Objective

Method

Results

Conclusions

Background: The present four studies aimed to develop comprehensive, succinct measures of psychosocial resources and system-wide physiological dysregulation (allostatic load) and integrate these into a conceptual model, a modified form of the Reserve Capacity Model (Gallo & Matthews, 2003), to characterize how socioeconomic status, stress, psychosocial factors, mood, physiology, and health behaviors contribute to health outcomes.

Methods: Identification of factors underlying psychosocial resources was conducted in four independent samples in which a range of psychological and social resources were measured. A systematic review of psychosocial resources and allostatic load was conducted by retrieving all articles with "allostasis" or "allostatic load" in the title, abstract, or keywords from major databases. An allostatic load factor was examined using data from the large Midlife in the United States (MIDUS) study, which was also used for the final study linking SES, psychosocial resources, health behaviors, allostatic load, and a health outcome.

Results: In the first study, two factors, psychological and social resources, provided the best fit to all the psychosocial resources assessed. In Study 2, evidence of a common factor, allostatic load, underlying 23 biomarkers in MIDUS emerged, although there was also evidence of unique system-specific factors. In the systematic review of psychosocial resources and AL, results were mixed, with some studies finding null effects, and others finding significant positive or negative effects of psychosocial resources on allostatic load. In a fourth study testing the modified Reserve Capacity Model, results largely supported the model's predictions. SES was associated with better health outcomes indirectly via lower allostatic load, lower negative mood, and higher physical activity. These associations were themselves linked to SES via psychological resources and major stressful life events. Psychological resources were associated with higher physical activity, but not directly to allostatic load or health outcomes, and social resources had no association independent of psychological resources.

Conclusions: Psychological resources, social resources, and allostatic load form coherent constructs. Psychosocial resources appear more strongly associated with health behaviors than directly to allostatic load or health outcomes. Results generally supported the modified Reserve Capacity Model, suggesting it is a useful conceptual framework to guide future research.

The human experience is marked by emotion. Particularly with regard to distressing emotions, a commonly endorsed belief in the lay public and some clinical circles is that reflecting on and disclosing one’s emotions will reduce reactivity and buffer negative impact (McDaniel et al., 1981; Papageorgiou & Wells, 2001; Scheff, 2007; Wilson & Gilbert, 2008). However, findings from studies examining the effects of emotional reflection and expression on psychological and physical well-being are mixed. Although some research indicates that analyzing and verbalizing one’s emotions facilitates adaptive coping and psychological adjustment (e.g., Martin & Tesser, 1996; Pennebaker & Graybeal, 2001; Smyth, 1998; Stanton & Low, 2012; Wilson & Gilbert, 2008), other findings suggest that examining and expressing one’s emotions engenders rumination, ultimately intensifying negative affect (Mor & Winquist, 2002; Nolen-Hoeksema et al., 2008; Smith & Alloy, 2009).

The present research aims to investigate the conditions that facilitate adaptive emotional reflection and expression among individuals facing profoundly challenging stressors. Three interrelated studies explore the constructs of psychological distance (i.e., adopting a less personal perspective of one’s experiences), universality (i.e., viewing one’s experiences as shared by other people), and generativity (i.e., using one's experiences to benefit others) as factors hypothesized to facilitate adaptive emotional reflection and expression with regard to psychological and physical well-being. Study 1 examined linguistic indicators of psychological distance in expressive writing essays as a predictor of subsequent depressive symptoms in a sample of women diagnosed with metastatic breast cancer (N = 31). Study 2 was an experimental study that built on Study 1 to examine perceptions of psychological distance and universality in expressive writing essays altered to include linguistic indicators of psychological distance, and potentially universality (N = 171). Study 3 explored the influence of the social context surrounding emotional expression on adjustment using an experimental design. Specifically, an expressive helping intervention designed to facilitate emotional processing, psychological distance, a sense of universality, and generativity was compared to traditional expressive writing and a fact-writing control condition in a sample of bereaved young adults (N = 178).

