International Journal of Behavioral Medicine

, Volume 25, Issue 2, pp 216–222 | Cite as

The Pain of Ambivalence over Emotional Expression




Ambivalence over emotional expression (AEE) is defined as the desire to express emotion but failing to do so. Recent studies have revealed that AEE is associated with more pain. Pain is common among cancer survivors. This cross-sectional study investigated the association between AEE and pain, its underlying mechanism, and cultural relevance among cancer survivors.


Ninety-six Chinese American breast cancer survivors completed a questionnaire package assessing AEE and pain.


AEE was positively associated with pain severity and pain interference. The association between AEE and pain interference was mediated by intrusive thoughts.


Cancer survivors who are ambivalent over emotional expression may experience high levels of intrusive thoughts, which results in high levels of symptom reports in their pain. The study confirmed the association between AEE and pain and its underlying mechanism among a group whose culture generally encourages emotional suppression. Findings suggest interventions focusing on reducing intrusive thoughts may be effective at reducing pain.


Ambivalence over emotional expression Pain Breast cancer Intrusive thoughts Asian-American 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the University of Houston Institutional Review Board.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Carson JW, Keefe FJ, Lowry KP, Porter LS, Goli V, Fras AM. Conflict about expressing emotions and chronic low back pain: associations with pain and anger. J Pain. 2007;8(5):405–11. Scholar
  2. 2.
    King LA, Emmons RA. Conflict over emotional expression: psychological and physical correlates. J Pers Soc Psychol. 1990;58:864–77. Scholar
  3. 3.
    Lu Q, Uysal A, Teo I. Need satisfaction and catastrophizing: explaining the relationship among emotional ambivalence, pain, and depressive symptoms. J Health Psychol. 2011;16:819–27. Scholar
  4. 4.
    Norman SA, Lumley MA, Dooley JA, Diamond MP. For whom does it work? Moderators of the effects of written emotional disclosure in women with chronic pelvic pain. Psychosom Med. 2004;66:174–83. Scholar
  5. 5.
    Porter LS, Keefe FJ, Lipkus I, Hurwitz H. Ambivalence over emotional expression in patients with gastrointestinal cancer and their caregivers: associations with patient pain and quality of life. Pain. 2005;117(3):340–8. Scholar
  6. 6.
    Servaes P, Vingerhoets AJJM, Vreugdenhil G, Keuning JJ, Broekhuijsen AM. Inhibition of emotional expression in breast cancer patients. Behav Med. 1999;25:23–7. Scholar
  7. 7.
    Tucker JS, Winkelman DK, Katz JN, Bermas BL. Ambivalence over emotional expression and psychological well-being among rheumatoid arthritis patients and their spouses. J Appl Soc Psychol. 1999;29(2):271–90. Scholar
  8. 8.
    West SG, Aiken LS. Toward understanding individual effects in multicomponent prevention programs: design and analysis strategies. In: Bryant KJ, Window M, West SG, editors. The science of prevention: methodological advances from alcohol and substance abuse research. Washington, DC: American Psychological Association; 1997. p. 167–209.CrossRefGoogle Scholar
  9. 9.
    Manne S, Ostroff J, Winkel G, Goldstein L, Fox K, Grana G. Posttraumatic growth after breast cancer: patient, partner, and couple perspectives. Psychosom Med. 2004;66:442–54.PubMedGoogle Scholar
  10. 10.
    Stanton AL, Danoff-Burg S, Sworowski LA, Collins CA, Branstetter AD, Rodriguez-Hanley A, et al. Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. J Clin Oncol. 2002;20:4160–8. Scholar
  11. 11.
    Gold DB, Wegner DM. Origins of ruminative thought: trauma, incompleteness, nondisclosure, and suppression. J Appl Soc Psychol. 1995;25:1245–61.CrossRefGoogle Scholar
  12. 12.
    Horowitz MJ. Stress-response syndromes: a review of posttraumatic and adjustment disorders. Hosp Community Psychiatry. 1986;47(3):241–9.Google Scholar
  13. 13.
    Lu Q, Man J, You J, LeRoy AS. The link between ambivalence over-emotional expression and depressive symptoms among Chinese breast cancer survivors. J Psychosom Res. 2015;
  14. 14.
    Ashing KT, Padilla G, Tejero J, Kagawa-Singer M. Understanding the breast cancer experience of Asian American women. Psycho-Oncology. 2003;12(1):38–58. Scholar
  15. 15.
    Figueiredo MI, Fries E, Ingram KM. The role of disclosure patterns and unsupportive social interactions in the well-being of breast cancer patients. Psycho-Oncology. 2004;13:96–105. Scholar
  16. 16.
    Sue DW, Sue D. Counselling the culturally diverse: theory and practice. 5th ed. New York: Wiley; 2008.Google Scholar
  17. 17.
    Kim HS, Sherman DK, Ko D, Taylor SE. Pursuit of comfort and pursuit of harmony: culture, relationships, and social support seeking. Personal Soc Psychol Bull. 2006;32:1595–607. Scholar
  18. 18.
    Lee B. Ambivalence over emotional expression and symptom attribution are associated with self-reported somatic symptoms in Singaporean school adolescents. Asian J Soc Psychol. 2013;16:169–80. Scholar
  19. 19.
    Parker G, Gladstone G, Chee KT. Depression in the planet’s largest ethnic group: the Chinese. Am J Psychiatr. 2001;158:857–64.CrossRefPubMedGoogle Scholar
