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Expressive Writing Intervention Study on the Post-traumatic Growth in Breast Cancer Patients: -- A Qualitative Study to Explore the Intervening Mechanisms

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Abstract

To explore the mechanism of the effect of expressive writing on the post-traumatic growth of breast cancer patients, and to provide evidence for the rehabilitation of cancer patients. A qualitative interview study was done among 15 young convalescent breast cancer patients who participated in expressive writing intervention in a tertiary A hospital in Guangdong Province, The interview focused on the psychological experience of post-traumatic growth in the process of expressive writing, while content analysis focuses on the content of expressive writing. The interview materials were sorted and analyzed using the Colaizzi 7-step analysis method, and the themes were organized. Results showed that Five themes were extracted from the psychological experience of the post-traumatic growth, including the personality change, the relationship change, the life change, the meaning of illness, the gratitude and dedication. The text content of breast cancer patients' expressive writing includes five dimensions: fact description, emotional expression, self affirmation, cognitive reappraisal, and meaning discovery. There were obvious post-traumatic growth in convalescent young breast cancer patients, while experiencing the negative events and negative psychology of illness. The potential therapeutic mechanism of expressive writing in breast cancer survivors includes five factors: fact description, emotional expression, self affirmation, cognitive reappraisal, and meaning discovery.
International Journal of Biology and Life Sciences
ISSN: 2957-9511 | Vol. 7, No. 2, 2024
35
ExpressiveWritingInterventionStudyonthePost
traumaticGrowthinBreastCancerPatients
‐‐AQualitativeStudytoExploretheInterveningMechanisms
Jianfeng Tan 1, *, Lvchang Wen 1, Yongcun Wang 2, Yanhua Liu 3
1 Deptment of Psychology, Guangdong Medical University, Zhanjiang Guangdong, 524023, China
2 Cancer Center of Affiliated Hospital, Guangdong Medical University, Zhanjiang Guangdong, 524023, China
3 Nursing Administration of Affiliated Hospital, Guangdong Medical University, Zhanjiang Guangdong, 524023, China
* Corresponding author: Jianfeng Tan (Email: tjftjf@gdmu.edu.cn)
Abstract: To explore the mechanism of the effect of expressive writing on the post-traumatic growth of breast cancer patients,
and to provide evidence for the rehabilitation of cancer patients. A qualitative interview study was done among 15 young
convalescent breast cancer patients who participated in expressive writing intervention in a tertiary A hospital in Guangdong
Province, The interview focused on the psychological experience of post-traumatic growth in the process of expressive writing,
while content analysis focuses on the content of expressive writing. The interview materials were sorted and analyzed using the
Colaizzi 7-step analysis method, and the themes were organized. Results showed that Five themes were extracted from the
psychological experience of the post-traumatic growth, including the personality change, the relationship change, the life change,
the meaning of illness, the gratitude and dedication. The text content of breast cancer patients' expressive writing includes five
dimensions: fact description, emotional expression, self affirmation, cognitive reappraisal, and meaning discovery. There were
obvious post-traumatic growth in convalescent young breast cancer patients, while experiencing the negative events and negative
psychology of illness. The potential therapeutic mechanism of expressive writing in breast cancer survivors includes five factors:
fact description, emotional expression, self affirmation, cognitive reappraisal, and meaning discovery.
Keywords: Breast Cancer; Expressive Writing; Psychological Experience; Post-traumatic Growth; Qualitative Research.
1. Introduction
Breast cancer is a common malignant tumor among young
women. With the promotion of early screening for breast
cancer and the improvement of breast cancer diagnosis and
treatment techniques, the survival rate of breast cancer
patients for more than 5 years has significantly increased, and
it has become the norm for patients to enter the rehabilitation
period after clinical treatment[1,2]. Post-traumatic growth is
the positive change that occurs in an individual during the
process of experiencing a traumatic event[3]. Post-traumatic
growth can enable individuals to reconstruct cognitive
patterns, improve emotional regulation ability, change their
own views, enhance interpersonal relationships, and promote
understanding in life philosophy[4-6]. Some scholars have
found that after experiencing the loss of the breast and
changes in body shape, breast cancer patients began to reflect
positively on the disease and life, and post-traumatic growth
occurred 6 months after the end of surgical treatment[7].