Results from Study 1 indicated that linguistic indices of psychological distance significantly predicted declines in depressive symptoms 3 months after expressive disclosure, accounting for 24% of the variance in depressive symptoms. Findings from Study 2 demonstrated that participants who read essays altered to include linguistic indicators of psychological distance from Study 1 evidenced significantly greater perceptions of the essay author’s psychological distance and universality compared to participants who read the unaltered essays. Results from Study 3 revealed that participants in the expressive helping condition exhibited significant improvements in the primary outcomes of well-being and grief-related distress 2 months after engaging in the intervention relative to participants in the traditional expressive disclosure and fact-writing control conditions. In addition, findings supported the mediating roles of psychological distance, universality, and generativity in these observed improvements. Collectively, these studies demonstrate that psychological distance, universality, and generativity are important factors that can aid in facilitating adaptive emotional reflection and expression, especially in the context of severe stressors.

Background: Psychosocial correlates of mental and physical health related outcomes in poor-prognosis cancers are relatively understudied in comparison more favorable prognosis cancers. Relevant theory in stress and coping and social cognitive processes posit associations among cognitive appraisals, coping processes and adjustment to stressors and that these processes occur in a social context. Diagnosis of poor-prognosis cancer represents a profound health threat and activates cancer-related appraisals, including assessments of treatment goals and survival, as well as coping processes in attempts to mitigate the impact of the stressor. A cancer diagnosis typically involves additional individuals that serve in a supportive role, termed caregivers. Two studies were designed to examine facets of illness perceptions, coping, and mental and physical health-related outcomes to inform theoretical understanding of these constructs and to identify potentially malleable treatment targets in adults diagnosed with poor-prognosis cancer and their caregivers. Method: Adults diagnosed with lung (n = 52) or pancreatic (n = 36) cancer and their primary caregivers (n = 48) were enrolled from 2017 to 2020 in two separate studies focused on the experience of each respective cancer. Patients and caregivers in both studies reported sociodemographic and medical characteristics as well as completed measures of depressive symptoms, anxiety, life disruption from pain, and approach- and avoidance-oriented coping processes. In Study 1, patients completed a measure of prognosis and treatment perceptions. Study 1 examined the association of prognosis and treatment perceptions with depressive symptoms, anxiety, and life disruption from pain as and the moderating capacity of coping processes in these hypothesized associations using multiple regression analysis. Study 2 examined the interdependence of patient and caregiver coping processes and depressive symptoms, anxiety, and life disruption from pain using Actor Partner Interdependence Modeling. Results: Participants were adults who were diagnosed lung (n = 52) or pancreatic (n = 36) and their primary caregivers (lung n = 20, pancreatic n = 28). Both patients and caregivers were mostly older adults (patient M age = 66, caregiver M age = 62) who were white, well-educated, and financially secure. Nearly two-thirds of caregivers were women (n = 30, 62.5%), while about half the patients were women (n = 48, 54.5%). The overall sample was nearly 3 years post-initial diagnosis. Average depressive symptoms and anxiety were below clinical cutoffs, and average life disruption from pain was “within normal limits,” for both patients and caregivers. Rates of clinically elevated depressive symptoms in patients were lower than other advanced cancer samples and comparable to rates found in people with more favorable prognosis cancers. Patients diagnosed with pancreatic cancer reported clinically elevated anxiety at rates comparable to more favorable prognosis cancers, and lung cancer patients reported anxiety comparable with the general population. Caregivers reported levels of clinically elevated depressive symptoms and anxiety that were comparable to other advanced cancer samples and substantially greater than rates in the general population. Caregivers reported significantly higher rates of anxiety than patients, and patients diagnosed with pancreatic cancer and their caregivers reported greater anxiety than those diagnosed with lung cancer. Depressive symptoms, anxiety, and life disruption from pain did not differ as a function of gender. About one-third of patients reported a terminal illness perception, and there was discordance between perceived prognosis and treatment intent in about half the sample. Terminal (vs non-terminal) illness perception was associated with greater depressive symptoms and anxiety, but not with life disruption from pain. In patients, greater use of active coping was associated with lower depressive symptoms and buffered the association between terminal prognosis perception and greater depressive symptoms. Greater use of emotional processing coping was also associated with lower anxiety symptoms and buffered the association between terminal prognosis perception and greater anxiety symptoms. Greater acceptance coping was also associated with lower depressive symptoms. In caregivers, greater emotional expression coping was associated with lower depressive symptoms and less life disruption from pain. In both patients and caregivers, greater avoidance-oriented coping was associated with greater depressive symptoms and life disruption from pain and was also associated with greater anxiety in caregivers. Interdependence was observed between patient avoidance and caregiver depressive symptoms, though no other evidence of interdependence between patient and caregiver coping and outcomes was observed. Conclusions: Both patients and caregivers reported clinically elevated depressive symptoms and anxiety at higher rates than the general population. Patients diagnosed with pancreatic cancer and their caregivers were particularly vulnerable to psychological distress. Approach-oriented coping processes related to the cancer experience of active coping, emotional processing, and acceptance coping were associated with favorable outcomes in patients, and active coping and emotional processing buffered the impact of terminal prognosis perception on depressive symptoms and anxiety, respectively. Emotional expression coping was beneficial in caregivers. Avoidance-oriented coping was maladaptive in both patients and caregivers and was interdependent between patients’ avoidance and caregivers’ depressive symptoms. Interventions may promote emotional expression in caregivers, and promote active coping, emotional processing, and acceptance in patients, and reduce experiential avoidance in patients in caregivers. Future research should focus on differential effects of prognosis perceptions and coping on mental and physical health-related outcomes at distinct points along the cancer trajectory, incorporate cultural considerations, and focus on adapting existing interventions to use in the context of poor-prognosis cancer.

