Abstract
Purpose. To evaluate the long-term effect of group intervention on enhancing cognitive emotion regulation (CER) strategies in female patients with early-stage breast cancer. Methods. The sample included 174 patients who were diagnosed with early-to-mid stage breast cancer, completed adjuvant therapy, and agreed to fill out demographic and cognitive emotion regulation questionnaires (CERQ). About half of the patients (86, 49.4%) chose to participate in an 8-session group intervention (intervention group) while the others (88, 50.6%) did not (comparison group). The structured intervention for enhancing coping strategies with special emphasis on emotion regulation was conducted at the oncology unit at Rabin Medical Center by 2 experienced therapists. Preliminary effects on CER evaluated 6, 12, and 24 months postintervention were compared to the CER of a group of patients that opted not to participate in the group intervention. Results. In the intervention group, the long-term effect (from baseline to 24 months) was assessed using the mix models module. Significant interaction effects were found for both the Negative CER scales (F(3, 268 ,404) = 3.66, P = .01) and for the Positive CER scales (F(3, 271 ,660) = 5.12, P = .002). No statistically significant differences in socio-demographic characteristics and medical variables were observed between the intervention and comparison groups. Conclusion. Our findings indicate that a group intervention aimed at empowerment of coping strategies had positive long-term outcomes that reinforce adaptive coping strategies and improve less effective strategies of cognitive emotion regulation.
Introduction
The psychological journey associated with a cancer diagnosis is characterized by a series of challenges including adjustment to diagnosis and treatment, disruption of one’s current life situation, reevaluation of life’s direction, and tolerance of ongoing uncertainty. 1 Adaptive coping may have an important role in managing these challenges as indicated by the inverse relationship between active coping and psychological distress and the coping deficits observed in a variety of mental disorders.2,3
Cognitive emotion regulation (CER) suggests a cognitive way of managing the intake of emotionally arousing information, that encompasses a broad range of cognitive, behavioral, emotional, and physiological responses.4,5 Following the experience of a stressful situation, CER refers to the conscious, cognitive methods an individual uses to cope that could be either maladaptive or adaptive. 6 Strategies that are self-blaming, blaming others, ruminating, and catastrophizing are maladaptive strategies that can lead to maladaptive behaviors and are not conducive to individual rehabilitation. Adaptive strategies include acceptance, refocusing on planning, positive refocusing, positive reappraisal, and putting into perspective, which are central to well-being and successful functioning and necessary for the initiation, motivation, and organization of adaptive behaviors following negative life events.4,7 Specific CER strategies may be used in certain situations that might differ from other strategies that could be used in different contextual situations. 8 Thus, CER strategies can possibly be changed and taught, 9 and individuals who are able to use positive CER strategies can effectively manage the intensity of their negative emotions by changing their appraisals. In line with this notion, Wang et al 7 reported that greater acceptance, positive refocusing, and positive reappraisal among breast cancer patients were associated with fewer depressive symptoms 1 month after their first assessment. Similarly, Schroevers et al 8 revealed that cancer patients who were engaged in positive refocusing and not rumination and catastrophizing had less negative and more positive affect. Moreover, a recent study found that maladaptive emotion regulation strategies were consistently related to higher levels of depressive symptoms as compared to adaptive strategies. 10 These findings might indicate that CER strategies seem to play an important role in patients’ psychological well-being and that the inclusion of specific interventions geared at practicing and improving these skills in clinical care contexts may increase health and well-being for these patients. 11 However, although previous research has identified CER strategies as targets for more effective interventions,9,10 to our knowledge, this is the first study that investigated the impact of group intervention on improving CER strategies. The current study aimed to explore whether self-selected participation in group intervention for breast cancer patients focusing on coping enhancement can improve the ability to employ cognitive emotion regulation strategies. Analyses of 8 sessions of group interventions was performed. Preliminary effects on CER evaluated 6, 12, and 24 months postintervention were compared with the CER of a group of patients that opted not to participate in the group intervention. Our hypothesis was that breast cancer patients who participate in the Intervention group will experience improvement in their coping strategies; reduction of their maladaptive strategies and enhancement of adaptive strategies, and that this improvement will be maintained over a 2-year period.
Patients and Methods
Participants and Procedures
The study was conducted at a tertiary university-affiliated hospital in central Israel. The study protocol was approved by the local review board, and all participants gave written informed consent.
