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The decisional processing model

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The decisional processing model medical decision making among cancer patients
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Petersen, Suni, 1944-
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English
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xii, 242 leaves : ill. ; 29 cm.

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Cognitive psychology ( jstor )
Coping strategies ( jstor )
Diseases ( jstor )
Modeling ( jstor )
Motivation ( jstor )
Need for cognition ( jstor )
Personality psychology ( jstor )
Physicians ( jstor )
Rumination ( jstor )
Social psychology ( jstor )
Counselor Education thesis, Ph.D ( lcsh )
Dissertations, Academic -- Counselor Education -- UF ( lcsh )
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theses ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (Ph. D.)--University of Florida, 1997.
Bibliography:
Includes bibliographical references (leaves 215-241).
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Also available online.
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Typescript.
General Note:
Vita.
Statement of Responsibility:
by Suni Peterson.

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University of Florida
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38755396 ( OCLC )

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THE DECISIONAL PROCESSING MODEL:
MEDICAL DECISION MAKING AMONG CANCER PATIENTS













By

SUM PETERSEN

















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 1997





























Copyright 1997

by

Suni Petersen


























To my husband, Ron Leon Straub,

my three sons, Lee, Greg, and Kevin, and

the women my sons brought into my life, Dianne and Coni.














ACKNOWLEDGMENTS


It is not possible to complete a doctoral program without the assistance, tolerance, and support of many people. I wish to acknowledge first my husband, Ron Straub, for his loving support and consistent willingness to "pick up the pieces of my life" thus affording me the opportunity to pursue a life-long dream.

My major goal in returning to school was to learn to do research. One person,

Martin Heesacker, PhD, my cochair, stands out among all others in helping me achieve this goal. I especially appreciate his generosity of spirit in sharing his time, knowledge, inspiring enthusiasm in the pursuit of good science, and, most of all, his belief in my ability to do good research. He will always have my deepest gratitude and respect.

T

especially thank James Archer, PhD, the best pinch-hitter who, in addition to his consistently insightful comments throughout, generously assumed chairmanship of my committee late in the game. I want to thank Robert Marsh, MD, for his significant role in assuring the assistance I received from Shands Cancer Center. It is through Dr. Marsh and his colleagues that I came to understand their work as an art as well as a science. I thank Silvia Rafuls, PhD, for teaching me the qualitative research that has so deeply influenced the core of my approach that it is integrated even in the pursuit of positivistic research. I will consistently work towards the balance and synthesis of both approaches.


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And it is to the patients that the greatest debt is owed for without them this research could not exist. These patients gave of their time and energy when both were precious commodities in order to help others in the fight against cancer. It is with their inspiring courage that I will continue to pursue my research.

I also wish to thank Robert I Hirsch for his belief in my abilities and his role in awarding a grant from the Milton Goodman Foundation to conduct this study.

Finally, I wish to thank the group of persons who constitute the most important and wonderful part of MY life: Vicky Pearson, for her nurturing friendship and one special breakfast at Camacho's Cafe that led to the pursuit of my doctorate; Cathy Wolfson for the depth of her friendship and unabashed belief in me; and Toni Sands and Lynn Goldman for their warmth and shared wonder dunna this entire process. I thank my parents, Doris and Ralph Guenther, who were not afraid to dream big dreams, and who t qrq t M., to t2'.k- risks,

Most of all, I thank my three sons, Lee, Greg, and Kevin, for being the essence of my life, providing meaning, motivation, and purpose.















V















TABLE OF CONTENTS




ACKNOWLEDGMENTS iv

LIST OF TABLES x

ABSTRACT xi

INTRODUCTION: THE DECISIONAL PROCESSING MODEL: MEDICAL
DECISION MAKING AMONG CANCER PATIENTS

Purpose
Rationale for Integration of Theories
Mindfulness
Elaboration Likelihood Model 4
Coping 9
Why Central Route Processing May Enhance Coping 10
Significance of Study 12


Definitions of Terms 19
Organization of the Remainder of the Study 22

REVIEW OF THE LITERATURE 23

Integration of Mind and Body 23
Appraisal 26
Self-Efficacy 27
Attributions 29
Health Behavior Change 3 1
Immune System Functioning
Physical Effects of Coping 3 2
Stress and Illness 3 4
The Role of Emotion 37
Constructivist Approaches to Perception 3, 8
Decision Making and Illness 44

V!









Some Decisional Styles May Enhance Coping 47
Coping 49
Cancer as a Stimulus for Coping 49
Coping Appraisal 50
Response to Coping: Coping Strategies 51
Outcomes of Coping 53
Integration of Mindfulness and Social Influence Theories 54
Decision Making and Different Modes of Processing 56
Evidence of Mindlessness 59
Cognitive Commitment 62
Cognitive Commitments Are Made .... 65
Categories of Decision Making 68
Necessary Conditions for Mindfulness 71
Motivation 76
Ability 76
Repetition 76
Physical cues 77
Comprehension 77
Comparisons and similarities 78
Evidence of Fourth Decisional Style-Ruminating 79
Methodologic Commentary 85
The Decisional Processing Model 86
Decisional Styles Follow Two Routes of Processing 87
Four Decisional Styles 88
Some Decisional Styles More Effective 89
Summary 92



Overview 94
Population 94
Sample and Sampling Procedures 95
Sampling Procedures 100
Research Procedures 101
The Interviews 102
Relevant Variables 104
Types of Analyses 104
Criterion Variables 106
Predictor Variables 108
Dependent Variable for Hypothesis Three: Coping 110
Measures and Instruments III
Criterion Variables Measures III
Predictor Variables Measures 114
Coping Measure 122

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Medical Data Form 12 3
Hypotheses 124
Data Analysis 125
Limitations 127
Limitations in Generalizability 127
Limitations in Assessment 129
Limitations in Analyses 130
Theoretical Limitations 13 1

RESULTS 132

Decisional Categories 121
Hypothesis One: Placement into Decisional Categories 133
Decisional Category Reliability 1314
Location Effects 136
Researcher Effects 138
Ancillary Analyses Related to Decisional Styles 139
Personal Characteristic Effects 139
Medical Data Effects 141
Hypothesis Two: Predicting the Decisional Processing Model 142
Hypothesis Three: Relationship Between Decisional Styles and Coping 144
Effects of Decisional Style on Coping 144
Most Troublesome Part of Cancer 149
Amount of Stress Generated 150
Hypothesis Four through Seven: Relationship of Each Scale
to Decisional Categories 150
T7r)l)r Need for Cognition Scale

Hypothesis Six Padua Inventory Rumination Subscale 154 Hypothesis Seven Ability to Process Questionnaire 154

DISCUSSION 157

Summary of Results 158
Decisional Categories 160
Mindless Decisional Style 160
Active and Passive Decisional Styles 164
Ruminating Decisional Style 167
Age and Decisional Style 168
Education and Decisional Style 169
Race and Decisional Style 170
Medical Data and Decisional Style 171
Elaboration Likelihood Model as Predictive of Decisional Style 172
Two Routes of Processing 172

4V1









Predictive Ability of ELM 174
Ability to Process 174
Motivation 175
Cognitive Responding 177
Limitations 179
Decisional Styles and Coping 180
Limitations 184
Decisional Processing Model 185
Implications of the Study 187
Four Decisional Styles: Extension of Langer's Theory 188
Using ELM to Change Decisional Styles: Extension of Theory 189 Implications for Practice 189
Methodological Issues 191
Future Research 192
Characteristics of Decisional Styles 192
Effects of Changing Decisional Styles 193
Interaction with Others and Decisional Style 193
Conclusion 194

APPENDIX 195

Assessment Instruments 195

REFERENCES 215

BIOGRAPHICAL SKETCH 242




















ix















LIST OF TABLES


Table Page

2-1 The Decisional Processing Model 91
3-1 Frequencies and Types of Diagnoses of Participants 96
.3-2 Construct Correlations for Need for Cognition Scale 104
3-3 Construct Correlations for Need for Closure Scale 118
3-4 Predictor and Criteria Variables for Hypothesis Two 124
3-5 Hypothesis Three: Decisional Style and Coping 126
4-1 Decisional Style Categories 134
4-2 Differences in Decisional Style based on Location 13 7
4-3 Researcher Coverage of Interviews 139
4-4 Decisional Style by Education Level 140
4-5 Effects of Age and Gender on Decisional Style 141
4-6 Means and Standard Deviations for Medical Data 142
4-7 Means for Five Coping Subscales for Each Decisional Style 146 4-8 Analysis of Variance for Coping Scales 132
4-9 Frequency within Decisional Styles for Most Troublesome Part 149 4-10 Means and Standard Deviations on Need for Cognition Scale 152
,,an and .-. ladac -n
~ &viailsanci anua cDviaiioris on ~iai on 6ucscaie
4- 13 Means and Standard Deviations on Ability to Process Questionnaire 155


















x















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE DECISIONAL PROCESSING MODEL: MEDICAL DECISION MAKING AMONG CANCER PATIENTS By

Suni Petersen

December, 1997

Chairperson: James Archer
CoChairperson: Martin Heesacker Major Department: Counselor Education

Many factors influencing coping, progression of disease, and survival time in

cancer patients depend on making decisions. Yet very little is known about how patients



Cacioppo's elaboration likelihood model, this study proposed a research-supported decisional model and tested its viability and its relationship with coping in cancer patients.

Results supported the model. Patients demonstrated the four categories of

decisional styles-- active, passive, mindless, and ruminating-- in making key medical decisions. Using discriminant function analysis, these styles were predicted by the elaboration likelihood model's constructs, providing information for the development of interventions which may change decisional styles. Finally, coping was significantly related to decisional styles. Those patients using central route processing (active and passive


x i











x


decisional styles) were more effective in coping than those using peripheral route processing.














CHAPTER ONE
INTRODUCTION
THE DECISIONAL PROCESSING MODEL:
MEDICAL DECISION MAKING AMONG CANCER PATIENTS PURPOSE

Little is known about th e way in which people arrive at crucial'decisions about medical treatment and coping when they are confronted with a life-threatening illness. Although no models have been generated that address this question, there is a substantial body of research that provides a framework from which to build a model. From different reference points Ellen Langer, Richard Petty, John Cacioppo, and other depth of processing theorists have researched different aspects of strikingly similar behavior. The purpose of this study is to provide some understanding of how people make important medical decisions in the face of life-threatening illness by creating a research-supported model and testing it's viability.

The research supporting Petty and Cacioppo's (1981) elaboration likelihood model (ELM) in a context irrespective of the message delivered will be integrated with Langer's (1989, 1994) research on decision-making to develop a decision-making model. The empirical support for both theories has demonstrated closely related, if not identical, routes of processing information. The variables which determine these routes of processing information are used in this study. Langer's decisional styles are used as criterion variables. The constructs of the ELM which determine the routes of processing are motivation,


I









2

cognitive responding, and ability to process. The variables measuring these constructs are Need for Cognition and Ability to Process Questionnaire, drawn from the work of Petty and Cacioppo (1986). The other variables measuring these constructs are Need for Closure Scale supported by the related research of Kruglanski and Webster (1994) and the Padua Inventory Rumination Subscale (Sanavio, 19 88).

This study will also include an exploration of the relationship between coping and styles of decision-making.

Rationale for Integration of Theories

Mindfulness

In Langer's theory (1989), information is processed in one of two ways, mindfully or mindlessly. Langer explicated a process in which mindless decisions were made considerably more often on the basis of a preconceived commitment to a schema. These

-decisions are, mad.- in resnorse to P clie th it rerresenTts a srn-i1 nortion of th~e nrf~ particular domain and preempts further elaboration on an issue prior to deciding. In contrast, mindful deciding is a two step process. The person first steps back to reconsider both the problem and the solution, and seeks discriminations which render the issue novel. The second task of mindful deciding then, is to choose between the options generated in the first step of this process.

The basic premises of the mindfulness theory are

1) There are qualitative differences between active and passive deciding. Active

deciding is the two step process described above and passive deciding is choosing between options presented.











2) Options form discrete categories when they become psychologically different for the person.

3) Deciding entails information gathering until disc ruminations are made and the concept is categorized.

4) There is no natural end point to this process. Information gathering simply stops when a person reaches a cognitive commitment.

5) There are three kinds of cognitive commitment: a) personal cognitive

commitment to content (i.e., the totality of attributes noticed), b) societal commitment to content (commitment to a schema assumed from cultural norms, and c) cognitive commitment to process (the amount of information gathering one is "supposed" to engage in prior to choosing). Commitment to process is content-independent and therefore operates separately from societal or personal commitment.

Personal commitment means an emoerience or perception is labeled as belon2in -a to a certain category and immediately is attributed with all the traits of that category without fur-ther scrutiny. If a person does not have a preconceived category into which a new experience fits, that is., it is psychologically different from the alternatives, the person will commit to a definition of the experience based on the opinions of others. The commitment to process is a preconceived notion, learned in a cultural context, that informs the decision maker about the amount of information a person is "supposed" to obtain before making a choice. Thus the hypothesis testing will continue a) until a personal experience category is found, or b) in its absence, until a culturally informed category is found. Barring either of









4

these being readily available. the hypothesis testing will only continue until thedecision making has satisfied the process commitment.

Until a cognitive commitment is made, preferences are not stable because the

person has not yet established differences that are psychologically distinct. Because all decisions result in a cognitive commitment, Langer saw the errors in judgement as being made in the information-gathering process. However, Langer maintained that mindless deciding will occur unless the following conditions exist: a) a novel situation is encountered in which no cognitive commitment has been previously made, b) mindless deciding is more effortful than mindful deciding, c) external factors do not allow completion of the commitment, d) significantly discrepant consequences occur that have occurred in the past, or e) there is insufficient involvement to see any need to respond. The "Illusion of calculated decisions is sustained by failure to realize the power of uncertainty (Langer, 1994, P. 45), According to Larger. it -is the desire for certainty that leads to -.I premati,re cognitive commitment that is made mindlessly. Elaboration-Likelihood Model

Petty and Cacloppo (1986), integrating attitude change literature, discovered the discordant findings were explained by the existence of two routes of processing information: central and peripheral. Attitude change processed centrally was enduring and less affected by envi ronmental cues while attitude change processed peripherally was transitory and heavily influenced by cues.

The basic postulates of the elaboration-likelihood model of persuasion relevant to this study are as follows:









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1. People are motivated to hold correct attitudes, but they differ both individually and situationally on the amount of effortful thinking they are willing to engage in to evaluate a message.

2. Effortful thinking is affected by the motivation to process, the ability to process, and the initial attitude towards the issue.

3. As motivation and ability to process is decreased, peripheral cues become important determinants of persuasion.

4. New cognitions must be stored in long-term memory.

5. Attitude change resulting from carefully thinking about a message is more

enduring, predictive, and resistant to counterpersuasion than changes occurring through responding to peripheral cues.

The ELM states that for people to process centrally, they must have 1) the ability to process, 2) cownitive responding that takes a position (discriminate between options). and 3) motivation to think carefully about the ifraonleading to a decision (Petty & Cacioppo, 1981). For a person to be motivated to process via the central route, three situational variables must exert influence: the personal relevance of an issue, personal responsibility for message evaluation, and the number of message sources.

Langer suggests that people will make decisions mindlessly (without entertaining any options) particularly when presented with only one alternative unless their mindless deciding is interrupted or more difficult than active or passive deciding or the situation is sufficiently novel or consequences sufficiently discrepant with the past exist to warrant effortful thought. She also asserts that people will engage in more active deciding when









6

they feet personally responsible for the outcome (Alexander, Langer, Newman, Chandler & Davies, 1989; Langer & Avorn, 1982). Each of these situations fit the motivation criteria identified in the ELM.

Whereas the ELM suggests that peripheral route processing will occur in states analogous to Langer's "mindless" condition, it does not distinguish between active and passive deciding. Petty and Cacioppo (1986, p. 3) define central route processing as "that which occurs as a result of a person's careful and thoughtful consideration of the true merits of the information presented in support of an advocacy." Langer describes this as passive deciding because the person focuses on only the options presented. Langer also identifies active deciding whereby the person "elaborates" on that which is presented, considers self-information, and generates alternatives beyond those presented. There is a difference here which appears to be in consonance with the elaboration likelihood model, although Petty and Cacionvo bave not made this discrimination. The difference F-I-em, s to focus on the content of the focused thought process, either self-generated or other generated. Since most of the research done on the ELM was conducted from a perspective of persuasion, the only content studied was that which was presented. Option generation has not been researched within the ELM. However, it is not theoretically inconsistent to assume that central route processing occurs both for active and passive deciders.

There is yet another category of decision making that, while alluded to in both the ELM and Langer's theories, is better explained through the research on the need to avoid closure. This category consists of people who ruminate, and do not adequately psychologically distinguish one choice from another and thereby avoid committing to any









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decision. One of the criteria for central route processing is that a person must have a position on a topic, essentially seeing enough of a difference between options as to determine whether arguments support or refute that position. Langer also theorizes that, unless people can discover differences between the choices, the choices remain, psychologically, the same. Although people may feel they "ought" to be able to decide, it is because they cannot establish any meaningful difference for themselves that they do not decide. Believing there are meaningful differences, yet not being able to establish differences, results in rumination.

Taken together, the research supporting the elaboration likelihood model of Petty and Cacioppo and the theory of mindlessness espoused by Ellen Langer, suggests four categories of decision makers. They are (a) active deciders (mindful), (b) passive decoders,

(c) mindless deciders, and (d) ruminators. Qualitative differences are seen by Langer between mindful and mindless deciding (Langer, ChanoWicz, & Blank., 1985) and by Petty and Cacioppo (1986) between central and peripheral route cognitive processing. Active deciding is better than any of the other styles because it leads to greater self-esteem, enhanced perceived control (Langer and White, 1993/1994), and diminished post-decision regret (Langer & Williams, 199' )). In addition, active deciding is more likely to lead to more accuracy in the fit between the choice made and the individual's needs in the current situation.

Stable, intrinsic differences exist among individuals in their motivation to process infon-nation effortfully (Petty & Cacioppo, 198 1; 1984; Cacioppo, Petty, & Morris, 198' ), This construct has been defined as a need for cognition. Need for cognition was found to









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be unrelated to intelligence (Cacioppo, Petty, & Morris, 1983; Eagly & Chaiken, 1976). Individuals high in need for cognition were more likely to extract information and think effortfuily about a message than those low in need for cognition. However, these individual factors can be overridden by situational factors.

If a person is to carefuldly evaluate information using central route processing, the individual must have the ability to do so. Some persons have more ability than others and certain situations facilitate ability more than others. Distraction, message repetition, recipient posture, forewarning, argument strength, relevance of message, and time to consider are some such factors.

Rumination is defined as shifting between a few options without generating new

associations and without making a commitment to any of the options. People may agree to an option and not be committed to it. Rumination prevents a cognitive commitment or coainitive resoses to be made. 'Ruination is also differentiated from effortful thought by accepting that which is presented or generating only a paucity of options and by the inflexibility of the schema involved. The need for closure construct of Kruglanski and Webster (1989; 1994) is used to expound upon the idea of rumination as a decisional style. Need for closure is "the desire for a definite answer on some topic, any answer as opposed to confusion and ambiguity (Kruglanski, 1989, p. 14). Kruglanski calls the need for closure a specific type of epistemic motivation. It is consonant with Langer's commitment to a process (perhaps, "Always keep your options open"). Those people high in need for









9

closure would likely use mindless deciding, those with moderate need for closure would engage in effortful thought, and those with high need to avoid closure would be ruminators.

Coping

For the basis of this study, the conceptualization of coping is taken from Lazarus and Folkman. Coping is defined as "the cognitive and behavioral efforts to manage specific external and/or internal demands appraised as taxing or exceeding the resources of the individual" (Folkman & Lazarus, 1988, p. 6). Rather than the traditional view of coping which posits an individual with certain traits, this conceptualization of coping is process oriented. Coping is seen as context dependent and changes as the person begins the adaptation to the stimulus event. Adaptation occurs through the continuing ongoing reappraisal process in the shifting person-environment relationship (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986). This conceptual ization of coping has as it's objective to manage rather than control or solve the encounter. Since cancer recovery is subject to so many known and unknown factors, both medical and psychological, coping requires management of the psychological, social, and physical impact rather than removal of the problem.

The Folkmnan and Lazar-us definition of coping also departs from the traditional

view by collapsing the hierarchy of coping activities. Ill-timed humor, while traditionally rated high, can be maladaptive. Specific to research on coping with cancer, denial has been shown to improve coping in some studies and deter coping in other studies. Rather than a hierarchy of coping mechanisms, this study takes the perspective that coping can only be judged relative to adaptative outcomes. Considerable research has been conducted









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which demonstrates certain ratios and patterns of coping are related to better outcomes (see Chapter Two). Therefore the complex pattern of coping and the ensuing ratios of more effective styles than less effective styles are equated with coping in this research.

Why Central Route Processing May Enhance Coping

Illness can certainly be construed as a situation with relatively uncontrollable

outcomes. When people respond to situations having uncontrollable outcomes there is an intervening step of hypothesis testing occuring just prior to the exhibition of helplessness (Wortman & Dintzer, 1978). Individuals seek out information when confronted with a new situation. Ideally, this process forestalls a commitment to a decision long enough to influence and modify the subjective experience of a serious diagnosis and its attributions. Ellen Langer suggests that people often determine and categorize these decisions on the basis of very little external information and a limited set of internalized cues. In a study of oe'-sons With hNertension. the part cipants were told by their physician that hvinertension is asymptomatic, yet all of them held well-formulated hypotheses about symptoms that informed them of changes in blood pressure. These hypotheses, while inaccurate, influenced how the patients monitored blood pressure and followed treatment regimens (Pennebaker, 1982).

Carefully considered appraisals are essential for the management of illness. In a series of studies, Leventhal (199 1) identified two channels of processing information that co-exist and both affect and are affected by the appraisal process: the schematic memory, consisting of automatic, nonverbal codes of the illness, and the perceptual memory, a composite of the individual's reflections and judgements. For effective appraisal to occur,









I I

the individual must negotiate the flow of information from sources in the environment and from self awareness of relevant internal data. To remain open to possibilities and conduct hypothesis testing, central route processing must be used.

Under central route processing, a person carefully considers both the information from external sources and self awareness (active-deciders) while conducting the appraisal process. The appraisals result in the formation of new ideas that are integrated into the underlying schema. This mechanism establishes the enduring nature of centrally processed decisions. Peripheral route processing functions by directly accessing a schema without the necessary thoughtfulness to determine if the schema still fits. The schemata invoked by peripheral route processing are intellectually impoverished forms of information, seriously inhibiting the appraisal process necessary to healthy coping with illness.

Taking time to conduct an in depth appraisal has been shown to affect health outcomes. Appraisal determines when a person seeks medical treatment (Cameron, Leventhal, & Leventhal, 1995). Early detection and treatment of cancer is one of the most significant actions toward a longer life-expectancy in a cancer diagnosis. Appraisals not only influence how symptoms are perceived and acted upon but can trigger a system of thoughts about illness which deter effective treatment and coping. In a study with cancer patients, the use of positive reappraisal was an indicator of long-term coping (Lazarus & Folkman, 1984). For example, cancer patients who have undergone surgery and believe the cancer was eliminated have difficulty choosing to undergo noxious chemotherapy treatment (Leventhal, Easterling, Coons, Luchterhand, & Love, 1986).









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It is more likely that under thoughtU consideration of information a more

informed decision could be made about such significant health decisions. In fact, crucial to the spirit of the law on informed consent is just such an understanding (Hodne, 1995) Significance of Study

The significance of this study lies in three domains: theory, practice, and future

research. Medical decision making literature focuses on the choices the physician makes in response to an illness and the physician's presentation of information to the patient. This body of knowledge ignores the agency of the patient. A model that attempts to explain the decision-making of the patient has not been created.

Efforts need to be made to extend theory. Given the extensive research support, it is time to bring social influence theories to applied settings, Studies are needed to investigate the prevalence of each route of processing and the circumstances under which t ev ratura!lv occur. Studies are needed to understand how ch ange ffrorr., one to the other occurs under different "real life" circumstances. Most of all studies are needed to focus on outcomes of interventions based on current research. And this can only be done by applying assessment strategies, such as those devised by Ellen Langer, which take advantage of naturally occurring events to understand the social influence theories.

The field of pyschoneuroinimunology has advanced knowledge about the

connections between our thoughts, feelings, behavior, and physical well-being. This mushrooming body of research is surprisingly devoid of studies on decision making. The way a person makes decisions determines when they consult a physician, the treatments they choose, their adherence to treatment, their ways of coping, and even their prognosis.











With the exception of a few researchers, decision-making studies have largely ignored the evidence that people process information along two routes. These two methods of processing may account for differences between people in thought patterns, appraisals, attributions, self-efficacy, and coping styles, all of which have been shown to have a powerful impact on quality of life (Leity & Haase, 1996), pain (Gil et al, 1995), health (Fawzy et al, 1993), progression of illness (Epping-Jordan et al, 1994), and even survival (Rogentine et al, 1979).

If, as hypothesized, active or passive decisional styles spawn more effective coping in people with serious illness, a psycho-educational program can be developed which increases awareness of decisional styles and facilitates use of central route processing in order to increase coping effectiveness. ELM constructs have been used to change core attitudinal processes. Since decisional styles are also core processes, the constructs iemnstratirqg effective attitude chameye mray also be effective wi chan;31i'r decisional styles.

In addition, the vast body of research from both Langer and Petty and Cacioppo explicating factors which impact how information is processed can be used to establish guidelines for physician communication that encourages central route processing in ways that enhance coping.

Mind and Body as Integrated System

More and more evidence is accruing linking cognitive, affective, and social factors with the biochemistry of the body. More effective coping has been shown to be one of the determinants of increased physical ability to fight cancer. Coping is affected by perception.









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Perception is socially constructed, learned behavior. One of the perceptions a person learns from his/her life experience is how certain decisions are made and what information is considered. Decision-making styles may be no different than other forms of learning with resultant links to biochemical events of the body.

Results of recent research are raising questions about how supposedly separate

human systems are bounded. Psychobiologists have been investigating the transduction of information between learning, memory, and the limbic-hypothalamus area of the brain, to understand how perception is integrated with thought and behavior (McGaugh, 1983). Studies of state-dependent learning, in which state-dependency is defined as including different states within normal biological rythyms (circadian, ultradian), have detected how even autonomic body functions are altered through experiential learning (Rossi & Ryan, 1986).

Researchlers investigating state-dependent learning agree that two routes exist for encoding thoughts and experience into memory: 1) a specific locus of memory on a molecular, cellular, synaptic level (Hawkins & Kandel, 1984) and 2) most importantly to the translation of experience, the transmission of sensory information to the limbic system (amygdala and hippocampus) which transforms learning and behavior into biochemical events (Mishkin & Petri, 1984). Mind and body are an inextricably linked information system.

The work of Hans Selye (1982) on the General Adaptation Syndrome and Lazarus and Folkman (1984) investigating the contrast between good stress (eustress) and bad stress (stress resulting from need deprivation) demonstrated that these different experiences









15

trigger different biochemical reactions in the body. Bandura (1985) found that as selfefficacy improved in people with phobias, a biochemical reaction occurred that was identical to the reaction of those people experiencing eustress. Taken together, these studies suggest that the interpretation of stress and the judgement of one's ability to handle the stress determine the biochemical reaction in the body.

Interpretation is a cognitive process learned through experience and amenable to change. When an illness strikes, a person's experience of the illness affects his/her biological and psychological functioning (Stenager, Knudsen, & Jensen, 1991; Ward, Leventhal, & Love, 1988). Shortly after patients hear from the doctor that their diagnosis is cancer, they are confronted with an onslaught of decisions that they themselves must make about Prognosis and coping. Within a short time, they are catapulted into making decisions about attribution and efficacy as well. People assigning meaning, attributing catusalitv, and copseciuentiv conminey to terms with their decision about causality,. are better able to cope with illness (Ward et al, 1988). Additionally, only if health enhancement is seen as within their control will patients feel capable of challenging the illness (Strecher, Devellis, Becker, & Rosenstock, 1986). These decisions are highly idiosyncratic (Rolland, 1987) and have a significant effect on survival, quality of life, and coping.

There is extensive theoretical and research support available to develop a model of decision making that enhances coping with life-threatening illnesses. This model builds on the existing body of knowledge by integrating the depth of processing models and decision making models and bringing that research into the field. To date, the work of Ellen Langer has not been conducted in a medical setting. However, in her study on preconceived









16

notions of aging she hypothesized two possible explanations for the results: 1) that the state of the body was modified by a preconceived schema of the condition of aging, or 2) that a greater degree of mindfulness was required to reverse the changes that occurred (Alexander & Langer, 1990). In bringing the theory of decision making into the field, this study will attempt to deepen understanding of this process.

