Discussion

Cancer invades the lives of people from all walks of life. HCWs working in large urban

cancer hospitals are introduced to the fragility and sacredness of life in their routine practice

(Pavelkova et al., 2015). Each day, they strive to make a difference in the lives of patients and their

families despite their work being endless, & challenges relentless. Studies on HCWs associated

with cancer care have focused on identification of demographics, prevalence, causes and

consequences of professional burnout with more emphasis on professional implications in

comparison to personal implications (Granek et al., 2012)

These studies are well documented to suggest most professional understandings of

workplace stress however, focus only on burnout rather than grief explicitly. Considering the

dearth of studies with this population, the current study aims to examine Disenfranchised Grief,

Compassion Fatigue and Emotional Processing among Health care workers associated with

Cancer Care. A cross-sectional comparative research design with three groups of Healthcare

Workers i.e Oncologists, Nurses & Health Care Assistants recruited with the help of purposive

sampling technique, was used following inclusion & exclusion criteria. The eligibility of 70

Oncology HCWS, working at one private hospital and two hospital based private oncology units in

Lucknow, was evaluated among which 12 participants did not meet the study criteria. Specifically,

5 reported experiencing a personal loss, 2 reported having a diagnosis of major illness in the family

in the past 6 months, 3 reported not experiencing death of a patient in the past 6 months & 2

reported practicing privately along with the current job. As a result after the screening, only 58

participants i.e 8 Oncologists, 30 Nurses & 20 Health Care Assistants qualified for the study. The

socio-demographic details for 58 participants were analyzed, following which scores on

psychological tools, i.e The Grief Support in Healthcare Scale, Compassion fatigue—Professional
Quality of Life Questionnaire—ProQOL & Emotional Processing Scale - 25 ( EPS-25) were

computed as per the guidelines of the respective manuals. The results were analyzed using

Kruskal-Wallis Test to assess significant differences in all variables among three groups &

Spearman’s Rank Order Method for correlation between the study variables among three groups.

In the present study, the sample consisted of 58 HCWs i.e 8 Oncologists, 30 Nurses & 20

Health Care Assistants associated with Cancer Care. Table 2 displays the mean (M) and standard

deviation (SD) of age of the participants in three groups. Group 1 consisted of 8 Oncologists with a

mean age of M= 35 years, and a standard deviation of S.D = 4.86., Group 2 consisted of 30 Nurses

with a mean age of M = 28.066 years, and a standard deviation of S.D = 5.07 , Group 3 consisted

of 20 Health Care Assistants with mean age of M = 32.05 years, and a standard deviation of S.D

= 8.38 respectively.

As shown in (Table 2.1) the age of the participants in Group 1 varied from 25 to 44 years,

in which majority (50%) participants fall within the age range of 35-39 years, age of participants

in Group 2 varied from 20-44 years, in which majority (33.3%) participants fall within the age

range of 30 -34 years, age of participants in Group 3 varied from 20-54 years, where majority

(25%) of participants fall within the age range of 20-29 years in Group 3.

Majority of participants in Group 1 ( 62.5% ) & Group 2 (63.3%) were females However,

an equal (50%) no of male & female Health Care Assistants constituted Group 3. This can be

understood from the findings of a recent survey done by Bajpai et al., (2020) to understand the

gender climate in Indian Oncology found that out of 324 Oncologists, 198 (61.1%) were women,

majority being medical oncologists (46.3%). Results of another survey done by Banarjee et al.,

(2016) to understand the gender related challenges among Oncologists also showed that out of 462

oncologists, 76.7 % were women and 45.5 % had a managerial or leadership role among female
respondents , compared with 65 % of male respondents (p<0.001) further providing an evidence of

under representation of women in Oncology specifically leadership roles. The findings of both the

survey suggests that despite women being equal or more in number in Oncology, more leadership

roles are assigned to the male oncologists thus, underrepresentation of women in the field. The

under representation of male nurses in the present study can indeed be majorly understood due to

gender discrimination, stereotyping, historical job titles, and societal perception that nursing is a

female dominating role, associated with the idea of nurturance (Vadivala, 2022)

The educational qualification of all participants in Group 1 was up-to Post Graduation level,

whereas the educational qualification of participants varied from Diploma to Post-Graduation &