Expressive writing is a psychological intervention method
that realizes emotional disclosure by writing about feelings
and thoughts related to an important or traumatic event
experienced by an individual, thereby regulating emotions
and cognitive processes to promote health [8]. Relevant
studies have shown that expressive writing can reduce anxiety
and depression levels, relieve post-traumatic stress symptoms,
and improve the quality of life[9-11]. What kind of expressive
writing content is effective for cancer patients? This study
aims to explore the potential healing mechanism of expressive
writing of breast cancer survivors through the content analysis
of the expressive writing texts of breast cancer patients.
2. Methods
2.1. Setting and Participants
The purposive sampling approach was employed to select
15 breast cancer patients who participated in the expressive
writing activity in the oncology department of a tertiary grade
A hospital in Guangdong Province from June 2023 to
December 2023 as the research subjects. Inclusion criteria: (1)
Female patients with breast cancer; (2) Aged 18-44 years; (3)
Diagnosed with breast cancer through pathology, being in the
rehabilitation period: more than six months after the onset and
more than two months after the end of treatment, with a
Karnofsky Performance Status score > 80 points; (4)
Informed consent and cooperative throughout the research
process. Meanwhile, the text materials of the expressive
writing of the 15 breast cancer patients were subjected to
content analysis. Exclusion criteria:(1) Patients with
recurrence or metastasis; (2) Those with severe cognitive
impairment or a previous history of mental illness. Patients
with breast cancer participated in expressive writing once a
week for three weeks, a total of three times. The first was to
write down the deepest feelings and thoughts of the breast
cancer experience, the second was to write about the stress
and coping strategies faced during the breast cancer
experience, and the third was to write about the positive
thoughts and feelings since the disease. Then the expressive
writing of the text materials to do content analysis.
2.2. Data Collection
The semi-structured interview approach was adopted and
conducted in the oncology outpatient room. Each
36
respondent's interview persisted for 30 to 50 minutes, with the
entire process being recorded using a voice recorder. Prior to
the interview, the respondents were apprised of the research
purpose, interview content, and requisite time. The content of
the interview includes the following aspects: (1) Does the
illness possess any positive significance for you? (2) What
alterations has the disease and treatment process brought to
your life? (3) What gains have you acquired from the process
of expressive writing?
2.3. Data Analysis
After the interview, convert the recording into text. Two
researchers independently analyzed the transcribed textual
data and written text content using the Colaizzi 7-step
analysis method. Carefully read the material, mark
meaningful statements, encode recurring information,
summarize the viewpoints that appear after encoding, write
detailed and exhaustive descriptions, identify similar
viewpoints, extract meaningful common concepts, and
elevate them to form a theme. In the process of data analysis,
researchers hold their own opinions, and in case of
disagreements, the research team of this study will jointly
discuss and determine.
3. Results
3.1. Themes of Post-Traumatic Growth
The psychological experiences of post-traumatic growth in
breast cancer patients during the rehabilitation period
comprise five themes: gratitude and post-traumatic growth
after cancer, encompassing personality change, changes in
relationships with others, changes in life, meaning of disease,
and gratitude and dedication. The theme of personality
change encompasses three factors: regulating emotions,
accepting changes, and affirming oneself. The theme of
changes in relationships with others consists of three factors:
more harmonious family relationships, more interaction with
friends, and greater concern for people around. The theme of
changes in life incorporates three factors: decelerating the
pace of life, cherishing the present life, and creating the
meaning of life. The theme of the meaning of disease includes
three factors: perceiving the power of life, experiencing the
true meaning of life, and contemplating the meaning of life.
The theme of gratitude and dedication encompasses three
factors: having a heart of gratitude, sharing experiences, and
helping others.
3.2. Themes of Expressive Writing
The text content of expressive writing by breast cancer
patients during the rehabilitation period features five
dimensions: factual description, emotional expression, self-
affirmation, cognitive reappraisal, and discovery of meaning.
The writing in the factual description dimension involves
detailed expressions in five aspects: me and breast cancer, me
and the doctor, me and my family, me and my friends, and me
and my beliefs. The description of the emotional expression
dimension comprises specific delineations in five aspects: the
shock and fear of diagnosis, the injustice and confusion of
illness, the pain and sadness of treatment, the unease and
anxiety about the future, and the expression of suppressed
emotions within the social support system. The description of
the self-affirmation dimension includes specific expressions
in five aspects: affirmation of the overall self-concept,
affirmation of trait self, affirmation of family relationships,
affirmation of social relationships, and affirmation of religion
and spirituality. The description of the cognitive reappraisal
dimension consists of specific expressions in five aspects:
reflection on the cause of cancer, rational attribution of cancer,
assessment of physical functions after cancer, evaluation of
social cognition of breast cancer, and attribution of attitude
towards death and changes in beliefs. The description of the
discovery of meaning dimension includes specific
expressions in five aspects: discovery of the meaning of
cancer, re-evaluation of personal value, changes and hopes in
life, gratitude and return in social relationships, and
affirmation and appreciation of nature and life.