One of Langer's hypotheses represents a process of assimilating existing cues

without mindful thought; the other represents mindfully correcting a formerly held opinion (contrast). Priester and Petty (1996) postulated that correction based processes require more effortful thinking. They further stated that the processes requiring effortful thinking are sequentially ordered by degree, and that correction-based contrast requires more effortful thinking than correction-based assimilation, which, in turn, requires less thinking than default. They recommend this relationship be tested. By using the categories su Qsested bV TLang~yes theories. this question cf'n b.- addressed..

Investigating decisional processes among cancer patients and the effects of these processes on coping paves the way for the development of programs which improve coping. A product of this investigation will be a new model created by extrapolating and combining the research on the elaboration likelihood model, other social influence theories, and the theory of mindfulness.

Hypotheses

It is reasonable to speculate that people engaging in active or passive decisionmaking use central route processing, and that those engaging in mindless deciding or rumination use peripheral route processing. It is also reasonable to speculate that central









17

route processing will improve coping with a serious illness because more relevant information is considered in the reappraisal process which is essential in making informed decisions. Because people can shift their modes of processing from peripheral to central, coping may be improved through a psychoeducational program using the ELM to increase the likelihood of cognitively elaborating on the directives of the physician and on information about new coping mechanisms. The hypotheses in this study are tested in order to assess the utility of the decisional processing model. Hypothesis One

It is anticipated that patients will exhibit different decisional styles. Although other decisional styles may exist, based on the theory and empirical evidence provided by Langer, Petty and Cacioppo, and Kruglanski, it is anticipated that patients will exhibit one of the four decisional styles in making medical decisions. Hypothesis One states that a lavze orooortion of DrartlijD~nts'%will palace themselves into the four decisioral sves (-,1ctiVe. passive, mindless, and ruminating) in making medical decisions related to a diagnosis of cancer. It is further hypothesized that judges will also place a large proportion of patients into the four categories and that there will be a high level of agreement between the; judges and the patients regarding the placement of patients into decisional categories. Hypothesis Two

The second question entertained in this study was whether constructs (cognitive responding, motivation, and ability to process) of the elaboration likelihood model are predictive of the decisional style a patient will fit. Hypothesis Two states that decisional style categories will be predicted by the main and interactive effects of cognitive responding









18

(as measured by the rumination subscale), motivation (as measured by Need for Cognition Scale and Need for Closure Scale), and ability to process (as measured by the Ability to Process Questionnaire).

Hypothesis Three

The third main question asked in this research was whether decisional styles are

related to coping. Hypothesis three states participants using active decisional styles will use more effective coping strategies (as measured by Ways of Coping Scale Cancer Version) than those using passive decisional styles. And participants using both active and passive decisional styles (central route processing) will use more effective coping strategies than those using peripheral route processing, mindless, and ruminating decisional styles. Hypotheses Four through Seven

In order to test whether any of the measures used in the model can alone predict decisional styles the following arov,",will test the. relatiorisHp et eecl n, ur m decisional style.

4. Participants using active deciding will demonstrate significantly higher mean scores on the Need for Cognition Scale than those using mindless deciding or ruminating.

5. Participants using mindless deciding will demonstrate significantly higher mean scores on the Need for Closure Scale than patients using the other three styles. There will

ben ignificant difference between the mean scores of those using passive deciding and the scores of those using active deciding. The mean scores of participants using either active, passive, or mindless decisional style will be higher than those of the participants using ruminating style..









19

6. Participants using the ruminating style will demonstrate significantly higher mean scores on the Padua Inventory Rumination Subscale than those patients using active deciding. Mean scores of those participants using both active and passive deciding will be equal. The mean scores of participants using active, passive, and ruminating will be significantly higher than the scores of those using mindless deciding.

7. Mean scores of participants using active deciding will be equal to the scores of those using passive deciding and significantly higher than the scores of those using ruminating. Mean scores of participants with ruminating styles will be significantly higher than the scores of those using mindless deciding on the Ability to Process Questionnaire.

Definition of Terms

For the purpose of this study, the following definitions are presented:

Active deciding is "a process consisting of two parts: 1) creating or modifying options followed by 2) selectinp- from arnon~r those options" (Lanaer. 1994). For cancer patients, active deciding means that they took the initiative to seek information beyond the sources presented by the physician, weighed self-knowledge about their life style and personality, and made a choice considering all three sources of information.

Central route processing is "a type of information processing discovered in research on persuasion which likely occurred as a result of a person's careful and thoughtful consideration of its true merits of the information presented in support of an advocacy" (Petty & Cacioppo, 1986, p.3))

Cognitive responding is taking a position on a particular topic and providing a response.









20

Elaboration is to carefully think about and "relate the recommendation and

arguments to other issue-relevant information in memory'" (Petty & Cacioppo, 1986, p. 14).

Foreclosed commitment is making a commitment to a decision based on simple decisional rules without effortful thought.

Heuristic thoughts are "those classified as relevant to the discussion yet unrelated to the arguments' contents" (Kruglanski, Webster, & Klein, 1993).

Mindfulness is a state of mind that results from drawing novel distinctions,

examining information from new perspectives, and being sensitive to context. (Langer, 1993, p. 44).

Mindlessness is a state in which a premature cognitive commitment is made to a rigid belief resulting from the unexamined acceptance of information and without

~~ of' ~~t"v<- 1QV

Need for closure is "the desire for a definite answer on some topic, any answer as opposed to confusion and ambiguity" (Kruglanski, 1989, p. 14). Kruglanski (1990) further discriminated between need for specific closure (need for specific answers in support a particular dimension, le ego-syntonic) and need for non-specific closure.

Need for cognition is "the statistical tendency of and intrinsic enjoyment

individuals derive from engaging in effortful cognitive activities" (Cacioppo & Petty, 1982).

Option-generation is "exploring more alternatives (than presented) that suggest new dimensions for comparison" (Langer, 1994).









21

Peripheral cues are "stimuli in the persuasion context that can affect attitudes without necessitating processing of the message arguments" (Petty & Cacioppo, 1986, p. 18).

Passive deciding is "choosing from among previously determined options" (Langer, 1994).

Peripheral route processing is "routes of processing in which simple cues rather than scrutiny of the central merits of the issue induce change" (Petty & Cacioppo, 1986, p-3).

Premature cognitive commitment is "a rigid belief that results from the mindless acceptance of information as true without consideration of alternative versions of that information" (Langer, 1993, p.45).

Rumination is shifting between options without generating new associations and

-r:ki q. nomtment t1C, P~rv of "he or~t1C'rs.

Schemata is the organization and structure of information regarding some domain of knowledge; "a prototypical abstraction of the complex concept it represents triggered by any reasonable approximation of a schema and guiding the incoming information that support the original schema" (Thorndyke & Hayes-Roth, 1979).

Systematic thoughts are "those dealing with specifically with contents of the arguments." (Kruglanski, Webster, & Klein, 1993 ).









22

Organization of the Remainder of the Dissertation

This dissertation is organized into five chapters. Chapter One has introduced the reader to the purpose, the theoretical rationale, and the significance of this study. Chapter Two includes a review of the literature addressing the relevance of decision-making among people with life-threatening illness, it's association with coping effectively, and a deeper explanation of the research supporting the theoretical underpinnings of the model to be tested. Chapter Two also introduces the Decisional Processing Model. Chapter Three, the methodology section, offers a detailed account of the population sample, research design, hypotheses, procedures for sampling and assessment, and planned analysis of the data. Chapter Four is the results section of the research, including results of the main and ancillary hypotheses. The dissertation is concluded with Chapter Five, an in-depth discussion of the findings in the following areas: decisional categories, the elaboration likelihood m0tel as predictive, and the relationshiD between decisional styles and coming. it provides a description of the decisional processing model based on this study's findings. Chapter Five concludes with implications, methodological issues, and future research.














CHAPTER TWO
REVIEW OF THE LITERATURE

The body of research reviewed in this chapter is organized into seven sections: (a) The integration of mind and body, (b) The social construction of perception, (c) Coping and medical decision-making, (d) The integration of mindfulness and social influence theories, (e) Evidence of a fourth decisional category, (f) Methodological commentary, and

(g) The decisional processing model.

In the review of the literature on psychological factors affecting physical illness a particular emphasis is placed on cognitive factors since decisions are cognitive in nature. The context of these empirical studies is subsequently placed in the framework of a constructivist perspective. Specific to the topic of this study, a review of coping and

T-

decision-making model is built upon the work of Ellen Langer, Richard Petty, John Cacioppo, and Arie Kruglanski. Their research is included. This examination of the literature will conclude with the presentation of the decisional processing model.

The Integration of the Mind and Body

When a person is diagnosed with cancer, he/she experiences acute stress

emotionally, socially, and physically. The intensity of this stress is not determined by the condition and treatment alone. Two parallel processes occur (Leventhal, Diefenbach, & Leventhal, 1992), one creating the cognitive assessment of the illness, the treatment, and 23









24
the prognosis; the other creating the subjective experience. Information is monitored by both the objective and the emotional aspects of the experience through two types of memory structures: a schematic memory "of' the illness and a perceptual memory "about" the illness. Schematic memory consists of automatic, nonverbal cues of the illness; perceptual memory is a composite of the individual's reflections and judgements. There are continuous feedback loops that inform the perceptual "memory," through which the individual appraises his/her responses to treatment and coping efforts.

Psychobiologists have been investigating the transduction of information between learning, memory, and the limbic-hypothalamus area of the brain, to understand how perception is integrated with thought and behavior (McGaugh, 1983) and have found that different perceptions are routed through different pathways of the brain. The reticular formation plays an important role in transducing information by reacting to novel stimuli through the locus coerulus. a cluster of norepinephrirne-containing neurons which stimulate a heightened psychobiologic state, a precondition for all forms of creatively-oriented psychotherapy and mind-body healing experiences. The frontal cortex with it's organizing and planning functions has a multitude of connections with the limbic-hypothalamus area. The organization and synthesis of external and internal information is essential for the regulation of body states and takes place when information is funneled through the limbichypothalamic system.

One of the important mediators of mind-body communication in relationship to healing is body image (Acterberg, 1985; Acterberg & Lawlis, 1984). Body image is a composite of visual imagery and cognitive judgements organized through the transduction









25

of information between both hemispheres of the brain. "The right hemisphere's modes of information transduction are more closely associated with the limbic-hypothalamic system and mind-body communication" (Rossi, 1986, p. 31). However, the raw imagery production of the right hemisphere must be in good communication to be transduced to the left hemisphere. This means information could be the "raw uninterpreted experience" (Leventhal's subjective perceptual memory) or the secondary process routed throught the left hemisphere (Leventhal's schematic memory).

Memory and learning depend on the flow of information from the limbichypothalamic system. Sensory stimulation also results in the release of hormones and a great deal of empirical evidence exists showing how learning and memory are affected by these hormones. McGaugh (1983) discovered that retention, for example, is influenced by epinephrine released from the adrenal medulla. "Hormones released by experience act to modulate the strenoth of the memorv of tbe experience and suigest that central moduthtimQ influences on memory (in the limbic-hypothalamic system) interact with influences from peripheral hormones" (Rossi, 1986). Following this description, all learning becomes statedependent learning.

Research by Murry and Mishkin (1985) suggests that the cross-modal association of sensory-perceptual information makes possible flexible patterns of information transduction into psychophysiological responses. To the degree that a person is able to react to novel stimuli, access learning from different states, synthesize the parallel processes, and make the cross-modal association needed to act, that individual will be able to influence autonomic functioning. Increasing the pathways of both self-reflective and









26

externally-derived information is the way in which mind-body communication can be enhanced.

Science has furthered only a few ways to enhance mind-body communication. The factors that have been shown in research to significantly affect the body and it's response to illness depend on the internal communication system described above. Making truly informed medical decisions may also depend on this information system. Appraisal

Appraisal is an interpretation of somatic sensations (Leventhal, Deifenbach, &

Leventhal, 1992). Two types of memory structures are involved in the appraisal process, one schematic and the other propositional. Schematic structures are nonverbal, nonpropositional codes of prior illness while propositional structures consist of abstractions or interpretations about the illness. Representations have five attributes which are (a) disease label (Baurnan & Leventhal, 1985: Crovlie & Sanide, 1988), (b) time-lire (Crovie. 1990), (c) physical, social, and economic consequences (Bishop, 1987; Croyle & Jemmott, 1989), (d) antecedent causes, and (e) potential for cure or control (Weinstein, 1988). This representation is set in motion by a novel somatic situation and determines the steps taken to remedy the illness or, if too much anxiety is evoked, can lead to denial of the symptoms (Safer, Tharps, Jackson, & Leventhal, 1979).

The illness representation drives the appraisal process. In a study of hypertensives, 80% of the people stated they knew hypertension was asymptomatic, yet when asked if they could detect when their blood pressure was high, 90% said they could (Meyer, Leventhal, & Gutman, 1985).









27

In another study, symptoms experienced in the presence of environmental stressors were appaised as signs of stress, whereas those experienced without the presence of a stressor were appraised as a sign of illness (Pennebaker, 1982). Cancer patients who have undergone surgery and believe the cancer was eliminated have difficulty choosing to undergo noxious chemotherapy treatment (Leventhal, Easterling, Coons, Luchterhand, & Love, 1986).

Appraisals not only influence how symptoms are perceived and acted upon but can trigger a system of thoughts about the illness which deter effective treatment and coping. In a laboratory study with induced noxious stimuli, negative thought patterns were found to be related to increased reporting of pain (Gil, Phillips, Webster, Martin, Abrams, Grant, Clark, & Janal, 1995). In an applied study, patients receiving cognitive coping skills training and restructuring of negative thought patterns reported more effective pain rnana~gerent, increased functional cauacitv. and better coping (A.hrnaier. Lehmnann. Russell, Weinstein, & Kao, 1992; James, Thorn, & Williams, 1993 ).

The initial representation of the illness, including both the non-verbal experience of somatic stimuli and the interpretation of that stimuli, is the process by which the integration of information leads to the factors that influence health. It would seem that the more information, both internal and external, entertained by the patient, the more likely this representation will guide the patient towards healthy choices. Self-Efficacy

Self-efficacy is defined as a subjective appraisal of one's ability to carry out specific behaviors to fight the illness and cope with the distress. Self-efficacy has consistently been









28

identified as playing a crucial role in health (Bandura, 1977; OLeary, 1985). Only if health enhancement is seen as within their control will patients feel capable of challenging the illness (Strecher, Devellis, Becker, & Rosenstock, 1986). Bandura (1995) stated that self-efficacy is an integral part of three domains of self-regulation: self-monitoring, judgements on oneself, and self-reactions. Anticipatory thoughts of self-inefficacy increase stress level more than actual encounters with the threat (Bandura, 1986). Perceived inefficacy in controlling a psychological stressor resulted in plasma catecholinamine secretion (Bandura, Reese, & Adams, 1982), activation of endogenous opioid systems (Bandura, Cioffi, Taylor, & Brouillard, 1988), and increased release of corticosteroids and catecholamines (Borysenko & Borysenko, 1982), all of which have immunosuppressant capabilities. In a study investigating phases of efficacy acquisition rather than the immunosuppressant effects of inefficacy, Widenfeld, OT'Leary, Bandura, Brown, Levine, and Raska (1990) demonstrated enhanced immunoconmetence d-ring the devenrTrent of competencies to adapt to a stressor. These findings suggest that there is a relationship between self-efficacy and immune system enhancement, that self-efficacy resulting from acquired confidence or skills can be taught, and that the more rapid the acquisition of an efficacious perspective, the more the likelihood of retaining higher levels of immunocompetence.

Efficacy also affects how closely a person adheres to medical regimens. Specific to cancer treatment, interventions to increase adherence were tested (Putnman, Finney, Barkley, &Bonner, 1994). Self-efficacy at pre-test did not correlate with adherence but self-efficacy at post-test significantly correlated with increased adherence. Another









29

investigation found that colorectal cancer screening among high risk men increased as selfefficacy increased (Myers, Ross, Jepson, & Wolf, 1994)

Expectations about one's abilities to effectively combat and cope with the illness are part of the appraisal of personal helplessness (Lazarus & Folkman, 1984). Personal helplessness is experienced when persons feel others can accomplish what they themselves cannot. Wortman and Dintzer (1978) suggest that before individuals arrive at a decision of causality or efficacy, they go through a series of hypothesis testing, a definite decisionmaking process.

Attributions

Attribution of causality is a major construct when determining the etiology of an illness, prognosis (Peterson & Seligman, 1987), and adherence to recommended medical regimens (Leventhal et al, 1992). The attribution process actually begins with interpretation of init'A svnm,torns. The anibimpiv of,*vsical sm'nrtoms nrior to dia,. osis may either prompt or delay action. A minimally threatening framework which normalizes symptoms prevents the person from seeking medical treatment until the symptoms exceed the attributed cause (Mechanic, 1972).

Once diagnosis occurs, even in illnesses with known causes, people tend to make personal attributions beyond the medical cause (Janoff-Bulman & Lang-Gunn, 1988). These personal attributions often involve self-blame and reflect a moral tone (i.e. "I got breast cancer because I had premarital sex.") Behavioral self-blame attributions, as opposed to characterological self-blame attributions, are efforts to establish a sense of a coherent, predictable, and controllable world (Janoff-Bulman, 1979). However, Wortman









30n

(1975) and Janoff-Bulman (1979) studies have shown that adjusting to a one time event such as an accident may be quite different than with an illness where the threat of recurrence continues.

Research has generally supported that people who assign meaning, attribute

causality, and then come to terms with their decision about causality are better able to cope with illness (Ward et al, 1988). However, several studies exist which refute this perspective. Although prior research suggests that one's own actions yield greater feelings of control (Langer, 1975) than reliance on a belief that another person is in control, Langer's studies were conducted on people who were equally competent. In medical situations, the trained medical staff may provide a sense of control vicariously through their competence. In a study with breast cancer patients (Taylor, Lichtman, & Wood, 1984), findings supported this notion. Either the sense of oneself being in control of the cancer or the sen-se of the medical staff being In control of the cancer were sio~mificantly ard curvilinearly related to adjustment.

The majority of the research on attributions of causality has explored the

relationship with coping and adjustment. In the few studies using physical factors as the dependent variable, compliance, preventive health behavior change, and immune system functioning were investigated. Attributions of causality affect the meaning a patient places on the outcome. If a patient feels the disease is self-caused, making personal changes would result in successful control of the illness. If the disease cannot be controlled in accordance with the attributions assigned, it may be interpreted as personal failure. One study on hemodialysis patients found that attempts to control outcomes that resulted in









31
"failure" were those who had the poorest compliance (Witenburg, Blanchard, Suls, Tennen, McCoy & McGoldrick, 1983).

Health behavior change: Perhaps the most well-researched area of attributions and health is health behavior change for the purpose of prevention. Undergraduates who were unsuccessful in health behavior changes attributed their setbacks to internal, unstable, and controllable causes, yet they minimized the importance of the cause (Schoeneman & Curry, 1990). Different health behaviors elicited different attributional styles. In another study, attributions changed over time as the intentions of the participant changed (Schoeneman, Stevens, Hollis, Cheek, & Fischer, 1988). Attributions are idiosyncratic and change over time and situation.

Immune system functioning: Immune system functioning is the newest area of investigation in the attribution literature. The few existing studies show conflicting fd is i detc-rminir whetlir a causal attribute predicts the rate of inmmne system decline in HIV seropositive gay men, an eighteen month follow-up study controlled for other health mediators such as depression and risk behavior, demonstrated a decline in CD4 (killer cells) in participants who assigned attribution for the negative events to aspects of themselves (Segerstrom, Taylor, Kemeny, & Reed, 1996). Another study on chronic fatigue patients found that those who assigned attributions to physical causes rather than psychological causes had more hospitalizations, increased reported fatigue, increased somatic symptoms, and were more functionally impaired, yet they had less perceived distress (Euba, Chalden, Deale, and Wessely, 1996). In a retrospective study on cancer patients who survived beyond all expectations, twice as many patients attributed their









32

survival (during and after treatment) to spiritual, attitudinal or behavioral changes they made rather than to the treatment they received (Berland, 1995). More than half of these patients experienced a spiritual/existential shift in their lives.

There is little doubt that attributions are important factors in response to illness.

Almost every study detected that a majority of people do make causal attributions to illness but the direction or degree of this influence is only beginning to be understood. What is clear from the literature on attribution of causality and medical illness is the variability related to outcomes, adjustment, and behavior change. Physical Effects of Coping

If psychological factors, i.e. what we think and feel, could affect coping and even the experience of pain, could they also affect survival? Initially, studies reported mixed results on the predictability of cancer survival and coping based on psychological factors. Snme studies Jhave four.d io ree.tionsbo en oc 1 Ttors bnd w'-r progression (Cassileth, Lusk, Miller, Brown, & Miller, 1985; Jamison, Burish, & Wallston, 1987), and have concluded that, with advanced cancer, the prognosis is dictated by the nature of the disease. Others (Derogatis, Abeloff, & Melisaratos, 1979; Spiegel, Bloom, Kraemer, & Gottheil, 1989) have identified suppression of dysphoria and cognitivebehavioral avoidance patterns as being associated with shorter survival. Patients who reevaluated their situation and reported having made considerable adjustments in their lives have significantly higher one year survival rates (Rogentine, van Kammen, Fox, Docherty, Rosenblatt, Boyd, & Bunney, 1979). From studies such as these we can extrapolate that those who thought more carefully about their situations took action and lived longer.












Newly adopted thought patterns and behavior are at least partial determinants of enhanced emotional and physical functioning. Support group participants who were taught stress management and coping skills showed significantly lower levels of depressive symptoms, fatigue, and confusion and demonstrated higher levels of vigor than controls. They also had significantly more large-granular lymphocytes and natural killer cells (which are anti-viral and anti-tumor agents; Fawzy, Fawzy, Hyun, Elashoff, Guthrie, Fahey, & Morton, 1993). At the six year follow-up, survival rates were decisively enhanced although the difference could not be accounted for solely by the participants' improved immune system function.

In another study, psychological symptoms, avoidance, and intrusive thoughts were used as variables to predict progression over one year (Epping-Jordan, Compas, & Howell, 1994). General psychological symptoms were not predictive of progression. This finding



perhaps reflect generalized distress rather than features that affect cancer more directly. Intrusive thoughts also did not predict disease status. However, avoidance of intrusive thoughts and emotions was significantly predictive. Other studies have reported similar findings (Billings & Moos, 1981; Holahan & Moos, 1986). When symptoms of distress are measured more broadly, no relationship is found; when specific symptoms (supported in research) are assessed, they do predict progression or survival. In ATDS patients, denial predicted a decline in CD4 cells (an important immunological predictor of HIV infection) and progression from FIIV to AIDS. This pattern was not seen in those demonstrating a









34

"fighting spirit" which was defined as an optimistic attitude accompanied by a search for more information (Solano, Costa, Salvatix, Coda, Auita, Mezzaroma, & Bertini, 1993).

Coping has previously been viewed as a quality that enhances life while an

individual deals with an illness. It is also emerging as a causal factor in the direction of the illness itself Research on the interrelated alliance between the mind and body has expanded considerably and previously undetected links are being revealed. Stress and Illness

Stress and the ability to cope with stress have significant effects on many physical illnesses and there is evidence that this effect occurs through the impact of stress on the immune system and the mediation of coping factors (Eysenck, 1985; Fox, 1983; Korneva, Klimento, & Shkhinek, 1985).

One of the well-investigated theories regarding immune system functioning and c .cer offered bv TeShp.n (1959). A ccordir cteShlKn.; I os to d-r-5 which leads to helplessness. Cancer had initially been associated with recent prior loss. Another early theory was that cancer patients suppress emotion and employ an excessive use of denial (Bahnson & Bahnson, 1964; Kissen & Eysenck, 1962). Evidence from many early studies both supported and contradicted this relationship (Dattore, 1978; Dattore, Stontz, & Coyne, 1980). The studies supporting these theories were conducted only on people who had cancer. In a longitudinal study of 1350 participants drawn from the general population and followed over a ten year period, results demonstrated chronic helplessness correlated with cancer (r=.59) and anti.-emtional behavior correlated (r=.5 1), (Grossarth-Maticek, Kanazir, Schmidt, & Vetter, 1982; 1985). In this series of studies, a









35
synergistic effect was found in lung cancer patients between smoking and the personality factors of chronic helplessness and anti-emotional behavior.

There is a difference between acute stress and chronic stress in the development of cancer. Acute stress has immunosuppressant qualities. Acute stressors have been shown to affect immunity (Herbert & Cohen, 1993; Kiecolt-Glaser, Cacioppo, Malarkey, & Glaser, 1992). In a first-time parachute jump, participants' NK cell activity increased immediately after the jump and within one hour, the NK cells fell to below baseline (Schedlowski, Jacobs, Stratmann, Richter, Hadicke, Tewes, Wagner, & Schmidt, 1993). Both NK cells and lymphocyte count have been shown to respond to stress and the perception of stress.

Chronic stress in some studies has been shown to have an opposite effect (Eysenck, 1983; 1984a; 1984b). Eysenck calls this factor the inoculation effect, which supports the idea that coping is a mediator to stressors. In a study by Rodin (1980;1986), elders subjected to stress and exhibiting helplessness were taught new coping strateaes. These adults not only became happier and more actively interested, but survived significantly longer than their cohorts without training. Cortisol levels (which display immunosuppressant capabilities) were also measured in this study. In the group that learned new coping strategies, the participants' cortisol level decreased significantly. A one year follow-up indicated these levels were maintained.

Cancer patients were provided with chemotherapy alone or chemotherapy and cognitive behavioral training to cope (Grossarth-Maticek, Kanazir, Vetter, and Jankovic (1983). Mean survival time of all patients was 15.7 months. Those receiving chemotherapy alone survived 2.8 months longer; those receiving coping training alone









36

increased their survival time 3.64 months. Patients receiving both treatments increased their survival time by 22.4 months. This clearly demonstrates a synergistic effect by using both treatments.

It is not enough, however, to know that what we think and how we express our

emotions affect autonomic functioning such as the immune system, lymphocyte count and hormone levels. It is equally important to know how the effect occurs. In his pioneering research, Robert Ader (198 1) demonstrated the ability to train rats through behavioral conditioning to increase or inhibit their immune system functioning thus suggesting that even the autonomic system functioning can be affected by learning.

When stress occurs, corticosteroids from the cortex of the adrenal glands raise

blood sugar levels, reduce inflammation, and suppress immune system functioning. They also prompt mood changes, especially depression. The medulla of the adrenal glands secrete em~nechrine and norenineDhrne which increase heart rate and blood pr-esslare to deliver blood to the large muscles in preparation for a flight or fight response. Norepinephrine also increases the natural killer cells, cells believed to attack cancer cells. These discoveries led to the question of how the transmission of the message releases certain hormones when certain perceptions occur. Neuropeptides flowing to and from the pituitary gland have been linked to the body's stress responses, the immune system, and the limbic system, that portion of the brain critical to drives and emotions. Furthermore, this interconnected message delivery system is reciprocal.









37

The Role of Emotions

Research has supported the notion that cognition affects both the experience of an illness and in at least some cases, the progression of the illness. Studies have shown that there is a correlation between cognition and these factors, that changing cognition positively affects these factors, and that cognitive restructuring can even predict long term survival.

But what about emotions? Other studies have demonstrated the effect of the lack of emotional expression and it's effect on the immune system and cancer. Aside from the expression of emotion, the linking of certain emotions with cancer has had a long history of exploration. The results in this body of literature are mixed. Mixed results demonstrating the link between depression and progression of disease have been found in the psychological literature. Some findings demonstrate effects of emotions on physical fimctioning (Erwninz-Jordan et al. 1994-;. Gressarth-Maticek. 1992: Herbert & Cohen,. 1993); other studies found no relationship (Buddeberg, Wolf, Sieber, Riehl-Emde, Bergant, Steiner, Landolt-Ritter, & Richter, 1991; Cassileth, Lusk, Miller, Brown, & Miller, 1985; Jamison, Burish, & Wallston, 1987). If the medical literature is consulted, depression is not associated with cancer (Hahn & Pettiti, 1988; Weissman, Myers, & Thompson, 1986). The difference lies in the methodology of these studies and the difference definitions of depression. The medical literature uses the standard of "clinical pathological depression", typically the IMPI Scale, while the psychological literature uses depression scales which detect depressive symptoms in fully-functioning people. Some of the psychological studies use broad measures of emotional distress and others use measures









'8

of specific emotional reactions. The medical literature contains an abundance of epidemiological surveys while the psychological literature uses more experimental and quasi-experimental designsAnother chronic emotional state associated with illness is hostility. Hostility has been identified as one of the causal factors in heart disease (Dembroski, MacDougall, Costa, & Grandits, 1989; Hecker, Chesney, Black, & Frautschi, 1988), and related to general health outcomes (Adams, 1994). A link between hostility and cancer has not been explored.

