Emotional disclosure and cognitive processing in couples coping with head and neck cancer

  • Jafar Bakhshaie
  • Mark Bonnen
  • Joshua Asper
  • Vlad Sandulache
  • Hoda BadrEmail author


Head and neck cancer (HNC) patients and their spouses experience communication problems and high rates of emotional distress. Couple-based interventions that encourage emotional disclosure hold promise for improving cognitive processing and distress in this population, but more research needs to examine when and for whom emotional disclosure is an effective coping strategy. In this observational study, 125 HNC patients (83% male) and their spouses were videotaped discussing a cancer-related concern in the laboratory. Discussions were coded with the specific affect coding system. Actor–partner interdependence models showed that patient expression of negative emotions (i.e., disdain, contentiousness, distress) was not related to his/her own or the spouse’s cognitive processing (assessed as reaction times to cancer and noncancer words on a computerized cognitive task administered immediately following the discussion). When spouses expressed support (e.g., interest, validation), they had better cancer- (effect size r = − 0.21) and noncancer-related cognitive processing (r = − 0.17), but patients did not. However, when spouses expressed disdain (e.g., contempt) and contentiousness (e.g., criticism, domineering), patients had poorer cancer- (r = 0.20–0.22) and noncancer-related cognitive processing (r = 0.19–0.26). Findings suggest consideration of the valence of affective expression and which partner is disclosing/listening before unilaterally encouraging HNC couples to openly express emotions as a means of alleviating distress.


Head and neck cancer Affective expression Disclosure Cognitive processing Implicit measures Cancer Stroop task 



This work was supported by K07CA124668 (PI: Badr) and P30CA125123 (PI: Osborne).

Compliance with ethical standards

Conflict of interest

Jafar Bakhshaie, Mark Bonnen, Joshua Asper, Vlad Sandulache, and Hoda Badr declare that they have no conflict of interest.

Human and animal rights and informed consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.


