Title Page
 Table of Contents
 Background and literature...
 Purpose of study and hypothese...
 Appendix 1: Slide-tape program...
 Appendix 2: Assessment instrum...
 Appendix 3: Sentence completion...
 Biographical sketch

Title: Coping style and response to radiation therapy patient education
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00097435/00001
 Material Information
Title: Coping style and response to radiation therapy patient education
Physical Description: viii, 185 leaves : ; 28 cm.
Language: English
Creator: Rainey, Lawrence Clifford, 1948-
Publication Date: 1982
Copyright Date: 1982
Subject: Patient education   ( lcsh )
Cancer -- Patients   ( lcsh )
Psychology thesis Ph. D   ( lcsh )
Dissertations, Academic -- Psychology -- UF   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Statement of Responsibility: by Lawrence C. Rainey.
Thesis: Thesis (Ph. D.)--University of Florida, 1982.
Bibliography: Bibliography: leaves 173-182.
Additional Physical Form: Also available on World Wide Web
General Note: Typescript.
General Note: Vita.
 Record Information
Bibliographic ID: UF00097435
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 000334797
oclc - 09528635
notis - ABW4440


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Table of Contents
    Title Page
        Page i
        Page ii
        Page iii
        Page iv
    Table of Contents
        Page v
        Page vi
        Page vii
        Page viii
    Background and literature review
        Page 1
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    Purpose of study and hypotheses
        Page 47
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    Appendix 1: Slide-tape program script
        Page 118
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    Appendix 2: Assessment instruments
        Page 130
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    Appendix 3: Sentence completion test scoring criteria
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    Biographical sketch
        Page 183
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Full Text








Anyone who completes a dissertation is indebted to many

others. But when the process is protracted as long as was

the case in this instance, the list of those deserving

credit becomes very lengthy. Knowing that I may unwittingly

omit some who have helped make the completion of this work

possible, let me at least cite several of the individuals to

whom I owe gratitude.

I have benefited by having an outstanding doctoral

committee, comprised of five individuals each of whom has

provided valued guidance and assistance. Franz Epting,

Chairman, has been both mentor and respected friend through-

out my graduate education. He has conveyed a sense of

excitement about psychological research and a respect for

individual differences in construct systems. Cynthia Belar

taught my first seminar in medical psychology and helped

nurture my then nascent interest in applications of

psychology in medical settings. Ben Barger and Bob

Hornberger provided important clinical training experiences,

teaching me much about helping individuals in distress.

Sheldon Isenberg served as an important "transitional

object." When I was feeling quite out of my element in

"Gator Country," he served as a link to my previous

theological studies. All are to be thanked for their

patience and continuing interest in my doctoral research.

Several faculty members at UCLA became my "kitchen

committee" and provided invaluable assistance in diverse

ways. David Wellisch first served as my internship advisor

and has subsequently become a valued colleague in several

behavioral medicine endeavors. I have been impressed by his

dedication, his incredible energy, and his Porsche. Fawzy

Fawzy and Robert Pasnau generously involved me in several

behavioral medicine projects at the Department of Psychiatry

and, by their personal example, showed me psychiatry at its

best. Joseph Cullen gave me my first professional position.

Working with him at the UCLA Cancer Center has made the last

four years a productive, exciting time for me

professionally. Al Marcus provided expert consultation on

matters of design and statistics; he also provided much

needed moral support during the stretch drive of this

project. Mario Barras and his marvelous computer friend,

WYLBUR, amazed me with the number-crunching abilities of

modern technology.

When it looked like I would never find a way to juggle

profession, family, and dissertation, several good friends,

themselves PhD candidates in psychology, showed me the way.

They included Russell Lemle, Saul Shiffman, Lew Bank, Duncan

Clark, and David Rapkin. I look forward to the day when I

can say, "I knew when he was a student at UCLA."

Several persons at the Department of Radiation Oncology

facilitated the execution of this study. Robert Parker,

Professor and Chairman of the Department, supported the

study from its inception and ran interference when the Human

Subjects Protection Committee and other staff physicians

wanted to severely limit its scope. Nurses, Charolette

Miller and David Ewing, and receptionists, Rosie Gutierrez

and Karima Hamay, helped in the day-to-day problems of

conducting the study. My data collection team worked long

hours for little remuneration. They included Linda Kanim,

Paula Kanim, Debora Mueller, and Burton Ogata.

Deborah Haynes, Jeanie Shockey, and Margaret Noble

provided expert assistance in preparation of the manuscript.

My colleagues in the Office of Cancer Communications, Donna

Scarsciotti and Kay Balakrishnan, picked up the work load

when I was preoccupied with this project.

I must add a special word of appreciation to my family.

My wife Marcia has provided the most important ingredient

contributing to the completion of this project--her quiet

love and faith that, in due time, I would choose to jump

this hurdle. I owe an apology to my dynamite, two year old

"live-wire" Nicholas. He thinks evenings and weekends

simply mean that "Daddy's working on his dissertation."

(That will change) And, finally, my thanks to Maxwell

Oliver Rainey who joined us on November 15, 1982. He was

the final stimulus; I just had to finish before he arrived.


ACKNOWLEDGMENTS . . . . . . . . . .

ABSTRACT . . . . . . . . . . . .


Introduction . . . . . . .

The Challenge of Cancer . . . . .

Psychosocial Aspects of Cancer . . .

Psychosocial Aspects of Radiation Therapy

Preparation for Stressful Medical
Procedures . . . . . . . .

Interactions Between Preparatory
Information and Coping Style . . .


Overview . . . . . . . .

Research Questions and Hypotheses . .

CHAPTER III: METHODS . . . . . . . . .

Subjects . . . . . . . .

Independent Variables . . . . .

Dependent Variables . . . . . .

Procedures for Administration of the
Independent and Dependent Variables.

Summary of the Study Design . . . .

CHAPTER IV: RESULTS . . . . . . . .

Descriptive Statistics for Variables . .

Tests of Hypotheses . . . . .

Summary of Results in Relation to
Hypotheses . . . . . . . .























CHAPTER V: DISCUSSION . . . . . . . .




Value of Patient Education . . . .

The Role of Coping Style . . . .

Methodological Challenges of Field Research

The Reality of Information Needs. . . .




REFERENCES . . . . . .










. 173

. 183

Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

Lawrence C. Rainey
December, 1982

Chairman: Franz R. Epting
Major Department: Psychology

This study investigates the effects of a radiation

therapy patient education module on patients' treatment-

related knowledge and emotional state during the course of

radiotherapy. Second, the study explores whether individual

differences in coping style will affect patients' cognitive

and affective responses to the patient education interven-


Sixty patients undergoing their first course of radia-

tion therapy were assigned to one of two conditions:

Patients in the high information condition saw a twelve-

minute slide-tape program which presented sensory and proce-

dural information about radiation therapy; patients in the

low information condition received standard care and did not

see the patient education program. On the basis of the

modified Repression-Sensitization Scale and the Avoider-

Vigilant Coper Sentence Completion Test, patients were also

classified according to coping style. Outcome measures

included an objective test of treatment-related knowledge,

self-assessments of knowledge level, and two measures of


affect, the State/Trait Anxiety Inventory and the Profile of

Mood States. Patients were assessed at the beginning and at

the end of their radiation treatment.

Results indicated that the patient education interven-

tion was effective. Patients in the high information condi-

tion showed greater accuracy of treatment-related informa-

tion at the outset of treatment. The patients who received

the intervention also showed less affective distress as

treatment drew to a close. The predicted main effect for

coping style and the interaction effect (coping style by

intervention condition) were not statistically significant.

However, the pattern of group means was consistent with

predictions in several regards. For instance, repressors

and avoiders reported, in absolute terms, less affective

distress than sensitizers and vigilant copers. Among the

vigilant-sensitizing patients, those who received informa-

tion appeared to fair better emotionally than those who did

not receive the intervention. Highest knowledge scores, in

absolute terms, were obtained by sensitizers receiving the

patient education intervention; lowest knowledge scores were

reported by repressors not receiving the intervention.

The results are discussed in terms of methodological

constraints imposed by the field setting, the situation-

specific dimensions of coping, and the critical relevance of

patient education for persons facing stressful medical pro-






This study (a) examines cancer patients' affective

responses and knowledge about treatment as they undergo

radiation therapy treatment, (b) assesses the effect that

introductory patient education materials have on emotional

state and fund of information, and (c) explores possible

interactions between coping style variables and responses to

information provided about medical treatment. In order to

place the study in appropriate context, the following topics

will be addressed: 1) basic facts and figures about cancer

incidence, survival, and treatment interventions (parti-

cularly, radiation therapy); 2) key research areas in the

fast-developing field of psychosocial aspects of cancer; 3)

studies dealing specifically with psychosocial factors in

radiation therapy patients; 4) research in psychological

preparation for stressful medical procedures; and 5) studies

investigating interactions between coping style variables

and response to information about medical procedures.

The Challenge of Cancer

Cancer, in its many forms, continues to be an all too

common phenomenon. The American Cancer Society (1981) esti-

mates that in 1982 approximately 835,000 people in the

United States will be diagnosed as having cancer. (This

figure excludes approximately 400,000 cases of non-melanoma

skin cancer and all carcinoma in situ.) About 430,000 indi-

viduals will die of the disease this year--1,180 a day, one

person every 73 seconds. Of Americans now living, one in

four--almost 58 million Americans--will eventually have

cancer, according to current rates. On the brighter side,

important advances in detection and treatment of cancer have

lowered the death rates for several forms of cancer and

considerably extended survival periods for many patients.

Consider the following facts: 1) over 3 million Americans

are alive today who have had a history of cancer, 2 million

of them having been diagnosed more than five years ago, and

2) of the 835,000 persons diagnosed this year, approx-

imately 278,000 (about one-third of those diagnosed) will

survive for five years or more. (When survival rates are

adjusted for normal life expectancy factors (i.e., when

other causes of death in this population are taken into

consideration), 41 percent of patients diagnosed with

cancer, across sites, will survive for five years or more.)

In addition, with earlier diagnosis and prompt medical

treatment with modalities available today, the lives of

about 139,000 individuals who will die of cancer this year

could have been saved.

Cancer treatment is a rapidly changing field of medical

endeavor. The three major forms of treatment--surgery,

radiation therapy, and chemotherapy--may be used singly or

in various combinations. Experimental treatments include

new developments in the three standard treatments, as well

as treatments using immunotherapy, hormone therapy, hyper-

thermia, and bone marrow transplants, to cite but a few


Radiation therapy, the therapeutic modality being used

to treat the patients in the present study, is the second

most common form of cancer treatment. Approximately half of

all cancer patients receive radiation for either curative or

palliative purposes at some point in the course of their

disease. Radiation therapy techniques can be broadly

divided into two groups: external radiation and internal

radiation. (All patients in the present study were treated

with external source irradiation.) The so-called

"megavoltage" or "supervoltage" machines used to deliver

high energy radiation in contemporary radiation oncology

settings include a) linear accelerators, which produce high-

speed gamma rays; b) neutron radiation machines and

betatrons, which beam high-speed neutrons or atomic

particles into tumors; and c) machines which utilize cobalt

as an energy source. Treatment schedules vary, depending on

the particular diagnoses, tumor location, total dose needed,

and other factors. However, treatments are usually given

five days per week and average about four to five weeks.

Side effects of treatment vary greatly depending on type of

radiation therapy administered, part of body irradiated,

total dose, scheduling factors, and individual patient


Psychosocial Aspects of Cancer: An Overview

With increased survival times for many cancer patients

and the advent of more complex and extended treatment

regimens, medical personnel and behavioral scientists have

begun to give more attention to the psychosocial aspects of

living with cancer. No longer are issues related to

terminal care and bereavement the only concerns for those

dealing with the psychosocial dimensions of cancer.

Instead, the field has broadened considerably to include a

wide spectrum of issues which confront patients and their

families as they try to cope with the disease and its treat-

ment, throughout its many phases.

