emotional control in chinese female cancer survivors

PSYCHO-ONCOLOGY

Psycho-Oncology 13: 808–817 (2004)Published online 3 March 2004 in Wiley InterScience (www.interscience.wiley.com).DOI: 10.1002/pon.799

EMOTIONAL CONTROL IN CHINESE FEMALECANCER SURVIVORS

RAINBOW T.H. HOa,b,*, CECILIA L.W. CHANa,b and SAMUEL M.Y. HOb,c

aDepartment of Social Work and Social Administration, The University of Hong Kong, Hong KongbCenter on Behavioral Health, The University of Hong Kong, Hong KongcDepartment of Psychology, The University of Hong Kong, Hong Kong

SUMMARY

Chinese persons are not known as strong in expressing emotions, especially negative ones. However, being diagnosedwith cancer and going through treatment can be an emotionally traumatic experience and cancer patients aresupposed to have a stronger need to express these negative feelings. The control of expression of negative emotionssuch as anger, anxiety and depression in Chinese female cancer survivors (n=139) was examined in the present studyusing the Chinese version of the Courtauld Emotional Control Scale (CECS). The reliability, internal consistencyand validity of the Chinese CECS were comparable to the original English scale. Correlation analyses suggested thatcancer survivors with higher emotional control tended to have higher stress, anxiety and depression levels and toadopt negative coping with cancer. Regression analysis showed that emotional control would positively predictstress level even after the effect of depressed mood was under control. Further investigations are suggested in orderto elucidate the causal relationships and specific cultural factors affecting emotional control in Chinese cancersurvivors and, most importantly, its effect on health outcomes. Copyright # 2004 John Wiley & Sons, Ltd.

INTRODUCTION

Emotional control has long been argued to be animportant psychological factor affecting diseaseprogression and prognosis in cancer patients(Blumberg et al., 1954; Stavraky et al., 1968;Smith and Sebastian, 1976; Cox and Mackay,1982; Temoshok, 1987; Gross, 1989; Mckennaet al., 1999). Empirical evidence has been accu-mulated to support the link between cancerdevelopment and personality traits such as thesuppression (lack of expression) of emotion orinappropriate expression of negative emotion(Greer and Morris, 1975; Kissens and Eysenck,1962; Pettinglae et al., 1984, Weihs et al., 2000).The possession of a Type C personality character-ized by conflict avoidance, or a repressive,defensive character (a defense mechanism, usuallydefined as unable to cognitively aware of emotionsor feelings), has also been suggested to be

associated to cancer occurrence or even as animportant prognostic factor in patients (Greeret al., 1979; Dattore et al., 1980; Jensen, 1987;Watson et al., 1999; Tacon et al., 2001). However,some past studies have not demonstrated a directrelationship between personality, repression ornonexpression of negative emotions, fightingspirit, and cancer progression (Scherg et al.,1981; Cassileth et al., 1985; Persky et al., 1987;Jamison et al., 1987; Dean and Surtee, 1989;Silberfarb et al., 1991; Bleiker et al., 1996; Giraldiet al., 1997; Price et al., 2001). Recent discoveriesin the field of psychoneuroimmunology, however,seem to support a psychological link to cancerdevelopment and progression through the media-tion of the immune system (O’Leary, 1990; Snyderet al., 1993; Cohen and Herbert, 1996; Garssenand Goodkin, 1999; Wadee et al., 2001).

Emotional control, stress and psychological symp-toms in cancer patients

Cancer, as a life event, will usually induce stress,anxiety, and depression. Cancer patients aresupposed to have a stronger need to express their

Received 24 June 2003Copyright # 2004 John Wiley & Sons, Ltd. Accepted 24 December 2003

*Correspondence to: Center on Behavioral Health, TheUniversity of Hong Kong, G/F, Pauline Chan Building, 10,Sassoon Road, Pokfulam, Hong Kong.. E-mail: [email protected]

negative emotions than normal people. At thesame time, they have been reported to have agreater tendency to control or suppress theiremotions, though the underlying mechanism needsfurther clarification (Pettinglae et al., 1984; Foxet al., 1994; Bleiker et al., 1996; Servae et al., 1999;O’ Donnell et al., 2000; Giese-Davis and Spiegel,2001). In a study conducted by Weihs et al., theyreported increased mortality associated with emo-tional constraint and control of feelings in 32breast cancer patients suggesting the possiblepsycho-physical mechanisms and the effect ofemotional constraints on health outcomes (Weihset al., 2000). The significant relationship betweennegative emotional inhibition and psychologicaldistress was also reported recently by Iwamitsuet al. (2003). They found that cancer patients whorestrained their negative emotions were muchmore anxious, depressed and confused after beinggiven the diagnosis compared to patients whoexpressed negative emotion. As we know, stresscan be accumulated at a time when people cannotexpress or relieve the negative emotions it causes,and chronic stress will then be developed. Inpatients with a suppressive character, depressionmay be well resulted and stress will be furtherintensified. Recent discoveries in the field ofpsychoneuroimmunology have suggested thatstress plays an important role in cancer progres-sion and prognosis through the mediation of theimmune system (Jensen, 1987; O’Leary, 1990;Cohen and Herbert, 1996; Wadee et al., 2001).The interplay between stress, depression andemotional control is therefore worth more detailedinvestigation.