4. Discussion
The psychological experiences of the 15 patients with
breast cancer in the rehabilitation period demonstrated in this
study that the patients underwent cognitive defense upon
disease detection, disease adaptation and control during the
treatment process, and began to reflect actively on the disease
and life, presenting post-traumatic growth after cancer trauma,
which is in line with the relevant studies conducted by
scholars both domestically and internationally [12,13].
Studies on post-traumatic growth and post-traumatic stress
disorder have disclosed that at the initial stage of disease
diagnosis, post-traumatic stress symptoms predominate. Once
patients accept the reality of the disease, post-traumatic
growth ensues, and the two exhibit a curvilinear correlation
[14,15]. Studies on the influencing factors of post-traumatic
growth in breast cancer patients have indicated that early
cancer-related stress and anxiety are positively correlated
with post-traumatic growth [16, 17]. Individuals with minor
impacts from traumatic events have a low level of post-
traumatic growth, while those with moderate impacts from
traumatic events and cognitive processing of the events have
a high level of post-traumatic growth [18]. The post-traumatic
growth theory posits that negative cognition, negative
emotions, and helpless predicaments can induce mental
distress. Persistent distress prompts individuals to enter
repetitive thinking and rumination, and active rumination is a
key factor in the formation of post-traumatic growth [19, 20].
Post-traumatic growth does not emanate from the traumatic
event per se but rather from the individual's confrontation
with the traumatic event. The positive alterations following
trauma do not mitigate the pain but rather represent the
positive comprehension of core life issues such as self,
interpersonal relationships, and life during the process of
experiencing the pain [21]. Cancer, as a traumatic event, has
impacted the individual's original worldview, disrupted the
original life order, and introduced a high degree of uncertainty.
After experiencing the pain of rumination and being accepted
subsequent to self-disclosure, patients also commence to
exhibit acceptance of themselves, the disease, and changes.
When self-evaluation undergoes alterations, the individual's
social functions also change, manifesting as more harmonious
family relationships, increased interaction with friends, and
greater concern for others. The experiences of life and death
and various human conditions during the illness and treatment
process prompt individuals to think more profoundly about
the fragility of life and have a clearer orientation of life goals.
The theoretical model of this expressive writing research
design is emotional disclosure, narrative expression, and
benefit discovery. In the first week, by penning down the
innermost feelings and thoughts during the experience of
breast cancer, emotional disclosure was initiated. During the
37
stressful event of breast cancer diagnosis and treatment,
patients often conceal the fact of the disease, eschew social
interaction, and close their inner world [22]. Especially in the
Chinese cultural context, it is commonly held that "family
ugliness should not be exposed" and "illness is not a glorious
thing". For many people, disclosing personal experiences and
painful emotions verbally is a challenging undertaking.
Expressive writing can disclose the inner emotions and
thoughts of breast cancer patients in a private manner. "Thank
you for the opportunity to participate in this study. Through
writing, I can confide my experiences and tell my story
without concerns." The founder of expressive writing,
Pennebaker, discovered that the exposure and expression of
negative emotions and traumatic experiences can alleviate the
stress resulting from traumatic experiences and negative
emotions [23].
In the second week, by writing about the pressures and
coping strategies confronted during the experience of breast
cancer, narrative expression was emphasized. Narrative is a
verbal act and a fundamental mode of human cognition.
People construct an experience of practical significance to
themselves by recounting experienced events [24].
Expressive writing, as a narrative carrier, is a process of
clarifying inner activities through written language. Through
the description of the pressure, ideas, coping strategies, etc. in
the experience of breast cancer, reconstruct a complete
narrative about breast cancer, increase the level of clear
awareness of cancer events, and thus improve the
psychological feelings brought by cancer clinics. By writing
and concretizing the memory of negative events in the
narrative, and describing the pressures, thoughts, a complete
narrative of the stressful breast cancer event is reconstructed,
increasing the degree of clarity of awareness of the cancer
event. Klein et al.'s study found that expressive writing can
effectively reduce intrusive thoughts [25]. "Cancer is like a
bomb that tore my life apart. But after continuous writing for
some time, it seems to help me stick the fragments back
together." Chu et al.'s study on expressive writing by breast
cancer patients revealed that expressive writing can reduce
hypervigilance symptoms in patients and alleviate the
intrusive and avoidant symptoms brought about by cancer as
a stressful event, facilitating the patient's disease recovery
[26].
