Breast cancer is the most common type of malignant tumor among women with 2.2 million cases worldwide, although mortality numbers have been declining in recent years. [1] This phenomenon can be explained by the increase in early diagnosis and treatment effectiveness, leading to higher survival rates. [2] The diagnosis, treatment, and following remission stages often result in disruptive experiences that threaten patients’ mental health and increase their emotional vulnerability. [3] As such, patients face a wide range of persistent negative emotions, with anxiety and depression being the most frequent psychological reactions associated with breast cancer. [4] Other frequent emotional responses are fear (e.g., of dying, suffering or recurrence), anger, uncertainty (e.g., about the future), shock, despair, frustration, and sometimes guilt. Once emotional vulnerability becomes acute, it can increase psychological distress and disease severity, significantly impairing treatment outcomes, recovery time, and illness adaptation, even after being cancer-free. [3, 5] Hence, an adaptative regulation is crucial to reach emotional stability and ease women’s overall experience with breast cancer.
When emotions are harmful, whether because they are the wrong type, intensity, duration or frequency for a certain situation, patients can – and often try to – regulate their emotions and change the emotion trajectory, [6] manipulating which emotions are felt, when and how they are experienced and expressed throughout the emotional event. [7] Emotion regulation episodes can occur on an intrapersonal or interpersonal level with different associated psychological outcomes. Research has been mostly focused on intrapersonal regulating processes, even though recent studies highlight that regulatory episodes often occur in social contexts. [8] In fact, it is common for individuals to influence one another’s emotions and co-regulate them, determining which strategies and outcomes arise from the social regulatory episodes. [9] Particularly, intrapersonal regulation refers to strategies that people use to deal with their emotional experiences by themselves, [6] while interpersonal regulation involves the presence of others to regulate one’s emotions with or through them. [8] As a result, the effectiveness of the intrapersonal processes is strongly and exclusively linked to the individuals’ inner capacity to regulate their emotions alone. In interpersonal processes, others’ skills are also highly relevant for the success of the regulation, which can be most helpful when individuals do not know how to adequately reduce their negative emotions and rely on others to better select effective regulatory strategies. [9–10] Both regulatory levels exist on a continuum without a clear delimitation and can be used simultaneously or interchangeably during a single regulatory episode. [11]
On the intrapersonal level, the process model of emotion regulation is the most widely used conceptual framework to explain the emotional dynamics that influence the way individuals feel, think, and act, both immediately after the emotional event and over time. [6–7] According to the model, emotion regulation strategies can be distinguished between antecedent-focused and response-focused based on their primary impact during the regulation process. Antecedent-focused strategies act before the emotional response fully develops and alter the subsequent emotion trajectory, whereas response-focused strategies act after the emotional response has already begun and seek to modify external aspects, such as behavioral expression. [12] Cognitive reappraisal, an antecedent-focused strategy, and emotional suppression, a response-focused strategy, are two well-researched examples of intrapersonal regulation processes, frequently used to reduce the impact of negative emotions. Through reappraisal, individuals think about the situation from a different perspective as an attempt to change the emotional response (e.g., thinking that the disease can potentially be a positive personal growth experience), while suppression inhibits any verbal or nonverbal expression related to the emotion (e.g., try to hide from their loved ones the emotional impact of going through another round of chemotherapy). [6] Generally, an attempt to reappraise the emotional event is considered to be more effective than suppressing it, [13] successfully redirecting the individual back to neutral or positive feelings. [14] Contrarily, suppression involves a continuous and repetitive effort to deal with the lingering and unresolved emotion, [13] which might be counterproductive, intensifying the negative emotions or even repressing the positive emotions. [15]
On the interpersonal level, social sharing of emotions is one of the most frequent responses to an emotional event, considering that when people experience an emotion, they tend to feel a pressing need to talk about it, with 80–95% of the episodes being socially shared. [16] During these social encounters, people openly talk about the circumstances and emotions associated with the event. [17] The two-mode model states that even though verbalization is beneficial, it is not enough to effectively deal with an emotional event. It is also necessary to have in consideration the way people share their emotions. This model differentiates between two sharing modes: socio-affective sharing and cognitive-sharing. Socio-affective sharing involves a listener that gives a supportive response based on comfort, validation, and empathy. For instance, letting them know that it is normal to feel upset for being diagnosed with breast cancer. This mode is usually more effective during the initial phase, leading to a temporary state of emotional relief. Conversely, cognitive sharing involves a listener that stimulates the other person to work towards reformulating or reassessing the meaning of the emotional event, considerably reducing its’ negative impact. For example, helping one understand they are coping the best way possible given the circumstances. The premise of the model is that to achieve a positive and prolonged emotional recovery, both modes need to be implemented during the sharing episode. Thus, individuals not only feel supported by others, but also actively resolve the emotional stressor associated with the negative event. [16–17] For the purposes of the study, cognitive sharing is considered to have a focus on the antecedents of the emotion (i.e., thoughts) and socio-affective to be focused on the emotional response (i.e., emotional expression) to allow the comparison between intrapersonal and interpersonal regulation models.