Primary to Intermediate level in Group 2 & 3 respectively. There were equal no. of single &

married (50%) participants in Group 1, majority (53.3%) single participants in Group 2 whereas

majority (50%) married participants constituted Group 3. Majority of the participants in Group 2

(53.3%) & 3 (65%) were living with family However, the majority in Group 1 (62.5%) were living

alone. Majority of the participants (62.5%) in Group 1, (66.7%) in Group 2 & (17%) ) in Group 3

were working for 8-10 hours. Most of the participants i.e (50%) in Group 1 , (66.7%)in Group 2 &

(65%) in Group 3 were working during day shift ,with a minimum experience of 6 months and a

maximum experience of 18 years in oncology. Almost half participants in Group 2 & 3 (50%) and

all participants in Group 1 (100%) have experienced at least the death of 50 patients in the past 6

months, with few (5%) who have experienced the death of at least 300 patients.

Table 3 demonstrates a statistically significant difference in education (p =.000,> 0.05),

current annual income (p =.000,> 0.05), ward type (p=.000, >0.05), job role during previous

employment (p =.000, >0.05), previous annual income (p = .001, >0.05) previous working hours

(p=.033, >0,05), previous nature of shift (p =.010, >0.05), no. of cancer patient cared/ treated (
Group 2 reported caring/treating 3000-4000 patients & Group 1 & 3 participants reported at least

treating/caring 1000 - 3000 patients in the past 6 months) (p=.005, > 0.05), relationship with the

deceased patient(s) (p=.010,>0.05), grief most supported by (p=.024,>0.05), perception of support

being enough (p =.022,>0.05) among three groups.

As shown in (Table 3), Majority (75%) of participants in Group 1 & 2 have described their

relationship with the deceased patient as “ Not as close as most of rxn” whereas, majority ( 60%)

participants in Group 3 have described it as “ Closer than any other rxn.” These findings are in line

with previous literature emphasizing Health Care Aides & Assistants as a largely invisible group

of care providers despite the majority (63.3%) described sharing a very close & long-term

relationship with their patients (Cooper et al., 2016). Majority ( 75%) of the participants in Group

1 reported being most supported by their family members, whereas Group 2 & 3 reported being

most supported by their colleagues. These results are consistent with Dougherty et al., (2009)

study, where majority (88.1%) oncology personnel reported being most supported by their

professional team. Another study by Wenzel et al., (2011), supports the findings, where oncology

nurses working at the comprehensive National Institute-designated Cancer Center reported

debriefing and dialogue sessions with their colleagues as most helpful in facilitating a supportive

environment to process their grief following patient loss.

Majority ( 75%) participants in Group 1 find the support received being enough however,

(76.7%) & (65%) participants in Group 2 & 3 do not find the received support being enough.

These findings are consistent with the findings of Bram & Katz (2007) study, where lesser

opportunities to express work-related feelings and discuss problems in the workplace was reported

among hospital nurses than hospice nurses. This can be further understood from the findings of

another study by Dougherty et al .,(2009) where (30%) of Nurses & Health Care Aides working in
an inpatient and a palliative care unit reported perceived lack of resources to cope with

work-related stress as compared to the other oncology personnel.

In order to attain the aim of the study, four objectives were formulated. The first objective

was to assess and compare Disenfranchised Grief among Oncologists, Nurses and Health Care

assistants associated with Cancer Care. To fulfill this objective, it was hypothesized that there will

be no significant difference in Disenfranchised Grief among Oncologists, Nurses and Health Care

assistants. Table 4 demonstrates moderate levels of support on two domains of Disenfranchised

Grief i.e Recognition of Rxn (Mgp1=16.87,S.D = ± 4.16; Mgp2 =16.70,S.D = ±3.98; Mgp3

=14.65,S.D±4.20)& Acknowledgement of loss (Mgp1=15.25,S.D=±4.46;Mgp2=13.76,S.D=±5.55;

Mgp3=15.35,S.D= ± 4.49) However, lower levels of support on the third domain i.e Inclusion as a

griever (Mgp1=10.50,S.D= ± 2.13;Mgp2=10.60,S.D = ± 5.32; Mgp3=9.5, S.D= ±3.36 ) among the

three groups. An explanation of these findings could be found in a study by Anderson and Gaugler

(2006), where majority (65.5%) of the certified nursing assistants (CNAs) reported feeling

excluded from the grieving process despite the depth of the relationship and feelings of

connectedness shared with the patients suggesting, a denial of death in nursing homes & critical

care set ups. Another study by Spidell & colleagues (2011) is also consistent with the findings,

whereas an indicator of disenfranchised grief, authors found that majority (21%) of chaplains

reported that they were not considered as grievers & therefore their grief was not affirmed in their

workplace.