  20. 20.
    Lu Q, Stanton AL. How benefits of expressive writing vary as a function of writing instructions, ethnicity and ambivalence over emotional expression. Psychol Health. 2010;25:669–84. Scholar
  21. 21.
    Zhou X, Dere J, Zhu X, Yao S, Chentsova-Dutton YE, Ryder AG. Anxiety symptom presentations in Han Chinese and Euro-Canadian outpatients: is distress always somatized in China? J Affect Disord. 2011;135(1–3):111–4. Scholar
  22. 22.
    Lepore SJ. A social-cognitive processing model of emotional adjustment to cancer. In: Baum A, Anderson B, editors. Psychosocial interventions for cancer. Washington, DC: American Psychological Association; 2001. p. 99–116.CrossRefGoogle Scholar
  23. 23.
    Lepore SJ, Helgeson V. Social constraints, intrusive thoughts, and mental health in prostate cancer survivors. J Soc Clin Psychol. 1998;17:89–106. Scholar
  24. 24.
    Lepore SJ, Silver RC, Wortman CB, Wayment HA. Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers. J Pers Soc Psychol. 1996;70:271–82.CrossRefPubMedGoogle Scholar
  25. 25.
    Zakowski SG, Valdimarsdottir HB, Bovbjerg DH. Emotional expressivity and intrusive cognitions in women with family histories of breast cancer: application of a cognitive processing model. Br J Health Psychol. 2001;6:151–65.CrossRefPubMedGoogle Scholar
  26. 26.
    Dupont A, Bower JE, Stanton AL, Ganz PA. Cancer-related intrusive thoughts predict behavioral symptoms following breast-cancer treatment. Health Psychol. 2014;33(2):155–63. Scholar
  27. 27.
    McEwen BS, Seeman T. Protective and damaging effects of mediators of stress: elaborating and testing the concepts of allostasis and allostatic load. Ann N Y Acad Sci. 1999;896(1):30–47. Scholar
  28. 28.
    Chen SX, Cheung FM, Bond MH, Leung J. Decomposing the construct of ambivalence over emotional expression in a Chinese cultural context. Eur J Personal. 2005;19:185–204. Scholar
  29. 29.
    Horowitz MJ, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom Med. 1979;41:209–18.CrossRefPubMedGoogle Scholar
  30. 30.
    Cleeland CS, Nakamura Y, Mendoza TR, Edwards KR, Douglas J, Serlin RC. Dimensions of the impact of cancer pain in a four country sample: new information from multidimensional scaling. Pain. 1996;67:267–73.CrossRefPubMedGoogle Scholar
  31. 31.
    Wang XS, Mendoza TR, Gao S, Cleeland CS. The Chinese version of the brief pain inventory (BPI-C): its development and use in a study of cancer pain. Pain. 1996;67:407–16. Scholar
  32. 32.
    Stephenson M. Development and validation of the Stephenson Multigroup Acculturation Scale (SMAS). Psychol Assess. 2000;12(1):77–88. Scholar
  33. 33.
    Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: The Guilford Press; 2013.Google Scholar
  34. 34.
    Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40:879–91.CrossRefPubMedGoogle Scholar
  35. 35.
    Kelley JE, Lumley MA, Leisen JCC. Health effects of emotional disclosure in rheumatoid arthritis patients. Health Psychol. 1997;16:331–40. Scholar
  36. 36.
    Dere J, Sun J, Zhao Y, Persson TJ, Zhu X, Yao S, et al. Beyond “somatization” and “psychologization”: symptom-level variation in depressed Han Chinese and Euro-Canadian outpatients. Front Psychol. 2013;4:377. Scholar
  37. 37.
    Emmons RA, Colby P. Emotional conflict and interpersonal processes: linking ambivalence and repression to social support. J Pers Soc Psychol. 1995;68:947–59.CrossRefPubMedGoogle Scholar
  38. 38.
    King LA. Emotional expression ambivalence over emotional expression, and marital satisfaction. J Soc Pers Relat. 1993;10:601–17. Scholar
  39. 39.
    Butler EA, Lee TL, Gross JJ. Does expressing your emotions raise or lower your blood pressure? J Cross-Cult Psychol. 2009;40:510–7. Scholar
  40. 40.
    Soto JA, Levenson RW, Ebling R. Cultures of moderation and expression: emotional experience, behavior, and physiology in Chinese Americans and Mexican Americans. Emotion. 2005;5:154–65. Scholar
  41. 41.
    Hill CL, Updegraff JA. Mindfulness and its relationship to emotional regulation. Emotion. 2012;12(1):81–90. Scholar
  42. 42.
    Arch JJ, Craske MG. Laboratory stressors in clinically anxious and non-anxious individuals: the moderating role of mindfulness. Behav Res Ther. 2010;48(6):495–505. Scholar
  43. 43.
    Speca M, Carlson LE, Goodey E, Maureen A. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000;62(5):613–22.CrossRefPubMedGoogle Scholar
  44. 44.
    Feldman G, Greeson J, Senville J. Differential effects of mindful breathing, progressive muscle relaxation, and loving-kindness meditation on decentering and negative reactions to repetitive thoughts. Behav Res Ther. 2010;48(10):1002–11. Scholar
  45. 45.
    Lu Q, Wong C, Gallagher M, Tou R, Young L, Loh A. Expressive writing among Chinese American breast cancer survivors: a randomized controlled trial. J Health Psychol. 2016;
  46. 46.
    Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: a diathesis-stress framework. Psychol Bull. 1996;119(1):95–110. Scholar

Copyright information

© International Society of Behavioral Medicine 2017

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of HoustonHoustonUSA

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