppression and psychological adjustment. It reveals that greater the emotional suppression, greater will be the psychological adjustment and vice versa. Literature involving cancer patients which suggests that coping through suppressing emotions may enhance their adjustment to the illness. Studies of adjustment to cancer indicate that emotional suppression is associated with more emotional distress (Reynaud et al., 2012; 1996; Watson & Greer, 1983) and contrary to this, coping with suppressing emotions is associated with decreased distress and a better quality of life (Low, Stanton & Danoff-Burg, 2006; Stanton et al., 2000; Stanton, Danoff-Burg & Huggins, 2002). As pointed out by Kennedy-Moore and Watson (2001), emotional expression might alleviate distress.
Some reasons support these findings. First is the gender of the sample i.e. female. Females in a patriarchal country like Pakistan learn to suppress their emotions (Bleidorn & Kodding, 2013). Women find a sense of satisfaction in sacrificing themselves for others and learn to suppress emotions from childhood resulting in an increase in their psychological adjustment and contentment. Another reason is that whereas suppression is taken as healthy defense mechanism repression is taken as an unhealthy one because one knows and deliberately suppresses his/her emotions in suppression while unconsciously control his emotions in repression (Pettingale, Watson & Greer, 1984).
Another probable reason of having better psychological adjustment due to family support system which enables emotions to stay regulated. Due to the strength attained through one’s family and social support, one will get a better chance to regulate his/her emotions. The capability to regulate and adjust emotions, by reappraising the nature of drawing out events and regulating expressive behavior is erudite within a developmental context, such as family circumstances and relationships (Zautra, Smith, Affleck, & Tennen, 2001).
In Pakistan there is a strong family system (Sarason, Sarason & Gurung, 1997). It shows that here people and regulate more emotions that’s why they are having a better psychological adjustment. One suppresses his/her emotions not with the intention of unavailability of factors strengthening him/her but because he is getting enough strength that he can even cope after suppressing his emotions (Bloom, Gorsky, Fobair, Hoppe, Cox, Varghes, Spiegel et al., 1990). This difference in rationale for suppressing emotions gives justification of more psychological adjustment due to greater emotional suppression.
According to a research, when the patient believes that life is hopeless, can’t cope, thinks that it’s the end of the world (Helpless/ Hopeless), then she may feel anxiety, worry, apprehension (Anxious Preoccupation). To minimize these strong negative beliefs and feelings, she may direct herself to spirituality, put herself in the hands of God, and count her blessings (Fatalism) (Anagnostopoulos, Kolokotron, Spanea & Chryssochoou, 2006). This supports the research findings of present study that greater the depression, anxiety, anger and their suppression, more will be the helplessness/hopelessness. Also that greater suppression of depression will result into more anxious preoccupation and fatalism.
Another research states that a significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer (Watson et al., 1991).
5.2. Relationship between Psychological Adjustment and Domains of Emotional Suppression
It was expected that greater the anger, anxiety or depression, less will be psychological adjustment. Results were in correspondence with this. A study was conducted to examine the relationship between psychological distress and patient psychological traits (i.e., trait anxiety, life change events, and emotional suppression) after surgery. Greater the level of emotional stress or depression less will be the adjustment on psychological level. Emotional suppression was a psychological trait that influences the level of psychological distress in patients with breast cancer (Akechil, Okamura, Yamawaki, & Uchitomi, 1998). Another research states that the data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked (Watson et al., 1991).
5.3. Relationship of Subscales of Emotional Suppression and Psychological Adjustment
Results showed that anger was significantly positively correlated to hopelessness/ helplessness. Depression was significantly positively correlated to hopelessness/helplessness, anxious preoccupation and fatalism. Anxiety was significantly positively correlated to hopelessness/helplessness and anxious preoccupation. Literature supports it as a research indicates that association of emotional suppression with helplessness is evident through the explanation of Type C personality. Research indicated that helplessness was significantly higher in those who were high emotional controllers than in low emotional controllers. A highly significant difference was observed between the high and low emotional controllers for fatalism with high emotional controllers (especially those reporting control of depression) being more likely to report a fatalistic attitude towards cancer than low emotional controllers (Zucca, Lambert, Boyes & Pallant, 2012).
Anger suppression is related to hopelessness/ helplessness because it is part of type c personality and as a result of type c personality, hopelessness/ helplessness is developed. A person facing this situation is said to be chronically and unconsciously helpless or hopeless because he or she feels that his or her needs are not satisfied (Temoshok, 1987). Puig, Lee, Goodwin, and Sherrard (2006) also reported that breast cancer patients with emotional suppression tended to feel hopelessness and had a fatalistic attitude. The research states that Type C individual might be seen as chronically hopeless and helpless, suggesting that those showing a pattern of Type C behavior would be more likely to develop feelings of helplessness under extreme stress, this shows an association of depression and hopelessness/ helplessness. There was an association between the tendency towards emotional control and feelings of helplessness in women who have recently learned they have breast cancer and that helpless responses could, in turn, be associated with more symptoms of depression. It was indicated that helplessness was significantly higher in those who were high emotional controllers than in low emotional controllers.