Table 4.1 demonstrates that there are no statistically significant differences in the three

domains of Disenfranchised Grief i.e Recognition of Rxn. with the patient (p = 0.564, >0.05),

Acknowledgment of loss (p = .627, > 0.05), Inclusion as a griever (p = 0.567,> 0.05) among

Oncologists, Nurses and Health Care assistants. The results of the study are in accordance with the
null hypothesis, suggesting that Disenfranchised grief is a unique and a common phenomena

experienced by every HCW despite different and varied job roles, especially in settings where loss

is a daily occurrence for both patients and carers (Papadatou, 2009). A study by Gross et al.,

(2019) reported moderate levels of social acknowledgment of grief among Israeli

psycho‐oncologists & social workers having at least one year working experience in

hematology/oncology departments, or in medical clinics with a diverse range of cancer patients,

relative to the mean sample score (M = 48.73, SD = 7.41), with no significant difference found on

sub scales of Social Acknowledgment Questionnaire among the two groups (p=.65, >0.05) further

supports the findings of the current study. Additionally, an explanation for the findings could be

understood by Bram & Katz (2007) study, where the author found that hospice nurses scored

significantly lower on the measure of perceived disenfranchisement of loss compared to hospital

oncology nurses, suggesting a role of environment on the perception of disenfranchisement . Since

the three groups of Health Care Workers in the current study were recruited from hospitals having

similar work environments, therefore no significant difference in the perception of

disenfranchisement was found.

The second objective of the study was to assess and compare Compassion Fatigue ( i.e

Burnout & STS) among Oncologists, Nurses and Health Care assistants associated with Cancer

Care. To fulfill this objective, it was hypothesized that there will be no significant difference in

Compassion Fatigue (i.e Burnout & STS) among Oncologists, Nurses and Health Care assistants

associated with Cancer Care. The results are not in accordance with the null hypothesis, Thus,

H02 was rejected.

Table 4 demonstrates moderate levels of secondary traumatic stress among three groups
 (Mgp1=27.87,S.D= ± 5.16; Mgp2=30.50,S.D= ± 7.28;Mgp3=30.15 ,S.D=7.48). Table 4.1

shows a statistically significant difference in levels of Burnout (p=0.03,<0.05) reported among

Oncologists, Nurses and Health Care assistants associated with Cancer Care. Nurses scored

significantly higher on Burnout relative to sample score (M=30.83, S.D = ± 7.6) as compared to

Health Care Assistants (M= 28.35, S.D ± 7.09), & Oncologists (M= 23.37, S.D ± 4.74) suggesting

decreased self-efficacy, sense of frustration & failure related to workload demands and increased

perceived stress among Nurses as compared to the participants in Group 1 & 3. These results are

consistent with the findings of Kohli & Padmakumari (2019) study, where majority of the

oncology professionals, naming clinical oncologists, nurses, and psychologists reported moderate

levels of burnout (60.4%) and compassion fatigue (56%) and oncology nurses were found to be at

an elevated risk, scoring significantly higher on burnout and compassion fatigue domain.

Contrastingly, a study by Gross et al., ( 2019) found high levels of burnout (M = 23.56, SD =

4.92), among Oncologists as compared to other oncology personnels.

There was no significant difference in the levels of STS among three groups. As shown in

(Table 4.1) moderate levels of STS were reported relative to mean sample score (Mgp1= 27.87,

S.D= ± 5.16; Mgp2=30.50, S.D=±7.28; Mgp3= 30.15, S.D = ±7.48) among Group 1, 2 & 3

respectively. These results are contrary to the findings reported by (Pages et al., 2019; Li, 2018)

where the majority (37.4%) of oncology nurses working in different hospitals in Catalonia, Spain,

reported high secondary traumatic stress as compared to other Oncology HCWs. Additionally, a

study by Gross et al ., (2019) also found higher levels of STS among Israeli psycho-oncologists &

social workers M=15.81, S.D =6.88).