The role of emotion in illness goes far beyond contributing to the cause or

inhibiting recovery. Interactive effects between emotion and cognition are powerful determinants of health and enjoy a long history of research. Although there is an integral relationship between emotion and cognitions influencing illness, reviewing the literature devoted to this bodv of knowledge is beyond the scone of this research.

Constructivist Approaches to Perception Perception is the key to how events are interpreted and it is essentially social in its nature. Every culture has its images of illness and healing. The shaman drew on selfhealing through images of spirits, the Chinese drew on self-healing through facilitating the energy flow of the body. Even Western medicine has acknowledged the power of the placebo effect. In an analysis of eleven published double-blind studies conducted in various laboratories on pain relievers, Evans (1981) found that 36% of the patients taking a placebo experienced at least 50% pain relief In another study conducted on responses to a variety of medical problems (hypertension, cardiac pain, headaches, blood cell counts,









39

fever and others) Evans (1985) found a placebo effect of 55% across various medical procedures. The common feature among the cultural images of illnesses and the ensuing attempt to cure are the belief that the cure will work.

Even though the culture provides a framework for the interpretation of illness, images are not only cultural but are also highly idiosyncratic (Rolland, 1987). These culturally-bounded, idiosyncratic beliefs determine people's attributions of causality (Eklund & MacDonald, 1991), self-efficacy (Bandura, 1985), prognosis (Peterson & Seligman, 1987), and the actions they take (Ajzen & Timko, 1986).

How does a patient arrive at a definition of his/her disease? How does a "body of knowledge" about a disease become an accepted reality? The tenets of constructivistic approaches provide a framework from which to explore this problem. Both the social constructionist and the cognitive constructivists share an important perspective for this study. The commonality between these approaches are that reality is constructed (a process of mentation) and reality is heavily influenced by the social context. The perception of reality then, is a function of both the social context and an individual's active construal of events.

Beginning with the visit to the doctor, the "problem" takes the form of a

construction shared by the patient and the physician. Differences have been documented in the reporting of symptoms by patients based on different approaches from the physician, and by the gender, age, race, and class of the patient (Svarstad, 1976). In an early study by Klein (1967), spouses of the persons identified as having a serious illness often had significant illnesses themselves and, in some cases, more severe than the spouses but they









40

were never labeled as the "III" persons in the family. Apparently the image of illness and the roles of the family members took precedence in defining the "reality" although these constructs were clearly disparate from the biology of the people involved.

Constructionism is built on the premise that humans construe their realities.

Experience can only be known through the structures and functions of the nervous system, which according to Hayek (1952) is primarily a classification system. Themannerby which experiences are classified, rather than a lens from which to view the world, becomes a construct which drives a person toward the creation of experiences, definitions of those experiences, and ascription of meaning to those experiences. This proactive system of construing not only determines the output but also the input (Guidano, 1984). This is not to suggest, however, that the inner experience of "constructs" is an isolated system.

Maturanna and Varela (1987) state that the ascription of meaning regarding the

coordination of behavior occurs in the context of two or more people. But meaning is not always in the form of language. Meaning is socially constructed, an outgrowth of culture and context, and the process of assigning meaning goes beyond language and conscious categorization (Kelly, 1955).

Lakoff and Johnson (1980) distinguish between conception and experience.

Experience is direct interaction with the physical environment and bodily sensation and can occur without language. Conceptualization (perception) is grounded not only in this spatial experience and physical sensation but in a vast background of cultural presuppositions. Research suggests that people will change without conscious categorization of material. In a study by Langer (1989), a group of seventy-five year olds was placed in a retreat setting









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retrofitted with objects characteristic of twenty years earlier. They were simply told, "Be fifty-five again." Within a week, the participants demonstrated incredible changes in dexterity, hearing, taste, height, IQ, and attitude as compared with a control group in a setting without the retrofitted environment. Although this phenomenon occurred within a social context, the effects of meaning were outside the realm of conscious construction and outside language. The participants' co-constructed meaning was influenced by the interaction of the physical environment and their formerly constructed understanding of what it meant to be fifty-five.

It is quite likely also that the constructs of ill people and disease are unconsciously represented, are socially constructed and determine to a great degree the choices made regarding illness- How and with whom the information concerning one's disease is attained and processed will affect the patient and the disease. "Reality" is maintained by social processes and the presence of interaction is central to maintaining reality dulinc., a crisis. The most important vehicle in the maintenance of this reality is communication. The role of language begins with labeling the experience and sharing that label with another person.

Two processes are described by social constructionists that may influence the decision-making processes in a family when disease occurs: primary socialization and secondary socialization. Primary socialization consists of the information presented to us as children that we accept as "reality" without further scrutiny. Later in life, we are presented with other socialization messages garnered from our experience with other people. Berger and Luckman (1966) described secondary socialization as the acquisition of role-specific knowledge, internalized through the role-specific vocabulary. On both a









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cognitive and an emotional level, a cohesive "reality" is internalized along with the institutionalized body of meanings that accompany the role. However, because this secondary socialization is imposed on an already formed primary socialization, discrepancies may arise between the two. For secondary socialization to take precedence, it must be reinforced. Berger and Luckman suggest that a person's social base serves as the laboratory for transforming the primary socialization, through strong affective bonds, to a secondary socialization. The family and friends of a cancer patient serve as this laboratory and the group mediates the illness experience.

George Kelly (1955) postulated that people are "personal scientists." He stated that, "Man looks at his world through transparent patterns or templets which he creates and then attempts to fit over the realities of which the world is composed. The fit is not always very good. ....These patterns are tentatively tried on for size" (Kelly, 1955, p. 42). It is tbrouq these attempts to fit experience to the constrLicts that the constructs are altered. This appears to be analogous to active decision-making and may be the most adaptive for effective coping and enhancement of treatment.

An imaginary example to demonstrate this point is the story about George and Louise. George and Louise had been married for twenty-four years when Louise was diagnosed with breast cancer. Louise's grandmother had died of cancer when Louise was eleven. Louise doesn' t know what kind of cancer. Visiting had come to a sudden halt and, for a long time, only her mother saw her grandmother. Just days before her death, Louise was told that her grandmother had cancer and was dying. As a result of this experience,









4 in

Louise's primary socialization around disease was formed: disease is not discussed, cancer leads to death, activity comes to a halt, and one isolates oneself when seriously ill.

When Louise herself was diagnosed with cancer, she automatically fell into the pattern she had seen with her grandmother. She did not discuss the issue with her husband and halted her activities without explanation to others around her. The definition, means of coping, and expected outcomes of her disease were defined by the construction she had learned in childhood. Her story is an example of a cognitive commitment made to a pre-existing schema.

After several months of depression while undergoing radiation, Louise was referred to a counselor. In the process, she and the counselor examined how she had arrived at the decisions about her illness. Together they began to construct new parameters for the disease. Louise began to question the silence with her husband. When she did discuss her cancer in depth with. him- he told her a very different story about cancer learned fftom his childhood. Together they were able to reconstruct her decisions relating to her illness. This reconstruction is what Berger and Luckman would define secondary socialization. Her depression lifted, her radiation therapy worked and Louise is now a "Bosom Buddy." (Bosom Buddies is a nationally organized support group for women who have/had breast cancer.)

Although perception plays a key role in coping and recovery, it is clearly influenced by cultural and individual factors. Schemata about events are forinulated through our experiences embedded within a culture and then when faced with that event on a more personal level, a person's perceptions are heavily influenced by this existing schema. The









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influence of this schema creates a frame from which the person actively construes the personal events as they unfold. It is from such a template and system of construal that decisions are made when a person faces a life-threatening illness. Acting upon perceptions and images requires making decisions.

Decision Making and Illness

Medical decision making has been viewed historically as a process carried out by the deliverers of medical services. The majority of contemporary literature reflects this stance. Considerable research has focused on physician judgement about illness and treatment (for example: Harris, Evans, Dennis, & Dean, 1996). A few studies considered patient variables in addition to the illness (for example: Mort, 1996). And many other studies investigated the effects of certain policy decisions affecting the delivery of services (for example: Larson, Christenson, Abbott, & Franz, 1996).

Only two topics brought the researchers to consider the patient's decis-ion-making process: the choice of when to seek treatment and the choice to die rather than treat. Research has been conducted on these topics since the early 1980's and is accruing. However, there are many decisions made in addition to seeking initial treatment and choosing to die. Yet this decision-making has been sorely neglected. In seventy-five articles published in psych-lit in 1997 on medical decision making (not including the two topics mentioned), only eight focused on decision making by the patient. In 1996, only six articles of the one hundred and sixty-nine published reflected the patient's point of view. Within the last few years, the medical literature contains more research, but many studies









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still reflect the biased perspective of convincing the patients to make decisions in accordance with medical providers.

Patients today are playing an increasingly central role in medical decisions that concern their well-being. However, what professionals believe are patient preferences often differ from what the patient really wants (Kane, 1996). Recent investigations of the choice to seek treatment reveal that the choice is more attitudinally based than symptom based. It was not the symptoms that prompted elderly patients in one study to seek medical treatment but the perception and causal attributions that proved to be the most predictive (Stoller & Forster, 1994). In another study (Hitchcock & Matthews, 1992), participants exhiubiting more sensitivity to illness words engaged in more catastrophic thought about their illness and sought medical treatment more frequently. Life satisfaction was shown to be more predictive than symptomatic discomfort in determining level of functioning among chronic nulmonarv disease patients (Cameron, Leventhal, & Leventhal. 19,95: Leidv & Haase, 1996).

Specific to decisions concerning cancer treatment, two factors were found to influence decision-making: the amo unt and specificity of recommendations and the strength of the recommendations (Siminoff & Fetting, 1991). The first refers to the ability of a patient to comprehend and store the recommendations in long term memory. The second, strength of recommendation, was found to be a factor influencing a patient's motivation to process the information effortfully (Petty & Cacioppo, 1986). Both of these clearly posit the decision-making power with the physician rather than the patient. In the Siminoff and Fetting study, eighty percent of the patients accepted the physician's









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recommendations. Those who did not were more educated and considered themselves risk-takers.

Information about medical choices is often presented in probabilistic terms

(Kahneman, Slovic, & Tversky, 1982). Whether the problem is formulated as a loss or a gain influences the choices. The problem becomes socially constructed through language. For instance, one study investigated how medical decisions were influenced by whether a message was presented in terms of possibility of survival or morbidity. One experiment dealt with the choice of radiation or surgery for lung cancer; the other with the choice of a normal, risky, or abnormal pregnancy. People interpreted an ambiguous frame in highly selective ways that were in consonance with their values or beliefs. Those presented with a survival framework chose the riskier cancer treatment than those presented with a mortality framework. Fewer differences were found in the pregnancy decisions. Risk was more attractive in the positive frame than in the negative frame (McNeil, Pauker, & Tverskv. 1988).

A recent line of investigation queries whether patients wish to be involved in decisions about their treatment. Findings report that patients desire more involvement (Brody, Miller, & Lerman, 1989) and when they are involved, they report more satisfaction with their care(Valente, Antlizt, & Boyd, 1988), adhere to recommendations (Greenfield, Kaplan, & Ware, 1988), and experience better health outcomes (Greenfield, Kaplan, & Ware, 1985). In an investigation of women with breast cancer, 22% wanted to select their own treatment, 44% wanted to do so collaboratively with the physician, and 34% wanted their physician to choose (Degner, Kristjanson, Bowman, Jeffrey, Sloan,









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Carriere, ONeill, & Bilodeau, 1997). Only 42% of the women felt they achieved their desired role in the decision making about their treatment. The majority of these women wanted more control, while 14.9% of those who felt dissatisfied believed they were "pushed" to assume more decisional control than they wanted.

While the physician may make treatment decisions based on the symptoms and effectiveness of cure, the patient bases treatment decisions on a personal knowledge of his/her values and beliefs. In a study on men with prostatic hyperplasia, the possibility of sexual dysfunction predicted their decision about surgery (Barry, Fowler, Mulley, Henderson, & Wenniberg, 1995).

The results of these studies clearly indicate that decision-making for medical reasons is far from data-driven, is influenceable, and carries major consequences. Yet decision-making concerning medical issues is surprisingly neglected in the research literature.

Some Decisional Styles May Enhance Coping The growing perception of medical services as a consumer product (Reiter, Lench, & Gambone, 1989) and the health component of the women's movement (Rodin & Ickovics, 1990) have increased research on physician-patient communication, focusing on the patient's role in decision-making. Active information sharing in decision-making process enhance the patient's perception of control and self-responsibility (Lerman, Broday. Caputo, Smith, Lazaro, & Wolfson, 1990). Patients actively involved in their decisions about treatment demonstrated improved health outcomes (Garrity & Lawson,









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1989), less funrctional disability (Greenfield, Kaplan, & Ware, 1985), and faster recovery (Wallace, 1986).

Increased adherence to medication regimens has been linked with the sharing of more information between physician and patient (DiMatteo, Hays, & Sherbourne, 1992; DiMatteo, Sherbournie, Hays, Ordway, Kravitz, McGynn, Kaplan, & Rogers, 1993). Although information exchange does not necessarily constitute active decision-making, it does indicate a higher level of involvement on the part of the patient. These studies were conducted on people's naturally occurring style of reacting to a medical situation. One study investigated the effects of changing patient's participation through participation training. Training focused on question-asking and participation in informed consent. It did not lead to greater satisfaction with their visit and other measures of treatment outcome were not assessed (Greenfield, Kaplan, & Ware, 1985; Roter, 1984).

Even the perception of choice increa-ses a sense of control, which has been shown to positively affect health outcomes. Significantly more positive results have also been found when people chose their treatment than those who were not given a choice. Several studies gave people the identical treatment or protocols to follow, manipulating only their sense of choice. The groups of participants who attributed the choice to themselves responded more favorably to treatment (Gordon, Mendonca & Brehm, 1983), engaged in more healthful activities (Thompson & Wankel, 1980), and reported a reduction in anxiety and depression in response to a cancer diagnosis (Morris & Royle, 1988). However, the relationship exhibited in these studies are not so definitive when the perception of control variance is considered. The amount of perceived control over choice of treatment was









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associated with the participants' prior beliefs about control over their health rather than the circumstances presented by the medical system (England & Evans, 1992).

Having a choice and participating in one's medical decisions, as both active and

passive decisional styles do, could lead to positive health outcomes. While decision making, appears to be a critical factor in determining these health outcomes, evidence suggests individual differences rather than opportunity direct the process.

Coping

With the accepted theories of coping, two significant factors emerged: coping

mechanisms actually reduce stress and that coping mechanisms act as a buffer in the face of stress. Lazarus and Folkman (1984) conceptualized coping as consisting of four elements: stimulus, appraisal, response, and outcome. Coping involves purposeful thoughts and actions taken to reduce a threat. Coping is therefore a conscious decision to do or Tiet do somehinoIn this study, coping is viewed as a transactional model. Coping is situation and time-specific because it is constantly modified through appraisal and reappraisals of one's efforts and the situation. Coping is also individual and conforms to a generalized pattern of behavior in response to stress (Carver, Schenier, & Weintraub, 1989; Ntiller, Combs, & Stoddard, 1989).

Cancer as the Stimulus for Coping

Cancer has been investigated both as ageneralized experience and as a condition having unique and specific demands. When viewed as a unitary variable, results are likely to be haphazard because it assumes that all cancers pose the same demands or the same









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cancer poses the same demands on all individuals (Parle & Maguire, 1995). Evidence has been gathered indicating that coping with cancer is situation and time specific (Buddeberg, Sieber, Wolf, Landolt-Ritter, Richter, & Steiner, 1996). Inviting the patient to focus on the identification and response to one particular stressor elicits both the generalized pattern and the situation-specific response. The current study uses the latter approach. Specific stimuli demands that may trigger a need to invoke a coping strategy are severity (Aldwin & Revenson, 1987), controllability (Smith, Ackerman, & Blotcky, 1989), threats to selfesteem and self-identity (Curbow & Somerfield, 1991; Curbow, Somerfield, Legro, & Sonnega, 1990), threats to the integrity of the body, threats to quality of life (Mattlin, Wethington, & Kessler, 1990), threats imposed by limitations of treatment or illness, and inadequate social supports (Blanchard, Albrecht, Ruckdeschel, Grant, & Hemnick, 1995). Coping Appraisal

Appraisal includes both the individual's judgement on the threat (primary arnraisa! and the recognition of what options exist to manage the threat (secondary appraisal). Subjective appraisal has been found to play a significant role in coping (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1994; Folkman, Lazarus, Dunkel-Schetter, Delongis, & Gruen, 1986; Lazarus & Folkman, 1984). Maladaptive coping strategies were initiated in cervical cancer patients who selectively attend to negative features (MacLeod & Hagan, 1992). In another study, patients were assessed upon diagnosis about their worries and expectations for the cancer and coping. Those who used a negative assessment demonstrated significantly higher levels of affective disorders eight weeks later (Parle, Jones, & Maguire, 1994). In fact, appraisal has been shown to be more predictive of effective coping than the









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state of the illness (Dunkel-Schetter et al, 1992). Among cancer patients, a positive reinterpretation of the illness has been associated with reduced distress and a coping strategy of escape-avoidance has been associated with increased distress. Appraisal is clearly a pivotal mediating factor in coping.

One domain, attribution of causality, in which appraisal operates, is significant to coping. Attributions made in response to disease operate independently of the usual attributional style of the individual (Moulton, Sweet, Temoshek, & Mandel, 1987) and change over time (Schoeneman & Curry, 1990). Health attribution does not appear to be a stable feature but situation specific. How are health attributions determined? Social influence offers a possible answer; important to effective coping is the availability of partners to provide feedback on daily changes (Monge, 1982) and re-evaluation of the couple's common goals (Stetz, Lewis, & Primono, 1986).

Another domain determined by appraisal is self-efficacy. Studies on self-efficacy in coping have investigated coping variables that promote resolution of a specific aspect of the illness. Different patterns of coping were found in dealing with cancer-related problems than with other life problems (Cook-Gotay, 1984; Meyerowitz, 1983). Diet (Caesar & Tucker, 199 1), distressing medical procedures (Litt, 19 88) and coping with chemotherapy (Miller, Combs, & Stoddard, 1989) have all been shown to improve with increased self-efficacy.

Response to Coping: Coping Strategies

The idea that coping be viewed as a process rather than a trait fostered research focusing on specific strategies and the discovery of delineated patterns of coping. Less









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distress was demonstrated in cancer patients who used a more positive or confrontational approach to their illness (Burgess, Morris, & Pettingale, 1988; Feifel, Strack, & Nagy, 1987a). In contrast, those patients using avoidance and acceptance-resignation demonstrated more emotional distress (Rodrigue, Boggs, Weiner, & Behen, 1993). A positive reinterpretation of the illness experience (Felton, Revenson, & Heinrichsen, 1984) and more problem-focused coping (Billings & Moos, 1981) resulted in less distress. In the most extensive coping study conducted on 668 cancer patients, cognitive appraisals of stress were associated with three of the five coping patterns. Emotional distress was associated with focusing on the positive and escape-avoidance coping (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992).

Patients who mentally prepared themselves for chemotherapy took actions to

reduce the threat. Those who avoided thinking about it reported increased anxiety which led to unsuccessful actions to reduce their stress. The action taken by avoiders was not adaptive while that taken by the cognitive coping group reported less distress and improved adaptation (Lev, 1992).

In contrast, some studies found that both the cognitive approach to coping and avoidance reduced stress (Manuel, Roth, Keefe, & Brantley, 1987). But, these results were found immediately after diagnosis. When measured over time, stress increased in the avoidance group and decreased in the cognitive group. In a study by Dean and Surtees (19 89), time was also reported as a factor in coping effectiveness with very different results. They found that women with breast cancer were more likely to remain disease free during an eight year follow-up period if they reported using denial more than other coping









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strategies. The coping strategies denial was compared with were hopelessness/helplessness or stoic acceptance, neither of which could be considered a cognitive coping strategy. In a replication of this study (Buddeberg, Sieber, Wolf, Landolt-Ritter, Richter, & Steiner, 1996) the results were inconclusive with the exception of the discovery that patients use different patterns of coping over time. In an exploration including both individual patterns of coping and situation specific patterns of coping, Carver, Scheier, & Weintraub (1989) suggested that coping is determined by the "fit" between an individual's preferred way of coping and the demands of the situation. Flexibility has been identified by other researchers as essential in coping with illness demands (Rowland, 1989; Duiikel-Schetter et al, 1992).

Outcomes of Coping

Two types of outcomes have been explored. The first is the relationship between le-vel of d'isress. or affective dkorder a.nd. coning strategies. The second is nrr-rFsnn -nd recurrence of illness, or survival rates. Many of the earlier studies on coping with cancer measured distress broadly and found little relationship between coping and cancer outcomes. However, when the dependent measures were specific to certain types of distress and independent variables were measured for specific ways of coping, the results indicated a relationship.

Other outcomes measures of coping were physical in nature. Patients using

cognitive coping strategies required significantly less pain medication and reported less pain following cancer breast surgery than those using affective strategies (Jacobsen & Butler, 1996). Men with HIV who used a "fighting spirit" coping style were found to have fewer









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fHV related symptoms one year later (Mulder, Antoni, Duivenvoorden, Kaugmann, & Goodkin, 1994; Solano, Costa, Salvatis, Coda, Auiti, Mezzaroma, & Bertini, 1993). In a ten and fifteen year follow-up study of women with breast cancer, fighters and deniers were more than twice as likely to be alive than those who felt hopeless and helpless (Greer, Morris, Pettingale, & Haybrittle, 1990).

By studying the underlying mechanisms, such as decision-making, which may

influence the choice of coping strategies utilized, understanding of the complex nature of coping may be advanced.

Integration Of Mindfulness and Social Influence Theories

"Attitudes structure one's social universe and, in so doing, ease decision-making" (Fazio, 1995). Gordon Allport (1935, p. 806) stated,

"Without guiding attitudes the individual is confused and baffled Some
kind ofpreparation is essential before he can make a satisfactory
observation. pass suitable.,iudement, or make any but the most nrimitive



Attitudes provide the benchmark against which to weigh options. The following review of the research indicates that the postulates of both Langer's theory of mindfulness and Petty and Cacioppo's elaboration likelihood model (an attitude change theory) describe a strikingly similar process. Research supporting both theories has demonstrated similar variables affecting the processing of information. The strength of Langer's theory is the research in applied settings and the strength of Petty and Cacioppo's theory is the enormous amount of research support it has garnered. Integrating these theories provides evidence of









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three decisional styles and two routes of processing as well as the variables influencing which route of processing is likely to be used.

In spite of an obvious link between attitude and decisions, because of having

different goals in their research, the attitude theory literature and decision making literature rarely directly address this connection. Because of the link between socially constructed attitudes and relatively individual decision-making, it is theoretically logical to use both in an investigation of medical decision-making. This integration is further supported by the parallels found in the research on both the theory of mindfulness and attitude change theories. The postulates and their supporting evidence result in a common explanation for decision-making behavior. But theoretical consistency is not the only reason to integrate these theories. Practically speaking, the theory of mindfulness provides explanations for different styles of deciding when the message is uncontrollable (as in natural settings), while the social influence models provide a well-researched meclianism of change. n.e implications of using both for this study are that these theories may be expanded, will be tested in a "real world" serious threat situation, and should provide information in developing programs to assist people in efforts to cope with cancer.

One of the earliest and most researched of these attitude change theories is the elaboration likelihood model of attitude change. After culling through the inconsistent results of a decade of research on attitude change, Petty and Cacioppo (198 1) identified two modes of processing: central and peripheral. In integrating the attitude change research, Petty and Cacioppo placed the findings on a continuum ranging from low likelihood to evaluate a message (peripheral route) to high likelihood to evaluate a message









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(central). The low end is dominated by theories such as classical and operant conditioning and the high end dominated by theories emphasizing issue-relevant thinking, an example being Ajzen and Fishbein's theory of reasoned action (1980). Because of its inclusiveness, the elaboration likelihood model (ELM) provides a powerful framework for organizing and integrating these theories.

Decision Making and Different Modes of Processing

Conventional wisdom judges a "good" decision as one that has a "good" outcome. What then does a person do when the outcome is unpredictable? When the expected "good" outcome does not occur, does that mean the decision was "bad" and the decision maker "wrong"? Decision theorists suggest that the way a person makes a decision is far more crucial to this determination than outcome analysis. A cost-benefit analysis based on information gathered and then formulated into a problem to be solved leads to the best decision possible at the tin'.e.

Langer's theory (1994) suggested that people will arrive at a decision when they make a cognitive commitment, not when all the costs and benefits have been weighed. "Cognitive commitments are frozen or rigidly held beliefs that unwittingly are unmodulated by context" (Shank & Langer, 1994, p. 34). She suggested that the cost-benefits perspective is postdecisional and used merely to justify, the choice. In a study, Klein and Kunda (1992) manipulated participants' motivation to see a person as more or less capable by being told the person was going to be their opponent or their team member. Although they had no basis for judging this prior to their stated assessment, they post-decisionally constructed rational justifications for their choice.









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According to Langer, the dynamic process of choice is characterized by instability and uncertainty. Uncertainty drives a person to either gather information or induce stability by making a cognitive commitment. There is no natural end point to information gathering and a search ends when the person settles on a cognitive commitment.

The decision itself is automatic, i.e., not calculated. Information can be gathered but it does not inform us of our preferences. Our preferences are that which is stable. Stable preferences suggest a predetermined mindset that influenced the decision. When a mindset or schema is reached or constructed, the choice is made.

In this way, Langer viewed decision making not as a continuum or dichtotomy of rational vs. irrational, but as rational. She distinguished two forms of decision making: mindful and mindless. Mindful decision making (also termed active deciding) consists of self-awareness and the generation of new options based on information given or gathered. A choice is made from among that expanded list of choices. In the mindful condition, the information integration and gathering continues until one choice is psychologically different for the person. Schema still governs this process but it is broad enough to allow the investigation to continue until a cognitive commitment is made to a choice after effortful consideration.

Attitude change theorists also identified two modes of processing. Petty and Cacioppo (198 1) called these modes central and peripheral route processing, Chaiken (1984) called them heuristic and systematic, and Fazio (1995) described them as automatic activation and effortful, deliberate processing. All three theorists agree that central route, systematic, and effortful deliberate processing are the same. Central processing depends









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on the amount of elaboration or effortful. thinking a person is willing to engage in. Pe-tty and Cacioppo (1986, p. 14) state, "elaboration means the process of relating the to-beevaluated recommendations and arguments to other issue relevant information in memory .... (resulting) in self-generation of information unique to externally provided communication." The similarities to Langer's description of mindfulness (active deciding) are clearly evident.

Petty and Cacioppo (1986) interpreted mindfulness vs. mindlessness as automatic vs. controlled processing. They said that central route processing is a particular kind of controlled processing conducted for the purpose of evaluation. The stated purpose of their research program was to understand a person's specific attitudinal reaction to a particular message. Because they chose a narrowly proscribed aspect of attitude change with which to conduct their studies does not preclude their theory being broad enough to apply to people's decision-making patterns in natural settings.

Chaiken (1987) differentiated her heuristic/systematic processing from Petty and Cacioppo's central/peripheral route processing on only one dimension. She claims the distinction is that heuristic/systematic is a parallel processing mode occurring simultaneously, while central/peripheral route processing appears to be mutually exclusive. Fazio's research on strength of association explains the shift from one route to another. He stated that the association between the attitude and the object (or issue) in memory will determine the accessibility of that attitude in informing the decision. No studies were located that detected whether processing information occurs simultaneously or sequentially.









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However, extensive research has been conducted manipulating conditons through which central and peripheral route processing was changed.

Throughout social psychological literature a consensus has been garnered that people engage in mindless analysis (Craik, 1979;Eagly & Chaiken, 1984; Kahneman, Slovic, & Tversky, 1982; Langer, 1978; Schneider & Shiftrn, 1977). Petty and Cacioppo (1986) agree that people in natural settings use peripheral route processing far more than their laboratory experiments would lead one to believe. Evidence of Mindlessness

In study after study, Langer sought naturally occurring conditions to assess the degree of mindlessness engaged in by people. Much of her research has far-reaching implications for health. A recent study (Langer, Mueller, & Brown, 199 3) compared hearing and hearing-impaired people. They hypothesized that the hearing impaired would have had less on:nortuitv early in life to establish -nreconceived ideas on mer(-,v loss in the elderly and, therefore, would perform better on memory tests. If information cannot be retrieved from memory, a decision is more likely to be made by considering more carefully the current situation. The hypothesis was confirmed.

Langer and Piper (1987) studied elderly adults who lived with a grandparent at age two and others at age twelve. The assumption was that those who lived with elderly people at a young age would have a preconceived schema about age that elderly people were strong and capable (a two year old's perspective) and those at age twelve would have a mindset of more fragile elders. She hypothesized that the group which had lived with









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grandparents at age two would be stronger and healthier themselves as older adults. The hypothesis was confirmed.