Emotional control and coping styles in cancerpatients

It is a commonplace observation that somepeople are better at expressing their emotions thanothers. This difference in personality markedlyaffects psychological response and adjustment tocancer, and even health outcomes. Watson et al.(1991) observed a significant relationship betweenemotional control, especially anger control, ahelpless attitude, and increased anxiety anddepression in breast cancer patients. Classen et al.(1996) also suggested an association betweenfighting spirit, emotional expressiveness and betteradjustment, although no causal relationship wasclaimed due to the cross-sectional design of their

study. However, in the baseline of this study, theyfound a positive association between emotionalcontrol and mood disturbance in metastatic breastcancer (Giese-Davis and Spiegel, 2001). Copingattitudes played an important role in adjustmentto cancer and affected health outcomes. In a studyconducted by Greer et al., a significant linkbetween psychological response and cancer prog-nosis was observed. They found that patients withfighting spirit or denial were more likely to be aliveand relapse-free after the first cancer diagnosisthan patients with helplessness or stoic acceptance(Greer et al., 1979). Emotional expression, copingstyles and health outcomes in cancer patients arethen inter-related. In fact, Temoshok had sug-gested a model emphasizing the link betweenemotional expressions and coping style. He pro-posed that expression of emotion was an impor-tant contributor to the development of a copingstyle. The more expressive an individual is, themore genuine social support or resources ofsupport he can obtain, and the more likely he isto have a positive health outcome (Temoshok,1987).

Expression of emotion among Chinese

Chinese are generally considered to control theexpression of their emotions more than Europeansand Americans (Russell and Yik, 1996; Tsai andLevenson, 1997). Traditionally, Chinese culturehas placed a high value on maintaining harmo-nious relations with others, and this culturalpreference requires a high degree of circumspec-tion in the outward expression of emotions (Chanand Rhind, 1997). In a study of national char-acteristics Markus and Kitayama concluded thatmany Asians, including Chinese, were interdepen-dent, while most Americans were independent(Markus and Kitayama, 1991). Many Asiancultures ‘insist on the fundamental relatedness ofindividuals to each other.’ Under this interdepen-dent construct, ‘a high degree of self-control andagency to effectively adjust oneself to variousinterpersonal contingencies’ will be emphasized.The expression of private emotion, especiallyanger or other negative emotions will thereforebe handled with extreme caution, because it maydisturb the harmonious equilibrium of interperso-nal transactions (Bond, 1993).

Hong Kong was a British colony for 156 years(1841–1997), and Hong Kong Chinese have been

EMOTIONAL CONTROL 809

Copyright # 2004 John Wiley & Sons, Ltd. Psycho-Oncology 13: 808–817 (2004)

influenced both by traditional Chinese culture andby Western culture. It would therefore be inter-esting to discover whether Hong Kong Chinesecancer patients remain determined to suppressdisplays of negative emotion, or whether they aremore willing to express their emotions in theWestern style. In the present study, with the use ofthe Courtauld Emotional Control Scale (CECS),which was designed to measure the tendency ofcontrol (showing or not showing) the emotions ofanger, anxiety and depressed mood when anindividual is feeling it, we want to explore whetherthis Western scale could apply to Hong KongChinese.

Negative moods such as anxiety and depressionare usually the concomitants of stress. However,this relationship may not only be unidirectional.For a person with depressed mood, stress may beexacerbated. In this study, in addition to explorethe relationships among stress, emotional control,psychological symptoms such as anxiety anddepression as well as different coping styles tocancer in Chinese cancer survivors, we also wantto find out to what extent depressed mood couldpredict perceived stress and how this relationshipwould be influenced when a person tends tocontrol the expression of negative emotions anduses different coping strategies. Based on thefindings of previous studies, we hypothesized thathigher emotional control, more depressed moodand coping with negative emotions will lead tohigher perceived stress; while a positive attitudetowards cancer will work in reverse.

METHOD

Subjects

We sampled 139 female cancer survivors fromfour hospitals and community services centers indifferent geographical locations in Hong Kong.These centers included: the Queen Mary Hospital(n=35, 25.2%), The Queen Elizabeth Hospital(n=25, 18.0%), the Pamela Youde NethersoleEastern Hospital (n=20, 14.4%) and the Cancer-Link-support and Resource Centre (n=59,42.4%). Eligible participants who were disease-free in the past 5 years were identified by the socialworker in each center. They were invited to jointhe study and those who indicated interest in studyparticipation were asked to sign the written