In recent years the field of psychosocial oncology has

grown rapidly, not only in terms of the number and variety

of publications, but also with regard to the methodological

sophistication reflected in the studies. The recent

outpouring of books on this topic attests to the growing

interest and activity in the area (e.g., Ahmed, 1981;

Blumberg, Flaherty, & Lewis, 1980; Cassileth, 1979; Cohen,

Cullen, & Martin, 1982; Cullen, Fox, & Isom, 1976;

Kellerman, 1980; Spinetta & Deasy-Spinetta; 1981; and

Weisman, 1979; to cite but a few). A recent review of the

professional literature by Freidenbergs et al. (1981-82)

cites over 100 articles and monographs dealing with

psychosocial aspects of cancer in adult patients.

Until recently, however, the field was dominated by

anecdotal reports and uncontrolled clinical observations.

It has only been in the last few years that researchers have

begun to document the psychosocial difficulties of cancer

patients and their significant others with more objective,

standardized techniques and to evaluate interventions in a

controlled fashion.

Because of the breadth of the field, this review shall

be confined to empirically-based investigations focused on

adult patients. Although not every article can be discussed,

an attempt shall be made to delineate the major domains of

psychosocial research and to discuss representative studies

in each area. The intent here is to outline the scope of

work in this field to date and to summarize the more

important findings. Let us begin by briefly noting the

major threats and coping challenges presented by the


Coping Challenges Presented by Cancer

As we have already noted, cancer is a complex set of

diseases, presenting itself in different stages, taking a

variety of clinical courses, and treated by diverse methods.

Thus the coping challenges confronting patients can vary


On the physical plane cancer often entails an enormous

burden. The threat of death itself is present for many

patients (approximately 60%, across sites, eventually die of

their disease). Even those for whom the prognosis is

relatively good can be very concerned about the possibility

of dying. Though pain is usually well controlled today

through medications and other means, many patients will

experience acute and/or chronic pain at some juncture in the

illness, and almost all patients fear the possibility of

unrelieved pain. Physical disfigurement is an unfortunate

by-product of many treatments. Consider for example,

patients undergoing mastectomies, limb amputations,

operations in the head and neck region, or other major

surgeries. Chemotherapy and radiation therapy can be

accompanied by unpleasant, and sometimes quite disabling,

side-effects. These include nausea, vomiting, anorexia,

alopecia, fatigue, weakness, and other symptoms. Depending

on the site of the disease and the treatments necessary,

physical capacities such as speech, physical mobility,

bladder and bowel function, sexual functioning, and sensory

capacities can be compromised or altered. Beyond the

physical assault, cancer, like other chronic diseases, may

entail lengthy hospital stays, enforced dependence,

separation from one's normal environment and social milieu,

and repeated interactions with medical personnel and

institutions. Vocational, educational, and/or avocational

pursuits may be interrupted or halted altogether. And not

least of the patient's worries is the financial burden

presented by catastrophic illness. This list could be ex-

tended, but suffice it to say that bearing cancer is usually

an arduous and stressful task, taxing the coping resources

of patient and family alike.

Given this state of affairs, how do individuals respond

psychologically and what psychological interventions can be

helpful in preventing or ameliorating these problems?

Essentially, these are the broad questions which

psychosocial researchers have begun to investigate. We

shall discuss several studies dealing with each domain:

impact of the disease and psychological interventions.

Emotional Impact of the Disease

The emotional morbidity of cancer patients has been

investigated by numerous researchers. Craig and Abeloff

(1974), for instance, found that, on the basis of the Self-

Report of Symptoms Inventory (SCL-90), 50% of leukemia and

lymphoma patients surveyed were depressed, and 30% were

anxious. However, Worden and Weisman (1977) reported that

among 40 newly diagnosed breast cancer patients only 20%

reported being depressed (based on the MMPI, the Profile of

Mood States pomsS), and clinical ratings). When cancer

patients are compared to other goups (e.g., other medical

patients, healthy subjects, psychiatric samples, etc.),

results are mixed. For instance, Koenig et al. (1967) found

that 36 colo-rectal cancer patients manifested less

emotional distress in responses to the MMPI than a group of

patients hospitalized for depression and a group of

tuberculosis patients. Beck Depression Inventory scores for

97 cancer patients (varying sites) with advanced disease

were not significantly different than scores obtained by the

patients' next of kin, and they showed less depression than

hospitalized suicidal patients (Plumb & Holland, 1977). On

the other hand, when breast cancer patients were compared to

general surgery patients (Lee & Maguire, 1975) and to women

with benign breast tumors (Maguire, 1978; Morris, Greer, &

White, 1977), in both cases the cancer patients exhibited

significantly more anxiety and depression.

It is fair to surmise that reliable base rates for

emotional disturbance in cancer patient groups have not yet

been established, nor is it clear how cancer patients stand

on these dimensions relative to other groups of interest.

Furthermore, most research to date has focused on

psychosocial dysfunction and largely ignored more positive

dimensions of coping (cf. Rainey & Cullen, 1981). Empirical

documentation of affective states of various cancer patient

groups is still in a nascent stage, though, as we have seen,

researchers are beginning to utilize more objective means to

assess these factors. Teasing out the exact contribution of

disease-related factors (site, stage, time since diagnosis,

prognosis, etc.) and many treatment-related factors (whether

hospitalized, major modality of treatment, specific drug

effects, etc.) awaits further research.

Emotional Response to Cancer Treatment

The one treatment that has received the most extensive

examination by psychosocial researchers, to date, is

mastectomy. This is understandable in that breast cancer is

the most frequent cancer in women and because of the

obviously disfiguring effect of this treatment. We have

already cited, in the foregoing section, several studies

dealing with anxiety and depression experienced by women who

have had mastectomies for breast cancer. Several other life

changes accompanying the disease have also been described.

For instance, Maguire (1978) found that mastectomy patients

experienced more sexual problems than did a control group of

benign breast tumor patients at four months postoperatively

(40% vs. 11%) and at one year postoperatively (33% vs. 8%).

A questionnaire study of 31 husbands of mastectomy patients

(Wellisch, Jameson, & Pasnau, 1978) revealed frequent

reports of decreased sexual satisfaction since the wives'

operations. Generally decreased activity levels among

breast cancer patients, particularly in the weeks

immediately following surgery, have been documented by

Eisenberg and Goldenberg (1966). However; follow-up studies

of women five years after their mastectomies (Schottenfeld &

Robbins, 1970; Craig, Comstock, & Geiser, 1974) show that a

high percentage of these women eventually return to

preoperative employment and activity levels.

Meyerowitz (1980), who has comprehensively reviewed the

literature on psychological correlates of breast cancer,

summarizes the typical responses in this group as "(a) Some

degree of depression, anxiety, and/or anger; (b) some

disruption in everyday life patterns, including marital

and/or sexual relationships; and (c) considerable fear

regarding the danger and mutilation of cancer and

mastectomy" (p. 114). Variables observed to affect

intensity and duration of psychosocial impact, as summarized

by Meyerowitz, include the patient's age, preoperative

expectations, importance of physical appearance and the

breast to the patient, quality of preoperative preparation

by surgeon, quality of marital support, time passed since

surgery, and presence of additional medical treatments

(radiotherapy, chemotherapy). Other types of surgery have

not been studied nearly as much, though a few examples exist

such as Davis and Beumont's (1973) study of laryngectomies

and work by Brown et al. (1972) with pelvic exenteration


When one turns to other forms of treatment, a relative

paucity of studies documenting the psychosocial impact of

treatment is found. Some work has been done recently on the

effects of chemotherapy treatments on the quality of life

(e.g., Meyerowitz et al., 1979), though it has been very

hard to separate the effects of chemotherapy itself from

other disease- and treatment-related variables. Another

recent interest has been to understand possible

neuropsychological problems associated with lengthy

chemotherapeutic regimens (e.g., Peterson & Popkin, 1980;

Silberfarb et al., 1980). (The psychosocial studies done to

date on patients receiving radiation therapy will be

reviewed in a following section.) One must agree with the

conclusion of Freidenbergs et al. (1981-82) that "clearly

more studies are needed to adequately assess the impact of

the various medical treatments on the cancer patient"

(p. 307).

Other Areas of Psychosocial Impact

The psychosocial sequelae of cancer include much more

than emotional disruption. Other areas of life functioning

and social interaction may also be affected adversely.

Various surveys (Feldman, 1978; Wheatly et al., 1974)

suggest that a substantial number of cancer patients

experience denial of work, job discrimination, or other

vocational difficulty. Though many clinicians have noted

the impact that cancer can have for the family members

(e.g., Bloom, 1982; Kaplan, 1982; Vettese, 1981) relatively

little careful documentation and empirical investigation of

this dimension of living with cancer have been done. Krant

and Johnston (1977-78) found very limited communications

between family members of late stage cancer patients.

Leiber et al. (1976), studying sexual and affectional needs

of advanced cancer patients and their mates, found that,

whereas desires for sexual intimacy decreased in 37% of the

patients, approximately half of the patients desired more

non-sexual physical closeness with their partners. The

study of husbands of mastectomy patients by Wellisch et al.

(1978) also found that these men often reported

psychosomatic complaints and work difficulties due to

problems in concentrating and preoccupation with thoughts

about their partners. The myriad repercussions of the

disease for children of adult patients and for the entire

family constellation have not yet received sufficient


Psychosocial Response Across the Course of Disease

How does psychosocial impact change across the course

of the disease? Holland (1973) has discussed the widely

varying clinical courses that cancer can take and the

accompanying variability in psychosocial implications.

However, very few prospective, longitudinal investigations

1 It is interesting to note that psychosocial researchers
in pediatric oncology have attended more closely to the
impact of the disease on the family system (cf. Morrow et
al., 1981; Powzeck et al., 1980).

have been launched. Gordon et al. (1980) followed 308

breast, lung, and melanoma patients through the first 6

months of their disease. The most often noted problems at

the time of initial hospitalization were in the area of

worry about disease itself. Negative affect became the pre-

dominant concern in the period following discharge. Later,

at 3 months and 6 months post-discharge, a broader array of

problems was noted: physical discomfort, concern about

medical treatment, dissatisfaction with health care service,

mobility, financial concerns, family and social problems,

worry about disease, negative affect, and body image diffi-


Morris, Greer, and White (1977), studying psychosocial

adjustment of 61 breast cancer patients over a two-year

span, found that, at two years posttreatment, 83% of the

breast cancer patients had the same ratings of marital

adjustment as at the preoperative interview; work adjustment

had also improved demonstrably over this period.

Weisman and Worden (1977) found that site of cancer was

a significant factor in adjustment. Different site groups

(lung, breast, colon, melanoma, Hodgkin's) had peak distress

periods at different times during the first 100 days of

their illness. These data suggest, as one would expect,

that passage of time alone does not determine psychological

response; rather, there are complex interactions between

individual psychological factors, disease site and stage,

and treatment variables which affect psychological and

social status.

Patient Variables Related to Psychosocial Adjustment

Among cancer patients, who is "at risk" for

psychosocial difficulties? What variables account for good

versus poor adjustment to disease? These questions have led

investigators to develop profiles of "high risk" patients

and attempt to predict later distress.

The extent to which medical data are useful in

predicting psychosocial difficulties is unclear. Weisman

and Worden (1977) reported that medical data (staging of

disease, prognosis, etc.) collected at the time of initial

hospitalization accounted for 40-60% of the variance in

psychosocial distress ratings 6 months later. Studies by

Schonfield (1972), Morris et al. (1977), and Meyerowitz et

al. (1979), by way of contrast, found little correlation

between disease/treatment variables and later adjustment

ratings. Gordon et al. (1980) found that only 12% of the

variance in problems reported 6 months post-hospitalization

could be accounted for by medical data alone. Freidenbergs

et al. (1981-82) speculate that these discrepencies in

findings may be due to different forms of assessment

(examiner ratings versus self-report) used by different

research teams.

Psychological tests have shown some utility in

predicting later adaptation levels in cancer patients. Sobel

and Worden (1979) utilized MMPI profiles obtained fom 133

newly diagnosed patients (various sites) and found that MMPI

profiles alone could account for a majority of the variance

in "vulnerability" ratings at 6 months post-diagnosis.

Lower Morale Loss Scale scores (from the MMPI) and lower

anxiety scores (Cattell's Self Analysis Form) at the time of

diagnosis were predictive of return to work for a group of

42 patients (various sites) studied by Schonfield (1972).