OBJECTIVE: Emotional expression and receipt of social support can promote psychological and physical health in women diagnosed with breast cancer. Communication between breast cancer patients and their social network can be challenging, however. Study 1 of the current research aimed to characterize the experience of women who participated in the intervention arm of Project Connect Online (PCO), a randomized controlled trial for breast cancer patients to create personal websites to facilitate emotional expression and communication with supportive others. Study 2, a comparative effectiveness trial of PCO for women with metastatic breast cancer (MBC), examined the potential psychosocial and physical health-related benefits of sharing personal websites with other MBC patients, family, and friends (PCO PLUS condition) versus sharing with family and friends only (PCO ONLY condition).

METHODS: Study 1 examined the 46 women in the intervention arm of PCO, a three-hour workshop for creation of personal websites with a journal function. Participants completed assessments at baseline, one month, and six months. In Study 2, 30 women with MBC were randomly assigned to PCO PLUS (n = 14) or PCO ONLY (n = 16) and attended a similar workshop. General and cancer-specific psychosocial and physical functioning was assessed at baseline, two months, and four months. Multilevel models examined comparative effectiveness of the two conditions, potential mediating variables, and predictors of change in outcomes.

RESULTS: Women in Study 1 found the websites useful for telling the story of their experience and expressing emotions. Greater use of positive and negative emotion words on the websites was associated with improved psychological functioning at six months. Women with advanced cancer were more likely to use their websites than women with early-stage disease. In Study 2, significant increases in life appreciation, MBC-related altruism, and cancer-related physical symptoms and worsening physical functioning were observed across conditions. Anxiety decreased significantly in PCO PLUS and did not change in PCO ONLY. No significant mediated effects of PCO PLUS versus PCO ONLY on outcomes were observed.

CONCLUSIONS: Personal websites can help women with breast cancer, and, in particular, MBC, construct a narrative of their experience and receive support. For women with MBC, personal websites to communicate with family and friends may improve cancer-specific psychosocial adjustment. Communicating with other MBC patients via personal websites, even infrequently, may confer additional psychosocial benefits.

