Sherman Kerry (Orcid ID: 0000-0001-7780-6668)

Attachment Styles, Self-Compassion, and Psychological Adjustment in

Long-Term Breast Cancer Survivors
Jelena Arambasic1 , Kerry A. Sherman1* , Elisabeth Elder2 , Breast Cancer Network Australia

1
Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney,
Australia, 2109
2
Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Australia, 2145
* Corresponding author: Kerry Sherman, Centre for Emotional Health, Department of
Psychology, Macquarie University, Sydney, Australia. Email: kerry.sherman@mq.edu.au

Conflict of Interest: The authors have no conflict of interest to disclose

Keywords: cancer, oncology, self-compassion, survivorship, breast cancer, psychological

stress, attachment style, negative impact of cancer

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.5068

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Abstract
Objective. The increasing numbers of breast cancer survivors highlight the importance of
delineating factors that identify women who are at risk of poor psychological adjustment in
the long term. In breast cancer survivors, higher attachment anxiety and attachment
avoidance have been associated with poorer psychological adjustment. Moreover, there is
evidence that self-compassion, a kind manner of treating oneself during difficulties, is
associated with psychological distress in this population. This study aimed to extend the
association between attachment styles and psychological adjustment to the context of long-
term breast cancer survivors, and to determine whether lower self-compassion underlies this
association.
Methods. Participants (N=82) were recruited through emailed invitations to members of the
Review & Survey Group of Breast Cancer Network Australia. Following online consent,
participants completed measures assessing attachment styles, self-compassion, psychological
stress, and the perceived negative impact of cancer. Bootstrapping analyses using the
PROCESS macro were used to test the significance of indirect effects.
Results. As hypothesised, correlational analyses revealed that higher attachment anxiety and
attachment avoidance were significantly and positively associated with stress and perceived
negative impact of cancer. Bootstrapping analyses revealed significant indirect effects of
attachment anxiety and attachment avoidance (on both stress and perceived negative impact
of cancer) through lower self-compassion.
Conclusions. These findings suggest that self-compassion training may be useful for
enhancing the psychological adjustment of long-term breast cancer survivors. Future
longitudinal and experimental studies in more diverse samples are needed to confirm causal
directionality of these relationships and to expand upon these findings.

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 Breast cancer is the most commonly diagnosed female cancer in Australia. 1 With a
90% 5-year survival rate, there are estimated to be more than 200,000 women who are long-
term breast cancer survivors (> 5 years post-diagnosis) in Australia alone.1 Although many
long-term breast cancer survivors are well-adjusted, it is common for physical and
psychological issues to remain.2 Despite being cancer free, women may experience negative
psychological impacts such as body image concerns, worry and stress. 3 The increasing
survival rates highlight the importance of identifying risk factors for poor psychological
adjustment. One potential risk factor is attachment style, an individuals’ typical pattern of
feeling, thinking, and behaving in relation to close others. 4 Faced with physical or
psychological threat (e.g., cancer diagnosis) the attachment system motivates proximity-
seeking towards caring others (attachment figures), providing a sense of attachment security4
and the understanding that others can be helpful in times of need. 5 However, insecure
attachment is characterised by either anxiety (i.e., worry about their partners’ availability in
times of need, fear of rejection and abandonment, and low self- worth) or avoidance (i.e.,
discomfort with intimacy and dependence, and distrust of partners’ intentions). 5 In times of
threat, anxiously attached individuals typically regulate affect by seeking comfort through
exaggerating distress and amplifying their vulnerability and inability to cope alone (i.e.,
hyperactivating strategies). However, avoidantly attached individuals tend to downplay the
threat, seeking to be self- reliant, inflating their sense of self to distance themselves from
dependency needs or vulnerability.5

