‘Cognitive control can improve the quality of life of women with breast cancer’

You are the founder and director of BRiC – the Birkbeck Integrative Centre for Building Resilience in Breast Cancer. Can you tell me more about the aims of the centre?

The aims of the centre are twofold. The first aim is to provide psychological support for women who have been diagnosed with primary as well as secondary breast cancer, because psychological support and care are lacking for women with a breast cancer diagnosis… heavily so. The second aim is very much linked – as the name says, BRiC is an integrative centre for research and practice. We do research on understanding the mechanisms of vulnerability in cognitive and emotional health in women with breast cancer, and we try and devise interventions that can boost resilience and reduce psychological vulnerability to anxiety and depression, which they mostly suffer from. 

BRiC is unique in that, as it is a psychoeducational centre; it teaches the practice of resilience through scientific-based methods. Therefore, the aims of BRiC are to bring educational support to women, so that they learn how to empower themselves in breast cancer survivorship, become more resilient and flexible, improve their self-confidence and self-esteem and learn how to manage the anxiety-related side effects that the treatment and diagnosis have left them with. These aims are very much based on the gaps in the breast cancer care environment. 

The very name of the centre – 'building resilience' – perhaps begs the question of whether the 'battle metaphor' in cancer can be unhelpful and even damaging. It must be a pretty fine line to walk, ensuring an evidence-based focus on some psychological factors which can have an influence, without making people suffering with cancer feel that it's their fault for not fighting hard enough?

Yes, the battle metaphor is highly damaging and unhelpful! I can speak for everyone in BRiC as well as myself that we hate the terms 'fighting' etc. But building resilience is about learning how to be flexible and open to change, accepting our emotions, embracing them. Resilience is not about toughness or being a fighter, it's about being malleable and flexible, and accepting.

What types of projects take place at BRiC?

We have a forum called Panning for Gold which showcases BRiC's Collective Voice, based on the contribution of hundreds of women: support from women with breast cancer to other women with breast cancer, relatives, friend and professionals, in the form of guided discussions which I lead each Sunday. They focus on psychologically relevant issues that women who have breast cancer suffer with… PTSD, anxiety, depression, post-traumatic growth, talking to children about your diagnosis and treatment, etc. We have had over 170 of these discussions so far, which are all summarised for the public to enhance public understanding of the needs of women with breast cancer. We've also got very well-attended research-informed emotion regulation exercises which happen on Tuesday nights; and of course anyone around the world can contribute to Panning for Gold's blog. The Panning for Gold was ranked in the Top 10 UK Breast Cancer Blogs twice, recently by @healthline, due to what it provides for women with breast cancer.

We want to enhance public understanding of the needs of women with breast cancer, but also to empower other women with breast cancer. However, we're not just a support group; we're an integrative centre for research and practise of resilience, and we are just under five years old. I founded the centre back in October 2015 and we are, to date, 1837 members (UK women with breast cancer, primary or secondary). We're only UK-based, but anyone in the world can access and benefit from our blog.

What inspired you to create BRiC, and how did your research in experimental psychopathology influence the activity of the centre?

My own breast cancer diagnosis, back in January 2013, was the main motivation for me. I was diagnosed with multifocal breast cancer. I was quite young at the time and had to go through the entire treatment: multiple surgeries, chemotherapy, radiotherapy. That took about a whole year. I wanted to bring to other women in my position – rather helpless and hopeless – some input from the research that I did in psychopathology. 

Prior to being diagnosed with breast cancer, I worked on anxiety and depression, and on the neurocognitive structures underlying anxiety and depressive vulnerability for many, many years, with the main emphasis on attentional control. I then decided to get involved with research that used interventions targeting attentional control and its neural correlates to improve quality of life in women with breast cancer. In the past, we had shown that attentional control, an important neurocognitive marker of emotional vulnerability, can be targeted and boosted through interventions that exercised it. 