Background: The extensive literature on stress and coping primarily focuses on intra-individual processes. The vital role of close relationships in influencing psychosocial, physiological, and behavioral adaptation to stressors warrants greater attention. The construct of communal coping involves two processes: an appraisal of the stressor as shared (i.e., “our problem” as opposed to “my/your problem”) and cooperative efforts to manage the stressor (Lyons, Mickelson, Sullivan, & Coyne, 1998). Research suggests that communal coping is associated with greater relationship satisfaction, more positive relationship processes, and lower engagement in unhealthy behaviors. However, the current body of literature is entirely correlational and has yet to eliminate third variable or reverse causality explanations. Intended to provide a more definitive test of the effects of communal coping, the present controlled experiment was designed to test the effects of induced communal appraisal and coping intentions on relevant psychosocial, physiological, and behavioral outcomes.

Method: Adults currently in an intimate relationship (N = 133) were randomized to write about a conflict in their relationship from a communal perspective as the couple’s problem, a non-communal perspective as the participant’s problem, or a non-communal perspective as the partner’s problem over two in-person laboratory sessions. Participants completed psychosocial, relational, and behavioral measures within each writing session and one week prior to and following the writing sessions. The present study examined differences between experimental conditions in primary outcomes (negative affect, relationship satisfaction, physical symptoms, alcohol use, heart rate) and secondary outcomes (perceived stress, sleep, interpersonal approach behaviors) over time, as well as moderators (dispositional communion, attitudes toward emotional expression).

Results: Experimental condition produced a statistically significant effect on change in state partner-directed negative affect from Session 1 pre-induction to Session 2 post-induction, with greater decreases in state partner-directed negative affect for participants in the Communal Coping condition than participants in the Non-Communal Partner condition. Participants in the Communal Coping condition had increases in physical symptoms, whereas participants in the Non-Communal Partner condition had decreases in self-reported physical symptoms. Experimental condition had no significant effect on relationship satisfaction, heart rate reactivity or recovery, interpersonal approach behaviors, and sleep. Dispositional communion significantly moderated the effect of experimental condition on within-session state individual negative affect and perceived stress, as well as perceived stress at one-week follow-up, such that participants with greater dispositional communion assigned to the Communal Coping condition experienced greater improvement on those variables than did participants in the Non-Communal conditions. Attitudes toward emotional expression significantly moderated the relationship between experimental condition and change in alcohol use from baseline to follow-up, participants in the Non-Communal Partner condition with more positive attitudes toward emotional expression had greater increases in alcohol use from baseline to follow-up than participants in the Communal Coping condition.

Conclusions: Taken collectively, the findings suggest that experimentally-induced communal appraisal and coping intentions may benefit individuals during relationship conflicts, particularly by buffering against negative partner-directed affect, individual negative affect, and perceived stress. However, induced communal coping produced an increase in physical symptoms, and further research is needed to examine the potential costs of coping communally.