A related approach has been to describe adaptive and

maladaptive patient coping strategies. Most notable in this

regard is a series of longitudinal studies at Massachusetts

General Hospital (Weisman & Worden, 1976-77; Weisman &

Worden, 1977; Weisman, Worden & Sobel, 1980). Studying a

wide cross section of patients longitudinally from the point

of diagnosis, they found that "good copers" (i.e., those

manifesting better ratings on a cluster of self-report and

interviewer rating scales throughout the course of the

disease) tended to realistically face facts, focus on some

favorable components) of their situation, and then confi-

dently comply with doctor's recommendations. By contrast,

"poor copers" used suppression, passivity, stoic submission,

various tension reducing measures, social withdrawal, and


Psychological Intervention Studies

Anecdotal reports and theoretical discussions of

psychosocial interventions for cancer patients abound. The

roles of nurses (George, 1973; Tiedt, 1973; Rainey, 1981b;

Vachon et al., 1978), social workers (Barstow, 1982; Harper,

1975), specially trained oncology counselors (Gordon et al.,

1980), and multidisciplinary teams (Cromes, 1978; Izsak et

al., 1973; Lansky et al., 1976; Pfefferbaum et al., 1977-78;

Wieder et al., 1978) have been described. Various

therapeutic approaches which have been implemented include

supportive group psychotherapy (Herzoff, 1979; Wellisch et

al., 1978; Whitman et al., 1979; Yalom & Greaves, 1977),

family therapy (Cohen & Wellisch, 1978; Kaplan, 1982), home

care programs (Izsak et al., 1973; Wellisch et al., in

press; Yates et al., 1977), telephone help lines (Kramer et

al., 1981; Rainey, 1981a), community-based self-help groups

(Garfield & Clark, 1978), sex therapy (Witkin, 1975;

Mantell, 1982), and relaxation and imagery training

(Simonton & Simonton, 1975; Simonton et al., 1980).

Psychosocial training programs for health professionals

designed to sensitize them to the needs of cancer patients

and to prepare them to provide basic psychosocial services

have been reported by Richards and Schmale (1974) and Rainey

and Wellisch (1981).

Despite the apparent widespread interest in

psychosocial services in oncology settings, empirical

research on the efficacy of psychological interventions

remains scant. (An encouraging note is that several large

scale psychosocial intervention evaluations, funded by the

National Cancer Institute, are now underway and promise to

yield much valuable information in years to come.)

One already completed, relatively large-scale study

(Gordon et al., 1980) reported promising results. One

hundred fifty-seven cancer patients (breast, lung, and

melanoma) received a systematic psychosocial intervention

program which included patient education, supportive

counseling, and "environmental manipulations" (physician

cousultation, rehabilitation referrals, etc.). Psychosocial

treatment was administered by a specially trained social

worker, psychologist, or psychiatric nurse. A control group

of 151 patients received only the evaluation component of

the program (multiple evaluations over a one-year period).

Among other findings, the intervention group ".

evidenced a more rapid decline of negative affect (i.e.,

anxiety, hostility, depression), a more realistic outlook on

life, a greater proportion of return to previous vocational

status, and more active pattern of time usage than patients

in the control group" (p. 743).

In another carefully controlled, longitudinal,

intervention study, Weisman et al. (1980) found that both of

two intervention conditions (Intervention A: short-term,

problem-oriented psychiatric consultation; Intervention B:

short-term, cognitive-behavioral, stress management

training) were superior to the control condition (evaluation

only) on indices of mood disturbance and interviewers'

ratings of emotional vulnerability. An important additional

feature of this study was that the interventions were

targeted for "high risk" patients as identified by a

previously developed psychosocial screening battery.

There have been few controlled, empirically-based

studies of counseling with terminal patients. However,

there is some evidence for the value of supportive

counseling with this group of patients. Linn et al. (1982)

randomly assigned 120 men with end-stage cancer (various

primary sites) to an intervention condition (ongoing,

client-centered supportive therapy) or to a control

condition (evaluation only). Patients were assessed before

assignment to treatment arm and at one, three, six, and

twelve months. Measures included quality of life variables

(depression, alienation, life satisfaction, and self-

esteem), functional status, and survival time. Functional

status and survival did not differ between groups, but

patients receiving counseling showed significantly better

quality of life scores at three months. Among those who

survived, these differences held up through the one year

follow-up. Since "quality of life" issues are key concerns

for incurable patients, these findings are important.

Supportive group therapy for women with metastatic

breast cancer was evaluated by Spiegel, Bloom, and Yalom

(1981). Weekly discussions focused on practical coping

problems associated with terminal illness, feelings and

attitudes toward death, and interpersonal relationships with

family, friends, and physicians. Patients were assessed at

four-month intervals for a one-year period. As compared to

control patients, those receiving the intervention showed

significantly lower total mood disturbance, had fewer

maladaptive coping responses, and were less phobic.

More narrowly focused, yet nonetheless interesting,

recent work has evaluated the effectiveness of relaxation

training and guided imagery (Burrish & Lyles, 1981; Lyles et

al., 1982) and hypnotherapy (Dempster et al., 1976; Redd et

al., 1982) for controlling chemotherapy-induced nausea and

vomiting, as well as conditioned, anticipatory nausea which

plagues many patients.

Though not great in number, these studies report

promising results. As with psychotherapy research in

general, the pertinent question is not, "Does psychological

intervention help?" but "What interventions, directed toward

what ends, with what patients, and administered by whom, are


Psychosocial Aspects of Radiation Therapy

Approximately half of all cancer patients receive

radiation for either palliative or curative purposes at some

point in the course of their disease. At least 350,000

cancer patients receive radiotherapy each year. Although

radiation therapy has been and remains one of the three

major treatment modalities for cancer, its impact on

patients' psychological status has remained relatively

unexplored. This has been an unfortunate oversight since

radiation therapy can be the source of many fears and

considerable emotional distress to many patients. As Rotman

et al. (1977) have stated, "Few therapeutic modalities in

medicine induce more misunderstanding, confusion, and

apprehension, than the use of irradiation in cancer

treatment. The prospect of radiation therapy adds

considerably to the fears already generated by the diagnosis

of cancer, heightening the need for effective doctor/patient

communication" (p. 744). Among the more manifest concerns

observed clinically in patients undergoing radiation

therapy, these authors add, are fears related to death,

pain, "being burned" or disfigured, and loss or compromise

of bodily functions. Patients or family members may

perceive radiation therapy as a futile procedure in a

hopeless situation, and some even believe patients will

become radioactive and contaminated. If anything, fears and

misunderstandings about radiation therapy have been

exacerbated in recent years with the widespread publicity

given to links between radiation exposure and the

development of cancer. There is an obvious need in the

radiation therapy setting for correction of common misunder-

standings, dissemination of accurate information about how

radiation does control malignancies, and appropriate

reassurance related to the fears that patients express.

Until the mid-seventies there were no published reports

on psychological reactions to radiation treatment. Peck and

Boland (1977) published the first study in the area,

reporting the results of structured psychiatric interviews,

before and after treatment, with fifty radiation therapy

patients (various diagnoses). Initial interviews focusing

on what patients had been told when referred for radiation

treatment and their attitude toward it disclosed that only

60% had been told by their referring doctor that they had

cancer, and ". . all arrived at the treatment center

unprepared for the frequency, number, and procedure of

treatment and for the efficacy of treatment by radiation"

(p. 180). Ill-informed about their treatments, the majority

of patients also held negative attitudes toward

radiotherapy. Few expected it to be curative, most regarded

the referral as bad news (a "last resort," "sure sign that

surgery didn't get it al," etc.), and many feared radiation

as inherently damaging or carcinogenic. With regard to

emotional status, thirty-one (62%) were judged by the

interviewing psychiatrist to manifest depressed mood; ten

(20%) showed clinical signs of mild to moderate depressive

reactions. Two-thirds of the patients were noticeably

anxious, with three (6%) having clinically significant

anxiety states.

The second interview occurred at the end of treatment

when physical reactions to treatment were greatest,

undoubtedly adding to the distress felt by the patients.

Eight percent of patients were judged to have a mild to

moderate anxiety reaction, and 74% were judged to be mildly

to moderately depressed. When asked their opinion of the

result of treatment, only 30% felt that they had improved;

46% thought their condition had not changed; and 24%

considered their condition to have deteriorated. Peck and

Boland comment: "Patients suffer irrational fears of damage

and death because of erroneous preconceptions of radiation

which doctors fail to correct. Ironically, the lay and

medical concept of dismal manifestations and futility of

radiation treatment are entirely false. In this series,

only one patient suffered damage due to radiation. Sixty

percent were free of signs of cancer at follow-up 18-36

months later" (p. 180).

Holland et al. (1979) assessed emotional response to

adjuvant radiotherapy in breast cancer patients receiving

radiotherapy following mastectomy. Using the Gottschalk-

Gleser Content Analysis of verbal samples, these researchers

found that women undergoing a regimen of radiotherapy

exhibited higher levels of overall anxiety and hostility-

inward (depression) than those reported for several other

groups of medically ill patients. In addition, overall

anxiety scores for the radiotherapy patients were found to

be even higher than published norms for hospitalized and

ambulatory psychiatric patients. Looking at affective score

patterns across the course of six weeks of treatment, it was

found that patients were most fearful and anxious when they

began radiotherapy. However, it was also found that some

forms of dysphoric affect actually increased across the

course of treatment. Like Peck and Boland (1977), Holland

et al. attributed this, in part, to unpleasantness asso-

ciated with side effects of treatment, which tend to mount

as the treatment progresses, and to concerns about

terminating active treatment and separating from the

treatment staff. Thus, it was suggested that it is

important to attend to patients' psychological state not

only at the beginning of treatment but throughout the course

of therapy. Nonetheless, the point of highest overall

anxiety was at the beginning of treatment; this led to a

recommendation for orientation sessions in which new

patients would be given introductory information about the

personnel, procedures, and treatment equipment which they

would soon encounter.

Forester et al. (1978) evaluated the psychological

status of two hundred radiotherapy patients, half of whom

received betatron therapy and half of whom received linear

accelerator radiation therapy. Using a modified form of the

Schedule for Affective Disorders, these investigators found

the incidence and severity of anxiety and depression to be

high in both goups, though somewhat lower than anxiety and

depression levels in a psychiatric inpatient comparison

group. Affective patterns across the course of therapy

differed as a function of specific type of radiation

treatment: affective distress scores tended to increase

across the course of therapy for the betatron group and

decrease for the linear accelerator group. The authors

suggest that the linear accelerator treatment might have

been less distressing due to the quieter operation of this

machine and due to the fact that treatment sessions are much

shorter with the linear accelerator. It was also found that

patients who at the outset of treatment were able either to

deny their illness or claim honest ignorance showed

significantly less psychologic distress. This suggests that

denial can be a relatively effective coping mechanism, at

least within certain limits. However, denial may be

increasingly difficult to maintain as the disease and

treatment regimens continue over time.

Cassileth et al. (1980) examined 160 new and

experienced radiation therapy patients' knowledge of

radiation therapy, expectations about treatment, self-

assessment of adequacy of their knowledge, and desire for

additional information. Almost all patients (92%) were able

to accurately identify their diagnosis. (This is

considerably more than the 60% noted just a few years

earlier by Peck and Boland (1977).) However, knowledge

about radiation therapy was more limited. Only 55% of new

patients and 71% of experienced patients correctly

identified (multiple choice format) how radiation therapy

works. Over half of all new patients incorrectly stated

that radiation therapy is painful, and 11% of the total

sample incorrectly thought that the radiation therapy they

received would be harmful to others. Patients' self-

assessment of how well-informed they were was also elicited

by questionnaire. Relatively few new patients felt well-

informed about radiation therapy procedures, about treatment

side effects, and about what radiation therapy could do for

their illness. In regard to the desire for additional

information, it was found that 67% of the experienced

patients as well as 72% of the new patients wanted to know

more about radiation therapy. The authors indicate in their

discussion that "Patients' desire for information about

radiation therapy appears to be as much a function of

psychological coping mechanisms as of lack of information"

(p. 496). This is indicated, for instance, by the fact that

even among highly knowledgeable, experienced patients, over

two-thirds still wanted more information about radiation

therapy. Additionally, 36% of the sample did not want to

know in advance of treatment what the radiation therapy room

looks like, and 31% of patients did not want to know more

about radiation therapy. Cassileth notes that in an

unpublished, analogous pilot study of patients in an

outpatient chemotherapy clinic, 45% of those interviewed

said they did not want additional information about the

disease, prognosis, or treatment. In the opinion of

Cassileth et al., these seemingly confusing findings--i.e.,

knowledgeable patients wanting more information, and some

unknowledgeable patients not wanting information--may

reflect individual differences in preferred manner of

handling stressful situations.