Eligible patients included female, Hebrew-speaking patients, between the ages of 25 and 75 years, who were diagnosed with early-to-mid stage breast cancer (I-III), completed adjuvant therapy (chemotherapy and/or radiation) at least 3 months prior to study initiation, and had no other chronic illnesses. The computerized hospital registry (January 2009 to December 2012) was reviewed to identify all eligible patients. An invitation to participate in the group intervention study was mailed to all eligible patients together with a brochure that fully detailed the rationale, purpose (enhancing CER and building resilience), setting and format (8 weekly sessions of 1.5 hours each) of the program. Two weeks after the invitations were posted, patients were contacted by a trained research assistant who assessed their interest in the intervention group and obtained oral consent to participate in the study. All participants (those who opted to participate in the group intervention (“intervention” group) and those who opted not to participate (“comparison group”) were asked to complete several self-report scales at 4 time points (baseline, after 6, 12, and 24 months).
A total of 174 individuals agreed to fill out the questionnaires. About half (86, 49.4%) were interested in participating in the group intervention while the others (88, 50.6%) were not. According to the MCAR (missing completely at random) test, the pattern of missing data was random, χ2(3852) = 3450.77, P = 1.00.
Intervention
The intervention was conducted according to the guidelines for CER group intervention prepared in the psycho-oncology unit of Rabin Medical Center. The guidelines were based on the coping theory of Lazarus and Folkman 12 and Lazarus, 13 the “BASIC Ph” model for coping and resiliency 14 and the model of relaxation and guided imagery of Baider et al. 15 Since this was the first time this intervention was implemented in the psycho-oncology unit, we preferred to use first step self-selection participation. Following evaluation of the effectiveness of the initial group intervention, we plan to use a randomized control group as a second step (future study).
The sessions were co-led by 2 senior social workers who had extensive experience in psycho-oncology and group therapy. The groups met on a weekly basis for 8 sessions of 90 minutes each. All sessions were structured to include a psycho-educational component (30 minutes) and an experiential component (60 minutes). Each topic was introduced, discussed and experienced. The group intervention content included (a) regulation of physical sensations, (b) cognitive regulation, (c) regulation of emotions, (d) interpersonal regulation, and (e) expanding coping strategies (Table 1).
The Intervention Program: Sessions Structure.
On average there were 12 women in each group session, and the majority of women (75%) participated in all eight sessions.
Measures
Demographic and medical information was obtained from the patients’ electronic health records.
The Cognitive Emotion Regulation Questionnaire (CERQ), a multidimensional self-report instrument that evaluates the CER or coping strategies used by individuals who experience negative events or situations was used to investigate patients’ coping strategies. 16 The short CERQ is an 18-item questionnaire, consisting of the following 9 conceptually different dimensions, each consisting of 2 items measured on a 5-point Likert-type scale (from 1 = almost never to 5 = almost always). Individual subscale scores were computed based on the average scores of the items. Higher scores indicated greater use of a specific cognitive strategy. The reliabilities for the various CERQ-short subscales were acceptable to high and ranged from .68 to .81. 16 In the current study the CERQ- short subscales reliabilities were for the following: self-blame (α = .71), acceptance (α = .69), rumination (α = .66), positive refocusing (α = .75), refocusing on planning (α = .72), positive reappraisal (α = .66), putting into perspective (α = .69), catastrophizing (α = .85), and blaming others (α = .76). Two general scores were calculated: the CERQ positive score (the sum of items related to acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting into perspective; α = .83), and the CERQ negative score (the sum of items related to self-blame, rumination, catastrophizing, and blaming others; α = .74). The CERQ was used with different health problems, including cancer (eg, Wang et al 7 and Schroevers et al 17 ).
Statistical Analysis
Measurements of 8 group sessions (at baseline, 6, 12, and 24 months) were analyzed in order to determine the duration of the effects of the CER intervention. All analyses were performed using SPSS software, version 19.0 (IBM Corporation, Armonk, NY). Chi-square tests were used to assess the differences in demographic and medical variables between the 2 study groups.