In the general population, compared to secure attachment, insecure attachment is

consistently associated with poorer psychological outcomes in adults reporting no explicit life
stressor 6, 7 and with individuals facing threats.5 In chronic illness populations, insecure
attachment is associated with greater negative affect and depression, lower coping efficacy,
and poorer quality of life.8 Within the cancer context poor psychological adjustment has been
associated with insecure attachment of individuals with lung9 and gastrointestinal10 cancer
diagnoses, whereas those who are securely attached adjust better, reporting posttraumatic
growth.11-13 Within the breast cancer context, insecurely attached survivors within the first
year of diagnosis report lower mental well-being and higher distress, and greater symptom
severity and body image disturbance. 14 Despite the demonstrated association between
attachment styles and psychological adjustment generally, and in cancer populations, there is
a paucity of research on possible mechanisms underlying this link. One potential underlying
factor that has not yet been investigated is self-compassion, a kind and gentle manner of

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relating to oneself during difficult experiences, co mprising three interrelated components:
self-kindness, common humanity, and mindfulness. 15 Self-compassion is conceptualised as a
trainable characteristic, with targeted interventions in healthy and breast cance r3, 16
populations demonstrating its modifiable nature.
Research in healthy student and community populations has linked higher self-compassion
with greater physical17 and psychological well-being, less psychological distress,17, 18 positive
affect, positive coping, and fewer maladaptive strategies. 19 In an illness context, higher self-
compassion has been associated with lower negative affect, lower anxiety and depression
(i.e., influenza and asthma)18 and lower stress (i.e., HIV+),20 including in older adults.20, 21
One study comparing healthy individuals with those with cancer or chronic illness found that
self-compassion was particularly salient for cancer survivors, being associated with better
psychological adjustment.22 Research in the breast cancer context links greater self-
compassion with better quality of life in women recently diagnosed, 22 and with less
depression, anxiety, and stress, and less body image disturbance in survivors within five years
post-diagnosis;23, 24 however, this association has not been investigated with longer-term
breast cancer survivors (i.e., more than five years post-diagnosis). A targeted self-compassion
writing intervention indicates that low self-compassion may mediate the link between adverse
outcomes of breast cancer (i.e., body image disturbance) and psychological adjustment. 3, 23
These findings imply that attachment style and self-compassion are key factors in
adjustment to challenging situations. Conceptually, both attachment style and self-
compassion are relevant in the context of difficult experiences - attachment behaviours are
activated by threats (e.g., an illness), 5 whereas self- compassion is a manner of relating to
oneself during difficult times.16 Both constructs entail emotion regulation strategies, have
been related to an individual’s psychological adjustment to various circumstances, and are
associated with common adjustment outcomes, such as stress and anxiety. 5 According to the
evolutionary-based theory of self-compassion, self- compassion is implicated in the
“affiliative/soothing” affect regulation system, which is also important in forming attachment
bonds.25 However, self-compassion is regarded as a separate system to attachment, and when
warmth or kindness is displayed by others or self-directed, the affect regulation system is
impacted and feelings of safeness and soothing are created in the individual. Thus,
individuals with an insecure attachment who experienced an unpredictable and less
supportive environment, may have more difficulty accessing self-compassion, and rather
engage in more self-criticism. Alternatively, securely attached individuals may respond to life
challenges with gentleness and understanding (i.e., self-compassion).17 Consequently, self-

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compassion may mediate the link between attachment style and psychological wellbeing (or
distress). Growing evidence supports this indirect effect of self-compassion in physically
healthy samples of adolescents and adults. 6, 7, 26, 27 However, less is known about the
relationship between self-compassion and attachment in illness populations. Responses to an
acute and long- lasting physical illness, such as breast cancer, may elicit a different response
given the prolonged stressful experience. This study aimed to explore the relationships
between attachment, self-compassion, and psychological adjustment in long-term breast
cancer survivors with the following hypotheses: (1) lower self-compassion, and anxious and
avoidant attachment will be inversely related to psychological adjustment, and (2) there will
be an indirect effect of attachment style on psychological adjustment through self-
compassion (see Figure 1).