The third objective of the study was to assess and compare Emotional Processing among

Oncologists, Nurses and Health Care assistants associated with Cancer Care. To fulfill this
objective, it was hypothesized that there will be no significant difference in Emotional Processing

among Oncologists, Nurses and Health Care assistants associated with Cancer Care. The results of

the present study revealed that there is a statistically significant difference in the Experience

Sub-scale (p=0.03,<0.05) ) of Emotional processing among the three groups, Therefore, H3 was

rejected.

As shown in (Table 4.1) nurses scored significantly higher on the Experience sub-scale relative to

mean sample score (M=4.66,S.D = ± 1.69) as compared to Health Care Assistants (M=4.06, S.D =

± 1.64) & Oncologists (M= 2.75, S.D =± 1.93 ) indicating a difficulty in labeling their emotions

& a detachment from feelings, leading to misconstruing emotional sensations for physical illness .

Previous study by Pei et al .,(2021) is in consistent with the current findings, where higher scores

on Difficulties with identifying feelings (M= 18.13), Difficulty of describing feelings (M= 13.27),

Externally oriented thinking (M=21.86) and Alexithymia (M= 53.26) were reported among

emergency nurses in China. Additionally, a study by Franco & colleagues (2020), where higher

levels of alexithymia were reported among (13.6%) of Oncologists having a TAS-20 score while

majority (20.8%) showed the presence of alexithymic traits at a subclinical borderline level,

supports the present findings.

As shown in ( Table 4.1), there is no statistically significant difference on the Suppression

(p=0.688,>0.05) & Avoidance (p=0.468, >0.05) sub-scale of Emotional Processing among the

three groups. High Average scores on Suppression & Avoidance subscale of emotional

processing among Group 1 relative to mean sample score (Msupp.=5.12 ,S.D = ± 1.95,

Mavoid.=4.45 ,S.D =± 2.83), Group 2 (Msupp.= 5.53, S.D= ± 2.22, Mavoid.=5.58 ± 1.50) &

Group 3 (Msupp.=4.97,S.D= ± 2.00, Mavoid.=5.42, S.D =±1.40) were reported. Average scores

were reported on the Unprocessed & Controllability sub-scale of Emotional Processing among
Group 1 (Munpro.=4.75,S.D= ± 2.47,Mcont.= 4.40,S.D= ± 2.98), Group 2 (Munpro.= 4.88,S.D= ±

2.08,Mcont.= 4.46, S.D ± 1.49) & Group 3 (Munpro.=4.55, S.D= ± 1.80,Mcont.=3.65,S.D= ±

1.70). This can be explained by the findings of Helsel (2008) study, where frequent exposure to

death and loss, among those in helping professions, was found to be associated with

desensitization (ρ= 0.54; p <0.05) & development of coping mechanisms such as suppression (ρ=

0.34; p <0.05) & avoidance (ρ= 0.53; p <0.05) preventing them from fully acknowledging and

processing their own grief.

The fourth objective of the study was to explore the relationship between Disenfranchised

Grief, Compassion Fatigue and Emotional Processing among Oncologists, Nurses and Health

Care assistants associated with Cancer Care. To fulfill this objective, it was hypothesized that

there will be no significant relationship between Disenfranchised Grief, Compassion Fatigue and

Emotional Processing among Oncologists, Nurses and Health Care assistants. The results are not

in accordance with the null hypothesis. Therefore, H4 was rejected.

Table 5 depicts a Spearman correlation coefficient computed to assess the relationship

between Disenfranchised Grief & Compassion Fatigue (Burnout & STS) among the three groups.

A significant negative correlation was found between Burnout and the second sub-domain of

Disenfranchised Grief i.e Acknowledgment of loss. (ρ= -0.34; p <0.01), suggesting less

acknowledgement of loss following patients death at workplace, more will be feelings of

frustration, failure and a sense of detachment among Oncology HCWs & Vice -Versa. As shown

in (Table 5), a negative correlation was also found between Burnout and third subdomain of

Disenfranchised Grief i.e Inclusion as a griever (ρ = -0.40; p <0.01) , suggesting less HCWs are

included as grievers, more likely they are to report feeling of frustration , depersonalisation &

detachment from work & Vice Versa. A negative correlation was found between Disenfranchised
Grief (Total) & Burnout (ρ = -0.45;p <0.01), suggesting less an HCWs grief is supported , more

they are likely to report feelings of frustration, failure and a sense of detachment & Vice -versa.