Taken as a whole, the handful of extant studies on

psychosocial dimensions of radiation therapy indicate a

substantial amount of emotional distress among these

patients, both at the outset and across the course of

treatment. In addition, many patients appear to lack an

accurate, comprehensive understanding about radiation

therapy treatment procedures. Some observers (e.g., Peck &

Boland, 1977; Holland et al., 1979) note that lack of

accurate information and frank misconceptions may feed

anxiety and other forms of emotional distress in these

patients. However, it must also be remembered that,

according to the survey by Cassileth et al. (1980), desire

for more treatment-related information is not universal

among these patients.

Preparation for Stressful Medical Procedures

Psychological preparation of patients for stressful

medical procedures has been an active area of behavioral

medicine research for the past twenty-five years. A broad

range of intervention techniques has been utilized in

efforts to reduce the aversiveness of medical procedures.

Likewise, researchers have designed interventions for a

variety of different medical procedures, though preparation

for surgery has been the most active category. In a recent

review of the area, Kendall and Watson (1981) divide the

various intervention strategies into seven broad categories:

(1) psychological support, (2) skills training, (3) hypno-

sis, (4) relaxation training, (5) filmed modeling, (6)

cognitive-behavioral interventions, and (7) information

provision. I shall utilize this schema to provide an

overview of the field. It should be noted at the outset

that these categories are not, of course, wholly discrete;

many interventions intentionally combine more than one type

of preparation strategy. However, the categorization does

provide some structure to the field. I shall illustrate

each category briefly, focusing more intently on

"information provision," since the present study utilizes

that strategy.

Psychological Support

Probably the earliest strategy to develop,

psychological support includes methods such as brief

psychotherapy, group discussions to ventilate fears and

concerns, and play therapy with children. The unifying

theme of these methods is reassurance and support.

For instance, Lucas (1976), studying heart surgery

patients, utilized four preoperative intervention

conditions: (1) patients asked to actively focus on plans

for recovery and future life, (2) patients asked to merely

think about recovery and future plans, (3) a therapist-

attention placebo group, and (4) a no-treatment group. The

results showed that the first three groups had better post-

surgical recovery than did the no-treatment controls, but

the three intervention conditions did not differ

significantly from each other.

Schmitt and Woolridge (1973) combined psychological

support (small group discussions prior to surgery, plus a

brief one-to-one counseling session the morning of surgery)

with information provision (procedural and behavioral

information). Patients receiving this intervention, as

compared to controls ("normal hospital procedure"), slept

better prior to surgery, reported less anxiety on the day of

surgery, had less difficulty in urinary retention and

voiding, took less medication on the second and third day

postoperatively, resumed an oral diet sooner, and were

discharged sooner.

However, other studies utilizing general psychological

support interventions prior to surgery have not had positive

results (e.g., Lindeman & Stetzer, 1973; Surman et al.,

1974). Kendall and Watson (1981) conclude that studies to

date ". .. provide no unequivocal evidence supporting the

efficacy of psychological support for adult medical pa-

tients" (p. 201).

Skills Training

Sometimes specific behaviors can be taught which will

facilitate patient adjustment. For instance, a patient can

be taught how to cough, do leg exercises, turn properly in

bed, and perform other skills related to the particular

procedure being utilized.

Lindeman and Van Aernam (1971) provided "structured

teaching" diaphragmaticc breathing, leg and foot exercises,

and coughing and turning techniques) to their intervention

group, whereas other presurgical patients received only

normal preoperative teaching provided by nursing staff.

Although the two groups did not differ in the number of

postoperative analgesics needed, the intervention group

spent significantly fewer days in the hospital. In a

separate study Lindeman (1972) again confirmed the value of

this type of intervention, but found a significant

interaction between incisional site and teaching

effectiveness. Patients receiving incisions in the chest

and lower abdomen did not respond nearly so well to teaching

as did other incisional sites. This illustrates how

treatment-specific the benefits of a particular intervention

strategy can be.

It appears that skills training is most effective, when

it works at all, in getting the patient back on a normal

schedule and out of the hospital quickly. It has not been

shown to be helpful in reducing patients' anxiety and

subjective distress.


Though hypnosis has had a long and colorful history,

there are few published empirical studies applying these

techniques for medical procedure preparation. To prepare

orthopedic surgery patients, Field (1974) used a 20-minute

recorded tape which included "hypnotic preparation" in

addition to a description of the surgical procedures.

Control subjects heard a tape about hospital facilities. No

group differences were found on postoperative indices.

McAmmond et al. (1971) compared hypnosis and systematic

relaxation in reducing anxiety of severely stressed dental

patients. Both intervention conditions showed lower anxiety

in terms of skin conductance, but self-report measures of

anxiety did not differ between intervention and control

subjects. Pain tolerance did not differ between groups, but

on follow-up five months after treatment, significantly more

hypnosis patients had seen a dentist than patients in other

groups. Kendall and Watson (1981) conclude that in this

area, the data are weak and the studies few. They suggest

that future hypnosis researchers need to use more potent

interventions (e.g., individual induction with hypnotist

present) and screen subjects with hypnosis susceptability


Very recently, a few reports have appeared applying

hypnosis to cancer patients. For instance, Redd et al.

(1982) have reported positive results in reducing

conditioned nausea in chemotherapy patients. Spiegel et al.

(1981) have reported increased pain tolerance and lessened

subjective distress in children who have had hypnotic

preparation for bone marrow punctures. In both cases,

hypnotic inductions were administered personally and

multiple training sessions were utilized. These promising

results warrant further investigation.

Relaxation Training

Progressive relaxation training has been used with

success in a number of medical procedure preparation

studies. Miller (1976), for instance, used EMG feedback and

progressive relaxation training for patients with histories

of negative reaction to dental treatment. Self-reports on

state anxiety (State-Trait Anxiety Inventory), the Dental

Anxiety Scale, and EMG levels decreased significantly for

both treatment groups, but not for controls.

With elective surgery patients (cholecystectomy and

abdominal hysterectomy), Wilson (1981) compared information

provision to relaxation training. Relaxation reduced

hospital stay, subjective ratings of pain, and medication

used for pain, as well as increased strength, energy, and

postoperative epinephrin levels. The patients in the

information only condition had reduced length of hospital


Less clear cut results, however, have been found in two

studies utilizing relaxation training for cardiac surgery

patients. Pearson (1976) found no evidence of intervention

efficacy on a number of physiological, behavioral, and

subjective mood state variables. Relaxation condition

patients did, however, use less drugs postoperatively.

Aiken and Henrichs (1971) conducted extensive relaxation

training with patients prior to cardiac surgery. They found

no significant difference between treatment patients and

controls in number of postoperative psychiatric reactions.

Overall, relaxation training appears to be quite

effective in facilitating patients recovery, especially in

less catastrophic medical procedures.

Filmed Modeling

Rather strong evidence exists for the efficacy of

filmed modeling (sometimes called observational learning or

vicarious learning) to aid adjustment of patients undergoing

any of several different medical examination and treatment


Shipley et al. (1978) utilized a 18-minute videotape of

a patient undergoing endoscopic examination with patients

scheduled for this procedure. One group saw the tape three

times, another group saw it only once, and control patients

saw an unrelated videotape. All patients received extensive

procedural and sensory information. No group differences

were found in heart rate at baseline, one minute after

insertion, nor following the procedure. However, heart rate

was significantly lower five minutes after insertion for the

group who had three tape viewings. In addition, physicians

and nurses rated this group as less anxious before and

during the examination. Anxiety self-report (A-State)

scores were the same for all groups during the exam, but

lower for both treatment groups following the procedure.

Finally, significantly fewer patients in the three-exposure

group required diazapan (anxiety-reducing medication) than

patients in the other two conditions. A later study

(Shipley et al., 1979) produced similar results with ex-

perienced patients undergoing repeat endoscopic

examinations. (In a later section, we shall note findings

of these studies related to interactions between coping

style differences and preparation method.)

Melamed and Siegel (1975) demonstrated the

effectiveness of a filmed model as a preparatory

intervention for children undergoing surgical procedures.

The study showed significant, favorable results on pre- and

postoperative physiological, self-report, and observer

ratings of anxiety. A similar model was used by Melamed et

al. (1975) for children in a dental situation. Although no

differences between prepared and control subjects were found

on self-report or physiological measures of anxiety, both

observers and dentists rated the control subjects as

considerably more fearful and as engaging in more disruptive

behaviors during the tooth restoration procedures.

Kendall and Watson (1981) note that these studies (as

well as other similar ones) provide "strong support for the

usefulness of filmed modeling interventions" (p. 213), but

note that those positive results have been obtained for

patients facing less severe medical interventions (e.g.,

dental procedures, minor surgery, endoscopy).

Cognitive-Behavioral Interventions

One of the newest approaches, cognitive-behavioral

interventions are characterized by attempts to alter

patients' self-statements as well as their behaviors.

Illustrative of this method is the study by Kendall et al.

(1979) which compared the effectiveness of two interventions

for reducing stress for cardiac catheterization patients.

For the cognitive-behavioral intervention, therapists

trained patients to a) identify aspects of the hospital

experience which were stressful to them; b) identify methods

they themselves had used to reduce previous stressors; c)

think about ways these methods could be applied to the

current stressors in the hospital; and d) rehearse the

process of identifying anxiety-producing cues and applying

one's own coping strategies to lessen stress. A second

intervention condition, patient education, provided written

and verbal instruction about heart disease and

catheterization procedure. Other patients were assigned to

either a time-matched, attention placebo group or to a no-

treatment control group. During catheterization both

treatment groups had lower anxiety state scores than did

either control goup. On behavioral ratings of tension,

anxiety, cooperativeness, and adjustment during the

procedure, both physicians and technicians rated the

cognitive-behavioral group significantly better adjusted

than the information only group, which was, in turn, rated

better than the two control goups. Though these results are

very positive, this approach, as applied in medical

settings, is quite new and needs further investigation.

Information Provision

Among the several approaches to preparation for

stressful medical procedures, information provision has been

the most extensively investigated. We have already observed

in the foregoing section that several studies investigating

other procedures have also included information provision.

In fact, in most medical settings provision of a certain

amount of procedural information is considered an essential,

routine component of good medical practice. Several

investigators have, however, tried to study directly the

usefulness of different types and amounts of information.

A commonly made distinction in this context is that

between procedural information and sensory information. The

former refers to information about the medical procedure

itself, mortality rates, etc.; the latter refers to

information about actual sensations the patient can expect

to feel. The two types of information, though conceptually

distinct, are often utilized together in preparatory patient

education messages.

With regard to procedural information, little, if any,

effect on reducing anxiety was found by Vernon and Bigelow

(1974) who provided detailed, preoperative information to

male patients undergoing hernia repairs. Though the

intervention patients did learn more about their operations,

their self-report anxiety scores were not significantly

different than control subjects. However, the patient group

as a whole reported quite low anxiety scores, making it

difficult to further lower anxiety ratings.

For patients undergoing intraabdominal operations,

Egbert et al. (1964) utilized a combination of procedural

and sensory information plus pain-reducing behavioral

training (relaxation skills, turning procedures, etc.).

Patients receiving this intervention spent fewer days in the

hospital postoperatively, used fewer narcotics following the

surgery, and were rated as being in less pain by an

anesthesiologist (blind to condition). It is impossible to

judge from this study, of course, the relative contributions

of the multicomponent intervention.

Subsequent studies have attempted to assess the

relative contributions to recovery of the two types of

information. Johnson and Leventhal (1974), studying

patients udergoing endoscopy, utilized four conditions: 1)

prodedural information only; 2) specific sensory information

about what would be felt, tasted, seen, and heard during the

procedure; 3) behavioral training on what to do during the

throat puncture and tube insertion, plus procedural

information; and 4) procedural and sensory information plus

behavioral training. Results showed no differences between

groups in tension-related arm movements. Among younger

patients (under 50), all treatment groups showed slightly

lower heart rates, and the younger patients receiving

sensory information took fewer medications. Gagging was

reduced for both the combined information and the sensory

information only group. Tube passage actually took longer

for the combined information groups than for controls of all

ages. In sum, the study showed a moderate amount of support

for the value of sensory information, but clear superiority

of any intervention was not established.