Method
Participants (N=92) were women recruited from April to August 2016 from the Breast Ca ncer
Network Australia (BCNA) an online network providing Australians affected by breast
cancer with information and support. Members of the BCNA Review & Survey Group, a
voluntary registry of individuals willing to participate in breast cancer-related research, were
invited via an emailed invitation sent from the BCNA staff. Prospective participants self-
identified as meeting the eligibility criteria of being over 18 years of age, diagnosed with
breast cancer between 5 to 10 years ago, had completed active breast cancer treatment
(excluding hormone therapy), and were able to complete an online survey in English. A total
of 738 emails were sent with 109 women providing written informed consent (14.8%
response rate). Following online consent, participants co mpleted the anonymous online
questionnaire (20-25 minutes duration). Five women consented but provided no data, and a
further 12 participants’ data were excluded as they did not meet time since diagnosis
eligibility. Although demographic and medical characteristic data were provided by 92
participants, due to missing data, analyses were undertaken on N=82. Ethics approval was
obtained from Macquarie University Human Research Ethics Committee (Approval number:
5201500182).

Measures
General attachment style. The reliable 36- item Experiences in Close Relationships-Revised
scale (ECR-R)28 measured attachment styles regarding general attachment of Anxiety (fear of

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rejection and abandonment; e.g., “I worry a lot about my relationships”) and Avoidance
(discomfort with closeness and dependence; e.g., “I find it difficult to allow myself to depend
on others”). Items were rated on a 7-point Likert-type scale (1 ‘Strongly disagree’ to 7
‘Strongly agree’) and a mean subscale score calculated (possible range: 1 to 7; =.94
Anxiety; =.93 Avoidance). Attachment security is represented by lower scores on these
dimensions, as a securely attached individual generally does not fear abandonment in a
relationship (low anxiety) and is comfortable depending on others (low avoidance).
Self-compassion. Self-compassion was measured using the 26-item Self Compassion Scale
(SCS)15 containing six subscales (rated on a 5-point Likert-type scale ranging from 1 ‘Almost
never’ to 5 ‘Almost always’). Subscales included: Self-Kindness (e.g., “I’m kind to myself
when I’m experiencing suffering”), Self-Judgement (e.g., “I’m disapproving and judgmental
about my own flaws and inadequacies”), Common Humanity (e.g., “When things are going
badly for me, I see the difficulties as part of life that everyone goes through”), Isolation (e.g.,
“When I’m really struggling I tend to feel like other people must be having an easier time of
it”), Mindfulness (e.g., “When something upsets me I try to keep my emotions in balance”),
and Over-Identification (e.g., “When something upsets me I get carried away with my
feelings”). Following reverse scoring of negatively-worded items, the total score was
calculated as the average of the mean scores of the subscales15 (possible range: 1 to 5;
=.93).
Psychological Adjustment. (i) The 20- item Negative Impact Summary scale of the Impact of
Cancer scale version 2 (negative IOC)29 was used as an index of psychological adjustment
concerning negative domains relevant to the experiences of long-term cancer survivors,
including subscales assessing body change (e.g., “Having had cancer has made me feel old”)
and appearance (e.g., “I worry about how my body looks”) concerns, life interferences (“I
feel like cancer runs my life”) and worry (“I worry about my health”). Higher scores indicate
a more negative impact of cancer (possible range 1 to 5; =.94). (ii) Another measure of
psychological adjustment was the reliable and valid 7- item Stress scale of the Depression,
Anxiety, and Stress Scale 21 (DASS21)30 measuring chronic non-specific arousal reflecting
difficulty relaxing, and being easily upset/irritable and impatient, which are appropriate
indicators for long-term cancer survivors for whom the initial phase of acute psychological
distress has largely subsided.2 The extent to which items applied over the past week was rated
on a 4-point Likert-type scale (0 ‘Did not apply to me at all’ to 3 ‘Applied to me very much,
or most of the time’), with a summed total score (range 0 to 21; =.84), with higher scores