Many other researchers have demonstrated situations in which people do not use reasoned attribute-based analysis to determine a course of action but make decisions and perform tasks after only a minimal amount of processing (Abelson, 1976; Bargh, 1984; Chaiken & Yates, 1985; Cialdini, 1985; Craik & Lockhart, 1972; Langer, 1978; Petty & Cacioppo, 1981; Sanbonmatsu & Fazio, 1990, exp.2; Schneider & Shiffrhn, 1977; Tesser & Leone, 1977).

People rely primarily on previously formulated attitudes or schema. Evidence of

such a pre-existing schema was obtained in a study by Tesser (1978), in which people were instructed to think about an issue. As they did their attitudes toward the issue became polarized in the direction of their initial tendency.

Hlig-ins and Stangor (1988) demonstrated that once a person associate-s a fnw cues with a schema, they will base their judgement on that schema as if all the properties of the new situation fit the original source properties. Changing the standard by which a situation is measured changes the schema and allows for increased scrutiny of the attributes of the situation (Higgins & Lurie, 1983). Langer (1994) describes a situation in which one may like apples more than oranges and both more than grapefruit. When using the schema of taste preference, one would choose apples over oranges. She further states that the direction is not transitive because one may invoke a different schema such as "more is better when it comes to food" and therefore choose grapefruit.









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This organized schema was labeled by Chaiken (1984) as heuristic, i.e., simple

decisional rules in order to ease processing without effortful thought. In four experiments measuring the effects of priming manipulations that vary accessibility or reliability of simple heuristics showed a consistent, albeit low statistical significance, that both accessibility and reliability of these simple decisional rules influence the likelihood that they will be used to evaluate a message (Chaiken et al, 1985; I-licks & Chaiken, 1984). Furthermore, priming effects were more pronounced for those participants who typically rely on heuristics in decision making. Although the effects were not statistically robust, they were consistent.

The persuasion impact of cues which elicit the use of a heuristic are a function of the strength of their association. Fazio (1983) conducted four experiments in which the subjects were led to expect that they would have to answer questions on the messages presented. Condition one provided the cue of expectation prior to the message presentation, condition two provided the cue immediately after message Dresentation, and condition three provided no cues to consolidate the message. Spontaneous formation of attitudes occurred most frequently under the conditions of expectation cues provided prior to the message and no evidence of formation of attitudes occurred in the no consolidation cue condition.

Developed and rehearsed attitudes were shown to be more predictive of decisions that were unlikely to be modified later (Fazio et al, 1992). The strength of the association between memory and the issue explains this predictive power. More frequent use of the association will increase its accessibility (Fazio, Sanbonmatsu, Powell, & Kardes, 1986). Rehearsing increases the associations between an attitude and an object (Fazio et al, 1982),









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making it more likely to be invoked when a decision is needed (Fazio, 1989). Effortful thinking (Fazio et al, 1992, exp. 2) is avoided in this manner. This research conducted in four different laboratories all support the two routes of processing and the prevalence of mindless decision making according to pre-existing schema. But the parallels between mindfulness vs mindlessness and central vs. peripheral route processing are even more extensive.

Cognitive Commitment

Mindlessness is engendered by cognitive commitments made prematurely.

Cognitive commitments are based on rigidly held beliefs or schemata. Such schemata are essential in managing the inestimable amount of information available at any one moment. A stable set of schemata enables the individual to make the world comprehensible and predictable (Bannister & Franzella, 1971). Once a schema is invoked, new information, vnicue context, or unfamiliar aspects nf a situation will he overlooked. PTernatv:e cognitive commitment is uncritical acceptance of a choice without considering other choices even possible. What is accepted as truth is not reconsidered (Langer & Imber, 1979).

In one early study (Chanowicz & Langer, 198 1), cognitive commitments to

symptoms of a fictional disease were induced. When this group was later told they had the illness, they reported the fictitious symptoms at a significantly higher rate than the group who took in the information more mindfully. In another study subjects were presented with information in either conditional or unconditional language. The hypothesis that unconditional language would lead to cognitive commitments was confirmed. Generating









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options never occurred to the group presented information unconditionally (Langer & Piper, 1987).

Evidence of cognitive commitment is seen in the work of Chaiken (1980) (Eagly & Chaiken, 1984; Taylor & Fiske, 1978). Assessing the impact of communicator likability by manipulating response and issue involvement, Chaiken found that when involvement was low, participants responded more to likability than to message arguments. Petty and Cacioppo replicated these findings; in response to attractiveness (Petty, Cacioppo, & Schumann, 1983) and expertise (Petty, Cacioppo, & Goldman, 1981). Consonant with these findings, Langer, Blank, & Chanowicz (1978) found that subjects will comply mindlessly with a favor unless the favor requires too much effort. Although none of these studies directly assessed the underlying heuristic or commitment to a schema, there is evidence that unless a person is motivated to approach a situation with effortful thought, there is a hiOh likelihood that he/she will respond mindlessly, making a premature cognitive commitment.

Langer identified three types of cognitive commitments. The previously cited

research is representational of the first, i.e., a personal commitment to content. The second type occurs when a personal belief is not available, resulting in a cognitive commitment likely to be made to a societal commitment to content. For example, when a medical illness strikes, a person will make decisions based on vicarious learning and information from a referrent group (Monge, 1983; Rodin & Janis, 1979; Stetz, 1986). Most often the referrent group is the family, When others are perceived to hold the same attitude, confidence in its validity is increased (Holtz & Miller, 1985).









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Evidence from studies on multiple source effects within the ELM support Langer's contention. Harkins and Petty (1981) demonstrated that participants hearing three different arguments advocating a position from three different sources were more influenced than those hearing three arguments from one source. In a follow-up study (Petty & Cacioppo, 198 1) findings suggested that increased elaboration occurred when the arguments came from multiple sources due to ffirther elaboration when each argument was presented. This effect was shown to increase when the participants were presented as independent rather than from one cohesive group (Harkins & Petty, 1987). These studies suggest that people do elaborate more when information is presented by multiple sources and this effect is increased when the sources appear independent. These findings support Langer's theory stating that when a person does not arrive at a decision based on a cognitive commitment previously held, the individual is likely to arrive at a societal decision. It also suggests that to effectively deliver a message to a cancer patiert- sav to increase adherence, several arguments from several sources will enhance adoption of the suggestions.

In the third type of cognitive commitment, a person uses an existing schema to guide decision-making. A process schema dictates factors such as the number of questions asked, the amount of time spent deciding, and the type of resources consulted, prior to making a cognitive commitment. Although this process commitment is relatively stable for an individual, it may also include varying degrees of effort, depending on situational seriousness. Unless this process commitment is flexible enough to leave a









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question open long enough for a personal or societal commitment to be made, the decision will end before true relevance for the individual is established.

Eagly and Chaiken (1984) expanded on the concept of processing in response to cues by introducing the idea of heuristics, simple decision rules that are invoked in the absence of motivation and ability to process more effortfully. Sufficiency principle indicates that people will move from less effortful processing to more effortful processing. The reverse is also true (Wood & Eagly, 19 81). In a series of experiments, Chaiken (1980) found that participants used simple decisional rules, particularly when presented with minimal information on the topic. These participants refrained from effortfully thinking about the validity of the information and relied on the credibility of the source in forming their opinions.

In a study assessing factors affecting treatment decisions for a life threatening

illness. eiahtv nercent of the patients accepted the physician's recommendations. Factors influencing their acceptance were the amount and specificity of the instructions and the strength of the recommendation. More importantly, non-acceptors were better educated and tended to be risk-takers (Siminoff & Fetting, 199 1). The self-proclamation of risk taker is an example of a process schema such as, "I make my own decisions." which may govern their decision about how to treat an illness. Cognitive Commitments Are Made When Options Become Psychologically Distinct

The mpotane o conitive commitments cannot be underestimated since

preferences are only stable once a commitment is reached. Langer (1994) views this as a correction to one of the thorniest problems in any rational decision theory, that of









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systematic preference reversals (Cohen & March, 1974; Tversky & Kahneman, 1983). Attitude change research came close to being abandoned in the seventies because of the inconsistencies in the research attempts at explanation. Cialdini, Petty and Cacioppo (1981) and Eagly and Himmelfarb (1978) began a series of studies aimed at understanding these discrepancies. They saw evidence of cognitive commitments, both enduring and transient, which they sought to explicate through studying the conditions under which each operate.

Langer's hypothesis was supported in a study investigating conditional and

unconditional presentation of information to contact lens buyers. While in the store one group was given information about one lens solution, another group was given information about two lens solutions. Several months later, they were all contacted by phone offering them a consumer opportunity. The only difference between the lens solution now being offered and the original one was the price. Only those who had not formed a co"..itive commitment tried the new solution (Langer & Li, 1994). In another study by Cacioppo, Petty, and Sidera (1982) participants generated more topic relevant thought when the message was congruent with their self-schema about professed attitudes than when the message was incongruent with this schema.

Langer (1994) stated that a person will entertain the message until options become psychologically different from each other. The psychological difference is highly idiosyncratic. The decision will be made when one of the avenues to a cognitive commitment is accepted. Such commitment then renders meaningful any consistencies









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found in the environent. These experiences become relevant and will be used to strengthen the commitment (Craik & Lockhart, 1972).

To understand how the ELM supports the idea that a decision will be made when psychological differences are noticed and considered relevant, the research addressing its application to counseling must be considered. In a review of the ELM applied to counseling literature, Heesacker, Conner, & Pritchard (1995) addressed the issue of change. Although peripheral-route-processed information may change attitudes, the change is not enduring (Petty & Cacioppo, 1986). Only centrally processed material promotes enduring change. This suggests that a preexisting cognitive schema will determine the decision until a person has the motivation to put forth effortful thought. Until then, peripheral cues consistent with the pre-existing schema will dominate the decisional process, and is analogous to a decision ending in premature cognitive commitment. Change will only take place when the person is motivated and enabled to engage in recogniizing and reconsidering the old schema. Essential to understanding what occurs when a person switches from peripheral to central route processing is recognizing the idiosyncratic thoughts which support the preexisting schema and assisting the client to generate arguments that dismantle the ineffective schema which will allow for a new schema to be built. The erection of a new schema enables options to become psychologically different in ways not previously entertained and enables an enduring choice associated with a new schema to be made.

Langer stated that the commitment can be made to either content or process.

Included in the new schema can be clues as to when to re-examine the parameters of the









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new schema, thereby instilling a commitment to process which overrides the commitment to content, increasing the person's flexibility. Categories of Decision Making

Langer (1994) described three categories of decision making: active deciding, passive deciding, and premature committing (mindless deciding). The categories she established for decisional-styles are discriminated from each other by how decisions are made and by the point at which the commitment is made. Active deciding consists of generating options and choosing from among those options. Option generation will conclude only when enough information is gathered to discriminate in terms of the person's preferences (i.e. the options are psychologically different from each other for that person). Passive deciding involves choosing between only those options presented without generating others based on personal awareness. The choice is settled when a commitment rs ade tn one of + o~e chioic, s. Laiigers thirdl caterorv of decision trakers is mndle, deciding, which is the form most often used.

Most research on decision making has been conducted on passive decision-making because laboratory studies use only a finite number of options and rarely allow for a creative participant to generate new options. Many of Petty and Cacioppo's studies (for example, those using a semantic differential) assess evaluation of a message through methods which limit the participant to responding to message options, but many others use a thought-listing procedure that enables the participant to generate options on their own. Petty and Cacioppo (1986, p. 14) stated that "elaboration means the process of relating the to-be-evaluated recommendation or arguments to other issue-relevant information in









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memory," resulting in self-generation of information unique to externally provided communication. Their work supports the idea that central route processing is synonomous with Langer's active and passive deciding. This point is critical in supporting the assumption that it is possible to combine the work of Petty and Cacioppo and that of Ellen Langer.

Passive vs. active deciding was demonstrated in a study investigating conflict situations (Langer & White, 1992). In one situation, the participants were instructed to settle their differences without using compromise. This approach forced the pairs to elaborate on a solution until a win-win situation was found. Subjects not instructed in this manner used the compromise solution which required less effortful thinking. Another study (Langer & Williams, 1992) asked participants to make a donation to a homeless shelter. One group was asked for a particular amount but not restr-icted from donating a different amount: the other was asked to actively decide the amount~ iven. Both grours had an equal number of donors but the ones who actively decided the amount gave more. The latter group also reported less post-decision regret.

The third category, mindless choosing, is foreclosure on a preexisting schema.

Premature foreclosure on a decision is devoid of active, ongoing information processing. Petty and Cacioppo describe this kind of processing as peripheral route processing, highly influenced by extraneous cues. For instance, a premature cognitive commitment is more likely to be made when information is given by an authority (Chanowicz & Langer, 198 1; Langer, 1988). In this category, decisions are based on peripheral cues (Petty & Cacioppo, 1986) or heuristics (Chaiken, 1980; Eagly & Chaiken, 1984). Once a person acts on these









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arbitrary decisions, the choice begins to operate as a schema because the person infers an attitude from their behavior (Fazio & Zanna, 198 1).

Reducing uncertainty may be the goal of mindless deciding (Langer, 1994). The dimension of uncertainty was labeled and extensively researched by Kruglanski and Webster (1991, 1993, 1996) as a need for closure. Kruglanski (in press) defined the need for closure as the desire for definite knowledge and an aversion of ambiguity. The term "need"' is borrowed from Cacioppo and Petty (1982) and identical in its meaning. It refers to a need for closure on the question and often any answer, rather than the "best" answer, is all that is required.

Need for closure can be an individual trait or situationally induced. A person high in need for closure generates fewer options, makes j udgements based on inconclusive evidence and, once committed to a decision, is relunctant to entertain the possibility of alternatives based on new information. In fact, new Information is not even tioticed. After such a rigid commitment to a decision, individuals report more certainty in their choice than individuals low in need for closure. There is theoretical consistency between Langer's mindless deciding and Kruglanski's need for closure construct. The evidence supporting the need for closure construct will be addressed in the subsequent section of this chapter.

Because premature commitments are so prevalent, information gathering may often be motivated by a need to explain and justify the decision after the fact rather than utilizing the information to think carefully prior to making a decision. Petty (1986) actually cautions the researcher by suggesting that the cognitive strategies demanded by the responses used in measuring may color the results.









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Necessary Conditions for Mindfulness

There is a considerable body of research conducted by all these theorists about the conditions under which a person will use one route of processing or the other. In this body of accumulated knowledge there are no studies which refute any of the others' theories. Research promoting one idea supports the others. Apparently, the differences are in the researchers' foci of attention and semantics.

In the theory of mindfulness, Langer (1989) stated that people will operate

mindlessly unless the following conditions exist: 1) a new situation involves novelty for which no cognitive commitment exists, 2) mindless deciding is more effortful than mindful deciding, 3) deciding is interrupted by external events that do not allow for completion of a commitment, 4) the experience leads to significantly discrepant consequences than those in the past, 5) there is insufficient involvement in the situation to warrant any reaction and therefom a sc ema is never invoked.

The most thorough investigation of these factors was conducted on the ELM.

Petty and Cacioppo (1986) found three pivotal factors encompassing many other variables. These factors are motivation, cognitive responding, and ability. Motivation

Motivation is requisite in determining message scrutiny. The factors influencing motivation are personal relevance, involvement, personal responsibility, multiple sources, and individual need for cognition. In a review of motivation studies across theorists, Fiske and ieuberg (1990) concluded that when people had motivation to assess a message, they










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were data-driven in their analysis; when people lacked the motivation, they were theorydriven.

Petty and Cacioppo consider the most important variable affecting motivation to process centrally is personal relevance. Issue-relevant elaboration results in new options and their integration into one's schema (Petty & Cacioppo, 1984). Active deciding would also depend on personal relevance. Langer, Blank, and Chanowicz (1978) conducted a study in which students were asked to give up their turn at a copy machine. Small requests were accepted without reasons but large requests required a reason. The large requests increased the personal relevance by making the student wait, thereby increasing their motivation to think about the request prior to granting the favor.

Manipulating advocacy or counterattitudinal messages in tape recordings, students were asked to report their views on a taped message (Petty & Cacioppo, 1979). Half the students were told that the message applied to their own university while the other half were told it applied to a distant college. Subjects in the high involvement condition (implementation at their own university) generated predominantly favorable thoughts to the proattitudinal message and predominantly unfavorable thoughts to the counterattitudinal message. Replications (Petty, Cacioppo, & Heesacker, 1981; Petty, Cacioppo, & Schumann, 1983) have been conducted that support the idea that, as personal relevance increases, people engage in more effortful thinking.

When applying the personal relevance issue to a natural setting, there are several caveats to consider: first, if personal interests are intense, processing may be conducted in service to an individual's core constructs and may be biased or terminate (Greenwald,









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198 1). Second, issues truly relevant to an individual may have been given enough prior thought that expending more energy on thinking is perceived to be useless. Third, people often seek information about relevant issues and may have an increased store of prior knowledge (Petty & Cacioppo, 1986). Should this thought have already been generated by the individuals in this study, it will only enhance the study by serving as a discriminator between categories of decision-making styles.

Related to relevance is involvement, another motivational variable which mediates thorough processing of information. Johnson and Eagly (1989) distinguish between three types of involvement which have a distinctly different effects on information processing. The first is value-relevant involvement, the activation of attitudes which are linked to core values. The higher the value relevant involvement, the wider the rejection range of the message (Sherif, Sherif, & Nebergall, 1965). The second type is impression-relevant involvement, concern for self-presenitation in the responses. The exo0ectation of public scrutiny of one's views leads to assuming a more moderate, flexible, and less polarized position when the audience's opinion is unknown (Cialdini & Petty, 198 1; Cialdini, Levy, Herman, & Evenbeck, 1973 ). Third, outcome relevent involvement (Petty & Cacioppo, 1979), originally referred to this as issue-relevant involvement) refers to the degree to which the issue personally affects an individual's current goals. This type of involvement increases the likelihood of elaboration (Chaiken, 1980; Petty, Ostrom, & Brock, 1981).

In a m-eta-analysis, Johnson and Eagly (1989) found that value-relevant

involvement typically inhibits attitude change. Outcome relevant involvement, the most extensively researched of the three, showed no main effect and interacted with strength of









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argument. Strong arguments persuaded, weak ones did not. However, whether effortful thought created this change in attitude in one condition and not in the other is unknown. It is just as possible that after thinking about the weak arguments, a mindful decision was made to retain one's position.

Petty and Cacioppo ( 1990) took exception with this meta-analysis, stating that personal importance and not which aspect of importance is what determines relevance. They made a distinction between the intensity of information processing and the direction of that processing, each comprised of separate variables. In testing this hypothesis, Petty and Cacioppo (1986) have shown that as the intensity increases, the quality of arguments account for more variance, With no bias, strong arguments increase elaboration and weak arguments decrease elaboration. In unfavorable biased condition, strong arguments had no impact on elaboration and weak arguments reduced elaboration. They conclude that the extent of personal importance increases the extent of information processing.

The literature on outcome relevant involvement has limited use in this study. The issues chosen for these studies were minor to moderate college related issues presented to undergraduate students. There are tremendous differences between still-dependent average undergraduate students and adults of all ages. The life and death issue faced by the participants in this study cannot be accurately compared with issues such as a format for exams or sharing dormitory space. Yet the most likely, outcome-relevant involvement is the type that is of greatest concern in this study and, as such, has an effect on motivation.

Stable, intrinsic differences exist among individuals in their motivation to process information effortfully (Cacloppo & Petty, 1981, 1984; Cacioppo, Petty, & Morris, 1983).









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Some people simply enjoy thinking more than others. This construct has been defined as a need for cognition. Need is viewed not as a deficit or having tension reduction goals but as an intrinsic desire. Taylor (1982) coined the term "cognitive misers" for people low in need for cognition. The concept of cognitive miser could account for the frequency of mindless deciding evident in Langer's and Chaiken's research.

Individual differences were found between university professors (assumed to have high need for cognition and assembly line workers (assumed to have low need for cognition). Those high in need for cognition generated more thoughts than those low in need for cognition. Jn a group brainstorming task, participants low in need for cognition generated fewer ideas when they shared responsibility to create a list than when they were held personally responsible (Petty, Cacioppo, & Kramer, 1985). In further testing of this constr-uct, need for cognition was found to be unrelated to intelligence in both abstract reasoning and verbal reasoning (Cacioppo, Petty, & Morris, 1983: Eagly & Warre-n, 1976).

In a series of three experiments (Cacioppo, Petty, & Morris, 1983) determining

how need for cognition affects message processing, findings demonstrated that individuals high in need for cognition were more likely to extract information and think effortfully about a message than those low in cognition. However, it would be inaccurate to assume that this individual characteristic is so intransigent that it cannot be overridden by situational factors. The meaning and implications of a decision will have a strong impact as well as message presentation and prior knowledge. Need for cognition is neither a necessary nor sufficient cause of message elaboration.









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Ability

If a person is to carefully evaluate a message using central route processing, the individual must have the ability to do so. Some persons may have greater ability than others and certain situations facilitate ability more than others. Distraction, message repetition, recipient posture, forewarning, argument strength, relevance of message, and time to consider have all been found to influence message processing ability.

In a series of four experiments, Petty, Wells, and Brock (1976) demonstrated that distraction made processing more effortfal. Unfavorable responses were increased as distraction increased, but, the number of unfavorable responses increased significantly more for messages with weak arguments than for those with strong arguments. High distraction reduced the number of unfavorable thoughts for the weak message but not the overall message and the number of favorable thoughts for the strong message. Attitudinal effect's were most evident in tl e low and medium ran !7- of distraction. (Lammers & Becker, 1980) were consistent in their findings that distraction disrupts the thoughts that would normally be elicited by a message. Distraction inhibits ability especially when the motivation is high (Petty & Brock, 1981). Interference during message presentation decreases elaboration likelihood as well (Petty, Cacioppo, & Heesacker, 1981). Langer's theory states that if deciding is interrupted, a cognitive commitment is not made.

Repetition: Moderate message repetition theoretically should enhance message

acceptance since it extends the time an individual has to attend to the message required in any new learning situation. Repetition of verbal stimuli has been shown to increase liking









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in some studies (McCullough & Ostrom, 1974) and decreasing liking in others (Grush, 1976). Petty and Cacioppo (1979) proposed that message repetition elicits a two-stage reaction. Repeated presentations provide the recipient with extended opportunity to evaluate and think about the message during the first stage. Tedium sets in when a person has exhausted associations to think about and the second stage elicits a negative reaction. Argument strength was again a factor. Moderate repetition of strong arguments led to a favorable response; moderate repetition of weak arguments led to more negative attitudes (Cacioppo & Petty, 1985).

Physical cues: Based on the close association between cognition and body cues,

recipient posture was explored. In a series of experiments (Petty, Wells, Heesacker, Brock, & Cacioppo, 1983), reclining subjects expressed more agreement than standing subjects. However, comfort was not the intervening variable since those who were seated reported being the. most comfortable and vet had insi.rificant message ageement. Stro:- .rd wek arguments were not differentiated by the standing subjects. Other physiological factors involved in message elaboration are heart rate (Cacioppo, Sandman, & Walker, 1978) and right brain activity (Cacioppo, Petty, & Quintarar, 1982).

Comprehension: Assessing ability in the absence of motivation is difficult. In one study (Ratneschwar & Chaiken, 1986), the researchers attempted to manipulate ability to process systematically (centrally). They manipulated comprehensibility by using a written description of a novel product with or without an accompanying picture. (The product was relatively undiscemable without picture.) Subjects in low comprehensibility condition manifested less comprehension and was more easily influenced by the peripheral cue of the









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inventor is status in rating the usefulness of the product. When the comprehension was medium or high, participants rated usefulness based on the attributes of the product and reported more effortful thinking in a debriefing. Comparisons/Similarities

Extensive similarities exist between the social influence theorists, Petty, Cacioppo, Chaiken, and Fazio and Langer's theory of mindfulness. Ellen Langer researched decisionmaking processing by focusing on the person making the decisions. The social influence theorists researched the interaction between people by focusing on particular messages and their effects on a person's processing. In researching these distinctly different topics, each has resulted in strikingly similar findings.

Both the processes involved explained by each of these theories and the ensuing research variables are similar. The semantics are different but the theories support each other Two routes of processing has been proposed in all these theories. Langer cajs hSe routes mindfulness and mindlessness; Petty and Cacioppo call them central and peripheral route processing; Chaiken and Shelley call them heuristic and systematic; Fazio calls them automatic activation and effortful, deliberate processing. The authors draw find distinctions between the routes of processing they describe and those of the other theorists, however, the differences described are a result of the focus of their research rather than any qualitative difference.

The research variables that may affect processing independently chosen for

exploration by each theorist are also surprisingly similar. The largest body of research on different variables was conducted on Petty and Cacioppo's ELM, chosen for use in this









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research. With the exception of relevance and individual differences that may affect processing, Langer's decision making research and Petty & Cacloppo's social influence research investigated the identical variables in very different ways, resulting in identical findings.

An integration of these theories is used for this research in order to draw upon the strengths of each. The topic under discussion in this research is decision making. The reason for studying this topic is to understand how a person's decisions about medical treatment affects coping and the variables which may improve coping. Langer's theory is provides a decision making theory that has been researched in applied settings with medical and other physical conditions. Petty and Cacioppo's theory has a demonstrated ability to both identify and change core attitudinal processes through changing the route of processing. How a person processes information related to medical conditions and arrives at a decision may affect hislher ability to cope.

Evidence of a Fourth Decisional Style Ruminating

Ellen Langer (1994) identified three decisional styles: active, passive, and mindless deciding. However, she also stated that a person will entertain a message until options become psychologically different from each other. The decision is made when one of the avenues to a commitment is accepted as the "best option".

The purpose of making a cognitive commitment is to reduce uncertainty (Langer, 1994). But what happens when a person worries about making the "right" decision? Although there may be a great deal of effort to discriminate between the options, when reviewed over and over again, the person still cannot "psychologically discriminate" enough









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to reduce the accompanying anxiety. Engaging in effortful thought might indicate central route processing but thought alone does not determine route of processing. The determination is made through the creativity and richness of the thoughts produced. In central route processing, effortful thought is engaged in only as long as new ideas emerge. Langer (1994) states that there is a two-part process: generating options and then choosing. Some people, however, do not generate new options and do not choose, thus making their effortful thought fruitless.

This inability to choose may be explained by the Yerkes-Dodson curve (Yerkes & Morgulis, 1988). This theory suggests that with too little anxiety, a person is uninvolved and lacks the motivation to act; too much anxiety and the person lacks the ability to act, It is suggested in this research that some people, although a minority, will shift between a few options and never discriminate enough to come to a cognitive commitment to any options, thereby indicating peripheral route processing. For example, patients may agree under pressure to do something, such as enter into chemotherapy treatment, yet they internally experience tremendous anxiety due to equivocating about the wisdom of their decision.

This category of decisional style is named ruminating style. Persons fitting into this category would express considerable worry and fear about whether their decision was correct in spite of having begun to act. They would remain uncertain regardless of new incoming information and they would continue to put forth a great deal of effort into thinking the same thoughts repeatedly, ignoring the new information. The ruminating style fits the definition of peripheral route processing because of it's continual shifing of opinions. Ruminating style will also be marked by high anxiety.









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Rumination is an intrusive thought process that prevents a cognitive com mitment to a decision. For example, until patients can see a clear choice that radiation is better for their condition and life situation than surgery, they will not feel certain with either decision.

Rumination is differentiated from active deciding by the options generation process and by the flexibility of the schema involved. In active deciding, a person's information gathering and the ensuing association process continues only while new ideas are being generated. Rumination generates very few options or accepts only the few options presented without establishing any new associations so that new information is never entertained. In active deciding, once the options are felt to be exhausted, a decision is made and the schema that the decision rests upon is altered and allowed to remain flexible. Rumination becomes an impossible choice between two or a few options that are based on one or more rigidly-held, unadjustable schemata.

The epistemology studies of Kruglanski and Webster, especially those dealing with the need for closure construct support the idea of adding rumination as a decisional style. Kruglanski asked the question, "How does one attain knowledge?" The construct of the need for closure emerged from his search to account for the inevitable differences in how people go about selectively absorbing and processing information. Using the same definition of need as Petty and Cacioppo (1986), the need for closure was defined by Kruglanski (1989, p. 14) as "the desire for a definite answer on some topic, any answer as opposed to confusion and ambiguity." In 1990, Kruglanski discriminated between a need for specific closure and a need for non-specific closure.









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Individuals may process only a limited amount of information before making a decision or they may generate numerous hypotheses. They may pay careful attention to IF on-line" details, revising their conceptions as they entertain options or they may base their decisions on information in memory. They may spend time elaborating on information and deepening their processing or they may use only the most accessible information.

The foundation for these patterns, Kruglanski stated, was motivation. A specific type of epistemic motivation is the need for closure. The need for closure is both dispositional and situational and as such has generated considerable research seeking to understand the conditions under which the need for closure will be heightened or diminished outside the normal range for a particular individual.