Mohros (1977) divided gastrointestinal endoscopy

patients into similar groups: 1) specific, reassuring

sensory information, 2) procedural information, 3) general

sensory information only, 4) no information controls. No

significant group differences were found on either avoidance

movements during examination or tranquilizer dosage. Some

support for the sensory information conditions was found in

that both general and specific sensory information reduced

distress scores slightly and produced a significant decrease

in heart rate.

Finally, Johnson et al. (1973), also studying

gastrointestinal endoscopy patients, performed a similar

manipulation: some patients receiving only general hospital

preparatory procedures, others hearing a detailed procedural

message, and a third group hearing a detailed sensory

message prior to the procedure. Measures of heart rate,

gagging, and restlessness showed no differences between

groups. However, both of the information groups showed

fewer tension-related hand and arm movements than did the

control groups. Once again, there was modest support for

the value of preparatory information, but no clear

superiority could be established for sensory or procedural


Interactions Between Preparatory Information
and Coping Style

Several researchers have posed the question of whether

or not standardized preparatory messages for medical

procedures have uniform effects across individuals. Might

not individual differences in personality have an impact on

a person's responses to these messages? Are there different

adaptational dispositions (e.g., coping styles) which might

predispose individuals to benefit more or less from explicit

messages about threatening situations? Indeed, could

preparation actually have untoward effects in some


One line of such research grew out of laboratory

studies on individual differences in response to stress

conducted by Goldstein and his associates (see Goldstein

(1973) for a summary of this work). Goldstein construed

coping response patterns for dealing with threatening

stimuli along a dimension of avoidance--vigilance. Various

instruments (e.g., self-report, perceptual defense tasks,

projective techniques) were investigated as means to

efficiently and effectively classify individuals on this

dimension. The one proving most fruitful was an application

of projective testing in which a version of the Sentence

Completion Test (SCT), as modified by Mainord (1956), was

used. Criteria were developed by which judges could

reliably scale subjects' sentence completions on a

vigilance--avoidance continuum. Vigilant subjects are those

who attend to and elaborate fully on the threatening meaning

conveyed by the incomplete sentence. They give personalized

and specific responses, readily acknowledging feelings.

Avoiders use arbitrary stereotyped responses, denying or

evading the threatening content. To the stem, "I hate,"

vigilant responses might be: "my parents," "nosey people,"

or "anyone who is smarter than me." Avoidant responses

might be: "to be caught in the rain without an umbrella" or

"no one." Or to the stem, "If I am struck," the vigilant

subject might write, "by someone, I would be furious,"

whereas the avoidant subject might say "It's not likely."

Responses to a number of such items were summed, and the

resulting scores were utilized to divide subjects into

vigilant, avoidant, and neutral (mid-range score) groups.

Individuals so classified were shown to differ in their

physiological responses (Goldstein et al., 1965) and in

their instrumental responses (Adams & Goldstein, 1970;

Goldstein & Adams, 1967) to laboratory-induced stress.

Subsequently, two field investigations of naturally

occurring stressors (namely, the stress of surgery) were

carried out.

Andrew (1970) hypothesized that surgical patients whose

preferred coping style was that of vigilance toward, rather

than avoidance of, stressful stimuli should be expected to

welcome explicit information about surgical procedures they

were to undergo, to learn such information, to reduce stress

thereby, and to have less complicated recoveries. Coping

style was assessed via the Sentence Completion Test method

just described. Some of the patients, who were scheduled

for hernia operations, heard an audio tape about hernias,

surgical process, and recovery; control subjects did not

hear the tape. Andrew found that avoiders required more

medications, though not a longer recovery time, when in-

structed; the middle group recovered quicker and with fewer

medications when instructed than when not instructed; and

sensitizers recovered well whether or not they received


In a subsequent study, with different surgical groups

(patients underoing hysterectomies and gall bladder

operations), DeLong (1971) again classified patients on the

vigilant-avoider dimension, using the Goldstein Sentence

Completion Test. Patients were assigned to hear one of two

tapes--one containing specific information about surgery,

and the other containing general information about the

hospital. With regard to recovery, individuals given

specific information had less complicated recoveries and

were discharged earlier than those given general informa-

tion. Coping style did interact with instruction to affect

recovery indices, but the pattern of results was somewhat

different than that found by Andrew (1970). DeLong found

that specific information had little effect on the middle

("neutral") group, who recovered well regardless of tape

heard. Vigilant patients who heard specific information

recovered better on both subjective and objective indices

than did vigilant subjects who heard the general information

tape. Avoiders, as a group, tended to have slow,

complicated recoveries. Specific information had little

effect on objective indices of recovery in the avoider

group; however, avoiders who heard the specific information

tape did voice more complaints than avoiders who heard the

general information tape. Thus, these results suggest that

vigilant patients did much better when they received

relevant information about the stressor and much more poorly

when they did not receive it. Conversely, the avoidant

group, in this study, manifested some adverse effects when

they received explicit information.

Other researchers have performed similar investigations,

but have used different means to assess coping style

variables. For instance, Shipley et al. (1978) recently

investigated interactions between coping style and

preparation for endoscopy. Coping style was measured by a

modified form of the Repression-Sensitization Scale (Byrne,

1961; Epstein & Fenz, 1967) which is conceptually similar to

the vigilant-avoidant dimension. "Sensitizers" are

characterized by typically seeking information about

stresses as a means of anxiety management, whereas

repressorss" avoid anxiety by shutting out awareness of

anxiety producing cues and thoughts. Studying patients

scheduled for their first endoscopy, Shipley et al. (1978)

investigated anxiety as a function of number of prior

viewings of an explicit videotape and of repression-

sensitization coping style. On the dependent measures of

heart rate, clinicians' behavioral ratings, tranquilizers

required, and self-reported anxiety (State/Trait Anxiety

Inventory), an increased number of viewings of the

preparatory tape resulted in less distress. The

physiological measure of heart rate interacted significantly

with the repression-sensitization factor. "Sensitizers"

showed decreased heart rate with more tape exposures (0, 1

or 3), whereas repressorss" manifested increased heart rate

with one exposure and decreasing heart rates with subsequent

exposures (i.e., an inverted U function). The later finding

is interpreted as resulting from disruption of repressive

defenses after one tape exposure, followed by extinction of

fear through repeated exposures. In a second study, Shipley

et al. (1979) repeated essentially the same experiment but

this time used experienced endoscopy patients who had to re-

experience that examination. On several dependent anxiety

measures (physiological, behavioral, and self-report), more

extensive preparation tended to decrease anxiety in

sensitizers, and it had no effect or produced increased

anxiety in repressors. When the data were analyzed without

regard to the repression-sensitization coping style, tape

viewing appeared to produce little or no effect. These

results led Shipley and his associates (1979) to conclude

that sensitizers be "prepared extensively and repressors

left alone or at least left with their defenses" (p. 506).

In other words, for optimal effect, preparation for

stressful procedures should take individual personality

differences into account.

Auerbach et al. (1976) used general and specific

information tapes to determine their impact on anxiety and

behavioral adjustment during dental surgery. This group

investigated how another personality dimension, locus of

control (Rotter, 1966), interacted with specific versus

general information. They found no main effects for either

locus of control or specificity of information. However,

when the personality variable was considered, they did find

significant interactions. Internals had better adjustment

ratings if they viewed the specific tape rather than the

general tape. The opposite pattern was found for externals.

The overall pattern of results from these studies is

complex and, in some instances, less clearcut than one might

hope. Further complicating matters is a study by Cohen and

Lazarus (1973) which attempted to compare different methods

of assessing coping style. Cohen and Lazarus compared

dispositionall measures" (i.e., trait measures, including

the Goldstein Sentence Completion Test and the modified

Repression-Sensitization scale) with "process measures"

(i.e., observer ratings of coping style based on information

seeking by patients during interviews). To obtain "process"

ratings, patients were interviewed to assess their coping

behavior "on the spot," prior to surgery. They were also

given several psychological tests. After surgery, several

recovery indices were monitored. (It should be noted that

no patient education intervention was carried out as part of

this study.) With regard to recovery variables, results

showed that the group rated by observers as most vigilant

had the most complicated recoveries. Coping disposition

measures, anxiety scores, and life change event scores

showed no clear relationship with recovery indices.

Additionally, process ratings of coping were not

significantly correlated with SCT scores, and only

moderately correlated (.27, p<.05) with the modified

Repression-Sensitization scale.

Wilson (1981) compared the effectiveness of two

interventions, relaxation training and preparatory sensory

information, in a study of elective surgery patients (gall

bladder operations and abdominal hysterectomies).

Personality variables (denial, fear, aggressiveness) were

also taken into account. However, each of these personality

variables was assessed simply by patients' ratings of three

self-report items pertaining to each variable. Recovery

indices showed positive effects for both intervention

strategies (particularly for the relaxation training). In

addition, personality factors were associated with recovery

and influenced patients' responses to preparation. Non-

aggressive patients (i.e., patients who reported that they

would respond to hypothetical situations involving pain or

discomfort with relatively little anger or aggressiveness)

reacted to information with decreased hospital stay, but

with increased pain, medication, and epinephrine levels.

Aggressive patients responded to information with shortened

hospital stays, less pain, less medication, and lower

epinephrine levels. No significant interactions were found

between the three-item self-report scale of denial and the

interventions. With regard to patients' fear ratings, less

frightened patients benefitted more from relaxation than did

very frightened patients.

Though the personality constructs assessed, and the

methods utilized to measure them, have varied from case to

case, studies by Andrew (1970), DeLong (1971), Auerbach et

al. (1976), and Wilson (1981) all suggest that coping style

characteristics of the individual patient affect response to

preparatory interventions in medical situations.




This study focuses on the following domains: affective

responses of patients undergoing medical treatment for

serious illness, preparatory patient education for medical

procedures, and individual differences in styles of coping

with threatening medical situations. In particular, this

study is concerned with selected psychosocial factors

affecting patients undergoing their first course of

radiation therapy.

The specific objectives of the investigation are 1) to

assess patients' affective and cognitive responses to a

radiation therapy patient education module, and 2) to assess

to what degree individual differences in coping style affect

responses to patient education materials. Thus the study

first seeks to evaluate an intervention. It investigates

what effects, if any, a preparatory audiovisual patient

education module has on a) the patient's fund of treatment-

related information, and b) the degree of dysphoric affect

experienced during treatment. Second, the study explores

whether individuals who differ in coping style will manifest

different patterns of response (both in terms of what they

learn and how they feel emotionally) to the patient educa-

tion intervention.

This study builds on and extends earlier research by 1)

providing further objective documentation of oncology

patients' psychological status; 2) investigating patients'

responses to a major treatment modality (radiation therapy);

3) attempting to ameliorate emotional distress through a

brief intervention which offers relevant, treatment-related

information; and 4) exploring whether individual differences

in coping style modulate patients' responses to psychosocial


Research Questions and Hypotheses

There are three main research questions posed by this

study, entailing six specific hypotheses.

First Research Question: What effect will an audio-

visual patient education program, presented at the beginning

of radiation therapy treatment, have on the patients' level

of treatment-related knowledge and on their affective


Hypothesis 1: Patients receiving the patient education

intervention will manifest greater accuracy of

information about radiation therapy treatment than

patients not receiving the intervention.

Hypothesis 2: Patients receiving the patient education

intervention will report lower levels of affective

distress than will patients not receiving the interven-


Second Research Question: Will individual differences

in coping style dispositions (repression-sensitization,

avoidant-vigilant) be related to acquisition of treatment-

related information and to affective status?

Hypothesis 3: Patients with a sensitization (vigilant)

coping style will manifest greater accuracy of treat-

ment related information than will those with a repres-

sive (avoidant) style.

Hypothesis 4: Patients with a sensitization (vigilant)

coping style will tend to report greater affective

distress than will those with a repressive (avoidant)

coping style.

Third Research Question: Will individual differences

in coping style dispositions (sensitization-repression,

avoidance-vigilance) interact with intervention condition

(high vs. low patient education) to affect outcome measures

(treatment-related knowledge and affective status)?

