Emotional Expression, Suppression and Breast Cancer Patient Preferences about Physician Driven Referrals to Psychotherapy

Background and purpose:

Health care as a human right should include access to integrated medical-behavioral health treatment when battling cancer, particularly for womxn of color, who are more likely to be diagnosed with and die from breast cancer. Literature indicates a need for psychological interventions for patients during and after breast cancer treatment, yet few physicians make referrals to behavioral health providers during the process (Admiraal et al., 2020). Breast cancer patients who present with Type C coping strategies (emotional suppression), are individuals who appear fine and present as cooperative, non-argumentative, and suppress their own needs in favor of others, are at greatest risk for emotional distress post-treatment. At the onset of an overwhelming stressor such as breast cancer, Type C coping patients can either: a) continue with Type C coping, resulting in a worse outcome, b) develop hopelessness and learned helplessness, or c) develop improved coping styles through psycho-intervention, leading to improved emotional expression and increased social support (Temoshok, 1987). This paper presents findings of a mixed methods study of 69 womxn currently fighting or in remission from breast cancer and explores what factors influence emotional coping, particularly Type C, and their preferences about physician-driven referrals to therapy.

Methods:

A sequential concurrent design in two phases included a demographics-based about treatment, emotions, stressors, and opinions on therapy referrals. The Courtauld Emotional Control Scale (CECS), which measures the extent of breast cancer patients’ ability to control (or suppress) their emotions was administered. High scores relating to anger, depressed mood, and anxiety indicate increased levels of control/suppression, whereas lower scores indicate emotional expression. Participants could self-select into Phase Two which comprised of a semi-structured interview. Inclusion criteria: 21 years+ and a diagnosis with breast cancer at any stage, grade, or hormone/HER2 status. National recruitment occurred at hospital cancer centers and through support organizations. Bivariate analysis including Chi-square and t-tests were used to determine significance of demographic factors of emotional expressers and suppressors. Content analysis was used to determine preferences about referrals to therapy.

Results:

There was no statistical association between suppression or expression and current cancer status (currently in treatment vs. no evidence of disease), however, participants 40 years+ are more likely to be emotionally suppressive (69.6%) compared to those aged 21-39 (p<.05). Participants who participated in therapy pre-diagnosis (56.5%) were more likely to be emotionally expressive compared to those who did not participate (43.5%) (p<.05). 71% of all participants (43/59 suppressors and 6/10 expressers) held beliefs that physicians should specifically refer each newly diagnosed patient to therapy. 29% of participants (16/59 suppressors and 4/10 expressers) held beliefs that the physician should offer some form of support. All participants, including Type C, believed some form of support should be offered, particularly post-treatment.

Implications

Physicians should consider referring all newly diagnosed patients to a therapist/counselor and create opportunities throughout treatment for psychotherapeutic support. Breast cancer patients have specific recommendations for medical providers related to the timing of referral, type of treatment and suggestions for collaborative care but often do not feel heard.