The current findings can be understood from the findings of Brown & Wood (2009) study, where a

negative correlation was found between disenfranchisement of open expression of grief following

patient death, on the part of nurses caring for patients in critical care units & compassion fatigue

(ρ = -0.55;p <0.01) and burnout (ρ = -0.65;p <0.01). Similarly, a negative correlation was also

found between social acknowledgement of grief & burnout (p=−0.26, p < 0.01) among Israeli

Psycho oncologists and Social Workers (Gross et al.,2019). The current findings are also consistent

with the findings of a study by Pei et al ., (2019) where a negative correlation was found between

Burnout & Subjective support (r=−.415,p <0.01), Burnout & Objective support (r=−.249,p

<0.01)& Burnout & Support availability(r=−.348,p <0.01) , Burnout & Social Support (r=−.444,p

<0.01) among emergency nurses in China suggesting decreasing alexithymia represents a

potentially viable approach to alleviating the incidence of burnout among emergency nurses

As shown in (Table 5), a negative correlation was found between third domain of

Disenfranchised Grief i.e Inclusion as a griever & Secondary Traumatic Stress (ρ=-0.34,p<0.01),

suggesting that less the inclusion of HCWs as griever, the more they are likely to get affected by

the traumatic & illness experiences of their patients. As shown in (Table 5), a negative correlation

was found between Disenfranchised Grief (Total) & Secondary Traumatic Stress (ρ=-0.39,

p<0.01), suggesting the more an individual sustain in the feeling of loss that is not or cannot be

openly acknowledged, publicly mourned, or socially supported, more they are likely to get affected

by the traumatic & illness experiences of their patients. This can be understood from the findings

of Gross et al., (2019) study where a negative correlation between social acknowledgment of loss

following a patient death and STS (r = 0.41, p < 0.01 among psycho-oncologists was found,
specifically higher levels among those who found their loss less acknowledged (M=19.43,

S.D=5.66)

A positive correlation was found between Burnout & Secondary Traumatic Stress

(ρ=0.46,p<0.01) suggesting the more exposure to the illness & traumatic experiences of others,

more likely a HCW experiences a state of emotional exhaustion & depersonalisation. This finding

is consistent with the findings of a study conducted by Whippen and Canellos (1991) where out

of 598 oncologists, (56%) of respondents reported burnout, (53%) of whom attributed their

burnout to excessive exposure to fatal illness. These findings are also consistent with a study by

Zakeri et al., (2020) that found a positive correlation between Secondary Traumatic Stress and

Burnout (r=0.571 , p < 0.01) among Nurses working in public hospitals in south Iran (Rafsanjan).

Table 5.1 depicts a Spearman correlation coefficient computed to assess the relationship

between Disenfranchised Grief & Emotional Processing among the three Groups. A negative

correlation was found between third subdomain of Disenfranchised Grief i.e Inclusion as a

griever & Controllability sub-scale of Emotional Processing (ρ = -0.34, p <0.05), suggesting less

HCWs are likely to be included as a griever, the more they are likely to control their thoughts

about difficult or unpleasant events related to patients death especially when an overt expression is

not socially approved or seen as appropriate at workplace. As shown in (Table 5.1), a negative

correlation existed between Disenfranchised Grief (total) & Controllability sub-scale of Emotional

Processing (ρ =-0.28,p<0.05) .These findings are consistent with the Emotional Processing

Model, given by Baker et al., (2009) which states that in presence of powerful externally oriented

emotions involving high arousal, frustration, agitation or anger, the perception of how much

control one should have over their emotional expression related to emotional rules or beliefs about

feelings and emotions comes into play. Individuals try to control their thoughts about difficult or
unpleasant events especially when an overt expression is not socially approved or seen as

appropriate, which later may or may not surface as an inability to control emotions.