  1. Ackerman, R. A., Donnellan, M. B., & Kashy, D. A. (2011). Working with dyadic data in studies of emerging adulthood: Specific recommendations, general advice, and practical tips. In F. Fincham & M. Cui (Eds.), Romantic relationships in emerging adulthood (pp. 67–100). New York: Cambridge University Press.Google Scholar
  2. Ang, K. K., Harris, J., Wheeler, R., Weber, R., Rosenthal, D. I., Nguyen-Tân, P. F., et al. (2010). Human papillomavirus and survival of patients with oropharyngeal cancer. New England Journal of Medicine, 363, 24–35.CrossRefGoogle Scholar
  3. Babcock, J. C., Graham, K., Canady, B., & Ross, J. M. (2011). A proximal change experiment testing two communication exercises with intimate partner violent men. Behavior Therapy, 42, 336–347.CrossRefGoogle Scholar
  4. Badr, H. (2017). New frontiers in couple-based interventions in cancer care: refining the prescription for spousal communication. Acta Oncologica, 56, 139–145.CrossRefGoogle Scholar
  5. Badr, H., Herbert, K., Chhabria, K., Sandulache, V. C., Chiao, E. Y., & Wagner, T. (2019). Self-management intervention for head and neck cancer couples: Results of a randomized pilot trial. Cancer, 125, 1176–1184.CrossRefGoogle Scholar
  6. Badr, H., Herbert, K., Reckson, B., Rainey, H., Sallam, A., & Gupta, V. (2016). Unmet needs and relationship challenges of head and neck cancer patients and their spouses. Journal of Psychosocial Oncology, 34, 336–346.CrossRefGoogle Scholar
  7. Badr, H., Pasipanodya, E. C., & Laurenceau, J.-P. (2012). An electronic diary study of the effects of patient avoidance and partner social constraints on patient momentary affect in metastatic breast cancer. Annals of Behavioral Medicine, 45, 192–202.CrossRefGoogle Scholar
  8. Baucom, D. H., Porter, L. S., Kirby, J. S., Gremore, T. M., Wiesenthal, N., Aldridge, W., et al. (2009). A couple-based intervention for female breast cancer. Psycho-Oncology, 18, 276–283.CrossRefGoogle Scholar
  9. Baumeister, R. F., Bratslavsky, E., Finkenauer, C., & Vohs, K. D. (2001). Bad is stronger than good. Review of General Psychology, 5, 323.CrossRefGoogle Scholar
  10. Beck, A., & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.Google Scholar
  11. Berlin, K. L., Andreotti, C., Yull, F., Grau, A. M., & Compas, B. E. (2013). Mother-daughter communication about breast cancer risk: Interpersonal and biological stress processes. Journal of Behavioral Medicine, 36, 328–339.CrossRefGoogle Scholar
  12. Bhayani, M. K., Hutcheson, K. A., Barringer, D. A., Lisec, A., Alvarez, C. P., Roberts, D. B., et al. (2013). Gastrostomy tube placement in patients with oropharyngeal carcinoma treated with radiotherapy or chemoradiotherapy: Factors affecting placement and dependence. Head and Neck, 35, 1634–1640.CrossRefGoogle Scholar
  13. Bjordal, K., Ahlner-Elmqvist, M., Hammerlid, E., Boysen, M., Evensen, J. F., Biörklund, A., et al. (2001). A prospective study of quality of life in head and neck cancer patients. Part II: Longitudinal data. The Laryngoscope, 111, 1440–1452.CrossRefGoogle Scholar
  14. Blanchard, C., Toseland, R., & McCallion, P. (1996). The effects of a problem-solving intervention with spouses of cancer patients. Journal of Psychosocial Oncology, 14, 1–21.CrossRefGoogle Scholar
  15. Bultz, B. D., Speca, M., Brasher, P. M., Geggie, P., & Page, S. (2000). A randomized controlled trial of a brief psychoeducational support group for partners of early stage breast cancer patients. Psycho-Oncology, 9, 303–313.CrossRefGoogle Scholar
  16. Cann, A., Calhoun, L. G., Tedeschi, R. G., Triplett, K. N., Vishnevsky, T., & Lindstrom, C. M. (2011). Assessing posttraumatic cognitive processes: The event related rumination inventory. Anxiety Stress and Coping, 24, 137–156.CrossRefGoogle Scholar
  17. Carnelley, K. B., & Janoff-Bulman, R. (1992). Optimism about love relationships: General vs. specific lessons from one’s personal experiences. Journal of Social and Personal Relationships, 9, 5–20.CrossRefGoogle Scholar
  18. Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284.CrossRefGoogle Scholar
  19. Coan, J. A., & Gottman, J. M. (2007). The specific affect coding system (SPAFF). In J. Coan & J. Allen (Eds.), Handbook of emotion elicitation and assessment (pp. 267–285). New York, NY: Oxford University Press.Google Scholar