informed consent before they completed thequestionnaires. Participants were between 28 and69 years old (M=49.28 years, S.D.=8.41 years).18.0% of the sample were single, 67.6% married,6.5% divorced or separated, and 5.8% widowed.2.2% (n=3) did not report their marital status. ofthe subjects stated that they had no formaleducation, 21.6% had completed primary educa-tion, 13.7% had completed lower secondaryeducation (F.1–F.3), 40.3% had completed higherschool (F.4–F.5), 7.2% had finished matriculation,and 15.1% had obtained a degree or completedpost-matriculation. Two subjects (1.4%) did notreport their educational level. A slight majority ofthe participants were housewives (52.5%); theothers included part-time workers (7.2%), full-time workers (17.3%), retired workers (15.8%),and workers in other forms of employment(5.0%). 2.2% did not respond. Cancer typesreported were: breast cancer (n=89, 64%), naso-pharyngeal cancer (n=12, 8.6%), gynaecologicalcancer (n=15, 10.8%), colon cancer (n=6, 4.3%),lymphoma (n=4, 2.9%), leukemia (n=4, 2.9%),stomach cancer (n=3, 2.2%), liver cancer (n=2,1.4%), bladder cancer (n=1, 0.7%), brain cancer(n=1, 0.7%), kidney tumor (n=1, 0.7%) and lungcancer (n=1, 0.7%).

Measures

Emotional control. The CECS (Watson andGreer, 1983) was developed to assess the extentof emotional control when a particular negativeemotion is experienced. It contains 21 itemsseparated into three subscales for the report ofthe suppression or the expression of feelingstowards anger, anxiety, and unhappiness (de-pressed mood). Subjects were asked to respondto the phrases such as ‘When I feel angry. . .,’‘When I feel anxious (worried)’ or ‘When I feelunhappy (miserable)’ with statements such as ‘Ikeep quiet,’ ‘I bottle it up,’ ‘I tell others about it’ or‘I let others see how I feel.’ They were also asked toindicate the extent of such feelings by qualifyingthem with phrases such as ‘almost never,’‘sometimes,’ ‘often’ and ‘almost always.’

The original instrument obtained good test–retest reliability, good internal consistency for eachsubscale, and predictive validity (Watson andGreer, 1983; Fox et al., 1994). A Chinese version

R.T.H. HO, C.L.W. CHAN AND S.M.Y. HO810


of the scale was developed through the proceduresof translation and back translation to ensure themeaning of each statement corresponded accuratelyto the meaning of the original one. Subscale alphacoefficients of the Chinese version are 0.74 (anger),0.80 (anxiety), and 0.84 (depressed mood), whichwere comparable with those reported in Watson’sstudy (Anger: 0.86, anxiety: 0.88; depressed mood:0.88), showing the internal consistency of eachsubscale. Cronbach’s coefficient a was 0.92 for thewhole scale, suggesting that the Chinese version ofthe scale has acceptable reliability (Nunnally andBernstein, 1994). Moreover, the correlation coeffi-cient r for each subscale with CEC total score was(anger to CEC total) 0.86, p50.01, (anxiety to CECtotal) 0.92, p50.01 and (depressed mood to CECtotal) 0.94, p50.01, respectively.

Perceived stress. The Perceived Stress Scaleused in this study is a 10-item scale (Cohen andWilliamson, 1988). It was adapted from theoriginal 14-item scale to measure the degree towhich a situation in one’s life is perceived asstressful (Cohen et al., 1983). Participants wereasked to describe how often they felt stressed in thepast month using a 5-point Likert scale thatranged from never (1) to very often (5). Four ofthe statements were reversal items which includeditems such as ‘felt confident about your ability tohandle personal problems,’ ‘felt things were goingyour way,’ ‘been able to control irritations in yourlife’ and ‘felt you were on top of things.’ Thehigher the scores, the higher the perceived level ofstress will be implied. Cronbach’s coefficient alphawas 0.82 in the present study.

Psychological symptoms. The Hospital Anxietyand Depression Scale (HADS) was originallydesigned to access the psychological states ofpatients with physical problems (Zigmond andSnaith, 1983). Previous studies have indicated itsusefulness in psycho-oncological research andpractice (Ford et al., 1990; Razavi et al., 1990).The Chinese version was developed to be equiva-lent in language usage, scale and structural aspectsto the English original (Leung et al., 1993), andhas been shown to be so. Cronbach’s coefficientalpha for anxiety and depression subscales was0.88 and 0.77, respectively, in this study.

Mental adjustment to cancer. The Mini-MentalAdjustment to Cancer Scale (Mini-MAC) is ashorter version of the 40-item Mental Adjustment

to Cancer Scale (MAC) (Watson et al., 1988). TheChinese version of the Mini-MAC (CMMAC)consists of 29 items, and has been validated by Hoet al. (2003). A three-factor structure was identifiedfor the Chinese version as being more appropriatefor a Chinese population. The items in Help-lessness–Hopelessness and the Anxious Preoccu-pation subscale in the original five-factor modelare included in the same factor (negative emotion)in Chinese versions. The Fighting Spirit and theFatalism subscales in the original version aregrouped into one factor named the positiveattitude. Cognitive avoidance remained the samein both versions. The Chinese version has beendemonstrated to have good internal consistency.Cronbach’s alpha coefficients for the three sub-scales were 0.91 (negative emotion), 0.77 (positiveattitude) and 0.65 (cognitive avoidance), respec-tively, in Ho’s study and were 0.89, 0.79, and 0.63in the present study.