In the third week, by writing about the positive thoughts
and feelings since the illness, patients were guided to discover
benefits. Post-traumatic growth is the positive change that
occurs in individuals during the process of experiencing a
traumatic event [27]. Relevant studies have shown that breast
cancer patients, after experiencing disease adaptation and
control, begin to reflect positively on the disease and life,
demonstrating post-traumatic growth after cancer six months
after surgery [28,29]. The thinking and rational attribution of
the cause of cancer by breast cancer rehabilitators are the
information processing and cognitive reappraisal processes of
cancer patients regarding cancer stress events. Tedeschi, the
proponent of the concept of post-traumatic growth, believes
that the individual's cognitive processing of trauma
information is a crucial process for generating post-traumatic
growth, and self-disclosure is an important factor in post-
traumatic cognitive processing [30]. "Since it's like this, let it
go with the flow, follow the changes, and also allow myself
to change." Due to the disease, patients commence to reflect
on their past lifestyle and attempt new healthy lifestyles.
The self-affirmation theory posits that through the re-
anchoring of significant self-values, individuals no longer
focus on the threat of the stressful traumatic event but rather
on the meaning and value of the event itself. Thus, the
stressful event that threatens the self loses its threatening
capacity [31]. "I will donate some money to the victims of the
earthquake-stricken area because I deeply understand how
much people in difficulties need others to extend a helping
hand." People can view themselves and the traumatic
experience from a broader perspective by affirming self-
values in areas unrelated to the threat. Patients who have
experienced a cancer event develop a "survivor's mission"
during the rehabilitation period, transforming the individual's
perception from vulnerability and distrust after trauma to a
more positive view of others and the world [32]. "Now I no
longer complain about this disease. It has enabled me to
perceive true human feelings, return to my family, and truly
understand life." Cafaro and Gallagher et al.'s studies on
cancer patients also indicate that expressive writing has a
positive impact on post-traumatic growth after cancer and
promotes cancer rehabilitation patients' cognitive reappraisal
and discovery of meaning regarding the disease and life [33,
34]. Meaning is the product of various human practical
activities, a creative activity of human survival methods.
Expressive writing, as a narrative carrier, provides an
opportunity to return to factual description, emotional
expression, self-affirmation, cognitive reappraisal, and
discovery of meaning, allowing individuals facing trauma to
achieve the process of re-constructing the meaning of life,
from "becoming ill in a muddled way" to "living
meaningfully and clearly".
5. Conclusion
The expressive writing can promote the post-traumatic
growth of breast cancer patients. The potential therapeutic
mechanism of expressive writing in breast cancer survivors
includes five factors: fact description, emotional expression,
self affirmation, cognitive reappraisal, and meaning discovery.
Acknowledgments
We would like to thank the breast cancer survivors who
participated in this study and contributed to its
accomplishment;
This work was supported by a grant from the Guangdong
Philosophy and Social Sciences 13th Five Year Plan Project
(GD20XXL06).
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This multicenter study investigates the efficacy of the guided disclosure protocol in promoting posttraumatic growth, through meaning reconstruction, in cancer patients after adjuvant chemotherapy. Participants will be randomized to guided disclosure protocol or to an active control condition. Both conditions consist of three 20-minute writing sessions. Experimental participants verbalize emotions, describe events and reflect on trauma effects. Control participants write about their past week’s daily routine. Patients, blinded to treatment assignment, will complete questionnaires at pre-, post-intervention and 6-month follow-up. This study will improve knowledge concerning the effects of writing interventions on psychological health and well-being in cancer patients.
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Background: Breast cancer treatment can negatively affect psychosocial outcomes for breast cancer survivors (BCS), but these outcomes present differently for younger and older survivors. Objectives: The objective of this study was to compare psychosocial outcomes between younger and older BCS and identify predictors of loneliness in younger BCS. Methods: This cross-sectional descriptive study of 90 BCS evaluated data on sociodemographic and clinical characteristics and self-reported measures of psychosocial outcomes (fatigue, depressive symptoms, anxiety, loneliness, daytime sleepiness, and stress). Participants were dichotomized into two groups by age (aged less than 50 years and aged 50 years or older). Descriptive statistics, bivariate correlations, and multiple regression were also examined. Findings: Younger BCS reported greater fatigue, loneliness, daytime sleepiness, and stress than older BCS. No between-group differences were found in depressive symptoms or anxiety. Having children and less time since chemotherapy completion were significant predictors of less loneliness in younger BCS.
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