  20. Creamer, M., Burgess, P., & Pattison, P. (1992). Reaction to trauma: A cognitive processing model. Journal of Abnormal Psychology, 101, 452–459.CrossRefGoogle Scholar
  21. Dagan, M., Sanderman, R., Hoff, C., Meijerink, W. J., Baas, P. C., van Haastert, M., et al. (2014). The interplay between partners’ responsiveness and patients’ need for emotional expression in couples coping with cancer. Journal of Behavioral Medicine, 37, 828–838.CrossRefGoogle Scholar
  22. Dahlstrom, K. R., Calzada, G., Hanby, J. D., Garden, A. S., Glisson, B. S., Li, G., et al. (2013). An evolution in demographics, treatment, and outcomes of oropharyngeal cancer at a major cancer center. Cancer, 119, 81–89.CrossRefGoogle Scholar
  23. Derogatis, L. R. (1992). The brief symptom inventory (BSI): Administration, scoring and procedures manual-II. Baltimore: Clinical Psychometric Research.Google Scholar
  24. Erblich, J., Montgomery, G., Valdimarsdottir, H., Cloitre, M., & Bovbjerg, D. (2003). Biased cognitive processing of cancer-related information among women with family histories of breast cancer: Evidence from a cancer Stroop task. Health Psychology, 22, 235–244.CrossRefGoogle Scholar
  25. Fang, C. Y., & Heckman, C. J. (2016). Informational and support needs of patients with head and neck cancer: Current status and emerging issues. Cancers of the head & neck, 1, 15.CrossRefGoogle Scholar
  26. Foa, E., Steketee, G., & Rothbaum, B. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155–176.CrossRefGoogle Scholar
  27. Funk, J. L., & Rogge, R. D. (2007). Testing the ruler with item response theory: Increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. Journal of Family Psychology, 21, 572.CrossRefGoogle Scholar
  28. Glinder, J. G., Beckjord, E., Kaiser, C. R., & Compas, B. E. (2007). Psychological adjustment to breast cancer: Automatic and controlled responses to stress. Psychology and Health, 22, 337–359.CrossRefGoogle Scholar
  29. Goldsmith, D. J., & Miller, G. A. (2014). Conceptualizing how couples talk about cancer. Health Communication, 29, 51–63.CrossRefGoogle Scholar
  30. Goldsmith, D. J., Miller, L. E., & Caughlin, J. P. (2007). Openness and avoidance in couples communicating about cancer. Communication Yearbook, 31, 62.Google Scholar
  31. Gordis, E. B., & Margolin, G. (2000). The family coding system: Studying the relation between marital conflict and family interaction. In P. K. Kerig & K. M.Lindahl (Eds.), Family observational coding systems: Resources for systemic research (pp. 123–138). Mahwah, NJ: Lawrence Erlbaum Associates, Inc.Google Scholar
  32. Gottman, J. M. (1979). Detecting cyclicity in social interaction. Psychological Bulletin, 86, 338.CrossRefGoogle Scholar
  33. Gottman, J. M. (1994). What predicts divorce? The relationship between marital processes and marital outcomes. Hillsdale, NJ: Erlbaum.Google Scholar
  34. Gottman, J. M., Levenson, R. W., Swanson, C., Swanson, K., Tyson, R., & Yoshimoto, D. (2003). Observing gay, lesbian and heterosexual couples’ relationships: Mathematical modeling of conflict interaction. Journal of Homosexuality, 45, 65–91.CrossRefGoogle Scholar
  35. Gottman, J. M., McCoy, K., Coan, J., & Collier, H. (1996). The specific affect coding system (SPAFF) for observing emotional communication in marital and family interaction. Mahwah, NJ: Erlbaum.Google Scholar
  36. Graeff, A., Rob, J., Leeuw, J., Ros, W. J. G., Hordijk, G.-J., Blijham, G. H., et al. (2000). Pretreatment factors predicting quality of life after treatment for head and neck cancer. Head and Neck, 22, 398–407.CrossRefGoogle Scholar
  37. Graham, J. M., Diebels, K. J., & Barnow, Z. B. (2011). The reliability of relationship satisfaction: A reliability generalization meta-analysis. Journal of Family Psychology, 25, 39–48.CrossRefGoogle Scholar
  38. Hagedoorn, M., Puterman, E., Sanderman, R., Wiggers, T., Baas, P. C., van Haastert, M., et al. (2011). Is self-disclosure in couples coping with cancer associated with improvement in depressive symptoms? Health Psychology, 30, 753.CrossRefGoogle Scholar