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indicating greater symptom severity.
Potential covariates. Current perceived physical health may impact adjustment to breast
cancer and was treated as a potential covariate, measured by the Physical Component
Summary (PCS) score of the 12- item Short-Form Health Survey version 2 (SF-12v2).31
Information on age, marital status, country of birth, education, household income, and
employment status were collected as was self-reported medical characteristic information
(age at diagnosis, time since diagnosis, breast cancer type and treatment including breast
reconstruction, recurrence of breast cancer, other cancer diagnoses; 1 st and 2nd degree
relatives with prior breast cancer diagnoses).
Data Analysis. Data were analysed using the Statistical Package for the Social Sciences
version 25 on the 82 participants with complete data. Descriptive statistics were computed for
demographic and medical characteristics, key variables of interest, and for potential
covariates. Pearson’s correlation coefficients and analyses of variance (ANOVAs) were used
where appropriate to assess bivariate relationships and to identify covariates. The PROCESS
macro (version 3)32 was used to conduct bootstrap analyses with 5000 samples using the
ordinary least squares regression method32 to test the indirect effect of attachment style
(anxious, avoidant) on psychological adjustment (negative impact of cancer, stress) through
self-compassion, controlling for identified covariates. Bootstrapping is considered to be
superior to alternative tests of indirect effects. 32, 33 A significance criterion of p < .05 was
used for all statistical analyses.

Results
Demographic and medical data and t-test comparisons of mean outcomes are depicted in
Table 1. The current sample displays: (1) similar DASS Stress scores to other samples of
similar aged breast cancer survivors recruited from Breast Cancer Network Australia 23, 24, 34
and elsewhere22 , and higher scores than healthy individuals22 ; (2) similar scores on self-
compassion to older adults35 (mean age = 51.26) and other breast cancer survivor samples 23,
24
; (3) higher (worse) scores on negative IOC than breast and non-Hodgkins’ lymphoma
survivors36 ; (4) Overall, the present sample is generally securely attached, with a tendency to
be less secure for the attachment avoidance dimension. The mean scores on attachment
anxiety in the present study M = 2.51 (SD = 1.05), are slightly (but not significantly) lower
than that reported in a study37 of healthy community adults in Serbia M = 2.85 (SD = 1.45)
and similar to that reported in an illness sample38 of individuals with ulcerative colitis M =
2.5 (SD = 1.4). For avoidant attachment, the mean for the current study M = 3.12 (SD = 1.11)

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is similar to that reported in the healthy adult37 M = 3.27 (SD = 1.39) but higher than illness38
M = 2.7 (SD = 1.2) populations. This is similar to the conclusions of a cancer-related
systematic review12 that reported scores on the attachment dimensions are typically within
normative data expectations.
Correlation coefficients are reported in Table 2. From the correlation analyses, the
only demographic or medical variable identified as a covariate was perceived physical health
(for both outcomes). For the remaining categorical variables considered as co variates,
ANOVA results revealed no significant differences across levels of breast cancer type,
reconstruction type, chemotherapy status, hormone therapy status, marital status, income, or
employment status on stress or negative IOC (all p’s > 0.110). As predicted, both attachment
anxiety and attachment avoidance were significantly and positively correlated with stress and
negative IOC, and negatively correlated with self- compassion.
The results of the tests of indirect effect controlling for physical health, for attachment
anxiety and attachment avoidance are presented in Table 3. As hypothesised, there was a
significant indirect effect of attachment anxiety on stress (B=0.86, SE=0.46, 95%CI:
LL=0.033, UL=1.81) and negative IOC (B=0.16, SE=0.06, 95%CI: LL=0.05, UL=0.29)
through self-compassion. There were also significant indirect effects of attachment avoidance
on both stress (B=1.19, SE=0.48, 95%CI: LL=0.33, UL=2.20) and negative IOC (B=0.19,
SE=0.06, 95%CI: LL=.09, UL=.32) through self-compassion.

Discussion
This study aimed to extend the relationship between attachment styles and
psychological adjustment to the context of long-term breast cancer survivors, and to explore
whether attachment styles are associated with psychological adjustment indirectly through
self-compassion. Consistent with the attachment literature 5-7, 11, 26, 39 and our predictions,
long-term breast cancer survivors with higher attachment anxiety and attachment avoidance
reported poorer psychological adjustment in terms of greater stress and more negative impact
of breast cancer. Thus, it seems that long-term survivors with fears of rejection or
abandonment, low self-worth, and exaggerated distress (i.e., higher attachment anxiety), and
who prefer emotional distance, are heavily self- reliant, and inhibit negative feelings (i.e.,
higher attachment avoidance), are more likely to experience adverse long-term outcomes
following breast cancer.5 This is consistent with prior research illustrating a positive
association between an insecure attachment style and poor psychological adjustment (e.g.,
mental distress, poor quality of life) in more recently diagnosed women with breast cancer39,