The need for closure is a continuum with people at the high end exhibiting

impulsivity, rigidity of thought, and reluctance to consider other's views. People at the low end, those demonstrating a need to avoid closure, represent the group identified in the new model as ruminators. These are people who suspend judgement when possible, generate competing alternatives, and experience doubt and ambivalence. The mid range on the need for closure continuum would be those people who are more likely to elaborate on an idea arriving at a well-thought out decision. The descriptions of these categories of people fit both the depth of processing models and the mindfulness model.

Certain antecedent conditions will affect a person's moving toward increased or decreased need for closure. Two benefits of closure are predictability and impetus for action and when either of these is perceived as a need, the person will be motivated to obtain closure on the issue in question, Time pressure increases the need for closure and









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perceived effort decreases the need for closure. Using ELNrs conceptualization that effortful thinking is aversive to some people, the need for closure, under some circumstances, would be enhanced because it is simply easier than elaborating.

In the other direction, the need for closure may be decreased in the face of fear of invalidity. The need for closure conflicts with the need to determine the right answer. Kruglanski (unpublished manuscript, p. 10) asserts, "Under heightened need for closure a person may generate fewer competing hypotheses and/or suppress attention to information inconsistent with one's hypothesis. Both may result in a sense of valid closure, uncontested by alternative interpretations or inconsistent evidence." Alternatively, other individuals may react to a heightened demand for validity by postponing closure or even avoiding it. If a credible source is added to the equation, the fear of invalidity may increase the tendency to operate on the source's advice and rather than maintaining openness and continuing to process centrally, a peripheral route of processing will determine the direction of the decision.

In a study (Mayseless & Kruglanski, 1987, exp. 2) directing participants to operate a tachistoscope under conditions to either increase or decrease the need for closure, the extent of their information search was higher in the need to avoid closure than in the need for closure condition. In experiment three, participants were shown photographs of unusual perspectives of common items and asked to create lists of hypotheses about the identity of the items, and asked to then select one- To establish a need for validity condition, subjects were told that clear cut opinions correlated with intelligence. When compared with a neutral condition, participants in the need to avoid closure condition









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generated more hypotheses than those in the neutral condition and, in turn, more than those in the need for closure condition. Similar to the studies conducted by Petty and Cacioppo and Langer, participants in this study and others (Webster, 1992; Krugianski, Webster, & Klein, 1992; Kruglanski & Webster, 199 1) exhibited more confidence in the need for closure condition than any of the others.

Several studies also point to differences in the type of information sought under the high or low need for closure conditions. In one study (Trope & Bassok, 1983), diagnostic information was sought in the need to avoid closure state and more stereotypic information was sought in the need for closure condition. Petty and Cacioppo would view these results as reliance on peripheral route processing whereas Langer would see the results as mindless deciding. Similar to studies on these forms of processing are studies that have demonstrated identical priming effects (Kruglanski & Freund, 1983, exp. 1). Manipulating the need for closure also resulted in overestimation of conjunctive events and underestimation of disjunctive events in a high need for closure condition (Kruglanski & Freund, 1983, exp. 2). Other situations in which a high need for closure resulted in biased processing were correspondence bias (Webster, 1993) and overattribution bias (Webster, 1993, exp. 2).

This evidence supports the notion that early "seizing" and "freezing" upon

peripheral cues and subsequent inattention to new relevant information occurs in need for closure conditions. This end of the continuum constitutes the individual differences in people who inherently possess a high need for closure. Such people also fit the description of mindless deciding. Evidence also supports the definition of ruminators as people with a









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high need to avoid closure. These results were consistent across different manipulations of the need for closure as well as differentiating among people with a dispositional high or low need for closure.

The need for closure construct and the research supporting it are consistent with both Langer's theory and the ELM. To understand decisional styles, it may be essential to include those people who cannot seem to make a decision as well as those who come to their decisions via different methods of processing.

Methodologic Commentary

The body of research upon which this study stands was conducted by some of the most highly respected social psychological researchers in the country. The number of high quality studies making fine discriminations between the variables under consideration were too numerous to cite- This review purports to give only an overview of the available data. Still certain concerns about methodology must be addressed.

Generalizability must be questioned. Constraints imposed by the laboratory setting and the undergraduate student samples diminish the external validity of previously conducted research. This is particularly true for the attitude change theories and need for closure studies. After decades of accumulating laboratory evidence, several studies have been conducted on social influence theories in natural settings, but they are far too few to rely on with confidence.

Eagly (1987) suggested adopting a wider range of methods to bring the

investigation of social influence theory forward. One contribution of Ellen Langer's research is demonstrated in her ability to find natural occurrences to use as variable









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manipulations. For example, the study investigating perceptions of elderly people having been raised by grandparents at different ages and that using hearing vs. non-hearing people to determine pre-existing schema. Because of using such naturally occurring events, it is possible to place greater trust in the external validity of these studies. Overall, the variety of ways in which these theories were tested and the consistency of the results emanating from several researchers' laboratories provides a strong foundation for this study.

Cacioppo and Petty (1987) raised some doubts about the use of self-report

measures in social influence research because of the possibility of their cogmtive nature forcing a cognitive process that biases the results. They suggest that affect could play a considerably larger role than is evidenced in their studies. Cognitive scales were found to be more predictive with cognitive passages and less so with affective passages (Crites, Fabrigar, & Petty, 1994). Many of the scales used have been idiosyncratic to attitude about a specific item or idea leaving validity and reliability somewhat suspect. They call for a demonstration of consistently high reliability across objects and comparability across both affective and cognitive material.

The Decisional Processing Model

The Decisional Processing Model for medical decision-making states that patients will use two routes of processing, central and peripheral. It further states that the central route processing will include active decisional style and passive decisional style and that peripheral route processing will include mindless decisional style and ruminating decisional style. Earlier argui-nents on the factors influencing physical response to treatment and









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coping, suggest how a person arrives at a medical decision will determine influence the direction of these factors. In addition to testing the existence of decisional styles, Decisional Styles Follow Two Routes of Processing

Social influence theorists, focusing on persuasion, integrated the diverse literature on attitudes. Their discoveries, led by Richard Petty and John Cacioppo, uncovered two routes of processing information. The semantic differences are inconsequential. There exist only subtle differences in that some theories emphasize one route over another in their exploration. Petty and Cacloppo emphasized the central route because they were looking for enduring qualities of persuasion. Shelley and Chaiken (Chaiken, 1987) emphasized the heuristic route. Both acknowledged people's use of the alternative route. Simultaneously, Ellen Langer began to study the effects of decision making that seemed to occur in the absence of conscious thought. She coined the term mindlessness for the reactionary way people had of unthinkingly following cues. She also discovered what Petty and Cacioppo would have labeled peripheral route processing.

Evidence has been presented in previous sections of this review suggesting a

possible integration of not only the three social influence theories but also the theory of mindfulness. Ina symposium on social influence, Alice Eagly (1987) closed the conference with a summary of the topics presented along with a review of the history of research in the social influence arena. She stated, "'Progress (to end the confusion) might have been more continuous had investigators been more skilled at integrating research findings. The need for insightful integration and accurate aggregation of findings has been particularly great for social influence research because of its early popularity" amassing




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FILES


THE DECISIONAL PROCESSING MODEL:
MEDICAL DECISION MAKING AMONG CANCER PATIENTS
By
SUNI PETERSEN
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1997


Copyright 1997
by
Suni Petersen

To my husband, Ron Leon Straub,
my three sons, Lee, Greg, and Kevin, and
the women my sons brought into my life, Dianne and Cori.

ACKNOWLEDGMENTS
It is not possible to complete a doctoral program without the assistance, tolerance,
and support of many people. I wish to acknowledge first my husband, Ron Straub, for his
loving support and consistent willingness to "pick up the pieces of my life" thus affording
me the opportunity to pursue a life-long dream.
My major goal in returning to school was to leam to do research. One person,
Martin Heesacker, PhD, my cochair, stands out among all others in helping me achieve this
goal. I especially appreciate his generosity of spirit in sharing his time, knowledge,
inspiring enthusiasm in the pursuit of good science, and, most of all, his belief in my ability
to do good research. He will always have my deepest gratitude and respect.
T "V0'!’",d -'Vd pi*20 ir* r*-»v to t}ii¿ T
especially thank James Archer, PhD, the best pinch-hitter who, in addition to his
consistently insightful comments throughout, generously assumed chairmanship of my
committee late in the game. I want to thank Robert Marsh, MD, for his significant role in
assuring the assistance I received from Shands Cancer Center. It is through Dr. Marsh and
his colleagues that I came to understand their work as an art as well as a science. I thank
Silvia Rafuls, PhD, for teaching me the qualitative research that has so deeply influenced
the core of my approach that it is integrated even in the pursuit of positivistic research. I
will consistently work towards the balance and synthesis of both approaches.
IV

And it is to the patients that the greatest debt is owed for without them this research
could not exist. These patients gave of their time and energy when both were precious
commodities in order to help others in the fight against cancer. It is with their inspiring
courage that I will continue to pursue my research.
I also wish to thank Robert J. Hirsch for his belief in my abilities and his role in
awarding a grant from the Milton Goodman Foundation to conduct this study.
Finally, I wish to thank the group of persons who constitute the most important and
wonderful part of my life: Vicky Pearson, for her nurturing friendship and one special
breakfast at Camacho's Cafe that led to the pursuit of my doctorate; Cathy Wolfson for
the depth of her friendship and unabashed belief in me; and Toni Sands and Lynn
Goldman for their warmth and shared wonder during this entire process. I thank my
parents, Doris and Ralph Guenther, who were not afraid to dream big dreams, and who
tausht me to take risks.
Most of all, I thank my three sons, Lee, Greg, and Kevin, for being the essence of
my life, providing meaning, motivation, and purpose.
v

TABLE OF CONTENTS
ACKNOWLEDGMENTS
LIST OF TABLES
ABSTRACT
INTRODUCTION: THE DECISIONAL PROCESSING MODEL: MEDICAL
DECISION MAKING AMONG CANCER PATIENTS 1
Purpose 1
Rationale for Integration of Theories 2
Mindfulness 2
Elaboration Likelihood Model 4
Coping 9
Why Central Route Processing May Enhance Coping 10
Significance of Study 12
Vf-, •- Jtt4 T^TOr^^t'* fVn 1'n
i"i\ pOulCSCA i 0
Definitions of Terms 19
Organization of the Remainder of the Study 22
REVIEW OF THE LITERATURE
23
Integration of Mind and Body
Appraisal
Self-Efficacy
Attributions
Health Behavior Change
Immune System Functioning
Physical Effects of Coping
Stress and Illness
The Role of Emotion
Constructivist Approaches to Perception
Decision Making and Illness
23
26
27
29
31
31
32
34
37
38
44

Some Decisional Styles May Enhance Coping 47
Coping 49
Cancer as a Stimulus for Coping 49
Coping Appraisal 50
Response to Coping: Coping Strategies 51
Outcomes of Coping 53
Integration of Mindfulness and Social Influence Theories 54
Decision Making and Different Modes of Processing 56
Evidence of Mindlessness 59
Cognitive Commitment 62
Cognitive Commitments Are Made .... 65
Categories of Decision Making 68
Necessary Conditions for Mindfulness 71
Motivation 76
Ability 76
Repetition 76
Physical cues 77
Comprehension 77
Comparisons and similarities 78
Evidence of Fourth Decisional Style-Ruminating 79
Methodologic Commentary 85
The Decisional Processing Model 86
Decisional Styles Follow Two Routes of Processing 87
Four Decisional Styles 88
Some Decisional Styles More Effective 89
Summary 92
Overview 94
Population 94
Sample and Sampling Procedures 95
Sampling Procedures 100
Research Procedures 101
The Interviews 102
Relevant Variables 104
Types of Analyses 104
Criterion Variables 106
Predictor Variables 108
Dependent Variable for Hypothesis Three: Coping 110
Measures and Instruments 111
Criterion Variables Measures 111
Predictor Variables Measures 114
Coping Measure 122
vii

Medical Data Form 123
Hypotheses 124
Data Analysis 125
Limitations 127
Limitations in Generalizabiiity 127
Limitations in Assessment 129
Limitations in Analyses 130
Theoretical Limitations 131
RESULTS 132
Decisional Categories 121
Hypothesis One: Placement into Decisional Categories 133
Decisional Category Reliability 134
Location Effects 136
Researcher Effects 138
Ancillary Analyses Related to Decisional Styles 139
Personal Characteristic Effects 139
Medical Data Effects 141
Hypothesis Two: Predicting the Decisional Processing Model 142
Hypothesis Three: Relationship Between Decisional Styles and Coping 144
Effects of Decisional Style on Coping 144
Most Troublesome Part of Cancer 149
Amount of Stress Generated 150
Hypothesis Four through Seven: Relationship of Each Scale
to Decisional Categories 150
Hvnothesis Four - "Need for Cognition Scale 1
l~lj £ -.. Li C ~ * iidi -w iObU- C QvUiC i . .
Hypothesis Six - Padua Inventory - Rumination Subscale 154
Hypothesis Seven - Ability to Process Questionnaire 154
DISCUSSION 157
Summary of Results 158
Decisional Categories 160
Mindless Decisional Style 160
Active and Passive Decisional Styles 164
Ruminating Decisional Style 167
Age and Decisional Style 168
Education and Decisional Style 169
Race and Decisional Style 170
Medical Data and Decisional Style 171
Elaboration Likelihood Model as Predictive of Decisional Style 172
Two Routes of Processing 172
viii

Predictive Ability of ELM 174
Ability to Process 174
Motivation 175
Cognitive Responding 177
Limitations 179
Decisional Styles and Coping 180
Limitations 184
Decisional Processing Model 185
Implications of the Study 187
Four Decisional Styles: Extension of Langer's Theory 188
Using ELM to Change Decisional Styles: Extension of Theory 189
Implications for Practice 189
Methodological Issues 191
Future Research 192
Characteristics of Decisional Styles 192
Effects of Changing Decisional Styles 193
Interaction with Others and Decisional Style 193
Conclusion 194
APPENDIX 195
Assessment Instruments 195
REFERENCES 215
BIOGRAPHICAL SKETCH 242
IX

en en en
LIST OF TABLES
Table Page
2-1 The Decisional Processing Model 91
3-1 Frequencies and Types of Diagnoses of Participants 96
-2 Construct Correlations for Need for Cognition Scale 104
-3 Construct Correlations for Need for Closure Scale 118
-4 Predictor and Criteria Variables for Hypothesis Two 124
3-5 Hypothesis Three: Decisional Style and Coping 126
4-1 Decisional Style Categories 134
4-2 Differences in Decisional Style based on Location 137
4-3 Researcher Coverage of Interviews 139
4-4 Decisional Style by Education Level 140
4-5 Effects of Age and Gender on Decisional Style 141
4-6 Means and Standard Deviations for Medical Data 142
4-7 Means for Five Coping Subscales for Each Decisional Style 146
4-8 Analysis of Variance for Coping Scales 132
4-9 Frequency within Decisional Styles for Most Troublesome Part 149
4-10 Means and Standard Deviations on Need for Cognition Scale 152
-‘-t 1 n-j.J c .-n V-v -1 -'V r’cV'-‘ - ’ —
4-12 Means ana ¿tandara Deviations on Rumination Suoscaie ion-
4-13 Means and Standard Deviations on Ability to Process Questionnaire 155
x

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
THE DECISIONAL PROCESSING MODEL:
MEDICAL DECISION MAKING AMONG CANCER PATIENTS
By
Suni Petersen
December, 1997
Chairperson: James Archer
CoChairperson: Martin Heesacker
Major Department: Counselor Education
Many factors influencing coping, progression of disease, and survival time in
cancer patients depend on making decisions. Yet very little is known about how patients
■JTioVc1 TTcTtf? T or} q-pr’c; vpi r* ^ -p» ]1 rt P C <7.
Cacioppo's elaboration likelihood model, this study proposed a research-supported
decisional model and tested its viability and its relationship with coping in cancer patients.
Results supported the model. Patients demonstrated the four categories of
decisional styles-- active, passive, mindless, and ruminating— in making key medical
decisions. Using discriminant function analysis, these styles were predicted by the
elaboration likelihood model’s constructs, providing information for the development of
interventions which may change decisional styles. Finally, coping was significantly related
to decisional styles. Those patients using central route processing (active and passive
xi

Xll
decisional styles) were more effective in coping than those using peripheral route
processing.

CHAPTER ONE
INTRODUCTION
THE DECISIONAL PROCESSING MODEL:
MEDICAL DECISION MAKING AMONG CANCER PATIENTS
PURPOSE
Little is known about th e way in which people arrive at crucial decisions about
medical treatment and coping when they are confronted with a life-threatening illness.
Although no models have been generated that address this question, there is a substantial
body of research that provides a framework from which to build a model. From different
reference points Ellen Langer, Richard Petty, John Cacioppo, and other depth of
processing theorists have researched different aspects of strikingly similar behavior. The
purpose of this study is to provide some understanding of how people make important
medical decisions in the face of life-threatening illness by creating a research-supported
model and testing it's viability.
The research supporting Petty and Cacioppo's (1981) elaboration likelihood model
(ELM) in a context irrespective of the message delivered will be integrated with Langer's
(1989, 1994) research on decision-making to develop a decision-making model. The
empirical support for both theories has demonstrated closely related, if not identical, routes
of processing information. The variables which detennine these routes of processing
information are used in this study. Langer's decisional styles are used as criterion variables.
The constructs of the ELM which detennine the routes of processing are motivation,
1

2
cognitive responding, and ability to process. The variables measuring these constructs are
Need for Cognition and Ability to Process Questionnaire, drawn from the work of Petty
and Cacioppo (1986). The other variables measuring these constructs are Need for
Closure Scale supported by the related research of Kruglanski and Webster (1994) and the
Padua Inventory Rumination Subscale (Sanavio, 1988).
This study will also include an exploration of the relationship between coping and
styles of decision-making.
Rationale for Integration of Theories
Mindfulness
In Langefs theory (1989), information is processed in one of two ways, mindfully
or mindlessly. Langer explicated a process in which mindless decisions were made
considerably more often on the basis of a preconceived commitment to a schema. These
decisions are made in response to a cue that represents a small portion of the schemata of a
particular domain and preempts further elaboration on an issue prior to deciding. In
contrast, mindful deciding is a two step process. The person first steps back to reconsider
both the problem and the solution, and seeks discriminations which render the issue novel.
The second task of mindful deciding then, is to choose between the options generated in
the first step of this process.
The basic premises of the mindfulness theory are
1) There are qualitative differences between active and passive deciding. Active
deciding is the two step process described above and passive deciding is choosing between
options presented.

2) Options form discrete categories when they become psychologically different for
the person.
3) Deciding entails information gathering until discriminations are made and the
concept is categorized.
4) There is no natural end point to this process. Information gathering simply stops
when a person reaches a cognitive commitment.
5) There are three kinds of cognitive commitment: a) personal cognitive
commitment to content (i.e., the totality of attributes noticed), b) societal commitment to
content (commitment to a schema assumed from cultural norms, and c) cognitive
commitment to process (the amount of information gathering one is "supposed" to engage
in prior to choosing). Commitment to process is content-independent and therefore
operates separately from societal or personal commitment.
Personal commitment means an experience or perception is labeled as belonging to
a certain category and immediately is attributed with all the traits of that category without
further scrutiny. If a person does not have a preconceived category into which a new
experience fits, that is., it is psychologically different from the alternatives, the person will
commit to a definition of the experience based on the opinions of others. The commitment
to process is a preconceived notion, learned in a cultural context, that informs the decision
maker about the amount of information a person is "supposed" to obtain before making a
choice. Thus the hypothesis testing will continue a) until a personal experience category is
found, or b) in its absence, until a culturally informed category is found. Barring either of

4
these being readily available, the hypothesis testing will only continue until the decision
making has satisfied the process commitment.
Until a cognitive commitment is made, preferences are not stable because the
person has not yet established differences that are psychologically distinct. Because all
decisions result in a cognitive commitment, Langer saw the errors in judgement as being
made in the information-gathering process. However, Langer maintained that mindless
deciding will occur unless the following conditions exist: a) a novel situation is encountered
in which no cognitive commitment has been previously made, b) mindless deciding is more
effortful than mindful deciding, c) external factors do not allow completion of the
commitment, d) significantly discrepant consequences occur that have occurred in the past,
or e) there is insufficient involvement to see any need to respond. The "illusion of
calculated decisions is sustained by failure to realize the power of uncertainty " (Langer,
1994.. p. 45). According to Langer. it is the desire for certaintv that leads to a premature
cognitive commitment that is made mindlessly.
Elaboration-Likelihood Model
Petty and Cacioppo (1986), integrating attitude change literature, discovered the
discordant findings were explained by the existence of two routes of processing
information: central and peripheral. Attitude change processed centrally was enduring and
less affected by envi ronmental cues while attitude change processed peripherally was
transitory and heavily influenced by cues.
The basic postulates of the elaboration-likelihood model of persuasion relevant to
this study are as follows:

1. People are motivated to hold correct attitudes, but they differ both individually
and situationally on the amount of effortful thinking they are willing to engage in to
evaluate a message.
2. Effortful thinking is affected by the motivation to process, the ability to process,
and the initial attitude towards the issue.
3. As motivation and ability to process is decreased, peripheral cues become
important determinants of persuasion.
4. New cognitions must be stored in long-term memory.
5. Attitude change resulting from carefully thinking about a message is more
enduring, predictive, and resistant to counterpersuasion than changes occurring through
responding to peripheral cues.
The ELM states that for people to process centrally, they must have 1) the ability to
process, 2) cognitive responding that takes a position (discriminate between options'), and
3) motivation to think carefully about the information leading to a decision (Petty &
Cacioppo, 1981). For a person to be motivated to process via the central route, three
situational variables must exert influence: the personal relevance of an issue, personal
responsibility for message evaluation, and the number of message sources.
Langer suggests that people will make decisions mindlessly (without entertaining
any options) particularly when presented with only one alternative unless their mindless
deciding is interrupted or more difficult than active or passive deciding or the situation is
sufficiently novel or consequences sufficiently discrepant with the past exist to warrant
effortful thought. She also asserts that people will engage in more active deciding when

6
they feel personally responsible for the outcome (Alexander, Langer, Newman, Chandler
& Davies, 1989; Langer & Avom, 1982). Each of these situations fit the motivation
criteria identified in the ELM.
Whereas the ELM suggests that peripheral route processing will occur in states
analogous to Langer's "mindless" condition, it does not distinguish between active and
passive deciding. Petty and Cacioppo (1986, p. 3) define central route processing as "that
which occurs as a result of a person's careful and thoughtful consideration of the true
merits of the information presented in support of an advocacy." Langer describes this as
passive deciding because the person focuses on only the options presented. Langer also
identifies active deciding whereby the person "elaborates" on that which is presented,
considers self-information, and generates alternatives beyond those presented. There is a
difference here which appears to be in consonance with the elaboration likelihood model,
although Petty' and Cacioopo have not made this discrimination. The difference seems to
focus on the content of the focused thought process, either self-generated or other
generated. Since most of the research done on the ELM was conducted from a perspective
of persuasion, the only content studied was that which was presented. Option generation
has not been researched within the ELM. However, it is not theoretically inconsistent to
assume that central route processing occurs both for active and passive deciders.
There is yet another category of decision making that, while alluded to in both the
ELM and Langer's theories, is better explained through the research on the need to avoid
closure. This category consists of people who ruminate, and do not adequately
psychologically distinguish one choice from another and thereby avoid committing to any

7
decision. One of the criteria for central route processing is that a person must have a
position on a topic, essentially seeing enough of a difference between options as to
determine whether arguments support or refute that position. Langer also theorizes that,
unless people can discover differences between the choices, the choices remain,
psychologically, the same. Although people may feel they "ought" to be able to decide, it
is because they cannot establish any meaningful difference for themselves that they do not
decide. Believing there are meaningful differences, yet not being able to establish
differences, results in rumination.
Taken together, the research supporting the elaboration likelihood model of Petty
and Cacioppo and the theory of mindlessness espoused by Ellen Langer, suggests four
categories of decision makers. They are (a) active deciders (mindful), (b) passive deciders
(c) mindless deciders, and (d) ruminators. Qualitative differences are seen by Langer
between mindful and mindless deciding (Langer, Chanowicz, & Blank. 1985) and by Petty
and Cacioppo (1986) between central and peripheral route cognitive processing. Active
deciding is better than any of the other styles because it leads to greater self-esteem,
enhanced perceived control (Langer and White, 1993/1994), and diminished post-decision
regret (Langer & Williams, 1993). In addition, active deciding is more likely to lead to
more accuracy in the fit between the choice made and the individual's needs in the current
situation.
Stable, intrinsic differences exist among individuals in their motivation to process
information effortfully (Petty & Cacioppo, 1981; 1984; Cacioppo, Petty, & Morris, 1983).
This construct has been defined as a need for cognition. Need for cognition was found to

8
be unrelated to intelligence (Cacioppo, Petty, & Morris, 1983; Eagly & Chaiken, 1976).
Individuals high in need for cognition were more likely to extract information and think
effortfully about a message than those low in need for cognition. However, these
individual factors can be overridden by situational factors.
If a person is to carefully evaluate information using central route processing, the
individual must have the ability to do so. Some persons have more ability than others and
certain situations facilitate ability more than others. Distraction, message repetition,
recipient posture, forewarning, argument strength, relevance of message, and time to
consider are some such factors.
Rumination is defined as shifting between a few options without generating new
associations and without making a commitment to any of the options. People may agree to
an option and not be committed to it. Rumination prevents a cognitive commitment or
cognitive responses to be made. Rumination is also differentiated from effortful thought
by accepting that which is presented or generating only a paucity of options and by the
inflexibility of the schema involved. The need for closure construct of Kruglanski and
Webster (1989; 1994) is used to expound upon the idea of rumination as a decisional style.
Need for closure is "the desire for a definite answer on some topic, any answer as opposed
to confusion and ambiguity ” (Kruglanski, 1989, p. 14). Kruglanski calls the need for
closure a specific type of epistemic motivation. It is consonant with Langer’s commitment
to a process (perhaps, "Always keep your options open"). Those people high in need for

9
closure would likely use mindless deciding, those with moderate need for closure would
engage in effortful thought, and those with high need to avoid closure would be ruminators.
Coping
For the basis of this study, the conceptualization of coping is taken from Lazarus
and Folkman. Coping is defined as "the cognitive and behavioral efforts to manage
specific external and/or internal demands appraised as taxing or exceeding the resources of
the individual" (Folkman & Lazarus, 1988, p. 6). Rather than the traditional view of
coping which posits an individual with certain traits, this conceptualization of coping is
process oriented. Coping is seen as context dependent and changes as the person begins
the adaptation to the stimulus event. Adaptation occurs through the continuing ongoing
reappraisal process in the shifting person-environment relationship (Folkman, Lazarus,
Dunkel-Schetter, DeLongis, & Gruen, 1986). This conceptualization of coping has as it's
objective to manage rather than control or solve the encounter. Since cancer recoven7 is
subject to so many known and unknown factors, both medical and psychological, coping
requires management of the psychological, social, and physical impact rather than removal
of the problem.
The Folkman and Lazarus definition of coping also departs from the traditional
view by collapsing the hierarchy of coping activities. Ill-timed humor, while traditionally
rated high, can be maladaptive. Specific to research on coping with cancer, denial has
been shown to improve coping in some studies and deter coping in other studies. Rather
than a hierarchy of coping mechanisms, this study takes the perspective that coping can
only be judged relative to adaptative outcomes. Considerable research has been conducted

10
which demonstrates certain ratios and patterns of coping are related to better outcomes (see
Chapter Two). Therefore the complex pattern of coping and the ensuing ratios of more
effective styles than less effective styles are equated with coping in this research.
Why Central Route Processing May Enhance Coping
Illness can certainly be construed as a situation with relatively uncontrollable
outcomes. When people respond to situations having uncontrollable outcomes there is an
intervening step of hypothesis testing occuringjust prior to the exhibition of helplessness
(Wortman & Dintzer, 1978). Individuals seek out information when confronted with a
new situation. Ideally, this process forestalls a commitment to a decision long enough to
influence and modify the subjective experience of a serious diagnosis and its attributions.
Ellen Langer suggests that people often determine and categorize these decisions on the
basis of very little external information and a limited set of internalized cues. In a study of
persons with hypertension, the participants were told by their physician that hypertension is
asymptomatic, yet all of them held well-formulated hypotheses about symptoms that
informed them of changes in blood pressure. These hypotheses, while inaccurate,
influenced how the patients monitored blood pressure and followed treatment regimens
(Pennebaker, 1982).
Carefully considered appraisals are essential for the management of illness. In a
series of studies, Leventhal (1991) identified two channels of processing information that
co-exist and both affect and are affected by the appraisal process: the schematic memory,
consisting of automatic, nonverbal codes of the illness, and the perceptual memory, a
composite of the individual's reflections and judgements. For effective appraisal to occur,

11
the individual must negotiate the flow of information from sources in the environment and
from self awareness of relevant internal data. To remain open to possibilities and conduct
hypothesis testing, central route processing must be used.
Under central route processing, a person carefully considers both the information
from external sources and self awareness (active-deciders) while conducting the appraisal
process. The appraisals result in the formation of new ideas that are integrated into the
underlying schema. This mechanism establishes the enduring nature of centrally processed
decisions. Peripheral route processing functions by directly accessing a schema without the
necessary thoughtfulness to determine if the schema still fits. The schemata invoked by
peripheral route processing are intellectually impoverished forms of information, seriously
inhibiting the appraisal process necessary to healthy coping with illness.
Taking time to conduct an in depth appraisal has been shown to affect health
outcomes. Appraisal determines when a person seeks medical treatment (Cameron,
Leventhal, & Leventhal, 1995). Early detection and treatment of cancer is one of the most
significant actions toward a longer life-expectancy in a cancer diagnosis. Appraisals not
only influence how symptoms are perceived and acted upon but can trigger a system of
thoughts about illness which deter effective treatment and coping. In a study with cancer
patients, the use of positive reappraisal was an indicator of long-term coping (Lazarus &
Folkman, 1984). For example, cancer patients who have undergone surgery and believe
the cancer was eliminated have difficulty choosing to undergo noxious chemotherapy
treatment (Leventhal, Easterling, Coons, Luchterhand, & Love, 1986).