The aim of this dissertation was to examine emotional expression and positive affect in a sample of Latina and non-Latina white female undergraduate students at UCLA experiencing chronic financial stress. In order to assess the influence of dispositional emotional tendencies, stressor-specific coping, and cultural factors on outcomes of induced emotional expression, the first study examined the main and moderated effects of induced emotional expression on depressive symptoms, intrusive thoughts, negative affect, and positive affect. The second study examined a unifying model in order to elucidate possible pathways by which positive affect is sustained over time in the context of chronic stress through its relationship with dispositional emotional tendencies and stressor-specific coping. Method: After being screened to establish at least moderate chronic financial stress, women (N = 136) were randomly assigned to discuss the emotions regarding their financial stress (induced emotional expression) or the facts regarding their finances (control) during two laboratory sessions. Depressive symptoms, intrusive thoughts, negative and positive affect were assessed at baseline and one- and ten-week follow-ups. Study 1 Results: Multilevel modeling analyses demonstrated that approach-oriented dispositional and stressor-specific processes predicted better psychological adjustment over time, whereas avoidance-oriented processes predicted greater distress over time. Stressor-specific coping self-efficacy uniquely predicted better psychological adjustment across all four outcomes. There was no significant main effect of condition; however, the effect of condition was moderated by dispositional and stressor-specific factors. Induced emotional expression predicted lower distress across time than the control condition at high levels of avoidance processes and predicted greater positive affect across time than the control condition at low, mean, and high levels of stressor-specific coping self-efficacy and approach processes, with the magnitude of this effect increasing at higher levels of these processes. Study 2 Results: Path model analyses demonstrated that dispositional emotional acceptance and reflection were associated with higher baseline positive affect, which in turn was associated with greater stressor-specific coping self-efficacy. Both baseline positive affect and stressor-specific coping self-efficacy predicted greater positive affect at one week, which subsequently predicted greater positive affect at ten weeks. Conclusions: Findings suggest that induced emotional expression both counteracts engagement in avoidance-oriented processes to reduce distress and capitalizes on stressor-specific coping self-efficacy and approach-oriented processes to increase positive affect. Furthermore, stressor-specific coping self-efficacy predicts better psychological adjustment across time and specifically plays a role in the sustenance of positive affect over time in the context of chronic stress. Taken together, the two studies underline potential benefits associated with stressor-specific coping self-efficacy in young women coping with chronic financial stress and suggest that it may be a good target for intervention.

Few psychosocial interventions for adolescents and young adults (AYAs) with chronic illness aim to promote medical transition readiness (i.e., preparation to transfer from pediatric to adult medical care), an important developmental task. Inadequate medical transition readiness can result in poor psychological, financial and health-related outcomes. Guided by research and theory in Positive Youth Development (PYD), childhood chronic illness and medical transitions, the primary goals of the studies comprising this dissertation were to identify and promote factors that contribute to medical transition readiness. First, a systematic review of the literature was conducted to identify studies that assessed self-efficacy for disease management in AYA cancer survivors. In the second study, young adults with chronic illness were randomly assigned to a Coping Skills Intervention (CSI) condition, representing a life skills intervention in line with PYD theory; or a print control condition (Informational Materials; IM). All participants received weekly emails with information that aims to promote medical transition readiness. Participants in the CSI condition also attended an eight-week cognitive behavioral therapy group. Findings from the systematic review indicated 1) that self-efficacy for disease management is positively associated with health-promoting behaviors and inversely related to physical and mental health problems; and 2) that behavioral and educational interventions have the potential to increase self-efficacy. Results of the randomized controlled trial demonstrated that at two months (immediately post-intervention), CSI (vs. IM) participants were significantly more likely to have initiated the transition to adult medical care. There was no significant impact of group assignment on disease-related skills and knowledge, medical regimen adherence, quality of life, or depressive symptoms. CSI (vs. IM) group members demonstrated significantly higher illness-related benefit finding, self-efficacy and approach-oriented coping, as well as lower anxiety and perceived illness-related threat. Future research and clinical intervention refinement should build on the current findings by incorporating additional components of Positive Youth Development programs and by evaluating the CSI in diverse populations and settings. Additional directions for research include the need for validated measures of self-efficacy for disease management for AYA cancer survivors, as well as interventions that target the health care team’s role in promoting self-efficacy.

Stigma and discrimination confer risk for poor mental and physical health for lung cancer patients, and research is needed to understand how and for whom stigma and discrimination are associated with poorer health-related adjustment. Although research has consistently demonstrated that the majority of lung cancer patients report experiences of stigma, longitudinal studies are needed to assess temporal relationships between lung cancer stigma and health-related adjustment. Additionally, no study has tested the unique contributions of lung cancer stigma and discrimination on psychological and physical health-related outcomes. Study 1 examined internalized lung cancer stigma (i.e., feelings of guilt, shame, and self-blame about one’s lung cancer diagnosis) and perceived subtle discrimination (i.e., perceptions of unfair treatment due to one’s lung cancer status that are ambiguous or low in intensity) as predictors of psychological and physical health outcomes across 12 weeks in 101 men and women on active treatment for lung cancer (any stage, any diagnosis duration). Based on theory and evidence, Study 2 tested whether sleep disturbance mediated relationships between lung cancer stigma and discrimination with poorer health-related adjustment in the same sample of lung cancer patients. Participants completed questionnaires at study entry and at 6- and 12-week follow-up.