Table 5.2 shows a Spearman correlation coefficient computed to assess the relationship

between Compassion Fatigue (Burnout & STS ) & Emotional Processing. A positive correlation

was found between Burnout & Unprocessibility sub scale of Emotional Processing (ρ=0.27,

p<0.05), Burnout & Controllability sub scale of Emotional Processing (ρ = 0.28,p<0.05),

suggesting that individuals with more intense feelings of frustration, detachment &

depersonalisation are more unable to process their emotional experiences & more likely to exhibit

higher controllability over their emotions & Vice versa. Previous literature also suggests that in a

work setting, employees may be required and even forced to modify or control their emotional

expressions as part of their professional role to enhance organization task, performance and

efficiency (Joseph and Newman, 2010; Dijk et al., 2017) allowing them little space to process

their emotions.

As shown in (Table 5.2), a positive correlation between Burnout & Experience subscale of

Emotional Processing (ρ= 0.287,p<0.05), suggesting that individuals with higher levels of Burnout

are more likely to have difficulty identifying & labeling their emotions & a positive correlation

between Burnout & Emotional Processing (total) (ρ= 0.28, p <0.05) suggesting that HCWs with

higher levels of feelings of depersonalisation & frustration, are more likely to use multiple

mechanisms to move from emotional conflict to a state of resolution & Vice Versa. These findings

are consistent with previous studies which suggests that emotion regulation processes implied by

HCWs may generate an uncomfortable emotional dissonance indicating a discrepancy between

what employees feel and what they ought to feel (Gross, 1998; Thwaites, 2017) thus, leading to an

inability to understand their feelings. Additionally, a study by Pei et al ., (2021) also found a
positive correlation between burnout & Difficulties with identifying feelings(r= .561,p <0.01),

burnout & Difficulty of describing feelings (r=471,p <0.01), burnout & Alexithymia (r= .384,

p<0.01) among emergency department nurses in China.

As shown in (Table 5.2 ) a positive correlation was found between Secondary Traumatic

Stress (STS) & Unprocessibility sub scale of Emotional Processing(ρ= 0.36,p<0.05), suggesting

that HCWs with higher exposure to death & traumatic experiences of their patients, are more likely

to absorb & decline their emotional disturbances to the extent that other work related behaviors

can be continued without disruption & Vice Versa. This is consistent with the understanding of the

Emotional Processing Model, proposed by Baker et al., 2009 which suggests unprocessed

emotions following traumatic experiences are internally experienced as persistent , intrusive &

lead to inadequate resolution from the emotional event, further exaggerating the feelings of

vicarious traumatization. Additionally, these findings can also be understood from the concept of

"hysteria" developed by Sigmund Freud and Josef Breuer, where it was proposed that hysterical

patients suffer from "reminiscences" or memories of traumatic experiences. According to Freud

and Breuer, a patient treated by Breuer, Anna O. 's, symptoms were believed to have originated

from the period when she was caring for her sick father. They interpreted her symptoms as

memory symbols of her father's sickness, exposure to his illness experiences and subsequent death,

suggesting that they represented a form of mourning. While caring for her father, Anna O. had to

control intense emotions instead of expressing them through appropriate words and actions. This

failure to adequately process her emotions resulted in the development of various neurotic

symptoms later on.

 A positive correlation was found between Secondary Traumatic Stress & Controllability

sub scale of Emotional Processing (ρ=0.35,p<0.05) suggesting that HCWs with higher exposure to

death, traumatic & illness experiences of their patients, are more likely to exercise control over

their emotional feelings guided by emotional rules & beliefs. A positive correlation was found

between Secondary Traumatic Stress & Emotional Processing (total) (ρ= 0.27,p<0.05) suggesting

that HCWs with higher exposure to death, traumatic & illness experiences of their patients, are

more likely to use multiple mechanisms to move from emotional conflict to a state of resolution &

Vice Versa. Previous studies which aim to understand both positive & negative outcomes of

emotional regulation processes at the workplace support the findings & suggest that at the

organizational level, these processes can improve productivity, performance, and social

interactions. However, at the individual level, they are more likely to lead to negative outcomes,

given the lack of individuals' spontaneous manifestation of emotions,heightened controllability

causing exhaustion and frustration, ego-depletion and stress, fatigue and burnout, as well as

reducing self-identity in favor of a pseudo identity (Gross, 1998; Moon and Hur, 2011; Von

Scheve, 2012;Beal et al., 2013; van Dijk et al., 2017;Zaehringer et al., 2020).Overall, the findings

suggest that genuine expression of emotional state at the workplace, provide support for HCWs

emotional well-being to prevent negative outcomes associated with emotion regulation processes

following exposure to traumatic & illness experience of the patients.