  39. Harms, A., Kansara, S., Stach, C., Richardson, P. A., Chen, G., Lai, S., et al. (2019). Swallowing function in survivors of oropharyngeal cancer is associated with advanced T classification. Annals of Otology, Rhinology and Laryngology, 128, 696–703.CrossRefGoogle Scholar
  40. Heyman, R. E., Eddy, J. M., Weiss, R. L., & Vivian, D. (1995). Factor analysis of the Marital Interaction Coding System (MICS). Journal of Family Psychology, 9, 209.CrossRefGoogle Scholar
  41. Howren, M. B., Christensen, A. J., Karnell, L. H., & Funk, G. F. (2013). Psychological factors associated with head and neck cancer treatment and survivorship: evidence and opportunities for behavioral medicine. Journal of Consulting and Clinical Psychology, 81, 299–317.CrossRefGoogle Scholar
  42. John, O., & Robbins, R. (1994). Accuracy and bias in self-perception: Individual differences in self-enhancement and the role of narcissism. Journal of Personality and Social Psychology, 66, 206–219.CrossRefGoogle Scholar
  43. Kenny, D. A. (2017). APIM_MM: A web-based package for estimating the actor–partner interdependence model by multilevel modeling.Google Scholar
  44. Kenny, D. A., Kashy, D., & Cook, W. (2006). The analysis of dyadic data. New York: Guilford.Google Scholar
  45. Koster, E. H., De Lissnyder, E., Derakshan, N., & De Raedt, R. (2011). Understanding depressive rumination from a cognitive science perspective: The impaired disengagement hypothesis. Clinical Psychology Review, 31, 138–145.CrossRefGoogle Scholar
  46. Lee, Y., Lin, P.-Y., Chien, C.-Y., Fang, F.-M., & Wang, L.-J. (2018). a comparison of psychological well-being and quality of life between spouse and non-spouse caregivers in patients with head and neck cancer: A 6-month follow-up study. Neuropsychiatric Disease and Treatment, 14, 1697.CrossRefGoogle Scholar
  47. Lepore, S. (2001). A social-cognitive processing model of emotional adjustment to cancer. In A. Baum & B. L. Andersen (Eds.), Psychosocial interventions for cancer (pp. 99–116). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  48. Lepore, S. J., & Revenson, T. A. (2007). Social constraints on disclosure and adjustment to cancer. Social and Personality Psychology Compass, 1, 313–333.CrossRefGoogle Scholar
  49. Longacre, M. L., Ridge, J. A., Burtness, B. A., Galloway, T. J., & Fang, C. Y. (2012). Psychological functioning of caregivers for head and neck cancer patients. Oral Oncology, 48, 18–25.CrossRefGoogle Scholar
  50. MacLeod, C., & Hagan, R. (1992). Individual differences in the selective processing of threatening information and emotional responses to a stressful life event. Behaviour Research and Therapy, 30, 151–161.CrossRefGoogle Scholar
  51. Manne, S., Badr, H., & Kashy, D. (2012). A longitudinal analysis of intimacy processes and psychological distress among couples coping with head and neck or lung cancers. Journal of Behavioral Medicine, 35(3), 334–346.CrossRefGoogle Scholar
  52. Manne, S., Nelson, C., Kissane, D., Mulhall, J., Winkel, G., & Zaider, T. (2011). Intimacy enhancing psychological intervention for men diagnosed with prostate cancer and their partners: A pilot study. The Journal of Sexual Medicine, 8, 1197–1209.CrossRefGoogle Scholar
  53. Manne, S., Ostroff, J., Rini, C., Fox, K., Goldstein, L., & Grana, G. (2004). The interpersonal process model of intimacy: The role of self-disclosure, partner disclosure, and partner responsiveness in interactions between breast cancer patients and their partners. Journal of Family Psychology, 18, 589–599.CrossRefGoogle Scholar
  54. Manne, S. L., Ostroff, J., Winkel, G., Grana, G., & Fox, K. (2005). Partner unsupportive responses, avoidant coping, and distress among women with early stage breast cancer: Patient and partner perspectives. Health Psychology, 24, 635.CrossRefGoogle Scholar
  55. Marin, T. J., Holtzman, S., DeLongis, A., & Robinson, L. (2007). Coping and the response of others. Journal of Social and Personal Relationships, 24, 951–969.CrossRefGoogle Scholar
  56. McDonough, E. M., Boyd, J. H., Varvares, M. A., & Maves, M. D. (1996). Relationship between psychological status and compliance in a sample of patients treated for cancer of the head and neck. Head and Neck, 18, 269–276.CrossRefGoogle Scholar