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40
and other cancer survivors.9, 10 These findings also suggest that long-term inhibition (e.g.,
5 to 10 years) of negative emotions may prove difficult for survivors with an avoidant
attachment style and thus increase their risk of poor outcomes. 5 Overall, these findings
suggest that attachment styles are relevant to the psychological adjustment of long-term
breast cancer survivors, which includes their unique experience of negative cancer-specific
outcomes.
It was further predicted that attachment anxiety and attachment avoidance would be
indirectly associated with psychological adjustment via self-compassion. Our data provided
support for these predictions in that for both attachment anxiety and attachment avoidance the
indirect association was evident for the outcomes of stress and perceived negative impact of
cancer. Overall, this suggests that long-term breast cancer survivors with low self-worth, who
exaggerate distress, and over- identify with negative emotions (i.e., higher attachment
anxiety), and survivors who suppress painful thoughts and emotions, are highly self-reliant
and set strict self- standards (i.e., higher attachment avoidance)5 , are less likely to extend self-
kindness during difficult experiences, to recognise their pain as part of common humanity, or
to engage in mindfulness (i.e., lower self-compassion).7 In turn, survivors with low self-
compassion may be at risk of experiencing greater stress and a more negative impact of
cancer in the long term. These findings are consistent with and extend existing research on
healthy adolescent, student, and adult community samples whereby an insecure attachment
style has been associated with lower self-compassion, and in turn, lower subjective well-
being7 and poorer mental health.6, 27
Implications for practice
These findings align with the view that an insecure attachment style and lower self-
compassion19 may be risk factors for poor psychological outcomes following adverse
situations. This implies that it may be helpful for cancer care practitioners to utilise measures
of attachment style and self-compassion to identify at-risk survivors. Although therapeutic
attempts to alter attachment patterns may be difficult due to the relatively stable nature of
attachment styles,6 existing cancer support programs could use a counter-complimentary
approach to the clients’ typical attachment strategies. 41 This may entail displays of self-
compassion in order to counter their emotional experience and typical hyperactivating or
deactivating tendencies.7 In general, knowledge of survivors’ attachment patterns and how
they treat themselves may help clinicians better understand their clients’ psychological
adjustment and possibly lead to better tailored interactions. 42 Likewise, clinicians may assist
their clients in recognising how their attachment strategies may be affecting their capacity for

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self-compassion, and thus increasing their risk of poorer o utcomes.
Considering that lower self-compassion was associated with stress and perceived
negative impact of cancer, enhancing self-compassion may be an appropriate target for
intervention. In non-oncology populations short-term therapies cultivating self-compassion
have been demonstrated to improve adjustment by reducing depression, anxiety, stress, body
image distress and self-criticism, while enhancing life satisfaction. The Mindful Self-
Compassion training program35 has achieved positive outcomes at one year follow-up,
suggesting that self-compassion training may be useful for preventing long-term negative
outcomes, while enhancing positive outcomes in cancer survivors. Another approach applied
in the breast cancer context is the brief My Changed Body intervention, 23 entailing structured
self-compassion focused writing targeting body image-related distress, with trials indicating
that enhancement of self-compassion led to improvements in body image and affect, and
decreased psychological distress.3 A modified My Changed Body intervention focusing on
long-term survivorship more broadly, may be a helpful supportive approach for addressing
the enduring psychological adjustment concerns of long-term breast cancer survivors.
Limitations
The findings of this study need to be considered in the context of limitations. The
cross-sectional design and correlational analyses preclude causal conclusions, and there is
currently evidence both to support the proposed direction, 6 and for the possibility that self-
compassion and attachment styles are interchangeable mediators of subjective psychological
well-being.7 Clearly, longitudinal studies are needed to enable causal inferences.
Furthermore, the characteristics of the current sample may limit generalisability. The sample
was relatively securely attached, consisted of members of an Australian breast cancer support
network, and entirely women. Thus, the generalisability of the current findings to women
outside the BCNA, women with other cancer types, and male cancer survivors, is unknown.
However, the self-compassion16 scores are comparable to those found in healthy adults, and
stress scores similar to other breast cancer survivors. 22 Finally, the tendency for individuals
high in attachment avoidance to suppress negative emotions and thoughts5 may have
impacted the accuracy of their self- reported emotional experiences.
Future research
Given the interpersonal nature of attachment, these results highlight the potential
importance of considering the attachment style of the survivor and her partner, and how this
may impact long-term psychological adjustment. Since the partners’ insecure attachment has
been linked with the cancer survivors’ poor adjustment, attachment-based couple therapy