Data analysis

The internal reliability of the scale and thesubscales were examined by using Cronbach’salpha coefficient. Pearson’s product moment cor-relations were performed to investigate the asso-ciations among scales and variables measured. Anhierarchical multiple regression analysis was con-ducted to examine the predictive power of emo-tional control, negative mood and variousstrategies to cope with stress. We used stress as adependent variable because of its well-establishedrelationship with immune function and healthoutcomes. The depression subscale of HADS wasincluded in the first block as we want to know howthe effect of mood could predict the perceivedstress. Emotional control and other coping vari-ables were included in the second block aspredictor variables since we wanted to explore ifthe effect of mood was under control, to whatextent emotional control and coping styles couldpredict stress level.

RESULTS

The descriptive statistics

Table 1 shows the descriptive statistics foremotional control, perceived stress, anxiety, anddepression and coping styles.



The inter-relationship between emotional control,psychological morbidities, and coping variables

The associations among emotional control andother variables were examined using Pearson’s-product moment correlations (Table 2). Significantassociation was observed in our subjects betweenPSS score and CECS total score (r=0.358,p50.001). For HADS, weak associations hadbeen reported by Watson’s team in 1991 betweenCECS anxiety and HADS anxiety and CECSdepressed mood and HADS depression scores. Inthis study, however, significant correlation was

obtained between the CECS anxiety score andHADS anxiety score (r=0.291, p50.01) and theCECS depressed mood score and HADS depres-sion score (r=0.330, p50.01). The overall CECSscore was also well correlated with HAD anxiety(r=0.371, p50.001) and HAD depression(r=0.330, p50.001).

Strong association was also obtained betweenemotional control and negative emotion in MiniMAC scale (r=0.303, p50.001), which comprisedthe helplessness and anxious preoccupation sub-scales of the original English one. Negative but notsignificant association (r=–0.118, p=0.167) wasobserved between emotional control and thepositive attitude, which included the fighting spiritand fatalism subscales. The association of cogni-tive avoidance to emotional control was notsignificant at all (r=0.083, p=0.330) in the presentstudy.

As a whole, the CECS total score was signifi-cantly related to HAD anxiety, depression, per-ceived stress and negative emotion subscale inMiniMAC. Positive attitude and cognitive avoid-ance did not show significant relationships.

Moreover, for the associations among all thevariables measured, the findings were in accor-dance with Ho’s study (2003) and Watson’s study(1991). Significant inter-relationships were foundamong stress, anxiety, depression, negative emo-tion and positive attitude. Cognitive avoidance didnot relate to other scales except the subscales of itsown instrument, indicating the same concept(coping to cancer) they measured.

In order to further explore the relationshipsbetween emotional control, depression, and

Table 1. Descriptive statistics (n=139)

Mean (S.D.)

Emotional control

Control of anger 17.94 (4.28)

Control of anxiety 16.98 (4.67)

Control of depression 16.63 (5.03)

Total emotional control 51.55 (12.71)

Perceived stress

PSS 15.59 (7.10)

Hospital anxiety and depression

Anxiety 6.42 (4.08)

Depression 4.60 (3.53)

Mini MAC

Negative emotion 17.31 (8.23)

Positive attitude 18.81 (4.32)

Cognitive avoidance 7.06 (2.29)

Table 2. Correlation coefficients between emotional control, perceived stress, anxiety and depression and mental adjustment

to cancer

1 2 3 4 5 6 7 8 9 10

1. Anger }

2. Anxiety 0.67�� }

3. Depressed mood 0.71�� 0.82�� }

4. Emotional control 0.86�� 0.92�� 0.94�� }

5. Perceived stress 0.33�� 0.29�� 0.36�� 0.36�� }

6. HAD anxiety 0.31�� 0.29�� 0.40�� 0.37�� 0.66�� }

7. HAD depression 0.29�� 0.28�� 0.33�� 0.33�� 0.49�� 0.68�� }

8. Negative emotion 0.23�� 0.26�� 0.33�� 0.30�� 0.44�� 0.61�� 0.58�� }

9. Positive attitude –0.13 –0.11 –0.08 –0.12 �0.26�� –0.25�� –0.37�� –0.34�� }

10. Cognitive avoidance 0.03 0.08 0.11 0.08 0.04 0.11 0.09 0.20� 0.37�� }

�p50.05, ��p50.00.



different coping strategies for stress, hierarchicalmultiple regression analysis was conducted. Sincewe want to know the effect of mood in relation toperceived stress, we entered HAD depression asthe single predictor at the first place. Table 3displays the results of the regression analysis. Theregression equation for model 1 was significantwhen depression was the only predictor to stress(R2=0.24, adjusted R2=0.234, F (1,137) =43.15,p50.001). A high score in HAD depression wasoften an indication of a high score in perceivedstress. The final model was also significant(R2=0.315, adjusted R2=0.294, F (4, 134)=15.39, p50.001) when emotional control andcoping style variables were entered. R2 change was0.075, implying that emotional control and copingstyle variables could account for an additional7.5% of the variance of perceived stress. Cognitiveavoidance was not entered into the regressionanalysis because it did not correlate to othervariables as indicated in Table 2. The final modelmeans that when depression was under control,emotional control and negative coping style(hopelessness and anxiety preoccupation) couldstrongly and positively predict the level of stress.Of course, emotional control was a strongerpredictor than negative emotion in coping.Positive attitude in coping and cognitiveavoidance were not significantly related to stressbut we observed the negative direction in therelationship.