Hypothesis 5: Highest levels of treatment-related

knowledge will be found in sensitizers (vigilant

copers) exposed to the patient education module (high

information condition); lowest levels of treatment-

related knowledge will be found in repressors

avoiderss) in the low information condition.


Hypothesis 6: Lower levels of affective distress will

be reported by sensitizers (vigilant copers) receiving

patient education and repressors avoiderss) not

receiving patient education; higher levels of affective

distress will be reported by repressors avoiderss)

receiving patient education and sensitizers (vigilant

copers) not receiving patient education.




Selection Criteria

Participants in the study were recruited from patients

beginning their first course of treatment at UCLA's

Department of Radiation Oncology. The only exclusionary

criteria were the following: patient under 18 years old,

inability to read and write English, previous radiation

therapy treatment, anticipated course of treatment less than

four weeks, too ill to complete questionnaires.

Participation was not restricted on the basis of disease

site or stage, other treatment history, specific type of

radiation therapy being administered (all patients were

receiving external source radiation, either from a cobalt

machine or a linear accelerator), nor on the basis of any

demographic variables.

Recruitment Procedure

Typically, patients who are referred to the Radiation

Oncology Department come first for a "consultation visit."

During this appointment the patient is examined by the

radiation oncologist, the case is reviewed, and treatment

options are explained. If the decision is made to

administer treatment (some cases are not found to be

appropriate for treatment; others may receive radiation

therapy elsewhere), a treatment planning ("set-up")

appointment is scheduled. At this session, usually

scheduled for 90 minutes, radiation therapy equipment is

positioned, and plans are made for any additional materials

(lead blocks, molds, etc.) needed for treatment. The

patient is then scheduled for actual treatment. Though

treatment schedules vary, most patients are treated five

times per week (Monday-Friday) for a period of four to five

weeks. Treatment sessions are brief, being scheduled every

ten minutes. A period of one day to one week may elapse

between the set-up appointment and the initiation of

treatment, depending on the patient's physical condition,

time needed to prepare custom-made materials for treatment,

and other factors.

For purposes of recruitment into the study, patients

were personally contacted by a member of the research team

at the time of their treatment planning visit or, if this

1 A cadre of undergraduate and graduate students
assisted across the course of the study in the tasks of
recruiting patients for the study and administering the
questionnaires. Since patients could be scheduled for
any time between 8am and 5pm, Monday through Friday, it
was advantageous to have several assistants who could
cover various time periods.

was impossible, at the first treatment session.1 The

purpose and nature of the study would be explained briefly,

and, if the patient indicated willingness to participate, he

or she would be scheduled to participate in the study later

that day or at the next regularly scheduled visit. Thus the

experimental intervention and initial assessment for this

study occurred near the beginning of treatment, but not

before the patient had already had some contact with the


Since new patients could be scheduled at any time

throughout the forty-hour week, it was not possible to

attempt recruitment of every incoming patient. Instead the

sample was recruited from incoming patients scheduled for

times when one of the researchers could be present.

However, it is not likely that this factor presented any

biasing effects, since patients are randomly assigned to

treatment times as openings occur in the treatment schedule,

and in the course of the study all time periods throughout

the week were sampled.

1 Patients were not contacted at the initial consulta-
tion visit for two reasons. First, as explained above,
not all patients seen for a consultation would, in
fact, receive treatment. Second, the physicians felt
that the consultation visit was often a distressing
time for patients. In their opinion, it would have
been inappropriate and counterproductive to propose
research participation at that particular time.

Sample Characteristics

Seventy-two patients were recruited to participate in

the study. Among these patients, 12 could not be included

in the final sample used for analysis due to one of the

following reasons: 1) treatment discontinued early (four

patients); 2) physical condition deteriorated such that the

patient felt unable to complete final assessment (four pa-

tients); 3) deceased before final assessment (two patients);

or 4) the patient failed to complete all questionnaires (two

patients). This left a final sample of 60 patients who

completed the entire study.

Within the boundaries of the selection criteria set

forth above, the final study sample consisted of a

representative, heterogeneous sample of patients undergoing

their first course of radiation therapy treatment. Disease,

treatment, and demographic characteristics of the study

participants are summarized in Tables 1 and 2.

Independent Variables

Intervention Condition

Patients were assigned to either of two intervention

conditions: 1) the "high information" condition which

entailed exposure to an audiovisual patient education

module, or 2) the "low information" condition which

consisted of standard departmental procedures; i.e., no

audiovisual patient education program.


Disease and Treatment Characteristics
of Study Participants

Disease Site/Type

Head and Neck
Pituitary Adenoma
Metastatic Disease
(Unknown Primary)
Multiple Myeloma

Radiation Therapy

Linear Accelerator
Cobalt Machine


14 (46.7)
16 (53.3)



17 (56.7) 31 (51.7)a
13 (43.3) 29 (48.3)

aNumbers in parentheses represent percentages


Demographic Characteristics of
Total Sample (N=60)

No. (%)

30 (50.0)
30 (50.0)


Never Married


Working, Full-time
Working, Part-time
Unemployed, Looking for work
Too ill to work, disabled
Managing Household

Less than $10,000
$10,000 $19,999
$20,000 $29,999
$30,000 and over

Standard Deviation

Standard Deviation














Patients assigned to the high information condition

were shown a slide/tape program entitled "Introduction to

the Radiation Oncology Department." Developed by the UCLA

Office of Cancer Communications in conjunction with the

Office of Instructional Development, the slide/tape program

is approximately twelve minutes in length and is viewed on a

self-contained, automatically-forwarded, rear-projection

unit. The program is designed to orient the new patient to

the therapeutic process he/she is about to undergo and to

answer many commonly asked questions. More specifically,

it a) introduces the patient to the personnel of the

department and the variety of professional roles represented

(radiation oncologists, technicians, nurses, physicists,

dosimetrists, etc.); b) shows various types of radiation

therapy equipment; c) outlines the sequence of procedures to

which the patient will be subjected during treatment

planning and treatment itself; d) explains and demonstrates

what the patient will see, hear, and feel during treatment;

e) presents basic information about how radiation therapy

works; and f) attempts to dispel some common misconceptions

about radiation therapy. The slide/tape program thus

provides both "procedural" and "sensory" information, though

the emphasis is on the former.

A copy of the shooting script and photographic list can

be found in Appendix 1. The finished product reflects

professional production standards, having cost approximately

$4,000.00 to produce,1 not including considerable staff time

invested in its development. All statements in the script

were carefully reviewed and cleared by the radiation

oncology staff. The slide/tape program, though relatively

brief, does provide much more explicit and comprehensive

information than had been previously provided to patients,

and it covers orientation material in an organized,

systematic fashion. The program amounts to a formal

statement by the department, encouraging patients to be

informed about their treatment and the department's

procedures, and it explicitly encourages patients to ask

questions and seek further information.

The low information group consisted of patients who did

not see the slide/tape program but instead simply received

current departmental procedures. The procedures, prior to

the introduction of the slide/tape program, did not include

an organized patient education or orientation program,

although staff members (doctors, nurses, technicians) have

always been available to answer questions, if asked. A copy

of the booklet, "Radiation Therapy and You," produced by the

National Cancer Institute, was given to every patient in the

study. (This pamphlet had been available to patients in the

Support for the production of the patient education
module was provided by National Cancer Institute
Communications Contract #CN-85397.

waiting room, and we wished to insure that all study

participants had equal opportunity to read it, if desired.)

Assignment to Conditions

Due to logistical factors (including, most

significantly, the fact that each patient is seen five times

per week in the clinic and all patients share common waiting

rooms), it was deemed undesirable to assign successive new

patients randomly to either see or not see the patient

education module. The medical staff felt strongly that this

would create problems--e.g., patients asking, "Why didn't I

(or my family member) get to see the slide/tape program that

patient "X" was talking about?" Furthermore, there could

have been "contamination" problems with regard to the study

itself if, as one might anticipate, patients in the

intervention group began sharing their recollections

(accurate and inaccurate) with other patients who had been

assigned to the low information (no slide/tape program)


The plan adopted was to collect data first from a

series of thirty new patients receiving standard care and

procedures of the department. This group constituted the

"low information" group for the study. The slide/tape

program was then introduced and made available to all new

patients entering the department, and the intervention or

"high information" group was recruited and assessed. This

order (low information, then high information) was the most

practical since once the patient education module was

introduced, it would have been difficult and impractical to

withdraw it; both patients and staff would have become

accustomed to its availability.

Though this procedure for conducting the study

technically makes this a "non-equivalent control group"

design, there is no reason to believe that this method of

assigning patients to arms of the study introduced any

systematic bias into the patient groupings. New patients

constantly enter treatment at the department as they are

referred by their primary physicians throughout the region.

Thus, although the two groups for this study were taken from

two different time periods, one would not anticipate this

fact to produce meaningful group differences in factors such

as distribution of disease sites, stage of disease, specific

form of radiation treatment, and demographic variables (age,

sex, marital status, ethnic group membership, socioeconomic

class, etc.). Indeed, this proved to be the case. A

comparison of the two groups on disease, treatment, and

demographic variables, presented in Table 3 reveals that the

two groups are comparable on all of these dimensions.

Coping Style Measures

This study hypothesizes that the impact of high or low

levels of introductory patient education will vary as a

function of individual differences in coping style. Stated



Demographic Characteristics by
Intervention Group Assignment

N=30 N=30
Low High
Information Information

No. (%) No. (%)

Sex Male 13 (43.3) 17 (56.7)
Female 17 (56.7) 13 (43.3)

Marital Married 16 (53.3) 21 (70.0)
Status Widowed 5 (16.7) 2 (6.7)
Divorced 2 (6.7) 4 (13.3)
Never Married 7 (23.3) 3 (10.0)

Ethnic Caucasian 26 (86.7) 24 (80.0)
Group Hispanic 2 (6.7) 4 (13.3)
Asian 1 (3.3) 2 (6.7)
Other 1 (3.3) 0 (0.0)

Employ- Working, full-time 8 (26.7) 9 (30.0)
ment Working, part-time 0 (0.0) 4 (13.3)
Status Unemployed, looking for work 2 (6.7) 0 (0.0)
Too ill to work, disabled 9 (30.0) 7 (23.3)
Managing household 5 (16.7) 4 (13.3)
Retired 4 (13.3) 6 (20.0)
Other 2 (6.7) 0 (0.0)

Annual Less than $10,000 6 (20.0) 6 (20.0)
House- $10,000 $19,999 9 (30.0) 6 (20.0)
hold $20,000 $29,999 6 (20.0) 6 (20.0)
Income $30,000 and over 9 (30.0) 12 (40.0)

Age Mean 50.7 50.9
(years) Standard Deviation 15.2 15.0
Range 27-75 21-75

Educa- Mean 14.2 14.1
tion Standard Deviation 2.8 3.3
(years) Range 9-20 8-20

otherwise, the cognitive and affective outcomes of patient

education are posited to be not solely the result of degree

of information presented, but rather, to reflect an

interaction of dispositional factors (coping style) and

specificity of preparatory information.

Chapter I reviewed the handful of studies to date which

have assessed coping style dispositional variables in the

context of preparation for stressful medical procedures.

The present study employed two measures which had been used

in previous research.

Avoidant-Vigilant Sentence Completion Test (SCT). This

is an application of projective technique in which the

respondent completes a series of twenty sentence stems,l

each of which, as modified by Mainord (1956), contains a

threatening implication (see Appendix 3 for a list of the

sentence stems). As noted in the literature review, scoring

of the instrument for the avoidant-vigilant construct was

originally developed by Goldstein and associates at UCLA

(Adams & Goldstein, 1970; Goldstein & Adams, 1967;

Goldstein, 1973). More explicit and definite scoring

criteria for the construct were developed by DeLong (1971).

Concerning scoring criteria she says:

1 There are also five "filler" stems, containing
neutral content (Nos. 1, 6, 16, 21). These function as
"breaks" in what would otherwise be a very forbidding
set of stems and thus facilitate completion of the

Responses to the sentence stems are scored on a
three point scale depending on the degree of ap-
proach or avoidance [of potential threat] ex-
pressed. Responses indicating intense, immediate,
personalized involvement are scored 2. Responses
indicating denial, remoteness and lack of person-
alized involvement are scored 0. Intermediate
responses are scored 1. Recogition of the
[threatening] implication of the sentence stem,
intensity of the emotion expressed and
personalization of the answer, as well as
immediacy rather than remoteness, are all
considered in the scoring. (p. 63)

Individual item scores are summed, giving a final score

which can range from 0 to 40.