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(e.g., emotionally focused couple therapy)43 may be useful for insecurely attached couples.
This is particularly pertinent as self-compassion is not only believed to stem from prior
interpersonal interactions,27 but that it is implicated in romantic relationship formation post-
breast cancer34 and the quality of dyadic adjustment and communications among couples in
the cancer context.44
Conclusions
This study demonstrated that attachment theory may be a useful framework for
exploring the psychological adjustment of long-term breast cancer survivors. As expected,
higher attachment anxiety and attachment avoidance were related to greater psychological
stress and a more negative impact of cancer and self-compassion may underlie these
associations. These findings provide further support for the view that self-compassion may be
a promising target for psychosocial interventions aimed at enhancing long-term survivors’
psychological adjustment and contribute to the growing evidence base on the importance of
attachment styles in cancer populations, specifically breast cancer.

Data Availability Statement

The data that support the findings of this study are available on request from the
corresponding author. The data are not publicly available due to privacy and ethical reasons.

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Table 1.
Sample Demographics, Medical Characteristics and Key Predictor and Outcome Variables
Characteristic n (%), M (SD)
Age 58.46 (8.77)
Place of birth
Australia 66 (80.5%)
Other 16 (19.5%)
Education level
Grade 12 or less 26 (31.7%)
Vocation 16 (19.5%)
University Bachelor’s degree 27 (32.9%)
Masters or higher 13 (15.9%)
Marital status
In a relationship 64 (78.0%)
Not in a relationship 18 (22.0%)
Income
Up to $75 000 33 (40.7%)
$75 001 to $120 000 10 (12.3%)
> $120 000 20 (24.6%)
Not disclosed 18 (22.4%)
Employment status
Employed full-time or part-time 43 (52.4%)
Student 8 (9.8%)
Not currently employed 31 (37.8%)
Age at diagnosis (years) 51.77 (8.75)
Time since diagnosis (months) 82.14 (19.34)
Had breast cancer recurrence 5 (6.4%)
Type of breast cancer
Non-invasive 23 (28.0%)
Primary invasive 53 (64.7%)
Secondary 6 (7.3%)
1st or 2nd degree relatives with breast cancer 31 (37.8%)
Surgery 82 (100.0%)
Single mastectomy only 24 (29.3%)
Double mastectomy only 11 (13.4%)
Lumpectomy only 42 (51.2%)
Combination of two of the above 5 (6.1%)
Reconstruction breast surgery 21 (25.0%)
Implant reconstruction only 11 (52.4%)
Tissue flap reconstruction only 7 (33.3%)
Both implant and tissue flap reconstruction 3 (14.3%)
Treatment
Radiation therapy 59 (72.0%)
Chemotherapy 53 (64.6%)
Hormone therapy (e.g., Tamoxifen) 55 (67.1%)
Targeted therapy (e.g., Herceptin) 15 (18.3%)
Other 10 (12.2%)
Diagnosis of other type of cancer 9 (11.0%)
Time since diagnosis of other cancer (years) 7.3 (6.0)
Physical Component Summary Score 48.60 (9.16)
Table 1 (cont.).
Sample Demographics, Medical Characteristics and Key Predictor and Outcome Variables