DISCUSSION

The Chinese version of CECS showed goodinternal consistency and reliability when appliedto Chinese cancer survivors. The correlationbetween the subscales and the main scale wassignificant, indicating that the dimensions mea-sured by the three subscales are not totallyindependent, as suggested by Watson when thescale was originally constructed (Watson andGreer, 1983). The validity of the scale was alsoacceptable, as the relationships between CECS,HADS and MiniMAC followed the predicteddirection. In addition, none of our subjects foundany particular difficulty in responding to theChinese version, indicating that the Chineseversion of CECS can be applied to a Chinesepopulation. We also found Hong Kong Chinesecancer survivors scored higher on the subscale ofcontrol of anger than the British counterparts inWatson’s study (1983), while the scores in twoother subscales were comparable to each other(data not shown). This finding is consistent with areport that Chinese cancer patients tend to avoidexpressing their anger but use passive-aggressivedefenses in coping with the disease (Ho and Shiu,1995), although care must be taken as the samplesused in two studies were different in age range,cancer type and cultural background.

Examination of the correlations among emo-tional control, psychological morbidity and copingvariables revealed that emotional control wasclosely associated with perceived stress, anxiety,depression, and negative emotions in coping withcancer. Patients with high emotional control andnegative coping style may have higher stress,anxiety and depression, or we could say thatpatients would have higher stress and depressedmood when the expression of negative emotionswas under control or have a hopelessness attitude.It is understandable because when a person isfeeling the negative emotion, he or she may usuallyneed to find some ways to relieve it. If he or shetends to exert some control over the decision ofexpressing it or not, additional stress may beinduced and the negative emotions may be furtherintensified. Since it is only a cross sectional study,we cannot draw any conclusion on the causalrelationship or even the direction of those relation-ships. Nonetheless, it implies that interventionprograms dealing with stress management andemotional sharing would probably help patients to

Table 3. Results of hierarchical regression analysis

Model Independent

variables

Dependent variable

Perceived stress

B S.E.B Beta t

1 HAD depression 0.99 0.15 0.49 6.57��

R2 0.240

F 43.15��

2 HAD depression 0.58 0.19 0.29 3.13��

Emotional control 0.11 0.04 0.20 2.55�

Negative emotion 0.17 0.08 0.20 2.21�

Positive attitude –0.10 0.13 –0.06 –0.788

R2 0.315

F 15.39��

�p50.05, �� p50.01, ��p50.001.



reduce psychological stress. These findings, to-gether with the significant associations between theHADS subscales and MiniMAC subscales,matched the findings in Watson’s study (1991) asthey also demonstrated these relationships. How-ever, the strong positive association betweenfatalism and emotional control reported in Wat-son’s study did not appear here. In the presentstudy, emotional control was negatively related toboth the fatalism and fighting spirit subscales,although the relationship was not significant (datanot shown). This result supports the findings of Hoet al. (2003), whose study showed that fatalismcould be viewed as one method of ‘tolerating thesituation better.’ In Chinese, fatalism could becombined with fighting spirit to form one singlefactor, a ‘positive attitude’ towards cancer. In thisstudy, a positive attitude in coping was found to benegatively related to all psychological morbidityvariables, indicating that this coping style wasassociated with reduced stress, anxiety and depres-sion, although its effect on depression was themost significant. In addition, the negative relation-ship between positive attitude and emotionalcontrol, though not significant, suggested thatthe control of emotional expression would prob-ably lessen the positive attitude in patients to dealwith their diseases. As stated before, no causalrelationship could be concluded due to the cross-sectional design of the resent study. It would beworth pursuing this aspect further, and conductinga longitudinal study to investigate the influence ofemotional control and coping styles on healthoutcomes in Chinese cancer patients.

Regression analysis suggested that depressionwas a significant predictor of perceived stress.Depressed patients usually report a higher stress astheir bad mood may affect the way people thinkand feel about events that happen to them. In arecently published study in high risk youth, thesynergistic and causal relationships of stress anddepression has been found (Galaif et al., 2003),indicating the bidirectional relationship betweenthem. In this study, when depressed mood wasunder control, emotional control showed itsprofound effect on predicting stress. This isunderstandable because control of emotionalexpressions could deter the individual from seek-ing social support and resources even though he orshe was not in a depressed mood. This will inducethe feelings of being isolated or loneliness, andwould further enhance the stress level. Moreover,if a person always tends to control the expression

of negative emotions when he or she is feeling it,the negative feelings and stress will accumulateand the individual will then be more vulnerable tofurther stressful events. This can explain thesignificant relationship observed in this studybetween stress, emotional control and a negativecoping style. In fact, when someone feels hopelessor helpless or is preoccupied with anxiety, he orshe will often not seek out help, and will thereforefeel more helpless and isolated; and in turn willlead to further stress. Fox et al. (1994) indicatedthis strong relationship between emotional sup-pression and loneliness in cancer patients. He alsofound that cancer patients scored much higher inCECS score especially the anger and depressionsubscales than benign and normal group. Ofcourse, due to the limitation of the study design,we could not set limit to those relationships to anyspecific direction here. Further research is neededto clarify the directions of those relationships aswell as the presence of any specific mediators ormoderators.