12
It is more likely that under thoughtful consideration of information a more
informed decision could be made about such significant health decisions. In fact, crucial to
the spirit of the law on informed consent is just such an understanding (Hodne, 1995)
Significance of Study
The significance of this study lies in three domains: theory, practice, and future
research. Medical decision making literature focuses on the choices the physician makes in
response to an illness and the physician's presentation of information to the patient. This
body of knowledge ignores the agency of the patient. A model that attempts to explain the
decision-making of the patient has not been created.
Efforts need to be made to extend theory. Given the extensive research support, it
is time to bring social influence theories to applied settings. Studies are needed to
investigate the prevalence of each route of processing and the circumstances under which
thev naturally occur. Studies are needed to understand how change from one to the other
occurs under different "real life" circumstances. Most of all studies are needed to focus on
outcomes of interventions based on current research. And this can only be done by
applying assessment strategies, such as those devised by Ellen Langer, which take
advantage of naturally occurring events to understand the social influence theories.
The field of pyschoneuroimmunology has advanced knowledge about the
connections between our thoughts, feelings, behavior, and physical well-being. This
mushrooming body of research is surprisingly devoid of studies on decision making. The
way a person makes decisions determines when they consult a physician, the treatments
they choose, their adherence to treatment, their ways of coping, and even their prognosis.

13
With the exception of a few researchers, decision-making studies have largely ignored the
evidence that people process information along two routes. These two methods of
processing may account for differences between people in thought patterns, appraisals,
attributions, self-efficacy, and coping styles, all of which have been shown to have a
powerful impact on quality of life (Leity & Haase, 1996), pam (Gil et al, 1995), health
(Fawzy et al, 1993), progression of illness (Epping-Jordan et al, 1994), and even survival
(Rogentine et al, 1979).
If, as hypothesized, active or passive decisional styles spawn more effective coping
in people with serious illness, a psycho-educational program can be developed which
increases awareness of decisional styles and facilitates use of central route processing in
order to increase coping effectiveness. ELM constructs have been used to change core
attitudinal processes. Since decisional styles are also core processes, the constructs
demonstrating effective attitude change may also be effective with changing decisional
styles.
In addition, the vast body of research from both Langer and Petty and Cacioppo
explicating factors which impact how information is processed can be used to establish
guidelines for physician communication that encourages central route processing in ways
that enhance coping.
Mind and Body as Integrated System
More and more evidence is accruing linking cognitive, affective, and social factors
with the biochemistry of the body. More effective coping has been shown to be one of the
determinants of increased physical ability to fight cancer. Coping is affected by perception.

14
Perception is socially constructed, learned behavior. One of the perceptions a person
learns from his/her life experience is how certain decisions are made and what information
is considered. Decision-making styles may be no different than other forms of learning
with resultant links to biochemical events of the body.
Results of recent research are raising questions about how supposedly separate
human systems are bounded. Psychobiologists have been investigating the transduction of
information between learning, memory, and the limbic-hypothalamus area of the brain, to
understand how perception is integrated with thought and behavior (McGaugh, 1983).
Studies of state-dependent learning, in which state-dependency is defined as including
different states within normal biological rythyms (circadian, ultradian), have detected how
even autonomic body functions are altered through experiential learning (Rossi & Ryan,
1986).
Researchers investigating state-dependent learning agree that two routes exist for
encoding thoughts and experience into memory: 1) a specific locus of memory on a
molecular, cellular, synaptic level (Hawkins & Kandel, 1984) and 2) most importantly to
the translation of experience, the transmission of sensory information to the limbic system
(amygdala and hippocampus) which transforms learning and behavior into biochemical
events (Mishkin & Petri, 1984). Mind and body are an inextricably linked information
system.
The work of Hans Selye (1982) on the General Adaptation Syndrome and Lazarus
and Folkman (1984) investigating the contrast between good stress (eustress) and bad
stress (stress resulting from need deprivation) demonstrated that these different experiences

15
trigger different biochemical reactions in the body. Bandura (1985) found that as self-
efficacy improved in people with phobias, a biochemical reaction occurred that was
identical to the reaction of those people experiencing eustress. Taken together, these
studies suggest that the interpretation of stress and the judgement of one's ability to handle
the stress determine the biochemical reaction in the body.
Interpretation is a cognitive process learned through experience and amenable to
change. When an illness strikes, a person's experience of the illness affects his/her
biological and psychological functioning (Stenager, Knudsen, & Jensen, 1991; Ward,
Leventhal, & Love, 1988). Shortly after patients hear from the doctor that their diagnosis
is cancer, they are confronted with an onslaught of decisions that they themselves must
make about prognosis and coping. Within a short time, they are catapulted into making
decisions about attribution and efficacy as well. People assigning meaning, attributing
causality, and conseauently coming to terms with their decision about causality, are better
able to cope with illness (Ward et al, 1988). Additionally, only if health enhancement is
seen as within their control will patients feel capable of challenging the illness (Strecher,
Devellis, Becker, & Rosenstock, 1986). These decisions are highly idiosyncratic (Rolland,
1987) and have a significant effect on survival, quality of life, and coping.
There is extensive theoretical and research support available to develop a model of
decision making that enhances coping with life-threatening illnesses. This model builds on
the existing body of knowledge by integrating the depth of processing models and decision
making models and bringing that research into the field. To date, the work of Ellen Langer
has not been conducted in a medical setting. However, in her study on preconceived

16
notions of aging she hypothesized two possible explanations for the results: 1) that the state
of the body was modified by a preconceived schema of the condition of aging, or 2) that a
greater degree of mindfulness was required to reverse the changes that occurred
(Alexander & Langer, 1990). In bringing the theory of decision making into the field, this
study will attempt to deepen understanding of this process.
One of Langer’s hypotheses represents a process of assimilating existing cues
without mindful thought; the other represents mindfully correcting a formerly held opinion
(contrast). Priester and Petty (1996) postulated that correction based processes require
more effortful thinking. They further stated that the processes requiring effortful thinking
are sequentially ordered by degree, and that correction-based contrast requires more
effortful thinking than correction-based assimilation, which, in turn, requires less thinking
than default. They recommend this relationship be tested. By using the categories
suggested by Langer's theories, this Question can b-e addressed.
Investigating decisional processes among cancer patients and the effects of these
processes on coping paves the way for the development of programs which improve
coping. A product of this investigation will be a new model created by extrapolating and
combining the research on the elaboration likelihood model, other social influence theories,
and the theory of mindfulness.
Hypotheses
It is reasonable to speculate that people engaging in active or passive decision¬
making use central route processing, and that those engaging in mindless deciding or
rumination use peripheral route processing. It is also reasonable to speculate that central

17
route processing will improve coping with a serious illness because more relevant
information is considered in the reappraisal process which is essential in making informed
decisions. Because people can shift their modes of processing from peripheral to central,
coping may be improved through a psychoeducational program using the ELM to increase
the likelihood of cognitively elaborating on the directives of the physician and on
information about new coping mechanisms. The hypotheses in this study are tested in
order to assess the utility of the decisional processing model.
Hypothesis One
It is anticipated that patients will exhibit different decisional styles. Although other
decisional styles may exist, based on the theory and empirical evidence provided by
Langer, Petty and Cacioppo, and Kruglanski, it is anticipated that patients will exhibit one
of the four decisional styles in making medical decisions. Hypothesis One states that a
large proportion of participants will place themselves into the four decisional styles (active,
passive, mindless, and ruminating) in making medical decisions related to a diagnosis of
cancer. It is further hypothesized that judges will also place a large proportion of patients
into the four categories and that there will be a high level of agreement between the judges
and the patients regarding the placement of patients into decisional categories.
Hypothesis Two
The second question entertained in this study was whether constructs (cognitive
responding, motivation, and ability to process) of the elaboration likelihood model are
predictive of the decisional style a patient will fit. Hypothesis Two states that decisional
style categories will be predicted by the main and interactive effects of cognitive responding

18
(as measured by the rumination subscale), motivation (as measured by Need for Cognition
Scale and Need for Closure Scale), and ability to process (as measured by the Ability to
Process Questionnaire).
Hypothesis Three
The third main question asked in this research was whether decisional styles are
related to coping. Hypothesis three states participants using active decisional styles will use
more effective coping strategies (as measured by Ways of Coping Scale - Cancer Version)
than those using passive decisional styles. And participants using both active and passive
decisional styles (central route processing) will use more effective coping strategies than
those using peripheral route processing, mindless, and ruminating decisional styles.
Hypotheses Four through Seven
In order to test whether any of the measures used in the model can alone predict
decisional stvles the folio win 2 anovas will test the relationshin between each measure and
decisional style.
4. Participants using active deciding will demonstrate significantly higher mean
scores on the Need for Cognition Scale than those using mindless deciding or ruminating.
5. Participants using mindless deciding will demonstrate significantly higher mean
scores on the Need for Closure Scale than patients using the other three styles. There will
be no significant difference between the mean scores of those using passive deciding and
the scores of those using active deciding. The mean scores of participants using either
active, passive, or mindless decisional style will be higher than those of the participants
using ruminating style..

19
6. Participants using the ruminating style will demonstrate significantly higher mean
scores on the Padua inventory - Rumination Subscale than those patients using active
deciding. Mean scores of those participants using both active and passive deciding will be
equal. The mean scores of participants using active, passive, and ruminating will be
significantly higher than the scores of those using mindless deciding.
7. Mean scores of participants using active deciding will be equal to the scores of
those using passive deciding and significantly higher than the scores of those using
ruminating. Mean scores of participants with ruminating styles will be significantly higher
than the scores of those using mindless deciding on the Ability to Process Questionnaire.
Definition of Terms
For the purpose of this study, the following definitions are presented:
Active deciding is "a process consisting of two parts: 1) creating or modifying
ontions followed by 2) selecting from among those options" (Tánger. 1994). For cancer
patients, active deciding means that they took the initiative to seek information beyond the
sources presented by the physician, weighed self-knowledge about their life style and
personality, and made a choice considering all three sources of information.
Central route processing is "a type of information processing discovered in
research on persuasion which likely occurred as a result of a person's careful and
thoughtful consideration of its true merits of the information presented in support of an
advocacy" (Petty & Cacioppo, 1986, p.3)
Cognitive responding is taking a position on a particular topic and providing a
response.

20
Elaboration is to carefully think about and "relate the recommendation and
arguments to other issue-relevant information in memory" (Petty & Cacioppo, 1986, p.
14).
Foreclosed commitment is making a commitment to a decision based on simple
decisional rules without effortful thought.
Heuristic thoughts are "those classified as relevant to the discussion yet unrelated
to the arguments' contents" (Kruglanski, Webster, & Klem, 1993).
Mindfulness is a state of mind that results from drawing novel distinctions,
examining information from new perspectives, and being sensitive to context. " (Langer,
1993, p. 44).
Mindlessness is a state in which a premature cognitive commitment is made to a
rigid belief resulting from the unexamined acceptance of information and without
Need for closure is "the desire for a definite answer on some topic, any answer as
opposed to confusion and ambiguity" (Kruglanski, 1989, p. 14). Kruglanski (1990) further
discriminated between need for specific closure (need for specific answers in support a
particular dimension, ie ego-syntonic) and need for non-specific closure.
Need for cognition is "the statistical tendency of and intrinsic enjoyment
individuals derive from engaging in effortful cognitive activities" (Cacioppo & Petty,
1982).
Option-generation is "exploring more alternatives (than presented) that suggest
new dimensions for comparison" (Langer, 1994).

21
Peripheral cues are "stimuli in the persuasion context that can affect attitudes
without necessitating processing of the message arguments" (Petty & Cacioppo, 1986,
P-18).
Passive deciding is "choosing from among previously determined options "
(Langer, 1994).
Peripheral route processing is "routes of processing in which simple cues rather
than scrutiny of the central merits of the issue induce change" (Petty & Cacioppo, 1986,
P-3).
Premature cognitive commitment is "a rigid belief that results from the mindless
acceptance of information as true without consideration of alternative versions of that
information" (Langer, 1993, p.45).
Rumination is shifting between options without generating new associations and
without m skins? a commitment to anv of the cohorts.
Schemata is the organization and structure of information regarding some domain
of knowledge; "a prototypical abstraction of the complex concept it represents triggered by
any reasonable approximation of a schema and guiding the incoming information that
support the original schema" (Thomdyke & Hayes-Roth, 1979).
Systematic thoughts are "those dealing with specifically with contents of the
arguments." (Kruglanski, Webster, & Klem, 1993).

22
Organization of the Remainder of the Dissertation
This dissertation is organized into five chapters. Chapter One has introduced the
reader to the purpose, the theoretical rationale, and the significance of this study. Chapter
Two includes a review of the literature addressing the relevance of decision-making among
people with life-threatening illness, it's association with coping effectively, and a deeper
explanation of the research supporting the theoretical underpinnings of the model to be
tested. Chapter Two also introduces the Decisional Processing Model. Chapter Three, the
methodology section, offers a detailed account of the population sample, research design,
hypotheses, procedures for sampling and assessment, and planned analysis of the data.
Chapter Four is the results section of the research, including results of the main and
ancillary hypotheses. The dissertation is concluded with Chapter Five, an in-depth
discussion of the findings in the following areas: decisional categories, the elaboration
likelihood mode! as predictive, and the relationship between decisional styles and coning. It
provides a description of the decisional processing model based on this study's findings.
Chapter Five concludes with implications, methodological issues, and future research.

CHAPTER TWO
REVIEW OF THE LITERATURE
The body of research reviewed in this chapter is organized into seven sections: (a)
The integration of mind and body, (b) The social construction of perception, (c) Coping
and medical decision-making, (d) The integration of mindfulness and social influence
theories, (e) Evidence of a fourth decisional category, (f) Methodological commentary, and
(g) The decisional processing model.
In the review of the literature on psychological factors affecting physical illness a
particular emphasis is placed on cognitive factors since decisions are cognitive in nature.
The context of these empirical studies is subsequently placed in the framework of a
constructivist perspective. Specific to the topic of this study, a review of coping and
i-j" .ri o ] Tr"» ‘"l’ ■*'* O' 1 Q ■*“ V*1 (Í 4a (Í ¡j?". y f»-{-| r» o j íV» i' r* p *•* f.'x-!* bV r*. r- 7 /*»A1 t*** ."'•f* ■*>
decision-making model is built upon the work of Ellen Langer, Richard Petty, John
Cacioppo, and Arie Kruglanski. Their research is included. This examination of the
literature will conclude with the presentation of the decisional processing model.
The Integration of the Mind and Body
When a person is diagnosed with cancer, he/she experiences acute stress
emotionally, socially, and physically. The intensity of this stress is not determined by the
condition and treatment alone. Two parallel processes occur (Leventhal, Diefenbach, &
Leventhal, 1992), one creating the cognitive assessment of the illness, the treatment, and

24
the prognosis; the other creating the subjective experience. Information is monitored by
both the objective and the emotional aspects of the experience through two types of
memory structures: a schematic memory "of' the illness and a perceptual memory "about"
the illness. Schematic memory consists of automatic, nonverbal cues of the illness;
perceptual memory is a composite of the individual's reflections and judgements. There
are continuous feedback loops that inform the perceptual "memory," through which the
individual appraises his/her responses to treatment and coping efforts.
Psychobiologists have been investigating the transduction of information between
learning, memory, and the limbic-hypothalamus area of the brain, to understand how
perception is integrated with thought and behavior (McGaugh, 1983) and have found that
different perceptions are routed through different pathways of the brain. The reticular
formation plays an important role in transducing information by reacting to novel stimuli
through the locus coerulus. a cluster of norepinephrine-containing neurons which stimulate
a heightened psychobiologic state, a precondition for all forms of creatively-oriented
psychotherapy and mind-body healing experiences. The frontal cortex with it's organizing
and planning functions has a multitude of connections with the limbic-hypothalamus area.
The organization and synthesis of external and internal information is essential for the
regulation of body states and takes place when information is funneled through the limbic-
hypothalamic system.
One of the important mediators of mind-body communication in relationship to
healing is body image (Acterberg, 1985; Acterberg & Lawlis, 1984). Body image is a
composite of visual imagery and cognitive judgements organized through the transduction

25
of information between both hemispheres of the brain. "The right hemisphere's modes of
information transduction are more closely associated with the limbic-hypothalamic system
and mind-body communication" (Rossi, 1986, p. 31). However, the raw imagery
production of the right hemisphere must be in good communication to be transduced to the
left hemisphere. This means information could be the "raw uninterpreted experience"
(Leventhal's subjective perceptual memory) or the secondary process routed throught the
left hemisphere (Leventhal's schematic memory).
Memory and learning depend on the flow of information from the limbic-
hypothalamic system. Sensory stimulation also results in the release of hormones and a
great deal of empirical evidence exists showing how learning and memory are affected by
these hormones. McGaugh (1983) discovered that retention, for example, is influenced by
epinephrine released from the adrenal medulla. "Hormones released by experience act to
modulate the strength of the memory of the experience and suggest that centra! modulating
influences on memory (in the limbic-hypothalamic system) interact with influences from
peripheral hormones" (Rossi, 1986). Following this description, all learning becomes state-
dependent learning.
Research by Murry and Mishkin (1985) suggests that the cross-modal association
of sensory-perceptual information makes possible flexible patterns of information
transduction into psychophysiological responses. To the degree that a person is able to
react to novel stimuli, access learning from different states, synthesize the parallel
processes, and make the cross-modal association needed to act, that individual will be able
to influence autonomic functioning. Increasing the pathways of both self-reflective and

26
externally-derived information is the way in which mind-body communication can be
enhanced.
Science has furthered only a few ways to enhance mind-body communication. The
factors that have been shown in research to significantly affect the body and it's response to
illness depend on the internal communication system described above. Making truly
informed medical decisions may also depend on this information system.
Appraisal
Appraisal is an interpretation of somatic sensations (Leventhal, Deifenbach, &
Leventhal, 1992). Two types of memory structures are involved in the appraisal process,
one schematic and the other propositional. Schematic structures are nonverbal,
nonpropositional codes of prior illness while propositional structures consist of abstractions
or interpretations about the illness. Representations have five attributes which are (a)
disease label (Bauman & Leventhal, 1985; Crovle & Sands, 1988). (b) time-line (Crovle.
1990), (c) physical, social, and economic consequences (Bishop, 1987; Croyle & Jemmott,
1989), (d) antecedent causes, and (e) potential for cure or control (Weinstein, 1988). This
representation is set in motion by a novel somatic situation and determines the steps taken
to remedy the illness or, if too much anxiety is evoked, can lead to denial of the symptoms
(Safer, Tharps, Jackson, & Leventhal, 1979).
The illness representation drives the appraisal process. In a study of hypertensives,
80% of the people stated they knew hypertension was asymptomatic, yet when asked if
they could detect when their blood pressure was high, 90% said they could (Meyer,
Leventhal, & Gutman, 1985).

27
In another study, symptoms experienced in the presence of environmental stressors were
appaised as signs of stress, whereas those experienced without the presence of a stressor
were appraised as a sign of illness (Pennebaker, 1982). Cancer patients who have
undergone surgery and believe the cancer was eliminated have difficulty choosing to
undergo noxious chemotherapy treatment (Leventhal, Easterling, Coons, Luchterhand, &
Love, 1986).
Appraisals not only influence how symptoms are perceived and acted upon but can
trigger a system of thoughts about the illness which deter effective treatment and coping.
In a laboratory study with induced noxious stimuli, negative thought patterns were found to
be related to increased reporting of pain (Gil, Phillips, Webster, Martin, Abrams, Grant,
Clark, & Janal, 1995). In an applied study, patients receiving cognitive coping skills
training and restructuring of negative thought patterns reported more effective pain
management, increased functional capacity, and better cooing (Altmaier. Lehmann.
Russell, Weinstein, & Kao, 1992; James, Thom, & Williams, 1993).
The initial representation of the illness, including both the non-verbal experience of
somatic stimuli and the interpretation of that stimuli, is the process by which the integration
of information leads to the factors that influence health. It would seem that the more
information, both internal and external, entertained by the patient, the more likely this
representation will guide the patient towards healthy choices.
Self-Efficacy
Self-efficacy is defined as a subjective appraisal of one's ability to carry out specific
behaviors to fight the illness and cope with the distress. Self-efficacy has consistently been

28
identified as playing a crucial role in health (Bandura, 1977; O'Leary, 1985). Only if
health enhancement is seen as within their control will patients feel capable of challenging
the illness (Strecher, Devellis, Becker, & Rosenstock, 1986). Bandura (1995) stated that
self-efficacy is an integral part of three domains of self-regulation: self-monitoring,
judgements on oneself, and self-reactions. Anticipatory thoughts of self-inefficacy increase
stress level more than actual encounters with the threat (Bandura, 1986). Perceived
inefficacy in controlling a psychological stressor resulted in plasma catecholinamine
secretion (Bandura, Reese, & Adams, 1982), activation of endogenous opioid systems
(Bandura, Cioffi, Taylor, & Brouillard, 1988), and increased release of corticosteroids and
catecholamines (Borysenko & Borysenko, 1982), all of which have immunosuppressant
capabilities. In a study investigating phases of efficacy acquisition rather than the
immunosuppressant effects of inefficacy, Widenfeld, O'Leary, Bandura, Brown, Levine,
and Raska (19901 demonstrated enhanced immunocotnoetence during the development of
competencies to adapt to a stressor. These findings suggest that there is a relationship
between self-efficacy and immune system enhancement, that self-efficacy resulting from
acquired confidence or skills can be taught, and that the more rapid the acquisition of an
efficacious perspective, the more the likelihood of retaining higher levels of
immunocompetence.
Efficacy also affects how closely a person adheres to medical regimens. Specific to
cancer treatment, interventions to increase adherence were tested (Putnman, Finney,
Barkley, &Bonner, 1994). Self-efficacy at pre-test did not correlate with adherence but
self-efficacy at post-test significantly correlated with increased adherence. Another

29
investigation found that colorectal cancer screening among high risk men increased as self-
efficacy increased (Myers, Ross, Jepson, & Wolf, 1994)
Expectations about one's abilities to effectively combat and cope with the illness are
part of the appraisal of personal helplessness (Lazarus & Folkman, 1984). Personal
helplessness is experienced when persons feel others can accomplish what they themselves
cannot. Wortman and Dintzer (1978) suggest that before individuals arrive at a decision of
causality or efficacy, they go through a series of hypothesis testing, a definite decision¬
making process.
Attributions
Attribution of causality is a major construct when determining the etiology of an
illness, prognosis (Peterson & Seligman, 1987), and adherence to recommended medical
regimens (Leventhal et al, 1992). The attribution process actually begins with interpretation
of initial symptoms. The ambiguitv of physical symptoms orior to diagnosis mav either
prompt or delay action. A minimally threatening framework which normalizes symptoms
prevents the person from seeking medical treatment until the symptoms exceed the
attributed cause (Mechanic, 1972).
Once diagnosis occurs, even in illnesses with known causes, people tend to make
personal attributions beyond the medical cause (Janoff-Bulman & Lang-Gunn, 1988).
These personal attributions often involve self-blame and reflect a moral tone (i.e. "I got
breast cancer because I had premarital sex.") Behavioral self-blame attributions, as
opposed to characterological self-blame attributions, are efforts to establish a sense of a
coherent, predictable, and controllable world (Janoff-Bulman, 1979). However, Wortman

30
(1975) and Janoff-Bulman (1979) studies have shown that adjusting to a one time event
such as an accident may be quite different than with an illness where the threat of
recurrence continues.
Research has generally supported that people who assign meaning, attribute
causality, and then come to terms with their decision about causality are better able to cope
with illness (Ward et al, 1988). However, several studies exist which refute this
perspective. Although prior research suggests that one's own actions yield greater feelings
of control (Langer, 1975) than reliance on a belief that another person is in control,
Langer's studies were conducted on people who were equally competent. In medical
situations, the trained medical staff may provide a sense of control vicariously through their
competence. In a study with breast cancer patients (Taylor, Lichtman, & Wood, 1984),
findings supported this notion. Either the sense of oneself being in control of the cancer or
the serse of the medical staff being in control of the cancer were sisnificantlv and
curvilinearly related to adjustment.
The majority of the research on attributions of causality has explored the
relationship with coping and adjustment. In the few studies using physical factors as the
dependent variable, compliance, preventive health behavior change, and immune system
functioning were investigated. Attributions of causality affect the meaning a patient places
on the outcome. If a patient feels the disease is self-caused, making personal changes
would result in successful control of the illness. If the disease cannot be controlled in
accordance with the attributions assigned, it may be interpreted as personal failure. One
study on hemodialysis patients found that attempts to control outcomes that resulted in

31
"failure" were those who had the poorest compliance (Witenburg, Blanchard, Suls,
Tennen, McCoy & McGoldrick, 1983).
Health behavior change: Perhaps the most well-researched area of attributions
and health is health behavior change for the purpose of prevention. Undergraduates who
were unsuccessful in health behavior changes attributed their setbacks to internal, unstable,
and controllable causes, yet they minimized the importance of the cause (Schoeneman &
Curry, 1990). Different health behaviors elicited different attributional styles. In another
study, attributions changed over time as the intentions of the participant changed
(Schoeneman, Stevens, Hollis, Cheek, & Fischer, 1988). Attributions are idiosyncratic and
change over time and situation.
Immune system functioning: Immune system functioning is the newest area of
investigation in the attribution literature. The few existing studies show conflicting
ftndtn'Ts In determining whether a causal attribute predicts the rate of immune svstem
decline in HIV seropositive gay men, an eighteen month follow-up study controlled for
other health mediators such as depression and risk behavior, demonstrated a decline in
CD4 (killer cells) in participants who assigned attribution for the negative events to aspects
of themselves (Segerstrom, Taylor, Kemeny, & Reed, 1996). Another study on chronic
fatigue patients found that those who assigned attributions to physical causes rather than
psychological causes had more hospitalizations, increased reported fatigue, increased
somatic symptoms, and were more functionally impaired, yet they had less perceived
distress (Euba, Chalden, Deale, and Wessely, 1996). In a retrospective study on cancer
patients who survived beyond all expectations, twice as many patients attributed their

32
survival (during and after treatment) to spiritual, attitudinal or behavioral changes they
made rather than to the treatment they received (Berland, 1995). More than half of these
patients experienced a spiritual/existential shift in their lives.
There is little doubt that attributions are important factors in response to illness.
Almost every study detected that a majority of people do make causal attributions to illness
but the direction or degree of this influence is only beginning to be understood. What is
clear from the literature on attribution of causality and medical illness is the variability
related to outcomes, adjustment, and behavior change.
Physical Effects of Coping
If psychological factors, i.e. what we think and feel, could affect coping and even
the experience of pain, could they also affect survival? Initially, studies reported mixed
results on the predictability of cancer survival and coping based on psychological factors.
Some studies have found no relationship between usvcbolooical factors and car!c?r
progression (Cassileth, Lusk, Miller, Brown, & Miller, 1985; Jamison, Burish, & Wallston,
1987), and have concluded that, with advanced cancer, the prognosis is dictated by the
nature of the disease. Others (Derogatis, Abeloff, & Melisaratos, 1979; Spiegel, Bloom,
Kraemer, & Gottheil, 1989) have identified suppression of dysphoria and cognitive-
behavioral avoidance patterns as being associated with shorter survival. Patients who re¬
evaluated their situation and reported having made considerable adjustments in their lives
have significantly higher one year survival rates (Rogentine, van Kammen, Fox, Docherty,
Rosenblatt, Boyd, & Bunney, 1979). From studies such as these we can extrapolate that
those who thought more carefully about their situations took action and lived longer.