More recently, Maddahi and Rapkin (1981) have developed

an annotated version of the scoring manual which gives more

detailed guidelines for scoring criteria (see Appendix 3).

Raters trained with this manual achieve high levels of

interjudge reliability, and the instrument shows good

stability across time (test-retest reliability r = .75, over

a four month period) (Maddahi et al., in press).

For purposes of this study, experienced raters trained

with the Maddahi and Rapkin manual were utilized. Each SCT

form was scored by two raters, and the mean score from the

two ratings was utilized. Inter-rater reliability was very

good (r=.95, p < .001).

Repression-Sensitization Scale (R-S Scale). The R-S

scale, originally developed by Byrne (1961), is a

empirically-derived scale consisting of items from the MMPI.

Describing the construct, Byrne (1964) writes:

At one end of this continuum of defensive be-
haviors are those responses which involve
avoidance of the anxiety-arousing stimulus and its
consequents. Included here are repression, de-
nial, and many types of rationalization. At the
sensitizing extreme of the continuum are behaviors
which involve an attempt to reduce anxiety by
approaching or controlling the stimulus and its
consequents. The latter mechanism include in-
tellectualization, obsessive behaviors, and
ruminative worrying. (pp. 167-170)

Sensitizers can be described as handling stress in a

vigilant fashion. They are overtly anxious, keen to

threatening cues, and apt to use intellectualization as a

defense. By way of contrast, repressors are not overtly

anxious, and cope with the threat of stress by avoiding

thoughts about it, repressing it, or denying its potential

stressfulness. A considerable amount of research has been

done with the R-S scale, relating it to perceptual defense,

memory, clinical judgments of defensive behavior, awareness

of anxiety, self-concept, neurotic behaviors and various

other personality dimensions (see Byrne, 1964, for an

extensive review of this research).

With developments in psychosomatic medicine,

investigators began exploring relationships between

repression-sensitization and health behavior. If the R-S

dimension reflects characteristic ways of coping with

stress, it is reasonable to expect that repressors and

sensitizers would differ in health behaviors. Byrne et al.

(1968) reported that sensitizers indicated a greater

frequency and/or severity of illness than repressors and

that male sensitizers sought medical help more often than

did male repressors or intermediates. Gayton et al. (1978)

reported that sensitizers had significantly more visits

(both medically justified and unjustified) to an infirmary

than did repressors. Sensitizers and repressors did not

differ, however, in the proportion of justified/unjustified


A modified, short form of the R-S scale was developed

by Epstein and Fenz (1967) in order to eliminate the high

correlation between R-S and measures of anxiety. As already

discussed in Chapter I, scores on the modified R-S scale

have been found to interact with degree of preparatory

information, affecting patient adjustment to endoscopy

examination (Shipley, Butt, & Horowitz, 1979; Shipley, Butt,

Horowitz, & Farbry, 1978). The short form, modified R-S

scale was used in the present study (see Appendix 2 for

scale items).

Dependent Variables

The major outcome variables of interest are 1) the

patient's knowledge of radiation therapy, and 2) the

patient's emotional status during the course of therapy.

Thus, information is being collected both about cognitive

and affective variables.

Level of Knowledge

Each patient's knowledge of radiation therapy was

assessed by a 21-item, objective questionnaire entitled,

"Radiation Therapy Questionnaire" (see Appendix 2),

developed for this study. All items on the test have been

drawn from the scripts of the patient education materials

presented to the patients and cover the major points which

are presented. The test contains items on treatment

methods, sensations experienced during treatment, side

effects, departmental procedures, and common misconceptions

about radiation therapy. Total score on this instrument

consists simply of the number of correct responses (range 0-


In addition to the objective test of patient knowledge,

patients also answered a brief self-report questionnaire,

giving a subjective appraisal of the degree to which the

individual feels him/herself to be well informed about i)

radiation therapy procedure, ii) the side effects of

radiation therapy, and iii) the effects of radiation therapy

on one's illness. With regard to each of these dimensions

the patient rated himself/herself on a four-point scale.

These three items were summed yielding one score (range 3-

12) which is labelled Self-Assessment of Knowledge (SAK).

Affective Status Variables

Affective status was assessed via well-established,

psychometrically sound tests. Anxiety level during the

course of treatment was assessed by the State/Trait Anxiety

Inventory (STAI) (Spielberger et al., 1970). The STAI

entails two, 20-item, self-report scales: one in which

patients describe how they "generally" feel (trait), the

other indicating how they feel "at this moment in time" (see

Appendix 2). State anxiety scores were utilized for

purposes of this study.

A second, generalized affective arousal indicator was

obtained via the Profile of Moods States (POMS) (McNair et

al., 1971). It consists of 65 five-point objective ratings

describing mood states. Although the POMS can be scored for

clinical purposes in terms of six factors, giving an

affective "profile" ("Tension-Anxiety," "Depression-

Dejection," "Anger-Hostility," "Vigor-Activity," "Fatigue-

Inertia," and "Confusion-Bewilderment"), the sub-scales are

highly inter-correlated. The test developers have suggested

that, when researchers desire a global estimate of affective

state, a "Total Mood Disturbance" score (TMD) be calculated

by summing the individual factor scores (weighting vigor

negatively). The TMD score was utilized for this study.

These instruments, STAI and POMS, were selected not

only because of their well-established psychometric

qualities, but also because they are easily and quickly

administered and have been previously used in cancer

patients studies.


Procedures for Administration
of the Independent and Dependent Variables


The study was conducted at the Department of Radiation

Oncology located in the UCLA Center for Health Sciences.

The departmental conference room was utilized to show the

patient education slide-tape program and for administration

of questionnaires. This location afforded sufficient

privacy while at the same time being within the treatment

setting itself.

Each study participant completed the study procedures

individually. Family members were allowed to accompany the

patient during the study procedures, if they so desired.

The experimenter would sit with the subject, introducing

each questionnaire, checking for completeness and

legibility, and answering questions which might arise in

regard to the questionnaires.

Data Collection Schedule

Patients were assessed at two points: 1) at the outset

of their radiation therapy treatments, and 2) during the

last week of treatment. As explained above, the initial

assessment and patient education intervention (for the high

information group) were conducted as soon as possible after

treatment began (days 1 to 3). Patients then received

treatment five days per week for a period of four to five

weeks. The follow-up evaluation was administered during the

final five days of treatment. This schedule allowed us to

evaluate not only the immediate impact of the patient

education intervention, but also the patient's emotional

state and treatment-related knowledge as treatment drew to a


Data collection sessions were scheduled with the

patients to coincide with their regularly scheduled

treatment appointments. The initial intervention and data

collection session required 45 to 60 minutes. The follow-up

session at the end of treatment required only 15 to 20


Instructions to the Subjects

At the beginning of the first data collection session,

the experimenter would introduce himself and talk informally

for two or three minutes with the subject. The study would

be introduced by saying:

This study, which is being conducted with patients
like yourself who are beginning radiation therapy,
is concerned with what patients know about their
medical treatment and how they feel psycho-
logically. To gather this information, we will be
asking you to fill out a series of questionnaires.
In addition you will be given some information
about radiation therapy. Approximately 45 minutes
will be required to complete this session. As you
end your radiation therapy treatments, we will be
asking you to complete a few more questionnaires.
Do you have any questions?

Each questionnaire would then be presented individually

in the appropriate order. (See the following section for

order of presentation.) With regard to each questionnaire,

brief instructions would be given about how to complete it

appropriately. Any printed instructions on the question-

naires (e.g., on the State/Trait Anxiety Inventory and the

Profile of Mood States) would be read aloud by the

experimenter. Subjects would be prompted once to complete

any items which had been skipped.

If the subject was scheduled to see the slide-tape

program, it would be introduced at the appropriate juncture,

in the following manner: "Now we would like you to see a

brief slide-tape program about the radiation therapy

department. It will last about 12 minutes. Following it,

we will finish a few more questionnaires." The slide-tape

program would then be shown in the same room. Patients not

scheduled to see the program (low information condition)

would be allowed to take a brief break (staying in the room)

before completing the remaining questionnaires.

If questions were asked about radiation therapy or

other medical matters during the course of the study

procedures, the experimenter would not answer them directly.

Instead, he/she would acknowledge the question and suggest

to the patient that the regular staff members in the

Radiation Oncology Department were better qualified to

answer such questions and would be pleased to do so. The

patient would be encouraged to present his/her questions(s)

to the doctor or to one of the department's nurses or

radiation technologists.

Sequence of Procedures

The sequence in which the questionnaires and patient

education module were administered is given below. (Copies

of all instruments can be found in Appendix 2.)

1. Patient Information Questionnaire-demographic

2. Modified Sentence Completion Test-coping style

3. Modified Repression-Sensitization Scale-coping
style questionnaire

4. Intervention

a. High information condition--exposure to the slide-tape
program, "Introduction to the Radiation Oncology Department"

b. Low information condition-no exposure to the slide-tape

5. State/Trait Anxiety Inventory-affect questionnaire

6. Profile of Mood States--affect questionnaire

7. Self-Assessment of Knowledge--self report on knowledge about

8. Radiation Therapy Questionnaire--objective test of treatment-
related knowledge

The final assessment, which did not include the

demographic or coping style questionnaires, required 15-25

minutes. The order was as follows:

1. State Form of the State/Trait Anxiety Inventory

2. Profile of Mood States

3. Self-Assessment of Knowledge

4. Radiation Therapy Questionnaire

5. Self-Report on Amount of Patient Education Booklet Read

Summary of Study Design

The overall design of the study can be conceptualized

as a two-by-two factorial design, with two intervention

conditions (high vs. low information) and post-hoc

classification on coping style. As noted earlier, two

separate methods for measuring coping style are being

utilized, so separate analyses will be carried out for each

avoiderr vs. vigilant coper and repressor vs. sensitizer).

There are four dependent variables: 1) objective assessment

of treatment-related knowledge (RTQ); 2) subjective

assessment of knowledge (SAK); 3) Total Mood Disturbance

from the Profile of Mood States (TMD); and 4) State Anxiety

(A-State). Each dependent variable is assessed at two

points in time: Time 1--immediately after the "experimental

manipulation" (patient education module or not), during the

first week of treatment; and Time 2--four to six weeks

later, at the conclusion of radiation therapy treatment. It

is important to note that this is not a pretest-posttest

design; instead it is a design in which subjects are

assigned to condition, receiving one of two treatments, and

are evaluated at two points following intervention. The

results will be analyzed by appropriate statistical methods

to test, both a Time 1 and Time 2, for possible effects due

to intervention condition, coping style classification, and

interactions between these two factors.



Descriptive Statistics for Variables

Independent Variables

Table 4 presents descriptive statistics for the two

coping style variables utilized in this study. Possible

scores on the SCT range from 0 to 40; the actual range

obtained was from 4.5 to 30.5. The possible range of scores

on the R-S scale is from 0 to 30; the actual range obtained

in this sample was from 6 to 18. Both distributions were

within acceptable limits of skewness ( -0.48 for SCT and

-0.05 for R-S). The sampled scores thus appear to have

sufficient variability and normality of distribution for

utilization in the planned statistical procedures.

For purposes of subsequent analyses of variance, median

splits (at 20.5 for SCT, and 12.5 for R-S) were utilized to

classify subjects as repressorss" vs. "sensitizers" and

avoiderss" vs. "vigilant copiers" on the R-S scale and SCT

scale, respectively. Table 5 presents the resulting cell

frequencies. It will be noted that the cell frequencies are

relatively balanced in the case of R-S, but in the case of


Descriptive Statistics for Coping
Style Variables

Coping Style

S.C.T.a Mean


R.S. Mean


Low High
Information Information
(N=30) (N=30)









aAvoider-Vigilant Coper Sentence Completion Test.
scores are in the direction of vigilance.

Total Sample






bModified Repression-Sensitization Scale. Higher scores
are in the direction of sensitization.