Dropout rates over time among the intervention group were: T1 = 100% (n = 86); T2 = 63% (n = 54); T3 = 40% (n = 34); and T4 = 31% (n = 27) and among the comparison group: T1 = 100% (n = 88); T2 = 64% (n = 56); T3 = 59% (n = 52); and T4 = 28% (n = 25). The pattern of nonresponse was tested with Little’s test for MCAR. Test results indicated a general pattern of missing that was not MCAR, χ2(146) = 192.30, P = .006. We then tested whether the rate of missing values was different between time points and groups. We found that the difference between the rates of missing values at different time points was statistically significant. No similar pattern was found between the intervention and control groups. Following Enders, 18 we estimated the parameters of the statistical model as a growth modeling analysis using the Mix Models module in SPSS. 19 In this way, the data were analyzed using maximum likelihood imputation 20 that can be appropriate for designs characterized by substantial dropout rates. 21 Moreover, this method allows us to reduce the sphericity assumption. 22
With respect to change over time in coping strategies, between group differences were assessed using the interaction effect of time and intervention. A P value of less than .05 was considered statistically significant. In our power analysis for the regression models, we refer to the post hoc power value, 23 which was calculated by using G*Power 3.1 software. 24 The power (1 − β err probe) for medium effect size of f2 = 0.15, 25 α of .05, sample size of N = 174, and 3 predictors (time, intervention, and interaction) was .994.
Results
Patient Disposition and Sociodemographic/Medical Characteristics
Of 174 enrolled patients who completed the study questionnaires (baseline), 86 (49.4%) opted to participate (self-selected group intervention), and 88 (50.6%) declined to participate in the group intervention (comparison group). The most common reasons for refusal to attend were belief that they did not need help or could cope (28.6%), inconvenient time or day (24.7%), and need help but do not want group therapy (14.3%).
For the 174 patients included in the current analysis, mean (SD) age was 52 (10.6) years, most were native Israelis (73%), had more than 12 years of education (66.7%), were currently married (83.3%), and had children (93.6%). A total of 43.2% of participants worked full time and 40.7% were unemployed. The majority (75.9%) lived in urban areas.
Twenty-four percent of the patients had stage I breast cancer; 91.4% had been treated with chemotherapy and radiation. In addition, during the intervention period, 28.7% were receiving trastuzumab (as part of a 1-year trastuzumab regimen) and 71.8% were receiving hormonal therapy.
No statistically significant differences in sociodemographic characteristics (age, marital status, country of birth [Israel, former Soviet Union, other], level of education, and work status) were observed between the intervention and comparison groups. Similarly, no statistically significant differences were observed with respect to medical variables (type of treatment, disease stage, and treatment protocol) (Table 2).
Demographic and Medical Properties of Intervention and Comparison Groups.
With respect to coping strategies at baseline, the mean score of the positive CER was higher for subjects from the comparison group (3.52, SD = 0.80) then for the intervention group (3.31, SD = 0.78) but the difference was not statistically significant, F(1, 171) = 3.22, P = .07. The mean score of the negative CER at baseline was lower for subjects from the comparison group (2.02, SD = 0.71) than for the intervention group (2.42, SD = 0.68) and the difference was statistically significant, F(1, 170) = 5.69, P = .02, µ2 = 0.03.
Coping Strategies Among Intervention Group: From Baseline to 24 Months
In the intervention group, the long-term effect (from baseline to 24 months) of the intervention was assessed using the mix models module. Significant interaction effects were found for Negative CER (F(3, 268 404) = 3.66, P = .01), suggesting that the patients in the intervention group experienced improvement over time in negative CER (mainly in catastrophizing subscale) (Tables 3-5).
Means, Standard Errors (SE), and F-Test Results for the Research Models.
Abbreviation: CER, cognitive emotion regulation.
Means, Standard Error (SE), and F-Test Results for Negative Cognitive Emotion Regulation Subscales.
Means, Standard Error (SE), and F-Test Results for Positive Cognitive Emotion Regulation Subscales.
For Positive CER, the interaction effect was also found to be statistically significant (F(3, 271 660) = 5.12, P = .002). Patients in the intervention group experienced improvement over time in positive CER (mainly in positive refocusing and putting into perspective subscales). Nevertheless, the improvement in the “putting into perspective” subscale declined after 24 months, reverting close to the baseline score. In addition to the interaction effects, we found improvement over time for the entire sample in negative CER (F(3, 268 404) = 3.2, P = .02). That is, with passage of time, the use of negative CER decreases. Moreover, analyzing CER subscales revealed that the main effect of improvement over time was in rumination (F(3, 280 331) = 3.14, P = .03) and in positive refocusing (F(3, 275 104) = 5.32, P < .001).