Newly adopted thought patterns and behavior are at least partial determinants of
enhanced emotional and physical functioning. Support group participants who were taught
stress management and coping skills showed significantly lower levels of depressive
symptoms, fatigue, and confusion and demonstrated higher levels of vigor than controls.
They also had significantly more large-granular lymphocytes and natural killer cells (which
are anti-viral and anti-tumor agents; Fawzy, Fawzy, Hyun, Elashoff, Guthrie, Fahey, &
Morton, 1993). At the six year follow-up, survival rates were decisively enhanced
although the difference could not be accounted for solely by the participants' improved
immune system function.
In another study, psychological symptoms, avoidance, and intrusive thoughts were
used as variables to predict progression over one year (Epping-Jordan, Compás, & Howell,
1994). General psychological symptoms were not predictive of progression. This finding
perhaps reflect generalized distress rather than features that affect cancer more directly.
Intrusive thoughts also did not predict disease status. However, avoidance of intrusive
thoughts and emotions was significantly predictive. Other studies have reported similar
findings (Billings & Moos, 1981; Holahan & Moos, 1986). When symptoms of distress
are measured more broadly, no relationship is found; when specific symptoms (supported
in research) are assessed, they do predict progression or survival. In AIDS patients, denial
predicted a decline in CD4 cells (an important immunological predictor of HIV infection)
and progression from HIV to AIDS. This pattern was not seen in those demonstrating a

34
"fighting spirit" which was defined as an optimistic attitude accompanied by a search for
more information (Solano, Costa, Salvatix, Coda, Auita, Mezzaroma, & Bertini, 1993).
Coping has previously been viewed as a quality that enhances life while an
individual deals with an illness. It is also emerging as a causal factor in the direction of the
illness itself. Research on the interrelated alliance between the mind and body has
expanded considerably and previously undetected links are being revealed.
Stress and Illness
Stress and the ability to cope with stress have significant effects on many physical
illnesses and there is evidence that this effect occurs through the impact of stress on the
immune system and the mediation of coping factors (Eysenck, 1985; Fox, 1983; Korneva,
Klimento, & Shkhinek, 1985).
One of the well-investigated theories regarding immune system functioning and
cancer wrs offered bv I eSh?vn. (195*?). According to bcSbiin loss lends to -denression
which leads to helplessness. Cancer had initially been associated with recent prior loss.
Another early theory was that cancer patients suppress emotion and employ an excessive
use of denial (Bahnson & Bahnson, 1964; Kissen & Eysenck, 1962). Evidence from many
early studies both supported and contradicted this relationship (Dattore, 1978; Dattore,
Stontz, & Coyne, 1980). The studies supporting these theories were conducted only on
people who had cancer. In a longitudinal study of 1350 participants drawn from the
general population and followed over a ten year period, results demonstrated chronic
helplessness correlated with cancer (r=.59) and anti-emtional behavior correlated (r=.51),
(Grossarth-Maticek, Kanazir, Schmidt, & Vetter, 1982, 1985). In this series of studies, a

35
synergistic effect was found in lung cancer patients between smoking and the personality
factors of chronic helplessness and anti-emotional behavior.
There is a difference between acute stress and chronic stress in the development of
cancer. Acute stress has immunosuppressant qualities. Acute stressors have been shown to
affect immunity (Herbert & Cohen, 1993; Kiecolt-Glaser, Cacioppo, Malarkey, & Glaser,
1992). In a first-time parachute jump, participants' NK cell activity increased immediately
after the jump and within one hour, the NK cells fell to below baseline (Schedlowski,
Jacobs, Stratmann, Richter, Hadicke, Tewes, Wagner, & Schmidt, 1993). Both NK cells
and lymphocyte count have been shown to respond to stress and the perception of stress.
Chronic stress in some studies has been shown to have an opposite effect (Eysenck,
1983; 1984a; 1984b). Eysenck calls this factor the inoculation effect, which supports the
idea that coping is a mediator to stressors. In a study by Rodin (1980; 1986), elders
subjected to stress and exhibiting helplessness were taught new cooing strategies. These
adults not only became happier and more actively interested, but survived significantly
longer than their cohorts without training. Cortisol levels (which display
immunosuppressant capabilities) were also measured in this study. In the group that
learned new coping strategies, the participants' cortisol level decreased significantly. A one
year follow-up indicated these levels were maintained.
Cancer patients were provided with chemotherapy alone or chemotherapy and
cognitive behavioral training to cope (Grossarth-Maticek, Kanazir, Vetter, and Jankovic
(1983). Mean survival time of all patients was 15.7 months. Those receiving
chemotherapy alone survived 2.8 months longer; those receiving coping training alone

36
increased their survival time 3.64 months. Patients receiving both treatments increased
their survival time by 22.4 months. This clearly demonstrates a synergistic effect by using
both treatments.
It is not enough, however, to know that what we think and how we express our
emotions affect autonomic functioning such as the immune system, lymphocyte count and
hormone levels. It is equally important to know how the effect occurs. In his pioneering
research, Robert Ader (1981) demonstrated the ability to train rats through behavioral
conditioning to increase or inhibit their immune system functioning thus suggesting that
even the autonomic system functioning can be affected by learning.
When stress occurs, corticosteroids from the cortex of the adrenal glands raise
blood sugar levels, reduce inflammation, and suppress immune system functioning. They
also prompt mood changes, especially depression. The medulla of the adrenal glands
secrete eoinechrine and norepinephrine which increase heart rate and blood pressure to
deliver blood to the large muscles in preparation for a flight or fight response.
Norepinephrine also increases the natural killer cells, cells believed to attack cancer cells.
These discoveries led to the question of how the transmission of the message releases
certain hormones when certain perceptions occur. Neuropeptides flowing to and from the
pituitary gland have been linked to the body's stress responses, the immune system, and the
limbic system, that portion of the brain critical to drives and emotions. Furthermore, this
interconnected message delivery system is reciprocal.

37
The Role of Emotions
Research has supported the notion that cognition affects both the experience of an
illness and in at least some cases, the progression of the illness. Studies have shown that
there is a correlation between cognition and these factors, that changing cognition
positively affects these factors, and that cognitive restructuring can even predict long term
survival.
But what about emotions? Other studies have demonstrated the effect of the lack
of emotional expression and it's effect on the immune system and cancer. Aside from the
expression of emotion, the linking of certain emotions with cancer has had a long history of
exploration. The results in this body of literature are mixed. Mixed results demonstrating
the link between depression and progression of disease have been found in the
psychological literature. Some findings demonstrate effects of emotions on physical
functioning (Epning-Jordan et al. 1994; Grossarth-Maticek. 1992; Herbert Sc Cohen.
1993); other studies found no relationship (Buddeberg, Wolf, Sieber, Riehl-Emde,
Bergant, Steiner, Landolt-Ritter, & Richter, 1991; Cassileth, Lusk, Miller, Brown, &
Miller, 1985; Jamison, Burish, & Wallston, 1987). If the medical literature is consulted,
depression is not associated with cancer (Hahn & Pettiti, 1988; Weissman, Myers, &
Thompson, 1986). The difference lies in the methodology of these studies and the
difference definitions of depression. The medical literature uses the standard of "clinical
pathological depression", typically the MMPI Scale, while the psychological literature uses
depression scales which detect depressive symptoms in fully-functioning people. Some of
the psychological studies use broad measures of emotional distress and others use measures

38
of specific emotional reactions. The medical literature contains an abundance of
epidemiological surveys while the psychological literature uses more experimental and
quasi-experimental designs.
Another chronic emotional state associated with illness is hostility. Hostility has
been identified as one of the causal factors in heart disease (Dembroski, MacDougall,
Costa, & Grandits, 1989; Hecker, Chesney, Black, & Frautschi, 1988), and related to
general health outcomes (Adams, 1994). A link between hostility and cancer has not been
explored.
The role of emotion in illness goes far beyond contributing to the cause or
inhibiting recover}'. Interactive effects between emotion and cognition are powerful
determinants of health and enjoy a long history of research. Although there is an integral
relationship between emotion and cognitions influencing illness, reviewing the literature
devoted to this body of knowledge is beyond the scone of this research.
Constructivist Approaches to Perception
Perception is the key to how events are interpreted and it is essentially social in its
nature. Every culture has its images of illness and healing. The shaman drew on self-
healing through images of spirits, the Chinese drew on self-healing through facilitating the
energy flow of the body. Even Western medicine has acknowledged the power of the
placebo effect. In an analysis of eleven published double-blind studies conducted in
various laboratories on pain relievers, Evans (1981) found that 36% of the patients taking a
placebo experienced at least 50% pain relief. In another study conducted on responses to a
variety of medical problems (hypertension, cardiac pain, headaches, blood cell counts,

39
fever and others) Evans (1985) found a placebo effect of 55% across various medical
procedures. The common feature among the cultural images of illnesses and the ensuing
attempt to cure are the belief that the cure will work.
Even though the culture provides a framework for the interpretation of illness,
images are not only cultural but are also highly idiosyncratic (Rolland, 1987). These
culturally-bounded, idiosyncratic beliefs determine people’s attributions of causality
(Eklund & MacDonald, 1991), self-efficacy (Bandura, 1985), prognosis (Peterson &
Seligman, 1987), and the actions they take (Ajzen & Timko, 1986).
How does a patient arrive at a definition of his/her disease? How does a "body of
knowledge" about a disease become an accepted reality? The tenets of constructivistic
approaches provide a framework from which to explore this problem. Both the social
constructionist and the cognitive constructivists share an important perspective for this
study. The commonality between these anproaches are that reality is constructed (a
process of mentation) and reality is heavily influenced by the social context. The
perception of reality then, is a function of both the social context and an individual's active
construal of events.
Beginning with the visit to the doctor, the "problem" takes the form of a
construction shared by the patient and the physician. Differences have been documented
in the reporting of symptoms by patients based on different approaches from the physician,
and by the gender, age, race, and class of the patient (Svarstad, 1976). In an early study by
Klein (1967), spouses of the persons identified as having a serious illness often had
significant illnesses themselves and, in some cases, more severe than the spouses but they

40
were never labeled as the "ill" persons in the family. Apparently the image of illness and
the roles of the family members took precedence in defining the "reality" although these
constructs were clearly disparate from the biology of the people involved.
Constructionism is built on the premise that humans construe their realities.
Experience can only be known through the structures and functions of the nervous system,
which according to Hayek (1952) is primarily a classification system. The manner by
which experiences are classified, rather than a lens from which to view the world, becomes
a construct which drives a person toward the creation of experiences, definitions of those
experiences, and ascription of meaning to those experiences. This proactive system of
construing not only determines the output but also the input (Guidano, 1984). This is not
to suggest, however, that the inner experience of "constructs" is an isolated system.
Maturanna and Varela (1987) state that the ascription of meaning regarding the
coordination of behavior occurs in the context of two or more people. But meaning is not
always in the form of language. Meaning is socially constructed, an outgrowth of culture
and context, and the process of assigning meaning goes beyond language and conscious
categorization (Kelly, 1955).
Lakoff and Johnson (1980) distinguish between conception and experience.
Experience is direct interaction with the physical environment and bodily sensation and can
occur without language. Conceptualization (perception) is grounded not only in this spatial
experience and physical sensation but in a vast background of cultural presuppositions.
Research suggests that people will change without conscious categorization of material. In
a study by Langer (1989), a group of seventy-five year olds was placed in a retreat setting

41
retrofitted with objects characteristic of twenty years earlier. They were simply told, "Be
fifty-five again." Within a week, the participants demonstrated incredible changes in
dexterity, hearing, taste, height, IQ, and attitude as compared with a control group in a
setting without the retrofitted environment. Although this phenomenon occurred within a
social context, the effects of meaning were outside the realm of conscious construction and
outside language. The participants' co-constructed meaning was influenced by the
interaction of the physical environment and their formerly constructed understanding of
what it meant to be fifty-five.
It is quite likely also that the constructs of ill people and disease are unconsciously
represented, are socially constructed and determine to a great degree the choices made
regarding illness. How and with whom the information concerning one's disease is attained
and processed will affect the patient and the disease. "Reality" is maintained by social
processes and the presence of interaction is central to maintaining reality during a crisis.
The most important vehicle in the maintainance of this reality is communication. The role
of language begins with labeling the experience and sharing that label with another person.
Two processes are described by social constructionists that may influence the
decision-making processes in a family when disease occurs: primary socialization and
secondary socialization. Primary socialization consists of the information presented to us
as children that we accept as "reality" without further scrutiny. Later in life, we are
presented with other socialization messages garnered from our experience with other
people. Berger and Luckman (1966) described secondary socialization as the acquisition
of role-specific knowledge, internalized through the role-specific vocabulary. On both a

42
cognitive and an emotional level, a cohesive "reality" is internalized along with the
institutionalized body of meanings that accompany the role. However, because this
secondary socialization is imposed on an already formed primary socialization,
discrepancies may arise between the two. For secondary socialization to take precedence,
it must be reinforced. Berger and Luckman suggest that a person's social base serves as the
laboratory for transforming the primary socialization, through strong affective bonds, to a
secondary socialization. The family and friends of a cancer patient serve as this laboratory
and the group mediates the illness experience.
George Kelly (1955) postulated that people are "personal scientists." He stated
that, "Man looks at his world through transparent patterns or templets which he creates
and then attempts to fit over the realities of which the world is composed. The fit is not
always very good These patterns are tentatively tried on for size" (Kelly, 1955, p. 42).
It is through these attempts to fit experience to the constructs that the constructs are altered.
This appears to be analogous to active decision-making and may be the most adaptive for
effective coping and enhancement of treatment.
An imaginary example to demonstrate this point is the story about George and
Louise. George and Louise had been married for twenty-four years when Louise was
diagnosed with breast cancer. Louise's grandmother had died of cancer when Louise was
eleven. Louise doesn't know what kind of cancer. Visiting had come to a sudden halt and,
for a long time, only her mother saw her grandmother. Just days before her death, Louise
was told that her grandmother had cancer and was dying. As a result of this experience.

43
Louise's primary socialization around disease was formed: disease is not discussed, cancer
leads to death, activity comes to a halt, and one isolates oneself when seriously ill.
When Louise herself was diagnosed with cancer, she automatically fell into the
pattern she had seen with her grandmother. She did not discuss the issue with her
husband and halted her activities without explanation to others around her. The definition,
means of coping, and expected outcomes of her disease were defined by the construction
she had learned in childhood. Her story is an example of a cognitive commitment made to
a pre-existing schema.
After several months of depression while undergoing radiation, Louise was referred
to a counselor. In the process, she and the counselor examined how she had arrived at the
decisions about her illness. Together they began to construct new parameters for the
disease. Louise began to question the silence with her husband. When she did discuss her
cancer in deoth with him. he told her a very different story about cancer learned from his
childhood. Together they were able to reconstruct her decisions relating to her illness. This
reconstruction is what Berger and Luckman would define secondary socialization. Her
depression lifted, her radiation therapy worked and Louise is now a "Bosom Buddy."
(Bosom Buddies is a nationally organized support group for women who have/had breast
cancer.)
Although perception plays a key role in coping and recovery, it is clearly influenced
by cultural and individual factors. Schemata about events are formulated through our
experiences embedded within a culture and then when faced with that event on a more
personal level, a person's perceptions are heavily influenced by this existing schema. The

44
influence of this schema creates a frame from which the person actively construes the
personal events as they unfold. It is from such a template and system of construal that
decisions are made when a person faces a life-threatening illness. Acting upon perceptions
and images requires making decisions.
Decision Making and Illness
Medical decision making has been viewed historically as a process carried out by
the deliverers of medical services. The majority of contemporaiy literature reflects this
stance. Considerable research has focused on physician judgement about illness and
treatment (for example: Harris, Evans, Dennis, & Dean, 1996). A few studies considered
patient variables in addition to the illness (for example: Mort, 1996). And many other
studies investigated the effects of certain policy decisions affecting the delivery of services
(for example: Larson, Christenson, Abbott, & Franz, 1996).
Only two topics brought the researchers to consider the patient's decision-making
process: the choice of when to seek treatment and the choice to die rather than treat.
Research has been conducted on these topics since the early 1980's and is accruing.
However, there are many decisions made in addition to seeking initial treatment and
choosing to die. Yet this decision-making has been sorely neglected. In seventy-five
articles published in psych-lit in 1997 on medical decision making (not including the two
topics mentioned), only eight focused on decision making by the patient. In 1996, only six
articles of the one hundred and sixty-nine published reflected the patient's point of view.
Within the last few years, the medical literature contains more research, but many studies

45
still reflect the biased perspective of convincing the patients to make decisions in
accordance with medical providers.
Patients today are playing an increasingly central role in medical decisions that
concern their well-being. However, what professionals believe are patient preferences
often differ from what the patient really wants (Kane, 1996). Recent investigations of the
choice to seek treatment reveal that the choice is more attitudinally based than symptom
based. It was not the symptoms that prompted elderly patients in one study to seek medical
treatment but the perception and causal attributions that proved to be the most predictive
(Stoller & Forster, 1994). In another study (Hitchcock & Matthews, 1992), participants
exhibiting more sensitivity to illness words engaged in more catastrophic thought about
their illness and sought medical treatment more frequently. Life satisfaction was shown to
be more predictive than symptomatic discomfort in determining level of functioning among
chronic pulmonary disease patients (Cameron, Leventbal, & Leventhal. 1995: Leidv &
Haase, 1996).
Specific to decisions concerning cancer treatment, two factors were found to
influence decision-making: the amount and specificity of recommendations and the
strength of the recommendations (Siminoff & Fetting, 1991). The first refers to the ability
of a patient to comprehend and store the recommendations in long term memory. The
second, strength of recommendation, was found to be a factor influencing a patient's
motivation to process the information effortfully (Petty & Cacioppo, 1986). Both of these
clearly posit the decision-making power with the physician rather than the patient. In the
Siminoff and Fetting study, eighty percent of the patients accepted the physician's

46
recommendations. Those who did not were more educated and considered themselves
risk-takers.
Information about medical choices is often presented in probabilistic terms
(Kahneman, Slovic, & Tversky, 1982). Whether the problem is formulated as a loss or a
gain influences the choices. The problem becomes socially constructed through language.
For instance, one study investigated how medical decisions were influenced by whether a
message was presented in terms of possibility of survival or morbidity. One experiment
dealt with the choice of radiation or surgery for lung cancer; the other with the choice of a
normal, risky, or abnormal pregnancy. People interpreted an ambiguous frame in highly
selective ways that were in consonance with their values or beliefs. Those presented with a
survival framework chose the riskier cancer treatment than those presented with a mortality
framework. Fewer differences were found in the pregnancy decisions. Risk was more
attractive in the positive frame than in the negative frame (McNeil. Pauker, & Tverskv.
1988).
A recent line of investigation queries whether patients wish to be involved in
decisions about their treatment. Findings report that patients desire more involvement
(Brody, Miller, & Lerman, 1989) and when they are involved, they report more
satisfaction with their care(Valente, Antlizt, & Boyd, 1988), adhere to recommendations
(Greenfield, Kaplan, & Ware, 1988), and experience better health outcomes (Greenfield,
Kaplan, & Ware, 1985). In an investigation of women with breast cancer, 22% wanted to
select their own treatment, 44% wanted to do so collaboratively with the physician, and
34% wanted their physician to choose (Degner, Kristjanson, Bowman, Jeffrey, Sloan,

47
Carriere, O'Neill, & Bilodeau, 1997). Only 42% of the women felt they achieved their
desired role in the decision making about their treatment. The majority of these women
wanted more control, while 14.9% of those who felt dissatisfied believed they were
"pushed" to assume more decisional control than they wanted.
While the physician may make treatment decisions based on the symptoms and
effectiveness of cure, the patient bases treatment decisions on a personal knowledge of
his/her values and beliefs. In a study on men with prostatic hyperplasia, the possibility of
sexual dysfunction predicted their decision about surgery (Barry, Fowler, Mulley,
Henderson, & Wennberg, 1995).
The results of these studies clearly indicate that decision-making for medical
reasons is far from data-driven, is influenceable, and carries major consequences. Yet
decision-making concerning medical issues is surprisingly neglected in the research
literature.
Some Decisional Styles May Enhance Coping
The growing perception of medical services as a consumer product (Reiter, Lench,
& Gambone, 1989) and the health component of the women’s movement (Rodin &
Ickovics, 1990) have increased research on physician-patient communication, focusing on
the patient's role in decision-making. Active information sharing in decision-making
process enhance the patient's perception of control and self-responsibility (Lerman,
Broday, Caputo, Smith, Lazaro, & Wolfson, 1990). Patients actively involved in their
decisions about treatment demonstrated improved health outcomes (Garrity & Lawson,

48
1989), less functional disability (Greenfield, Kaplan, & Ware, 1985), and faster recovery
(Wallace, 1986).
Increased adherence to medication regimens has been linked with the sharing of
more information between physician and patient (DiMatteo, Hays, & Sherboume, 1992;
DiMatteo, Sherboume, Hays, Ordway, Kravitz, McGynn, Kaplan, & Rogers, 1993).
Although information exchange does not necessarily constitute active decision-making, it
does indicate a higher level of involvement on the part of the patient. These studies were
conducted on people's naturally occurring style of reacting to a medical situation. One
study investigated the effects of changing patient's participation through participation
training. Training focused on question-asking and participation in informed consent. It did
not lead to greater satisfaction with their visit and other measures of treatment outcome
were not assessed (Greenfield, Kaplan, & Ware, 1985; Roter, 1984).
Even the perception of choice increases a sense of control, which has been shown
to positively affect health outcomes. Significantly more positive results have also been
found when people chose their treatment than those who were not given a choice. Several
studies gave people the identical treatment or protocols to follow, manipulating only their
sense of choice. The groups of participants who attributed the choice to themselves
responded more favorably to treatment (Gordon, Mendonca & Brehm, 1983), engaged in
more healthful activities (Thompson & Wankel, 1980), and reported a reduction in anxiety
and depression in response to a cancer diagnosis (Morris & Royle, 1988). However, the
relationship exhibited in these studies are not so definitive when the perception of control
variance is considered. The amount of perceived control over choice of treatment was

49
associated with the participants' prior beliefs about control over their health rather than the
circumstances presented by the medical system (England & Evans, 1992).
Having a choice and participating in one's medical decisions, as both active and
passive decisional styles do, could lead to positive health outcomes. While decision making
appears to be a critical factor in determining these health outcomes, evidence suggests
individual differences rather than opportunity direct the process.
Coping
With the accepted theories of coping, two significant factors emerged: coping
mechanisms actually reduce stress and that coping mechanisms act as a buffer in the face
of stress. Lazarus and Folkman (1984) conceptualized coping as consisting of four
elements: stimulus, appraisal, response, and outcome. Coping involves purposeful
thoughts and actions taken to reduce a threat. Coping is therefore a conscious decision to
do or not do somethins.
In this study, coping is viewed as a transactional model. Coping is situation and
time-specific because it is constantly modified through appraisal and reappraisals of one's
efforts and the situation. Coping is also individual and conforms to a generalized pattern of
behavior in response to stress (Carver, Schenier, & Weintraub, 1989; Miller, Combs, &
Stoddard, 1989).
Cancer as the Stimulus for Coping
Cancer has been investigated both as a generalized experience and as a condition
having unique and specific demands. When viewed as a unitary variable, results are likely
to be haphazard because it assumes that all cancers pose the same demands or the same

50
cancer poses the same demands on all individuals (Parle & Maguire, 1995). Evidence has
been gathered indicating that coping with cancer is situation and time specific (Buddeberg,
Sieber, Wolf, Landolt-Ritier, Richter, & Steiner, 1996). Inviting the patient to focus on the
identification and response to one particular stressor elicits both the generalized pattern and
the situation-specific response. The current study uses the latter approach. Specific stimuli
demands that may trigger a need to invoke a coping strategy are severity (Aldwin &
Revenson, 1987), controllability (Smith, Ackerman, & Blotcky, 1989), threats to self¬
esteem and self-identity (Curbow & Somerfield, 1991; Curbow, Somerfield, Legro, &
Sonnega, 1990), threats to the integrity of the body, threats to quality of life (Mattlin,
Wethington, & Kessler, 1990), threats imposed by limitations of treatment or illness, and
inadequate social supports (Blanchard, Albrecht, Ruckdeschel, Grant, & Hemnick, 1995).
Coping Appraisal
Aopraisal includes both the individual's judgement on the threat Corimarv anoraisal)
and the recognition of what options exist to manage the threat (secondary appraisal).
Subjective appraisal has been found to play a significant role in coping (Dunkel-Schetter,
Feinstein, Taylor, & Falke, 1994; Folkman, Lazarus, Dunkel-Schetter, Delongis, & Gruen,
1986; Lazarus & Folkman, 1984). Maladaptive coping strategies were initiated in cervical
cancer patients who selectively attend to negative features (MacLeod & Hagan, 1992). In
another study, patients were assessed upon diagnosis about their worries and expectations
for the cancer and coping. Those who used a negative assessment demonstrated
significantly higher levels of affective disorders eight weeks later (Parle, Jones, & Maguire,
1994). In fact, appraisal has been shown to be more predictive of effective coping than the

51
state of the illness (Dunkel-Schetter et al, 1992). Among cancer patients, a positive
reinterpretation of the illness has been associated with reduced distress and a coping
strategy of escape-avoidance has been associated with increased distress. Appraisal is
clearly a pivotal mediating factor in coping.
One domain, attribution of causality, in which appraisal operates, is significant to
coping. Attributions made in response to disease operate independently of the usual
attributional style of the individual (Moulton, Sweet, Temoshek, & Mandel, 1987) and
change over time (Schoeneman & Curry, 1990). Health attribution does not appear to be a
stable feature but situation specific. How are health attributions determined? Social
influence offers a possible answer; important to effective coping is the availability of
partners to provide feedback on daily changes (Monge, 1982) and re-evaluation of the
couple's common goals (Stetz, Lewis, & Primono, 1986).
Another domain determined by appraisal is self-efficacy. Studies on self-efficacy
in coping have investigated coping variables that promote resolution of a specific aspect of
the illness. Different patterns of coping were found in dealing with cancer-related
problems than with other life problems (Cook-Gotay, 1984; Meyerowitz, 1983). Diet
(Caesar & Tucker, 1991), distressing medical procedures (Litt, 1988) and coping with
chemotherapy (Miller, Combs, & Stoddard, 1989) have all been shown to improve with
increased self-efficacy.
Response to Coping: Coping Strategies
The idea that coping be viewed as a process rather than a trait fostered research
focusing on specific strategies and the discovery of delineated patterns of coping. Less

52
distress was demonstrated in cancer patients who used a more positive or confrontational
approach to their illness (Burgess, Morris, & Pettingale, 1988; Feifel, Strack, & Nagy,
1987a). In contrast, those patients using avoidance and acceptance-resignation
demonstrated more emotional distress (Rodrigue, Boggs, Weiner, & Behen, 1993). A
positive reinterpretation of the illness experience (Felton, Revenson, & Heinrichsen, 1984)
and more problem-focused coping (Billings & Moos, 1981) resulted in less distress. In the
most extensive coping study conducted on 668 cancer patients, cognitive appraisals of
stress were associated with three of the five coping patterns. Emotional distress was
associated with focusing on the positive and escape-avoidance coping (Dunkel-Schetter,
Feinstein, Taylor, & Falke, 1992).
Patients who mentally prepared themselves for chemotherapy took actions to
reduce the threat. Those who avoided thinking about it reported increased anxiety which
led to unsuccessful actions to reduce their stress. The action taken by avoiders was not
adaptive while that taken by the cognitive coping group reported less distress and improved
adaptation (Lev, 1992).
In contrast, some studies found that both the cognitive approach to coping and
avoidance reduced stress (Manuel, Roth, Keefe, & Brantley, 1987). But, these results
were found immediately after diagnosis. When measured over time, stress increased in the
avoidance group and decreased in the cognitive group. In a study by Dean and Surtees
(1989), time was also reported as a factor in coping effectiveness with very different
results. They found that women with breast cancer were more likely to remain disease free
during an eight year follow-up period if they reported using denial more than other coping

53
strategies. The coping strategies denial was compared with were hopelessness/helplessness
or stoic acceptance, neither of which could be considered a cognitive coping strategy. In a
replication of this study (Buddeberg, Sieber, Wolf, Landolt-Ritter, Richter, & Steiner,
1996) the results were inconclusive with the exception of the discovery that patients use
different patterns of coping over time. In an exploration including both individual patterns
of coping and situation specific patterns of coping, Carver, Scheier, & Weintraub (1989)
suggested that coping is determined by the "fit" between an individual's preferred way of
coping and the demands of the situation. Flexibility has been identified by other
researchers as essential in coping with illness demands (Rowland, 1989; Dunkel-Schetter et
al, 1992).
Outcomes of Coping
Two types of outcomes have been explored. The first is the relationship between
level of distress or affective disorder and cooine strategies. The second is nrosressior» and
recurrence of illness, or survival rates. Many of the earlier studies on coping with cancer
measured distress broadly and found little relationship between coping and cancer
outcomes. However, when the dependent measures were specific to certain types of
distress and independent variables were measured for specific ways of coping, the results
indicated a relationship.
Other outcomes measures of coping were physical in nature. Patients using
cognitive coping strategies required significantly less pain medication and reported less pain
following cancer breast surgery' than those using affective strategies (Jacobsen & Butler,
1996). Men with HIV who used a "fighting spirit" coping style were found to have fewer