Findings from Study 1 indicated that internalized stigma and perceived subtle discrimination were uniquely and significantly associated with worse global quality of life and poorer psychological outcomes at study entry. Internalized stigma also predicted significant declines in global quality of life and increases in depressive symptoms and anxiety across time. Overall, the pattern of findings indicated that higher internalized stigma was a robust and independent predictor of declines in health-related outcomes across 12 weeks, whereas perceived discrimination was not. Study 1 also tested whether protective psychological processes (i.e., self-compassion, coping strategies) attenuated significant relationships between stigma and discrimination with health outcomes. Higher self-compassion and lower avoidant coping significantly moderated relationships between stigma and discrimination and psychological health. Specifically, when self-compassion was relatively high and avoidant coping was relatively low, internalized stigma and discrimination were not associated significantly with poorer psychological health. When self-compassion was relatively low and avoidant coping was relatively high, however, higher internalized stigma and higher perceived discrimination were associated with higher depressive symptoms and cancer-related anxiety, respectively.

Results from Study 2 demonstrated that lung cancer patients evidenced prominent sleep disturbance, as measured through subjective and objective measures. Perceived subtle discrimination (but not internalized stigma) was associated significantly with higher subjective sleep disturbance at study entry and across time, and subjective sleep disturbance was robustly associated with poorer psychological and physical health. At study entry, higher subjective sleep disturbance significantly mediated the association between higher perceived subtle discrimination and higher depressive symptoms, worse global and cancer-specific quality of life, higher cancer-related anxiety, and more bothersome physical symptoms. Overall, the pattern of findings in Study 2 indicated that higher perceived discrimination was robustly associated with poor sleep, which may explain, in part, the significant relationships observed between higher perceived discrimination and poorer psychological and physical health-related outcomes in Study 1. Future research is recommended to develop health care provider- and patient-focused interventions to reduce lung cancer stigma and test whether such interventions promote health and well-being for this underserved and understudied population.

PURPOSE: Many interventions have been designed to promote psychological adjustment during and following cancer diagnosis and treatment; however, notably few studies have specified the mediating processes through which these interventions work. The primary aim of this research is to examine theoretically and empirically grounded mediators of a web-based psychosocial intervention for women with breast cancer.

METHODS: Women (N = 88) diagnosed with breast cancer (any stage, any time since diagnosis) were randomly assigned to participate in a three-hour workshop for hands-on creation of personal websites. Mediating variables were assessed at baseline, one month and six months following randomization, and dependent variables were assessed at baseline and six months following randomization. Indirect effects were tested using single and multiple mediator models.

RESULTS: Relative to control participants, women randomized to Project Connect Online (PCO) evidenced significant benefit six months later on depressive symptoms, positive mood, and life appreciation, but not negative mood, perceived strengthened relationships, or intrusive thoughts. Change in coping self-confidence, loneliness, and social support from friends mediated the relationship between the intervention and improvement in depressive symptoms. Coping self-confidence mediated the relationship between the intervention and enhanced positive mood, and social support from friends mediated the relationship between the intervention and increased life appreciation. The intervention did not produce a significant change in the hypothesized mediator of self-reported emotional processing/expression.

CONCLUSIONS: Findings indicate how PCO promoted adaptive change and highlight modifiable factors, including coping self-confidence, loneliness, and social support from friends, which contributed to positive adjustment to breast cancer. Examination of why emotional processing/expression was not associated with change in outcome variables suggests possible additional mediators of the treatment effect and ways in which the intervention can be enhanced.