Discussion
The goal of the present study was to examine whether self-selected participation in a group intervention for breast cancer patients that focused on enhancing coping improved the ability for CER. Our results showed that the women who attended the group intervention experienced improvement in their coping strategies over a 2-year period. More specifically, they improved their “positive refocusing” and “putting into perspective” strategies. In addition, their use of catastrophizing thinking was reduced. These improvements in cognitive and emotional coping strategies may be relevant to the ability of cancer patients to better manage the psychological consequences of cancer (ie, anxiety, depression, mental distress, fear of death) and psychosocial problems of cancer (namely family relationships, childcare, working career, financial situation). 26 Possible explanations for our results are in accord with the self-regulation theory, which argues that the coping process is dynamic and can be acquired. 27 Patients can elect to cope in ways that are consistent with their understanding of the experience. Thus, it is possible to assume that participation in the group intervention influenced the participants’ perceptions of their illness and its implications. This process enabled them to use adaptive rather than maladaptive coping strategies. Our findings are consistent with those of Schroevers et al 17 concerning CER strategies among cancer patients and with those conducted in other diseases, including HIV infection, 28 and peripheral arterial disease. 29
Our finding that the use of the strategy “putting into perspective” declined 24 months after baseline was unexpected. It may be attributed to the fear of recurrence, which may be frequent among cancer survivors. 30 The anxiety related to the fear of recurrence may actually increase over time as the active treatment tends to subside. Thus, for some patients, uncertainty about their health status after treatment can be a significant psychological burden, which might challenge the recovering patient’s attempts to put the event into perceptive. Further studies are warranted to investigate this issue.
Our results also showed that although the cancer patients in the intervention group scored higher at baseline in negative CER strategies than the comparison group, both groups displayed improvement over time in their reduction of negative CER strategies, particularly on the rumination subscale. This pattern of improvement may support the hypothesis regarding an increased likelihood of posttraumatic growth. The process of posttraumatic growth may manifest in significant changes in personal goals and priorities suggesting benefits across various domains, including appreciation for life, personal strength, relationships with others, recognition of new possibilities in life, and spiritual understanding.31 -33 Accordingly, one may assume that with no group intervention, cancer patients might achieve increased posttraumatic growth after reducing their negative CER. However, a recent study that was conducted among breast cancer patients revealed that participants who used group intervention that was focused on building resilience and enhancing CER strategies reported more constructive growth and less illusory growth, as compared with nonparticipants, 6 months postintervention. 34
Our results have several clinical implications: First, they provide some support for the presence of a self-appraisal process, which suggests that patients can assess their personal resources with respect to their ability to deal with their illness. Patients who felt that their coping strategies regarding their illness were not sufficient, opted to participate in the group intervention. Thus, health care professionals may need to rely on the patients’ self-appraisal of their need for help. 35 Moreover, CER seems to play an important role in cancer patients’ coping. It may influence their emotional responses by redirecting attention within a given situation and may change one or more of the appraisals that give rise to less distressing emotions. 36 Thus, the inclusion of CER strategies in clinical care contexts and settings seems to be of potential value in promoting psychological well-being. 8 Nevertheless, the next step of the current research should be randomization to intervention versus control groups in order to assess effectiveness of this type of intervention.
In evaluating the implications of our study, some limitations should be taken into account. First, the dropout rate limits the ability to generalize the findings. Second, 50.6% of the patients declined to participate in the group intervention. Many patients are reluctant to acknowledge or do not have an opportunity to acknowledge that their coping strategies are insufficient. We cannot exclude the possibility that those participants have different psychological characteristics although no between-group differences were found in sociodemographic and medical factors. Third, since we used group self-selection participation, caution should be used regarding the effectiveness of the intervention until a randomized study design is implemented.
Despite these limitations, this study demonstrates the positive long-term impact of group interventions that focus on enhancing regulation of physical sensations, emotions, thoughts, and interpersonal relationships that contribute to the empowerment of coping strategies among female patients with early breast cancer. Given the limited resources of the health care system, this type of intervention should be targeted to the individual patient’s needs and wishes. Further studies evaluating the effectiveness of group interventions are warranted to establish the evidence base needed to incorporate such interventions into the clinical practice of cancer care.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.