There's a lot of research to show that neuroplasticity-induced change, as a function of cognitive control training, can act as an important mechanism in psychopathology and resilience. Like we've done with many populations (anxious, depressed, highly ruminative, high worriers), we've looked at how cognitive control can improve the quality of life of women with breast cancer, how it can empower them and increase processing efficiency to manage their emotion regulation and so forth. We've had promising results and findings in previous studies, so it just makes sense to me to apply and tailor these interventions in a parallel fashion to women with breast cancer, whose emotional vulnerability levels are quite high. A high proportion suffer from PTSD for many years post-diagnosis, and up to 40 per cent of women with breast cancer suffer from anxiety and depression at clinical levels. The breast cancer diagnosis and treatment leave you with many side effects, including fatigue, impaired cognitive function, heightened sensitivity to anxiety and distress-related symptoms, so it just made sense. 

We are looking at numerous factors… how to improve work-ability in women with breast cancer by improving cognitive functioning, how cognitive training alone or in combination with other treatments like mindfulness and expressive writing can improve quality of life on a longer term in these women within longitudinal studies. We are also looking at the qualitative effects of Tamoxifen, which is a drug a high proportion of women with breast cancer take to protect against recurrence; this drug really impairs your cognitive functioning, memory and so forth. We are taking an experiential neuroscience approach to understand the multitude of factors that affect these women and how we can possibly empower them through the strategies we've developed. 

A large part of your work is based on the influential Attentional Control Theory, which you've developed with Professor Michael Eysenck at Royal Holloway. 

Attentional Control Theory has been very influential, with many applications not just to psychology, but to other disciplines like sports, a number of situations where attentional control is needed for efficient performance. Processing efficiency, i.e. attentional control, refers to our ability to regulate our attention away or towards relevant and irrelevant information. The ACT is based on the tenet that processing efficiency has a huge influence on our emotional states, such as anxiety, depression. Originally, this theory was developed to understand the effects of anxiety on performance, but later it was applied to depression as well. In the same sense, it attempts to explain anxiety and depressive vulnerability through the role of attentional control. 

The idea is that the more flexible we are in how we can engage and disengage with different types of emotional stimuli, the more plastic and the more resilient we are in terms of dealing with stressful situations. Attentional control can be considered a transdiagnostic mechanism for psychopathology, because if it's being as flexible as it needs to be, then it can protect against emotional vulnerability, it can boost resilience. As such it's a common mechanism for boosting cognitive and emotional health. There is research to show that people with better attentional control and working memory capacity are more flexible in their approaches. In terms of neurocognitive processing, they are more efficient in completing their tasks than people with higher levels of emotional vulnerability, who can have poorer efficiency. 

Attentional control is important in addressing worry and rumination in particular, because these are known mechanisms for anxiety and depression. People who worry and ruminate have lowers level of attentional control in general, because they get stuck in these negative cycles of worrying about the future or ruminating about the past, so they lack attentional flexibility. Poor attentional control can exacerbate the effects of worry and rumination, leading to emotional disorders like depression and anxiety. 

In a nutshell, attentional control is the best thing since sliced bread; it's a promising mechanism, playing an important role in emotional vulnerability.

What's been the biggest challenge of your career?

One of the biggest challenges for me in terms of the research that I do is to be able to communicate the research that we do in the lab out there, in terms of public engagement, public outreach. What is usually lacking is a connection between research and practice. As a cognitive neuroscientist, you want to be able to apply your work in real life, because of the implications that your research has quite widely. More and more researchers are becoming keen on doing this, which is really good, but translational neuroscience needs more resources and more integrative approaches in terms of multidisciplinarity amongst disciplines. Work with industry is important, work in the medical arena is important, but these two disciplines are usually divorced; the more we can integrate and bridge the gap, the better. The more measures you have, the more comprehensive your approach is, the stronger you are in terms of implementation. This is one of the biggest challenges not just for me, but for many researchers in my position.

The second biggest challenge in my career has been being a woman and being at a younger age. Age and gender have had a particular impact on my professional trajectory. I'm not just speaking for myself; many other women that I know in academia are often second-rated in terms of the impact of what they want to say; their voices are often unheard. That is changing slightly with the Athena SWAN initiative, but I think there are still strong implicit biases in terms of gender and age, which are related. The Athena SWAN is trying to address that, but whilst women's roles are being flagged up, they are often not being recognised in terms of strategic planning and management; women do the labour work. Women are not men, women are women in their own rights, and they have been more vulnerable in academia for decades. The trend continues, unfortunately. I myself have found that I need to be more aggressive and raise a louder voice to be heard. It doesn't always work, it often backfires: if I am assertive, I get labelled as emotional, whereas if men get angry, people take notice. These biases need to be worked on, because they are deeply ingrained implicit biases. I was promoted at a younger age to full professorship – that was eight years ago, and I don't feel any different. I also consider myself paid much less than other male professors.