  57. McGraw, K. O., & Wong, S. P. (1996). Forming inferences about some intraclass correlation coefficients. Psychological Methods, 1, 30.CrossRefGoogle Scholar
  58. McKenna, F. P., & Sharma, D. (1995). Intrusive cognitions: An investigation of the emotional Stroop task. Journal of Experimental Psychology. Learning, Memory, and Cognition, 21, 1595.CrossRefGoogle Scholar
  59. Milbury, K., & Badr, H. (2010). Development and implementation of a cancer Stroop task to assess biased cognitive processing in couples coping with head and neck cancer. Annals of Behavioral Medicine, 39, S165.Google Scholar
  60. Milbury, K., Tsao, A. S., Liao, Z., Owns, A., Engle, R., Gonzalez, E. A., et al. (2018). A research protocol for a pilot randomized controlled trial designed to examine the feasibility of a couple-based mind–body intervention for patients with metastatic lung cancer and their partners. Pilot and Feasibility Studies, 4, 37.CrossRefGoogle Scholar
  61. Niles, A. N., Haltom, K. E. B., Mulvenna, C. M., Lieberman, M. D., & Stanton, A. L. (2014). Randomized controlled trial of expressive writing for psychological and physical health: the moderating role of emotional expressivity. Anxiety Stress and Coping, 27, 1–17.CrossRefGoogle Scholar
  62. Norton, R. (1983). Measuring marital quality: A critical look at the dependent variable. Journal of Marriage and the Family, 45, 141–151.CrossRefGoogle Scholar
  63. Onitilo, A. A., Nietert, P. J., & Egede, L. E. (2006). Effect of depression on all-cause mortality in adults with cancer and differential effects by cancer site. General Hospital Psychiatry, 28, 396–402.CrossRefGoogle Scholar
  64. Porter, L. S., Keefe, F. J., Baucom, D. H., Olsen, M., Zafar, S. Y., & Uronis, H. (2017). A randomized pilot trial of a videoconference couples communication intervention for advanced GI cancer. Psycho-Oncology, 26, 1027–1035.CrossRefGoogle Scholar
  65. Rehman, U. S., Janssen, E., Newhouse, S., Heiman, J., Holtzworth-Munroe, A., Fallis, E., et al. (2011). Marital satisfaction and communication behaviors during sexual and nonsexual conflict discussions in newlywed couples: A pilot study. Journal of Sex and Marital Therapy, 37, 94–103.CrossRefGoogle Scholar
  66. Robbins, M. L., López, A. M., Weihs, K. L., & Mehl, M. R. (2014). Cancer conversations in context: Naturalistic observation of couples coping with breast cancer. Journal of Family Psychology, 28, 380.CrossRefGoogle Scholar
  67. Sandulache, V. C., Hamblin, J., Lai, S., Pezzi, T., Skinner, H. D., Khan, N. A., et al. (2015). Oropharyngeal squamous cell carcinoma in the veteran population: Association with traditional carcinogen exposure and poor clinical outcomes. Head and Neck, 37, 1246–1253.CrossRefGoogle Scholar
  68. Shapiro, J. P., McCue, K., Heyman, E. N., Dey, T., & Haller, H. S. (2010). Coping-related variables associated with individual differences in adjustment to cancer. Journal of Psychosocial Oncology, 28, 1–22.CrossRefGoogle Scholar
  69. Stanton, A. L. (2011). Regulating emotions during stressful experiences: The adaptive utility of coping through emotional approach. In S. Folkman & P. Nathan (Eds.), The Oxford handbook of stress, health, and coping (pp. 369–386). New York, NY, Oxford.Google Scholar
  70. Verdonck-de Leeuw, I. M., Eerenstein, S. E., Van der Linden, M. H., Kuik, D. J., de Bree, R., & Leemans, C. R. (2007). Distress in spouses and patients after treatment for head and neck cancer. Laryngoscope, 117, 238–241.CrossRefGoogle Scholar
  71. Vickery, L., Latchford, G., Hewison, J., Bellew, M., & Feber, T. (2003). The impact of head and neck cancer and facial disfigurement on the quality of life of patients and their partners. Head and Neck, 25(4), 289–296.CrossRefGoogle Scholar
  72. Zabora, J., Brintzenhofeszoc, K., Jacobsen, P., Curbow, B., Piantadosi, S., Hooker, C., et al. (2001). A new psychosocial screening instrument for use with cancer patients. Psychosomatics, 42, 241–246. CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of MedicineBaylor College of MedicineHoustonUSA
  2. 2.Department of Otolaryngology-Head and Neck SurgeryBaylor College of MedicineHoustonUSA
  3. 3.Department of Radiation OncologyBaylor College of MedicineHoustonUSA

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