Cell Frequencies for Intervention
Group by Coping Style Variables

Intervention Condition

Low Information

High Information

Intervention Condition

Low Information

High Information

R-S Classification

Repressor Sensitizer

14 16

16 14
N=30 N=30

SCT Classification

Avoider Vigilant Coper



SCT there are, by chance, more avoiders than vigilant copers

in the low information condition and more vigilant copers

than avoiders in the high information condition. However,

these cell frequencies are not significantly different (chi-

squared = 3.3 p>.05). Each cell N is sufficiently large to

permit further statistical analyses, utilizing analysis of

variance procedures for unbalanced cells.

The two coping style measures, R-S and SCT, proved to

be completely uncorrelated (r =-.04, n.s.) in this sample.

They are being treated as two independent, empirically unre-

lated means of classifying coping style. For purposes of

hypothesis testing, separate analyses are planned for each

coping style dimension.

Dependent Variables

Table 6 presents descriptive statistics for the depen-

dent variables for both the initial and follow-up evalua-

tions. These variables and their respective labels are

State Anxiety (A-State), Total Mood Disturbance from the

Profile of Mood States (TMD), objective test of radiation

therapy knowledge (RTQ), self-assesment of radiation therapy

knowledge (SAK), and self-report on the amount of the book-

let, "Radiation Therapy and You," which had been read by the

final assessment (Book).

Skewness scores, which indicate the deviation of the

distributions from normality, are within acceptable limits

(i.e., skewness <1.00) for all of the dependent variables


Descriptive Statistics for Dependent
Measures for Total Sample









































Min. Max.

21 65

21 66

-27 143

-19 121

8 21

9 21

3 12

3 12

0 100

aNumerals 1 and 2 following the variable abreviation
designate first and second evaluation times, respectively.

except the self-report on the amount of the booklet read.

This variable tended to be highly skewed toward the upper

limit; the average percent read was 79%, with 65% of the

patients reporting that they had read 100% of the booklet).

Fortunately, this variable did not play a key role in the

hypotheses being evaluated. (It was included in order to

have some check on the degree of self-administered patient

education obtained through reading, since the booklet was

routinely made available to all patients in the department.)

Due to the highly skewed distribution of this variable, it

will not be included in subsequent statistical analyses. It

is fair to surmise, however, that patients in both interven-

tion conditions, and across both coping styles, reported a

high rate of reading the patient education booklet.

The other dependent variables appear to have acceptable

distributions in terms of means, standard deviations,

ranges, and skewness. The A-State means for this sample are

similar to the norms for "general medical and surgical

patients without psychiatric complications" (A-State =

42.68, SD = 13.76) reported in the STAI manual (Spielberger

et al., 1970). Norms for the Total Mood Disturbance score

from the POMS are not available. It should be noted that

the sample in this study had rather large standard devia-

tions on the TMD score at both the initial and the follow-up

(RTQ), a knowledge test devised for this study, indicate

that, though the scores tended to cluster somewhat toward

the higher end, the instrument was sufficiently challenging

to produce a considerable range in scores and sufficient

variability. The SAK scores (self-ratings on how well-

informed patients considered themselves to be) show that the

patients tended to rate themselves as very well-informed

about their treatment. With a possible high rating of 12,

the means at initial and final evaluation were 9.70 and

9.98. These self-ratings also tended to be skewed toward

the high end and to have relatively little variability.

Inter-variable Correlations

The correlation matrix for the dependent variables is

presented in Table 7. Several of these correlations are

worthy of note:

1) The two measures of affective disturbance are posi-

tively and highly correlated, as expected (r [A-Statel,

TMD11 = .71, p<.001; r [A-State2, TMD2] = .74, p<.001).

2) The patients' subjective assessments of knowledge

are only modestly correlated with the objective measures of

knowledge at the initial evaluation (r [SAKl, RTQ11 = .26,

p<.05) and not at all correlated at the follow-up assessment

[SAK2, RTQ2] = .02, n.s.). As noted earlier, the patients

tended to rate themselves as quite well-informed. This

self-evaluation appears to be independent of their actual

degree of knowledge about treatment.



Correlation Matrix of Dependent
Variables for Total Sample

A-Statel A-State2 TMDl TMD2 RTQ1 RTQ2 SAK1







-.12 -.21

-.16 -.15 .69***

-.33* -.39**.26*

-.34** -.20 -.32* .21











3) The measures of affective disturbance tend to be

negatively correlated with knowledge assessments. These

correlations, modest in all cases, are more accentuated and

achieve statistical significance only with regard to the

subjective assessments of knowledge ( r [SAK1, A-Statel] =

-.27, p<.05; r[SAKI, TMDI] = -.33, p<.05; r[SAK2, A-State 2]

= -.34, p<.05; r[SAK2, TMD2] = -.32, p<.05). The correla-

tions between the objective measure (RTQ) and affect indica-

tors are in the same direction, but they do not achieve

statistical significance. It appears that there is a nega-

tive correlation between how good the patient feels emo-

tionally and how much the patient thinks he/she knows.

Tests of Hypotheses

Statistical Approach

It will be recalled that the hypotheses to be tested

(see Chapter II) postulate main effects for intervention

condition and coping style, and an interaction effect

between these two factors. For statistical analysis, this

calls for a two-way analysis of variance which will test for

possible effects due to each of the two factors (interven-

tion condition and coping style) and due to interaction

effects. Separate ANOVAs were carried out with regard to

each of the four dependent variables, both at Time 1 and at

Time 2.

An alternative statistical approach--namely,

Multivariate Analysis of Variance (MANOVA) was considered,

but ultimately rejected, for use in this case. The MANOVA

offers the advantage of simultaneously comparing all

dependent variable means, thus minimizing the risk of

falsely accepting a positive finding when multiple compari-

sons between variables are being made. Since there are

multiple outcome measures in this study, each measured two

times, it would seem desirable, if possible, to employ a

multivariate method. However, the MANOVA is more appro-

priately applied in studies with much larger samples (hence

larger cell frequencies) than afforded by this study. The

MANOVA is a rather conservative test from a statistical

perspective and provides little "power" to detect

differences, especially when the total N is small. Further-

more, this study has only four dependent variables, so the

number of separate mean comparisons is not exceedingly high.

Therefore, a univariate analysis of variance approach has

been chosen.

Results at Initial Testing (Time 1)

Tables 8-13 present the dependent variable means and

resulting analyses of variance for the initial evaluation.

The ANOVAs (Tables 10 and 13) show that, at the initial

assessment, there was a statistically significant main ef-

fect for intervention group on the objective measure of


Means for Affect Variables by
Group and SCT Classification at Time 1


Coping Style (SCT)

Avoider Vigilant Coper


Low Information

High Information







Total Mood Disturbance (TMD)


Low Information

High Information

Coping Style (SCT)

Avoider Vigilant Coper





29.76 33.71








Means for Knowledge Variables by
Group and SCT Classification at Time 1

Radiation Therapy Questionnaire (RTQ)

Coping Style

Avoider Vigilant Coper

Low Information 15.44 14.42

High Information 18.00 17.16

16.41 16.10

Self-Assessment of Knowledge (SAK)


Low Information

High Information

Coping Style

Avoider Vigilant Coper





8.72 9.65









Analysis of Variance for Intervention
by SCT Coping at Time 1



Source df SS F p

SCT Coping


SCT Coping

SCT Coping
x Coping

SCT Coping

59 82237.6


56 80600.8




56 212.4
















Means for Affect Variables by
Group and R-S Classification at Time 1


Coping Style (R-S)

Repressor Sensitizer

Low Information 39.64 45.19
(N=14) (N=16:

High Information 38.06 39.14
(N=16) (N=14

38.80 42.37
(N=30) (N=30:

Total Mood Disturbance (TMD)


Low Information

High Information

Coping Style (R-S)

Repressor Sensitizer

22.50 47.69

25.94 29.64

24.33 39.27











Means for Knowledge Variables by
Group and R-S Classification at Time 1

Radiation Therapy Questionnaire (RTQ)


Low Information

High Information






Style (R-S)





Self-Assessment of

Knowledge (SAK)


Low Information

High Information






Style (R-S)













Analysis of Variance for Intervention
by R-S Coping Style at Time 1



Source df SS F p


R-S Coping
x R-S

R-S Coping
x R-S

R-S Coping
x R-S

R-S Coping
x R-S

59 8370.6
1 217.1
1 163.9
1 74.4

56 7888.3

59 82237.6
1 796.6
1 3116.6
1 1722.9

56 76373.1



59 227.6
1 3.8
1 2.8
1 4.95










n. s.



knowledge (RTQ). The group receiving the patient education

slide-tape program showed greater accuracy of treatment-

related knowledge than the group not receiving the interven-

tion. There was no statistically significant main effect

for either coping style measure, nor was there any inter-

action effect (treatment by coping style).

In several regards the pattern of the group means is in

the predicted direction, though not reaching statistical

significance. Considering first the affective variables

(Tables 8 and 11), it can be seen that the high information

group had lower State Anxiety and Total Mood Disturbance

Scores than the low information group. There were also

somewhat lower affect scores (A-State and TMD) for repres-

sors as opposed to sensitizers, and avoiders as opposed to

vigilant copers. Thus, both main effects were in the direc-

tion expected, but not sufficiently large to reach signifi-


Although there is no clear overall interaction pattern

(intervention by coping style), it is interesting to note

that the highest affective disturbance scores were obtained

by sensitizers (RS scale) and vigilant copers (SCT scale) in

the low information condition. This pattern is consistent

across both coping style measures and both affect measures

(except for A-State by SCT, where the vigilant subjects in

low information had the second highest score). For

instance, the sensitizers in the low information condition

had TMD scores more than twice as high as the repressors in

that intervention group (47.7 vs. 22.5). Their anxiety

scores were also much higher than repressors in the low

information condition (45.2 vs. 39.6). Giving information

to sensitizers and vigilant copers appears to reduce their

affective distress. For instance, sensitizers in the high

information condition averaged only 29.6 on the TMD indica-

tor, as compared to 47.7 for sensitizers in the low informa-

tion condition. Similarly, their A-State scores differ

considerably (45.2 for low information sensitizers; 39.1 for

high information sensitizers). The pattern is similar,

though less marked, for vigilant copers. On the other hand,

there is no trend in the expected direction for interactions

between repressors avoiderss) and information condition.

Avoiders and repressors in the high information condition do

not have increased anxiety and mood disturbance; if

anything, their mood disturbance appears to decrease with


With regard to the knowledge variables (Tables 9 and

12), it can be seen that none of the results with the

subjective assessment of knowledge (SAK) even approach

significance. As noted before, these self-appraisals were

uncorrelated with actual knowledge and tended to cluster at

the top end of the scale. (Most patients felt themselves to

be very well-informed from the outset of treatment.)

Because of the lack of variability, this measure produced no

meaningful results at any point. The statistically

significant main effect for intervention group on objective

knowledge has already been noted.

With regard to the expected main effect for coping

style on knowledge acquisition, it can be seen that sensiti-

zers appeared to learn slightly more than repressors, but

the avoider-vigilant coping dimension showed no such

pattern. The predicted interaction effect (intervention by

R-S coping style) on patient knowledge (RTQ) did follow the

predicted pattern--i.e., the highest knowledge scores were

obtained by sensitizers in the high information condition

and the lowest scores were obtained by repressors in the low

information condition. This pattern was obtained for the R-S

coping variable, but not SCT.

Results at the Follow-up Evaluation (Time 2)

A somewhat different picture emerges when the results

for the follow-up evaluation are considered (see Tables 14-

19). The analyses of variance (Tables 16 and 19) show that

at this juncture, four to six weeks later, there is a sta-

tistically significant main effect for intervention groups

with regard to the two affective measures. When grouped by

SCT, the patients who received the patient education module

reported less state anxiety (37.9 vs. 43.6, p<.05) and lower

Total Mood Disturbance (19.5 vs. 41.2, p<.005). When

grouped by R-S, the F-value for state anxiety just misses


Means for Affect Variables by
Group and SCT Classification at Time 2



Low Information

High Information

Coping Style (SCT)

Avoider Vigilant Coper







Total Mood Disturbance (TMD)


Low Information

High Information

Coping Style (SCT)

Avoider Vigilant Coper





26.24 34.19







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