You mentioned age being one of the big challenges… what would you say to early-career researchers who want to build a career in psychological research?

The sky is your limit. There is no limit to what you can achieve, and you should be original. There are many setbacks early on in your career, but don't let those disappoint you, especially if you're a female. If you think about resilience, the harder you push, the more velocity you get, so you bounce back. Early career researchers will have many obstacles early on, after PhD etc., because of high competition and limited resources. But a good voice and original ideas can take you places. 

In the areas of affective neuroscience and cognitive affective neuroscience we need to be able to tackle the questions that have been open for a long time. We've got good neuroscientific methods, we've got electrophysiological methods, we're developing this area called experiential neuroscience, we want to bring in qualitative research to neuroscience. These are methods; methods are good, but they shouldn't lead the way. The ideas need to lead the way. Methods are just a tool, and for someone who's taught statistics her whole life, statistics can be blinding. We have all these fancy analyses, but what's the point if we do not know what they mean or what they are addressing? We need to be more than advanced technicians; we need to be more than people who know how to do amazing MRI or EEG etc. We need to be beyond that, we need to be the thinkers behind the methods, and that is when you make a difference and you will succeed. Don't be afraid to take that approach; it's scary, it's unusual, but it's worth the risk. 

When we published the Attentional Control Theory, there was hardly any research to support it. Since then, it's become one of the most cited theories of all time and there have been hundreds of studies taking it forward. Be bold, be like that, set the way for others to take over and extend your ideas. To females, in particular, I would say that competition is high. Academia research is a marathon, the minute you think 'I'm gonna have a rest now', hundreds of people will go past and they will take precedence. No time for rest, keep the momentum going, and every disappointment should make you bolder, stronger, and riskier. This is the way to go. Use the fear to motivate you, don't use it to set yourself back.

What do you think the centre is going to look like 10 years from now?

I want us to be a charity for research and practice; a big centre, like Breast Cancer Now, but focused on wellbeing in women with breast cancer. We need funding to do high quality research and we need funding to be able to implement that. 

Here is an opportunity for women finding themselves, coming to terms, adjusting, and making a good living in the timeframe they have. The median survival rate for women with secondary breast cancer is three to five years, but quality of life is still important, and it was shown to actually impact mortality. We need to start looking at ways by which we can improve quality of life in such women who have been neglected. The charity will be an institution of its own, with many scientists, many practitioners who want to contribute to this initiative. That's where BRiC will be in ten years' time: generating high quality research and implementing it with precision. 

At the moment, BRiC is a part of Birkbeck College, so a part of University of London. What I'm hoping to do is to reach out to women in many parts of the UK, whereby we can have not just online seminars, but face-to-face workshops and seminars, and we need funding for that. Perhaps BRiC will expand so widely and be more inclusive, that it can become part of a European project or maybe collaborate with the NIH in the States. I have had many queries about how it can be incorporated within the infrastructure for mental health funding like in the NIH, to reach out to women all across the world. Why just UK women – why not women everywhere, including in poorer countries? 

Socioeconomic status is an important factor for women with breast cancer. I gave a couple of seminars to big crowds of amazing women from Nigeria, researchers and practitioners, who want to implement something like BRiC in their country – for example, for women who have been diagnosed with breast cancer but want to go back to work. BRiC can extend its arms to women all over the world and in places like that, where there is more need of help. Of course, by extending to other parts of the world, we can disseminate the research: we can do cognitive training there and continue our research on women who are abroad. 

That's how I see the future of BRiC going. It's a research and practice centre, it's an integrative centre, so it needs to be evidence-based. We are doing the research behind it, and we will be able to implement this research so we can promote better quality of life in women who deserve it and who have been neglected.

Key sources 

BRiC Panning for Gold blog & BRiC's Collective Voice:
https://bcresiliencecentre.blogspot.com/

BRiC's Academic page:
http://briccentre.bbk.ac.uk/

BRiC's Facebook public page:
www.facebook.com/resilienceinbreastcancer/