The findings of this study supported ourhypothesis that emotional control, depressionand negative emotion in coping with cancer areassociated with a higher stress level. The negativerelationship between positive attitude and stress isalso supported. Furthermore, this result suggeststhe value and the usefulness of psychosocialinterventions facilitating emotional expressionand reducing negative thoughts in cancer patients.Stanton et al. (2000) and Kennedy-Moore andWatson (2001) have reported that making it easierfor people to express their emotions can help inreducing distress. Supportive-expressive interven-tion, which strives to encourage emotional expres-sion and diminish negative thoughts, has also beenclinically proven to be useful both in reducingpsychological distress and in improving survivalrates in cancer patients (Spiegel et al., 1999;Reynolds et al., 2000; Esplen et al., 2000; Goodwinet al., 2001). Further research in this area will helpto elucidate the mechanism behind those relation-ships and further investigation is also necessary toestablish more firmly the relationship betweenemotional control and health outcomes, especiallyin cancer progression and prognosis.

Given the ‘interdependent’ character of Chinesesociety, many Chinese consider that the expressionof negative emotions, especially anger, is sociallyundesirable, and such expression is rarely encour-aged. It is also a traditional Chinese medical beliefthat the immoderate expression of any emotion,



whether negative or positive, can be harmful tohealth (Chan et al., 2001). To what extent,therefore, should our emotions be expressed? Willit be beneficial to our health if we express variouskinds of negative emotion? Many Chinese believethat if they talk about a negative emotion, thisemotion will persist or even intensify. Conversely,if they do not mention it, the emotion willnaturally fade away over time. Therefore, non-expression of negative emotions may also be a wayto help people to cope, or expression may not benecessary in some situations, especially when it issupposed to influence the harmony of interperso-nal relationship. The negative direction of avoid-ance coping style in prediction of perceived stresswe observed in this study maybe also due to thiscoping approach usually found among Chinese. Ofcourse, we could not tell the mechanism or thereasons behind this from this study. However, inChinese culture, maybe what we concern is notonly whether the negative emotions are sup-pressed, but also whether the negative emotionsare expressed in a proper way and to anappropriate extent; and this is what we reallymeans for ‘control.’ In our clinical experience,interventions with suitable emotional sharing andpositive empowerment worked quite well with ourcancer patients (Chan et al., 2001). More investi-gations should be directed toward the under-standing of the pattern of emotional control inChinese and its health outcomes. Maybe not onlythe control of expression of negative emotions, butalso the control of expression of positive emotionssuch as hope, love, desires or belief is worthfurther investigations as well.

In conclusion, the present study supported theapplicability of the Chinese version of CECS inHong Kong Chinese cancer survivors. The scalehad good internal consistency, reliability andvalidity. Correlation study indicated that thecontrol of negative emotions was closely relatedto stress, anxiety, depression, and negative emo-tion towards cancer (helplessness and anxiouspreoccupation). In our subjects, a depressed moodwas strongly related to a higher stress level. Higheremotional control could predict a higher level ofperceived stress, even when the depressed moodwas under control. Negative emotion in adjust-ment to cancer was also a predictor of perceivedstress. Positive attitude did not have a significantrelationship with emotional control, but wasclosely related to reduced stress. Further researchis necessary to elucidate the causal relationships

between emotional control, coping styles andpsychological morbidity factors, and their impacton health outcomes in Chinese cancer patients.This may enable an effective psychosocial inter-vention approach to be developed. Finally, across-cultural study will help to establish theinfluence of specific cultural factors on the patternof emotional control in Chinese cancer patients.

ACKNOWLEDGEMENTS

This study was supported in part by the Hong KongCancer Fund and the Committee on Research andConference Grants (CRGC) of the University of HongKong.We appreciate the contributions of Wong Kam Fung,

CancerLink Support & Resource Center, Hong Kong;Yu Kin Wa, Patients Resource Center, Queen ElizabethHospital, Hong Kong; Josephine Yuk Yee Cheng andFion Sau Kuen So, Cancer Center, Queen MaryHospital, Hong Kong; and Sherman Wai Ha Tang,Cancer Patients Resource Center, Pamela YoudeNethersole Eastern Hospital, Hong Kong who assistedin data collection. We also wish to present our sinceregratitude to all the participants in this study.

REFERENCES

Bleiker EM, Van er Ploeg HM, Hendriks JHCL, AderHJ. 1996. Personality factors and breast cancerdevelopment: A prospective longitudinal study. J NatlCancer Inst 88: 1478–1482.

Blumberg E, West P, Ellis F. 1954. A possible relation-ship between psychological factors and human cancer.Psychosom Med 16: 27–86.

Bond MH. 1993. Emotions and their expression inChinese culture. J Nonverbal Behav 17: 245–262.