Research demonstrates that both regulatory levels have been used among breast cancer patients. On the intrapersonal level, the use of suppression is linked to worse mental health outcomes (e.g., negative humor, anxiety, and psychological distress), whereas the use of reappraisal is strongly associated with better outcomes (e.g., emotional self-efficacy, benefit finding, and posttraumatic growth), referring to the notion that cognitive strategies are often more adaptative. [18–21] Despite the limited number of studies regarding interpersonal regulation, research indicates that the vast majority of cancer patients benefit from socially sharing their emotions (e.g., [22]). In particular for breast cancer, a higher level of sharing avoidance was correlated to higher levels of psychological distress and intrusive thoughts. [23] Ultimately, both levels of emotion regulation influence the way women diagnosed with breast cancer perceive their current situation, playing an important role on their perception of quality of life. Cella [24] defends that quality of life in patients diagnosed with chronic diseases involves two underlying components: multidimensionality and subjectivity. The first component refers to the multiple dimensions of well-being that constitute quality of life, namely physical well-being (e.g., symptoms, treatments’ side effects), functional (e.g., physical capacity, mobility), emotional (e.g., negative feelings, concerns) and social (e.g., close relationships, social support). For breast cancer in particular, there is another dimension associated to the disease’s specific concerns (e.g., feelings of femininity, swelling in the arms). The second component is related to the notion that quality of life is a subjective construct that can only be evaluated from the patient’s perspective, through self-reporting. As such, the way breast cancer patients perceive their lives, illness and treatments, determines the way they perceive their quality of life. [24–25] Recent studies show that patients that use adaptative strategies, such as reappraisal and overall sharing, more frequently perceive their quality of life to be better in comparison to when they use strategies typically considered more dysfunctional, like suppression or sharing avoidance. [18, 26–27]
Current Study And Objectives
Few studies have compared intrapersonal and interpersonal emotion regulation processes and health outcomes, and to the best of our knowledge, none in the breast cancer field. Little is known about which level of regulation presents a better impact in breast cancer patients, especially since the relation between social sharing of emotions and breast cancer is still in need of further research.
The present study contributes to this area by exploring the effects of two levels of emotion regulation - intrapersonal and interpersonal - on quality of life in women previously diagnosed with breast cancer. Recollection was used as a strategy to assess these constructs during the active phase of the disease, including the diagnosis and treatment stages. For each regulation level, two well-researched strategies were selected based on their primary focus during the regulation process. On the intrapersonal level, cognitive reappraisal (antecedent-focused) and emotional suppression (response-focused) were selected, while cognitive sharing (antecedent-focused) and socio-affective sharing (response-focused) were considered on the interpersonal level (see Table 1).
Table 1
Levels and strategies of emotion regulation
|
Emotion regulation level
|
Type of strategy
|
Intrapersonal
|
Interpersonal
|
Antecedent-focused
|
Cognitive reappraisal
|
Cognitive sharing
|
Response-focused
|
Emotion suppression
|
Socio-affective sharing
|
First, we aim to explore which emotion regulation level - intrapersonal or interpersonal - and which type of regulatory strategy – antecedent-focused or response-focused - were most implemented by breast cancer patients to regulate their negative emotions. Likewise, we also assess the levels of consistency in using these strategies, that is, whether the same type of strategy – antecedent-focused or response-focused – was employed consistently through both regulatory levels. Secondly, we compare which level of regulation had a greater influencing role on patients’ perception of quality of life and explore the direction of the relation between these processes.