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Characteristic n (%), M (SD)
Stressabcd 7.22 (6.41)
Self-compassione fg 3.46 (0.57)
IOC Negative Impact of Cancerhi 2.76 (0.77)
Attachment Anxietyjk 2.51 (1.05)
Attachment Avoidance lm 3.12 (1.11)

Note:
a
t = 1.97, p=.051 (breast cancer)
b
t = 0.36, p=.72 (breast cancer)
c
t=0.11, p=.91 (breast cancer)
d
t=2.92, p<.0004 (healthy adults)
e
t=0.07, p=.95 (older adults)
f
t=1.17, p=.24 (breast cancer)
g
t=4.24, p<.0005(breast cancer)
h
t=7.81, p<.0005 (mixed cancer)
i
t =7.81, p<.0005 (non-Hodgkins lymphoma)
j
t = 1.54, p=.13 (healthy adults)
k
t=0.037, p=.97 (illness population)
l
t=0.85, p=.40 (healthy adults)
m
t=2.40, p=.019 (illness population)

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Table 2
Correlations between demographic and medical variables, predictor and outcome
variables
Variables 1 2 3 4 5 6 7 8 9 10 11 12
1. Age -
2. Edu. -.13 -
3. Age dia. .96* -.04 -
4. Time dia. .11 -.07 .01 -
5. Recurrence -.04 -.10 -.07 -.38* -
6. Rad iation -.10 -.03 -.13 -.02 -.15 -
7. Chemo. .26* .05 -.26* -.002 - .09 .22* -
8. PCS -.30* -.04 -.29* .23* .30* .12 -.13 -
9. Att An x .11 -.12 .16 -.19 -.21 -.15 .08 -.30* -
10. Att Avoid .18 -.17 .17 .08 -.05 .22* -.04 -.19 -.71* -
11. SCS .01 .13 -.02 .06 .09 .02 .06 .10 -.62* -.63* -
12. St ress .02 .02 .02 -.07 -.04 -.10 -.17 -.33* .41* .36* -.39* -
13. Neg IOC -.19 .07 -.12 -.15 -.14 -.16 -.08 -.35* .48* .36* -.53* .50*

Note. 2 = Education; 3 = Age at diagnosis; 4 = Time since diagnosis; 5 = Breast cancer

recurrence; 6 = Radiation therapy; 7 = Chemotherapy; 8 = Physical Component Summary
Score; 8 = Attachment Anxiety; 9 = Attachment Avoidance; 10 = Self-Compassion Scale;
12 = IOC Negative Impact of Cancer
*p < .05.

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Table 3. Results of the tests of indirect effect for attachment anxiety and attachment
avoidance

Effect IV on Effect M on
DV Direct effect Indirect effect
M DV
Boot CI CI
B P B P B P SE
B lower upper
Attachment anxiety
Stress (R2 = .26)
-
SCS - M 0.056 0.86 0.46 0.03 1.81
0.44
Att anx - IV -1.96 <.001 1.57 0.04
-
PCS -0.04 0.235 0.032
0.15
IOC Negative impact of cancer (R2 = .38)
-
SCS - M <.001 0.16 0.06 0.05 0.29
0.08
Att anx - IV -1.96 <.001 0.14 0.086
-
PCS -0.04 0.235 0.011
0.03

Attachment avoidance
Stress (R2 = .15)
-
SCS - M 0.008 1.19 0.48 0.33 2.20
0.64
Att avo - IV -1.86 <.001 0.39 0.592
-
PCS -0.01 0.874 0.009
0.19
IOC Negative impact of cancer (R2 = .22)
-
SCS - M <.001 0.19 0.06 0.09 0.32
0.10
Att avo - IV -1.86 <.001 - 0.820

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 0.02
PCS -0.01 0.874

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 Self-Compassion
Covariates
(M)

a b

Attachment Style Psychological

(IV) c’ Adjustment (DV)
(DV)

Figure 1. A conceptual diagram of the hypothesised mediation model, including

covariates. a = the effect of the independent variable (IV) on the mediator (M); b = the
effect of the M on the dependent variable (DV) holding constant the effect of the IV; c’ =
the direct effect of the IV on the DV, holding constant M.

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