Cassileth BR, Lusk EJ, Miller DS, Brown LL, Miller C.1985. Psychosocial correlates of survival in advancedmalignant disease? N Engl J Med 312: 1551–1555.

Chan C, Ho PSY, Chow E. 2001. A body-mind-spiritmodel in health: An eastern approach. Soc WorkHealth Care 34: 261–282.

Chan CLW, Rhind N (eds). 1997. Social Work Inter-vention in Health Care: The Hong Kong Scene. HongKong University Press: Hong Kong.

Classen C, Koopman C, Angell K, Spiegel D. 1996.Coping styles associated with psychological adjust-ment to advanced breast cancer. Health Psychol 15:434–437.

Cohen S, Herbert TB. 1996. Health psychology:Psychological factors and physical disease from the



perspective of human psychoneuroimmunology. AnnRev Psychol 47: 113–142.

Cohen S, Kamarch T, Mermelstein R. 1983. A globalmeasure of perceived stress. J Health Soc Behav 24:385–396.

Cohen S, Williamson GM. 1988. Perceived stress in aprobability sample of the United States. In The SocialPsychology of Health, Spacapan S, Oskamp S (eds).Sage: Newbury Park, CA; 31–67.

Cox T, Mackay C. 1982. Psychosocial factors andpsychophysiological mechanisms in the aetiology anddevelopment of cancers. Soc Sci Med 16: 381–396.

Dattore PK, Shontz FC, Coyne L. 1980. Premorbidpersonality differentiation of cancer and non-cancergroups: A test of the hypothesis of cancer proneness.J Couns Clin Psychol 48: 338–394.

Dean C, Surtees PG. 1989. Do psychological factorspredict survival in breast cancer? J Psychosom Res 33:561–569.

Esplen MJ, Toner B, Hunter J et al. 2000. A supportive-expressive group intervention for women with afamily history of breast cancer: Results of a phase IIstudy. Psycho-Oncology 9: 243–252.

Ford MF, Jones M, Scannell T, Powell A, Coombes RC,Evans C. 1990. Is group psychotherapy feasible foroncology outpatients attendees selected on the basisof psychological morbidity? Br J Cancer 62: 624–626.

Fox CM, Harper P, Hyner GC, Lyle R. 1994. Lone-liness, emotional repression, marital quality, andmajor life events in women who develop breastcancer. J Commun Health 19: 467–482.

Galaif ER, Sussman S, Chou CP, Wills TA. 2003.Longitudinal relations among depression, stress, andcoping in high risk youth. J Youth Adolescence 32:243–258.

Garssen B, Goodkin K. 1999. On the role of immuno-logical factors as mediators between psychosocialfactors and cancer progression. Psychiat Res 85:51–61.

Giese-Davis J, Spiegel D. 2001. Suppression, repressive-defensiveness, restraint, and distress in metastaticbreast cancer: Separable or inseparable constructs?J Pers 69: 417–449.

Giraldi T, Rodani MG, Cartei G, Grassi L. 1997.Psychosocial factors and breast cancer: A 6-yearItalian follow-up study. Psychother Psychosom 66:229–236.

Goodwin PJ, Leszcz M, Ennis M et al. 2001. The effectof group psychosocial support on survival in meta-static breast cancer. N Engl J Med 345: 1719–1726.

Greer S, Morris T. 1975. Psychological attributes ofwomen who develop breast cancer: A controlledstudy. J Psychosom Res 19: 147–153.

Greer S, Morris T, Pettingale K.1979. Psychologicalresponse to breast cancer: Effect on outcome. Lancet2: 785–787.

Gross J. 1989. Emotional expression in cancer onset andprogression. Soc Sci Med 28: 1239–1248.

Ho SMY, Shiu WCT. 1995. Death anxiety and copingmechanism of Chinese cancer patients. Omega JDeath Dying 31: 59–65.

Ho SMY, Wong KF, Chan CLW, Watson M, TsuiYKY. 2003. Psychometric properties of the Chineseversion of the Mini-Mental Adjustment to Cancer(Mini-MAC) scale. Psycho-Oncology 12: 547–556.

Iwamitsu Y, Shimoda K, Abe H, Tani T, Kodama M,Okawa M. 2003. Differences in emotional distressbetween breast tumor patients with emotional inhibi-tion and those with emotional expression. PsychiatClin Neurosci 57: 289–294.

Jamison RN, Burish TG, Wallston KA. 1987. Psycho-genic factors in predicting survival of breast cancerpatients. J Clin Oncol 5: 768–772.

Jensen MR. 1987. Psychobiological factors predictingthe course of breast cancer. J Pers 55: 317–342.

Kennedy-Moore E, Watson JC. 2001. How and whendoes emotional expression help? Rev Gen Psychol 5:187–212.

Kissens DM, Eysenck HJ. 1962. Personality in malelung cancer patients. J Psychosom Res 6: 123–127.

Leung CM, Ho S, Kan CS, Hung CH. 1993. Evaluationof the Chinese version of the Hospital Anxiety andDepression Scale: A cross-cultural perspective. Int JPsychosom 40: 29–34.