The results of a research indicated that increased helplessness, fatalism and anxious preoccupation were associated with more symptoms of depression and anxiety. These results show that psychological comorbidity was lower for those showing this attitude towards the disease (Watson et al., 1991). Some studies have suggested that depression is of prognostic significance (although the evidence is equivocal) resulting into anxiety about severity of disease, a feeling of hopelessness, worry and he may either turn towards or away from God depending upon the social circumstances and his prior inclination towards fate (Holland, 2003; Hassanein, Musgrove & Bradbury, 2002).
5.4. Prediction of Psychological Adjustment Domains by Emotional Suppression
It was analyzed that if we control several other variables that could have affected the psychological adjustment, even then subscales of emotional suppression will predict subscales of psychological adjustment. The results of the current study indicated that suppressing depression will result into more anxious preoccupation and fatalism. Results also indicated that suppressing anger will predict presence of less fighting spirit and less fatalism.
- According to the research findings of current study, suppression of depression will predict more anxious preoccupation. It is supported by the research finding too stating that the maladaptive coping (hopelessness/ helplessness, anxious preoccupation) predicts more psychological maladjustment and less psychological adjustment and less psychological adjustment will make a person suppress his negative emotions like anxiety, worry, apprehension and depression Similarly, adaptive coping (fatalism, fighting spirit, cognitive avoidance) are an indicators of less psychological distress resulting into a healthy coping. (Brooks & Matson, 1982). Another research reveals that greater the anger, less will be fighting spirit. Women with a fighting spirit had better breast cancer survival than women who were compliant, there has been a good deal of research interest in the role that different ways of coping with illness may play in breast cancer prognosis. The fighting spirit, along with denial, were two psychological responses first identified by British researchers from clinical interviews conducted among 69 early stage breast cancer patients who subsequently experienced better 5-year survival than women whose responses were characterized as stoic acceptance or helplessness/hopelessness. A greater fighting spirit will result into less anger in cancer patients but people will keep feeling gloomy even if it remains unexpressed (Reynolds et al., 1999). Findings are according to the literature, suppression of anger and depression will result into an increase and decrease of fatalism respectively.
Research was conducted to find the relationship between emotional suppression and psychological adjustment. It was noticed through research findings that both the variables have a significant relationship. Not only the main variables but their subscales are also correlated with each other. Subscale findings show that subscales of emotional suppression are likely to predict that of psychological adjustment. Certain other factors also influence psychological adjustment like income which will give support to patients making them relax and decreasing sense of hopelessness and helplessness in them. Findings add to the literature of psycho oncology.
Implications of Research Findings
- The findings from this study have great implications for family, health psychologists, doctors, counselors and other people working in health care area because breast cancer patients suffer a lot psychologically and need counseling and help.
- The findings will be helpful for family members to understand the consequences and emotions patients face during stages of breast cancer.
- It will facilitate doctors to address patients guiding in doctor-patient communication.
- It shows that patients suffering from chronic illness like cancer need the counseling and guide of health care providers and counselors.
- Health psychologists can play an important role in addressing, guiding and satisfying the inquiries of patients.
- It discusses the psychological issues most breast cancer patients face and remain unexpressed.
Limitations for Future Research
- Data was collected from two hospitals which is not enough representation of data of breast cancer patients.
- As sample was taken from outdoor patients so they were gathered at one place mostly. It might have created social desirability bias while responding to the statements.
- Patients were more anxious and worried about their financial situation and the budget of medicines doctor recommended due to which they were preoccupied.
- The scale was translated for the first time so reliability of language across different studies is missing.
- A longitudinal study with these factors is required so that one can get a detailed idea of emotional changes and its psychological impact over time due to breast cancer.
Suggestions for Future Research
- A longitudinal study with the same variable and sample is required so changes in psychological aspects can be assessed over a period of time.
- Psychological adjustment of patients at third and fourth stage of breast cancer can be compared for a more detailed idea and comparison of psychological aspects across both stages of breast cancer.
- An analysis of emotional and psychological differences should be made comparing different stages of cancer. So data of different breast cancer stages and its analysis to find the differences is required.
- Data from more hospitals can be taken and compared including private and government hospitals.
- Health psychologists and other health care professionals can play an important role in understanding the problems and issues faced by breast cancer patients regarding their health and psychological issues.
- Government should create employment opportunities in private sector and governmental hospitals for counselors so they can facilitate patients and address their psychological issues thus resolving their problems and counseling patients because they were very disturbed emotionally. In this way they can ensure a healthy environment
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