Markus HR, Kitayama S. 1991. Culture and the self:Implications for cognitive, emotion, and motivation.Psychol Rev 98: 224–253.

Mckenna MC, Zevon MA, Corn B, Rounds J. 1999.Psychosocial factors and the development of breastcancer: A meta-analysis. Health Psychol 18: 520–531.

Nunnally J, Berstein I. 1994. Psychometric Theory.McGraw-Hill: New York.

O’Donnell MC, Fisher R, Irvine K, Rickard M,McConaghy N. 2000. Emotional suppression: Can itpredict cancer outcome in women with suspiciousscreening mammograms? Psychol Med 30: 1079–1088.

O’Leary A. 1990. Stress, emotional, and human immunefunction. Psychol Bull 108: 363–382.

Persky VW, Kempthorne-Rawson J, Shekelle RB. 1987.Personality and risk of caner: 20-year follow-up ofthe Western Electric Study. Psychosom Med 49:435–449.

Pettingale K, Watson M, Greer S. 1984. The validity ofemotional control as a trait in breast cancer patients.J Psychosoc Oncol 2: 21–30.

Price MA, Tennant CC, Smith RC et al. 2001. The roleof psychosocial factors in the development of breastcarcinoma: Part I, The cancer prone personality.Cancer 91: 679–685.

Razavi D, Delvaux N, Farvacques C, Robaye E. 1990.Screening for adjustment disorders and major depres-sive disorders in cancer in-patients. Br J Psychiat 156:79–83.

Reynolds P, Hurley S, Torres M, Jackson J, Boyd P,Chen VW, the Black/White Cancer Survival StudyGroup. 2000. Use of coping strategies and breast



cancer survival: Results from the Black/White cancersurvival study. Am J Epidemiol 152: 940–949.

Russell JA, Yik SM. 1996. Emotion among the Chinese.In The Handbook of Chinese Psychology, Bond MH(ed.), Oxford University Press: Hong Kong, China.

Scherg H, Cramer I, Blohmke M. 1981. Psychosocialfactors and breast cancer: A critical reevaluation ofestablished hypotheses. Cancer Detect Prev 4:165–171.

Servaes PV, AJJM, Vreugdenhil G, Keuning JJ,Broekhuijsen AM. 1999. Inhibition of emotionalexpression in breast cancer patients. Behav Med 25:23–27.

Silberfarb PM, Anderson KM, Rundle AC, HollandJCB, Cooper MR, Mclntyre OR. 1991. Mood andclinical status in patients with multiple myeloma.J Clin Oncol 9: 2219–2224.

Smith WR, Sebastian H. 1976. Emotional historyand pathogenesis of cancer. J Clin Psychol 32:863–866.

Snyder BK, Roghmann KJ, Sigal LH. 1993. Stress andpsychosocial factors: Effects on primary cellularimmune response. J Behav Med 16: 143–161.

Spiegel D, Morrow GR, Classen C et al. 1999. Grouppsychotherapy for recently diagnosed breast cancerpatients: A multicenter feasibility study. Psycho-Oncology 8: 482–493.

Stanton AL, Danoff-Burg S, Cameron CL et al. 2000.Emotionally expressive coping predicts psychologicaland physical adjustment to breast cancer. J ConsultClin Psychol 68: 875–882.

Stavraky K, Buck C, Cott J, Wanklin J. 1968.Psychological factors in the outcome of humancancer. J Psychosom Res 12: 251–259.

Tacon AM, Caldera YM, Bell NJ. 2001. Attachmentstyle, emotional control, and breast cancer. FamiliesSyst Health 19: 319–326.

Temoshok L. 1987. Personality, coping style, emotionaland cancer: Towards an integrative model. CancerSurveys 6: 545–567.

Tsai JL, Levenson RW. 1997. Cultural influences onemotional responding; Chinese and European Amer-ican dating couples during interpersonal conflict.J Cross Cult Psychol 28: 600–625.

Wadee AA, Kuschke RH, Kometz S, Berk M. 2001.Personality factors, stress and immunity. Stress andHealth 17: 25–40.

Watson M, Greer S. 1983. Development of a ques-tionnaire measure of emotional control. J PsychosomRes 27: 299–305.

Watson M, Greer S, Rowden L et al. 1991. Relation-ships between emotional control, adjustment tocancer and depression and anxiety in breast cancerpatients. Psychol Med 21: 51–57.

Watson M, Greer S, Young J, Inayat Q, Burgess C,Robertson B. 1988. Development of a questionnairemeasure of adjustment to cancer: The MAC scale.Psychol Med 18: 203–209.

Watson M, Haviland JS, Greer S, Davidson J, Bliss JM.1999. Influence of psychological response on survivalin breast cancer: A population-based cohort study.Lancet 354: 1331–1336.

Weihs KL, Enright TM, Simmens SJ, Reiss D. 2000.Negative affectivity, restriction of emotions, and siteof metastases predict mortality in recurrent breastcancer. J Psychosom Res 49: 59–68.

Zigmond A, Snaith RP. 1983. The hospital anxiety anddepression scale. Acta Psychiatr Scand 67: 361–370.



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