54
HIV related symptoms one year later (Mulder, Antoni, Duivenvoorden, Kaugmann, &
Goodkin, 1994; Solano, Costa, Salvatis, Coda, Auiti, Mezzaroma, & Bertini, 1993). In a
ten and fifteen year follow-up study of women with breast cancer, fighters and deniers
were more than twice as likely to be alive than those who felt hopeless and helpless (Greer,
Morris, Pettingale, & Haybrittle, 1990).
By studying the underlying mechanisms, such as decision-making, which may
influence the choice of coping strategies utilized, understanding of the complex nature of
coping may be advanced.
Integration Of Mindfulness and Social Influence Theories
"Attitudes structure one's social universe and, in so doing, ease decision-making"
(Fazio, 1995). Gordon Allport (1935, p. 806) stated,
"Without guiding attitudes the individual is confused and baffled. Some
kind of preparation is essential before he can make a satisfactory
observation, pass suitable judgement, or make any but the most primitive
Attitudes provide the benchmark against which to weigh options. The following
review of the research indicates that the postulates of both Langer’s theory of mindfulness
and Petty and Cacioppo's elaboration likelihood model (an attitude change theory) describe
a strikingly similar process. Research supporting both theories has demonstrated similar
variables affecting the processing of information. The strength of Langer's theory is the
research in applied settings and the strength of Petty and Cacioppo's theory is the enormous
amount of research support it has garnered. Integrating these theories provides evidence of

55
three decisional styles and two routes of processing as well as the variables influencing
which route of processing is likely to be used.
In spite of an obvious link between attitude and decisions, because of having
different goals in their research, the attitude theory literature and decision making literature
rarely directly address this connection. Because of the link between socially constructed
attitudes and relatively individual decision-making, it is theoretically logical to use both in
an investigation of medical decision-making. This integration is further supported by the
parallels found in the research on both the theory of mindfulness and attitude change
theories. The postulates and their supporting evidence result in a common explanation for
decision-making behavior. But theoretical consistency is not the only reason to integrate
these theories. Practically speaking, the theory of mindfulness provides explanations for
different styles of deciding when the message is uncontrollable (as in natural settings),
while the social influence models provide a well-researched mechanism of change. The
implications of using both for this study are that these theories may be expanded, will be
tested in a "real world" serious threat situation, and should provide information in
developing programs to assist people in efforts to cope with cancer.
One of the earliest and most researched of these attitude change theories is the
elaboration likelihood model of attitude change. After culling through the inconsistent
results of a decade of research on attitude change, Petty and Cacioppo (1981) identified
two modes of processing: central and peripheral. In integrating the attitude change
research, Petty and Cacioppo placed the findings on a continuum ranging from low
likelihood to evaluate a message (peripheral route) to high likelihood to evaluate a message

56
(central). The low end is dominated by theories such as classical and operant conditioning
and the high end dominated by theories emphasizing issue-relevant thinking, an example
being Ajzen and Fishbein's theory of reasoned action (1980). Because of its inclusiveness,
the elaboration likelihood model (ELM) provides a powerful framework for organizing and
integrating these theories.
Decision Making and Different Modes of Processing
Conventional wisdom judges a "good" decision as one that has a "good" outcome.
What then does a person do when the outcome is unpredictable? When the expected
"good" outcome does not occur, does that mean the decision was "bad" and the decision
maker "wrong"? Decision theorists suggest that the way a person makes a decision is far
more crucial to this determination than outcome analysis. A cost-benefit analysis based on
information gathered and then formulated into a problem to be solved leads to the best
decision possible at the time.
Langer's theory (1994) suggested that people will arrive at a decision when they
make a cognitive commitment, not when all the costs and benefits have been weighed.
"Cognitive commitments are frozen or rigidly held beliefs that unwittingly are unmodulated
by context" (Shank & Langer, 1994, p. 34). She suggested that the cost-benefits
perspective is postdecisional and used merely to justify the choice. In a study, Klein and
Kunda (1992) manipulated participants' motivation to see a person as more or less capable
by being told the person was going to be their opponent or their team member. Although
they had no basis forjudging this prior to their stated assessment, they post-decisionally
constructed rational justifications for their choice.

57
According to Langer, the dynamic process of choice is characterized by instability
and uncertainty. Uncertainty drives a person to either gather information or induce stability
by making a cognitive commitment. There is no natural end point to information gathering
and a search ends when the person settles on a cognitive commitment.
The decision itself is automatic, i.e., not calculated. Information can be gathered
but it does not inform us of our preferences. Our preferences are that which is stable.
Stable preferences suggest a predetermined mindset that influenced the decision. When a
mindset or schema is reached or constructed, the choice is made.
In this way, Langer viewed decision making not as a continuum or dichtotomy of
rational vs. irrational, but as arational. She distinguished two forms of decision making:
mindful and mindless. Mindful decision making (also termed active deciding) consists of
self-awareness and the generation of new options based on information given or gathered.
A choice is made from among that expanded list of choices. In the mindful condition, the
information integration and gathering continues until one choice is psychologically different
for the person. Schema still governs this process but it is broad enough to allow the
investigation to continue until a cognitive commitment is made to a choice after effortful
consideration.
Attitude change theorists also identified two modes of processing. Petty and
Cacioppo (1981) called these modes central and peripheral route processing, Chaiken
(1984) called them heuristic and systematic, and Fazio (1995) described them as automatic
activation and effortful, deliberate processing. All three theorists agree that central route,
systematic, and effortful deliberate processing are the same. Central processing depends

58
on the amount of elaboration or effortful thinking a person is willing to engage in. Petty
and Cacioppo (1986, p.14) state, "elaboration means the process of relating the to-be-
evaluated recommendations and arguments to other issue relevant information in
memory....(resulting) in self-generation of information unique to externally provided
communication." The similarities to Langer's description of mindfulness (active deciding)
are clearly evident.
Petty and Cacioppo (1986) interpreted mindfulness vs. mindlessness as automatic
vs. controlled processing. They said that central route processing is a particular kind of
controlled processing conducted for the purpose of evaluation. The stated purpose of their
research program was to understand a person's specific attitudinal reaction to a particular
message. Because they chose a narrowly proscribed aspect of attitude change with which
to conduct their studies does not preclude their theory being broad enough to apply to
people's decision-making patterns in natural settings.
Chaiken (1987) differentiated her heuristic/systematic processing from Petty and
Cacioppo's central/peripheral route processing on only one dimension. She claims the
distinction is that heuristic/systematic is a parallel processing mode occurring
simultaneously, while central/peripheral route processing appears to be mutually exclusive.
Fazio's research on strength of association explains the shift from one route to another. He
stated that the association between the attitude and the object (or issue) in memory will
determine the accessibility of that attitude in informing the decision. No studies were
located that detected whether processing information occurs simultaneously or sequentially.

59
However, extensive research has been conducted manipulating conditons through which
central and peripheral route processing was changed.
Throughout social psychological literature a consensus has been garnered that
people engage in mindless analysis (Craik, 1979;Eagly & Chaiken, 1984; Kahneman,
Slovic, & Tversky, 1982; Langer, 1978; Schneider & Shiffrin, 1977). Petty and Cacioppo
(1986) agree that people in natural settings use peripheral route processing far more than
their laboratory experiments would lead one to believe.
Evidence of Mindlessness
In study after study, Langer sought naturally occurring conditions to assess the
degree of mindlessness engaged in by people. Much of her research has far-reaching
implications for health. A recent study (Langer, Mueller, & Brown, 1993) compared
hearing and hearing-impaired people. They hypothesized that the hearing impaired would
have had less opportunity early in life to establish oreconceived ideas on memorv loss in
the elderly and, therefore, would perform better on memory tests. If information cannot be
retrieved from memory, a decision is more likely to be made by considering more carefully
the current situation. The hypothesis was confirmed.
Langer and Piper (1987) studied elderly adults who lived with a grandparent at age
two and others at age twelve. The assumption was that those who lived with elderly people
at a young age would have a preconceived schema about age that elderly people were
strong and capable (a two year old's perspective) and those at age twelve would have a
mindset of more fragile elders. She hypothesized that the group which had lived with

60
grandparents at age two would be stronger and healthier themselves as older adults. The
hypothesis was confirmed.
Many other researchers have demonstrated situations in which people do not use
reasoned attribute-based analysis to determine a course of action but make decisions and
perform tasks after only a minimal amount of processing (Abelson, 1976; Bargh, 1984;
Chaiken & Yates, 1985; Cialdini, 1985; Craik & Lockhart, 1972; Langer, 1978; Petty &
Cacioppo, 1981; Sanbonmatsu & Fazio, 1990, exp.2; Schneider & Shiffrin, 1977; Tesser
& Leone, 1977).
People rely primarily on previously formulated attitudes or schema. Evidence of
such a pre-existing schema was obtained in a study by Tesser (1978), in which people were
instructed to think about an issue. As they did their attitudes toward the issue became
polarized in the direction of their initial tendency.
Higgins and Stangor (1988) demonstrated that once a person associates a few cues
with a schema, they will base their judgement on that schema as if all the properties of the
new situation fit the original source properties. Changing the standard by which a situation
is measured changes the schema and allows for increased scrutiny of the attributes of the
situation (Higgins & Lurie, 1983). Langer (1994) describes a situation in which one may
like apples more than oranges and both more than grapefruit. When using the schema of
taste preference, one would choose apples over oranges. She further states that the
direction is not transitive because one may invoke a different schema such as "more is
better when it comes to food" and therefore choose grapefruit.

61
This organized schema was labeled by Chaiken (1984) as heuristic, i.e., simple
decisional rules in order to ease processing without effortful thought. In four experiments
measuring the effects of priming manipulations that vary accessibility or reliability of simple
heuristics showed a consistent, albeit low statistical significance, that both accessibility and
reliability of these simple decisional rules influence the likelihood that they will be used to
evaluate a message (Chaiken et al, 1985; Hicks & Chaiken, 1984). Furthermore, priming
effects were more pronounced for those participants who typically rely on heuristics in
decision making. Although the effects were not statistically robust, they were consistent.
The persuasion impact of cues which elicit the use of a heuristic are a function of
the strength of their association. Fazio (1983) conducted four experiments in which the
subjects were led to expect that they would have to answer questions on the messages
presented. Condition one provided the cue of expectation prior to the message
presentation, condition two provided the cue immediately after message nresentation. and
condition three provided no cues to consolidate the message. Spontaneous formation of
attitudes occurred most frequently under the conditions of expectation cues provided prior
to the message and no evidence of formation of attitudes occurred in the no consolidation
cue condition.
Developed and rehearsed attitudes were shown to be more predictive of decisions
that were unlikely to be modified later (Fazio et al, 1992). The strength of the association
between memory and the issue explains this predictive power. More frequent use of the
association will increase its accessibility (Fazio, Sanbonmatsu, Powell, & Kardes, 1986).
Rehearsing increases the associations between an attitude and an object (Fazio et al, 1982),

62
making it more likely to be invoked when a decision is needed (Fazio, 1989). Effortful
thinking (Fazio et al, 1992, exp. 2) is avoided in this manner. This research conducted in
four different laboratories all support the two routes of processing and the prevalence of
mindless decision making according to pre-existing schema. But the parallels between
mindfulness vs mindlessness and central vs. peripheral route processing are even more
extensive.
Cognitive Commitment
Mindlessness is engendered by cognitive commitments made prematurely.
Cognitive commitments are based on rigidly held beliefs or schemata. Such schemata are
essential in managing the inestimable amount of information available at any one moment.
A stable set of schemata enables the individual to make the world comprehensible and
predictable (Bannister & Franzella, 1971). Once a schema is invoked, new information,
uniciue context, or unfamiliar aspects of a situation will be overlooked. Premature
cognitive commitment is uncritical acceptance of a choice without considering other
choices even possible. What is accepted as truth is not reconsidered (Langer & Imber,
1979).
In one early study (Chanowicz & Langer, 1981), cognitive commitments to
symptoms of a fictional disease were induced. When this group was later told they had the
illness, they reported the fictitious symptoms at a significantly higher rate than the group
who took in the information more mindfully. In another study subjects were presented
with information in either conditional or unconditional language. The hypothesis that
unconditional language would lead to cognitive commitments was confirmed. Generating

63
options never occurred to the group presented information unconditionally (Langer &
Piper, 1987).
Evidence of cognitive commitment is seen in the work of Chaiken (1980) (Eagly &
Chaiken, 1984; Taylor & Fiske, 1978). Assessing the impact of communicator likability by
manipulating response and issue involvement, Chaiken found that when involvement was
low, participants responded more to likability than to message arguments. Petty and
Cacioppo replicated these findings in response to attractiveness (Petty, Cacioppo, &
Schumann, 1983) and expertise (Petty, Cacioppo, & Goldman, 1981). Consonant with
these findings, Langer, Blank, & Chanowicz (1978) found that subjects will comply
mindlessly with a favor unless the favor requires too much effort. Although none of these
studies directly assessed the underlying heuristic or commitment to a schema, there is
evidence that unless a person is motivated to approach a situation with effortful thought,
there is a high likelihood that he/she will respond mindlessly, making a premature cognitive
commitment.
Langer identified three types of cognitive commitments. The previously cited
research is representational of the first, i.e., a personal commitment to content. The second
type occurs when a personal belief is not available, resulting in a cognitive commitment
likely to be made to a societal commitment to content. For example, when a medical
illness strikes, a person will make decisions based on vicarious learning and information
from a referrent group (Monge, 1983; Rodin & Janis, 1979; Stetz, 1986). Most often the
referrent group is the family. When others are perceived to hold the same attitude,
confidence in its validity is increased (Floltz & Miller, 1985).

64
Evidence from studies on multiple source effects within the ELM support Langer's
contention. Harkins and Petty (1981) demonstrated that participants hearing three
different arguments advocating a position from three different sources were more
influenced than those hearing three arguments from one source. In a follow-up study
(Petty & Cacioppo, 1981) findings suggested that increased elaboration occurred when the
arguments came from multiple sources due to further elaboration when each argument was
presented. This effect was shown to increase when the participants were presented as
independent rather than from one cohesive group (Harkins & Petty, 1987). These studies
suggest that people do elaborate more when information is presented by multiple sources
and this effect is increased when the sources appear independent. These findings support
Langer's theory stating that when a person does not arrive at a decision based on a
cognitive commitment previously held, the individual is likely to arrive at a societal
decision. It also suggests that to effectively deliver a message to a cancer patient, sav to
increase adherence, several arguments from several sources will enhance adoption of the
suggestions.
In the third type of cognitive commitment, a person uses an existing schema to
guide decision-making. A process schema dictates factors such as the number of
questions asked, the amount of time spent deciding, and the type of resources consulted,
prior to making a cognitive commitment. Although this process commitment is relatively
stable for an individual, it may also include varying degrees of effort, depending on
situational seriousness. Unless this process commitment is flexible enough to leave a

65
question open long enough for a personal or societal commitment to be made, the decision
will end before true relevance for the individual is established.
Eagly and Chaiken (1984) expanded on the concept of processing in response to
cues by introducing the idea of heuristics, simple decision rules that are invoked in the
absence of motivation and ability to process more effortfully. Sufficiency principle
indicates that people will move from less effortful processing to more effortful processing.
The reverse is also true (Wood & Eagly, 1981). In a series of experiments, Chaiken
(1980) found that participants used simple decisional rules, particularly when presented
with minimal information on the topic. These participants refrained from effortfully
thinking about the validity of the information and relied on the credibility of the source in
forming their opinions.
In a study assessing factors affecting treatment decisions for a life threatening
illness, eighty percent of the oatients accepted the physician's recommendations. Factors
influencing their acceptance were the amount and specificity of the instructions and the
strength of the recommendation. More importantly, non-acceptors were better educated
and tended to be risk-takers (Siminoff & Fetting, 1991). The self-proclamation of risk
taker is an example of a process schema such as, "I make my own decisions." which may
govern their decision about how to treat an illness.
Cognitive Commitments Are Made When Options Become Psychologically Distinct
The importance of cognitive commitments cannot be underestimated since
preferences are only stable once a commitment is reached. Langer (1994) views this as a
correction to one of the thorniest problems in any rational decision theory, that of

66
systematic preference reversals (Cohen & March, 1974; Tversky & Kahneman, 1983).
Attitude change research came close to being abandoned in the seventies because of the
inconsistencies in the research attempts at explanation. Cialdini, Petty , and Cacioppo
(1981) and Eagly and Himmelfarb (1978) began a series of studies aimed at understanding
these discrepancies. They saw evidence of cognitive commitments, both enduring and
transient, which they sought to explicate through studying the conditions under which each
operate.
Langer's hypothesis was supported in a study investigating conditional and
unconditional presentation of information to contact lens buyers. While in the store one
group was given information about one lens solution, another group was given information
about two lens solutions. Several months later, they were all contacted by phone offering
them a consumer opportunity. The only difference between the lens solution now being
offered and the original one was the price. Only those who had not formed a cognitive
commitment tried the new solution (Langer & Li, 1994). In another study by Cacioppo,
Petty, and Sidera (1982) participants generated more topic relevant thought when the
message was congruent with their self-schema about professed attitudes than when the
message was incongruent with this schema.
Langer (1994) stated that a person will entertain the message until options become
psychologically different from each other. The psychological difference is highly
idiosyncratic. The decision will be made when one of the avenues to a cognitive
commitment is accepted. Such commitment then renders meaningful any consistencies

67
found in the environment. These experiences become relevant and will be used to
strengthen the commitment (Craik & Lockhart, 1972).
To understand how the ELM supports the idea that a decision will be made when
psychological differences are noticed and considered relevant, the research addressing its
application to counseling must be considered. In a review of the ELM applied to
counseling literature, Heesacker, Conner, & Pritchard (1995) addressed the issue of
change. Although peripheral-route-processed information may change attitudes, the
change is not enduring (Petty & Cacioppo, 1986). Only centrally processed material
promotes enduring change. This suggests that a preexisting cognitive schema will
determine the decision until a person has the motivation to put forth effortful thought.
Until then, peripheral cues consistent with the pre-existing schema will dominate the
decisional process, and is analogous to a decision ending in premature cognitive
commitment. Change will only take place when the nerson is motivated and enabled to
engage in recognizing and reconsidering the old schema. Essential to understanding what
occurs when a person switches from peripheral to central route processing is recognizing
the idiosyncratic thoughts which support the preexisting schema and assisting the client to
generate arguments that dismantle the ineffective schema which will allow for a new
schema to be built. The erection of a new schema enables options to become
psychologically different in ways not previously entertained and enables an enduring choice
associated with a new schema to be made.
Langer stated that the commitment can be made to either content or process.
Included in the new schema can be clues as to when to re-examine the parameters of the

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new schema, thereby instilling a commitment to process which overrides the commitment
to content, increasing the person's flexibility.
Categories of Decision Making
Langer (1994) described three categories of decision making: active deciding,
passive deciding, and premature committing (mindless deciding). The categories she
established for decisional-styles are discriminated from each other by how decisions are
made and by the point at which the commitment is made. Active deciding consists of
generating options and choosing from among those options. Option generation will
conclude only when enough information is gathered to discriminate in terms of the person's
preferences (i.e. the options are psychologically different from each other for that person).
Passive deciding involves choosing between only those options presented without
generating others based on personal awareness. The choice is settled when a commitment
is made to one of those choices. Lancer's third cateeorv of decision makers is mindless
deciding, which is the form most often used.
Most research on decision making has been conducted on passive decision-making
because laboratory studies use only a finite number of options and rarely allow for a
creative participant to generate new options. Many of Petty and Cacioppo's studies (for
example, those using a semantic differential) assess evaluation of a message through
methods which limit the participant to responding to message options, but many others use
a thought-listing procedure that enables the participant to generate options on their own.
Petty and Cacioppo (1986, p. 14) stated that "elaboration means the process of relating the
to-be-evaluated recommendation or arguments to other issue-relevant information in

69
memory," resulting in self-generation of information unique to externally provided
communication. Their work supports the idea that central route processing is svnonomous
with Langer's active and passive deciding. This point is critical in supporting the
assumption that it is possible to combine the work of Petty and Cacioppo and that of Ellen
Langer.
Passive vs. active deciding was demonstrated in a study investigating conflict
situations (Langer & White, 1992). In one situation, the participants were instructed to
settle their differences without using compromise. This approach forced the pairs to
elaborate on a solution until a win-win situation was found. Subjects not instructed in this
manner used the compromise solution which required less effortful thinking. Another
study (Langer & Williams, 1992) asked participants to make a donation to a homeless
shelter. One group was asked for a particular amount but not restricted from donating a
different amount: the other was asked to actively decide the amount given. Both urouos
had an equal number of donors but the ones who actively decided the amount gave more.
The latter group also reported less post-decision regret.
The third category, mindless choosing, is foreclosure on a preexisting schema.
Premature foreclosure on a decision is devoid of active, ongoing information processing.
Petty and Cacioppo describe this kind of processing as peripheral route processing, highly
influenced by extraneous cues. For instance, a premature cognitive commitment is more
likely to be made when information is given by an authority (Chanowicz & Langer, 1981;
Langer, 1988). In this category, decisions are based on peripheral cues (Petty & Cacioppo,
1986) or heuristics (Chaiken, 1980; Eagly & Chaiken, 1984). Once a person acts on these

70
arbitrary decisions, the choice begins to operate as a schema because the person infers an
attitude from their behavior (Fazio & Zanna, 1981).
Reducing uncertainty may be the goal of mindless deciding (Langer, 1994). The
dimension of uncertainty was labeled and extensively researched by Kruglanski and
Webster (1991, 1993, 1996) as a need for closure. Kruglanski (in press) defined the need
for closure as the desire for definite knowledge and an aversion of ambiguity. The term
"need" is borrowed from Cacioppo and Petty (1982) and identical in its meaning. It refers
to a need for closure on the question and often any answer, rather than the "best" answer,
is all that is required.
Need for closure can be an individual trait or situationally induced. A person high
in need for closure generates fewer options, makes judgements based on inconclusive
evidence and, once committed to a decision, is relunctant to entertain the possibility of
alternatives based on new information. In fact new information is not even noticed. After
such a rigid commitment to a decision, individuals report more certainty in their choice
than individuals low in need for closure. There is theoretical consistency between Langer's
mindless deciding and Kruglanski's need for closure construct. The evidence supporting
the need for closure construct will be addressed in the subsequent section of this chapter.
Because premature commitments are so prevalent, information gathering may often
be motivated by a need to explain and justify the decision after the fact rather than utilizing
the information to think carefully prior to making a decision. Petty (1986) actually cautions
the researcher by suggesting that the cognitive strategies demanded by the responses used
in measuring may color the results.

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Necessary Conditions for Mindfulness
There is a considerable body of research conducted by all these theorists about the
conditions under which a person will use one route of processing or the other. In this
body of accumulated knowledge there are no studies which refute any of the others'
theories. Research promoting one idea supports the others. Apparently, the differences
are in the researchers' foci of attention and semantics.
In the theory of mindfulness, Langer (1989) stated that people will operate
mindlessly unless the following conditions exist: 1) a new situation involves novelty for
which no cognitive commitment exists, 2) mindless deciding is more effortful than mindful
deciding, 3) deciding is interrupted by external events that do not allow for completion of a
commitment, 4) the experience leads to significantly discrepant consequences than those in
the past, 5) there is insufficient involvement in the situation to warrant any reaction and
therefore a schema is never invoked.
The most thorough investigation of these factors was conducted on the ELM.
Petty and Cacioppo (1986) found three pivotal factors encompassing many other variables.
These factors are motivation, cognitive responding, and ability.
Motivation
Motivation is requisite in determining message scrutiny . The factors influencing
motivation are personal relevance, involvement, personal responsibility, multiple sources,
and individual need for cognition. In a review of motivation studies across theorists, Fiske
and Neuberg (1990) concluded that when people had motivation to assess a message, they

72
were data-driven in their analysis; when people lacked the motivation, they were theory-
driven.
Petty and Cacioppo consider the most important variable affecting motivation to
process centrally is personal relevance. Issue-relevant elaboration results in new options
and their integration into one's schema (Petty & Cacioppo, 1984). Active deciding would
also depend on personal relevance. Langer, Blank, and Chanowicz (1978) conducted a
study in which students were asked to give up their turn at a copy machine. Small requests
were accepted without reasons but large requests required a reason. The large requests
increased the personal relevance by making the student wait, thereby increasing their
motivation to think about the request prior to granting the favor.
Manipulating advocacy or counterattitudinal messages in tape recordings, students
were asked to report their views on a taped message (Petty & Cacioppo, 1979). Half the
students were told that the message applied to their own university while the other half
were told it applied to a distant college. Subjects in the high involvement condition
(implementation at their own university) generated predominantly favorable thoughts to the
proattitudinal message and predominantly unfavorable thoughts to the counterattitudinal
message. Replications (Petty, Cacioppo, & Heesacker, 1981; Petty, Cacioppo, &
Schumann, 1983) have been conducted that support the idea that, as personal relevance
increases, people engage in more effortful thinking.
When applying the personal relevance issue to a natural setting, there are several
caveats to consider: first, if personal interests are intense, processing may be conducted in
service to an individual's core constructs and may be biased or terminate (Greenwald,

73
1981). Second, issues truly relevant to an individual may have been given enough prior
thought that expending more energy on thinking is perceived to be useless. Third, people
often seek information about relevant issues and may have an increased store of prior
knowledge (Petty & Cacioppo, 1986). Should this thought have already been generated by
the individuals in this study, it will only enhance the study by serving as a discriminator
between categories of decision-making styles.
Related to relevance is involvement, another motivational variable which mediates
thorough processing of information. Johnson and Eagly (1989) distinguish between three
types of involvement which have a distinctly different effects on information processing.
The first is value-relevant involvement, the activation of attitudes which are linked to core
values. The higher the value relevant involvement, the wider the rejection range of the
message (Sherif, Sherif, & Nebergall, 1965). The second type is impression-relevant
involvement, concern for self-presentation in the responses. The expectation of public
scrutiny of one's views leads to assuming a more moderate, flexible, and less polarized
position when the audience's opinion is unknown (Cialdini & Petty, 1981; Cialdini, Levy,
Herman, & Evenbeck, 1973). Third, outcome relevent involvement (Petty & Cacioppo,
1979), originally referred to this as issue-relevant involvement) refers to the degree to
which the issue personally affects an individual's current goals. This type of involvement
increases the likelihood of elaboration (Chaiken, 1980; Petty, Ostrom, & Brock, 1981).
In a meta-analysis, Johnson and Eagly (1989) found that value-relevant
involvement typically inhibits attitude change. Outcome relevant involvement, the most
extensively researched of the three, showed no main effect and interacted with strength of

74
argument. Strong arguments persuaded, weak ones did not. However, whether effortful
thought created this change in attitude in one condition and not in the other is unknown. It
is just as possible that after thinking about the weak arguments, a mindful decision was
made to retain one's position.
Petty and Cacioppo (1990) took exception with this meta-analysis, stating that
personal importance and not which aspect of importance is what determines relevance.
They made a distinction between the intensity of information processing and the direction
of that processing, each comprised of separate variables. In testing this hypothesis, Petty
and Cacioppo (1986) have shown that as the intensity increases, the quality of arguments
account for more variance. With no bias, strong arguments increase elaboration and weak
arguments decrease elaboration. In unfavorable biased condition, strong arguments had no
impact on elaboration and weak arguments reduced elaboration. They conclude that the
extent of personal importance increases the extent of information processing.
The literature on outcome relevant involvement has limited use in this study. The
issues chosen for these studies were minor to moderate college related issues presented to
undergraduate students. There are tremendous differences between still-dependent average
undergraduate students and adults of all ages. The life and death issue faced by the
participants in this study cannot be accurately compared with issues such as a format for
exams or sharing dormitory space. Yet the most likely, outcome-relevant involvement is
the type that is of greatest concern in this study and, as such, has an effect on motivation.
Stable, intrinsic differences exist among individuals in their motivation to process
information effortfully (Cacioppo & Petty, 1981, 1984; Cacioppo, Petty, & Morris, 1983).

75
Some people simply enjoy thinking more than others. This construct has been defined as a
need for cognition. Need is viewed not as a deficit or having tension reduction goals but as
an intrinsic desire. Taylor (1982) coined the term "cognitive misers" for people low in
need for cognition. The concept of cognitive miser could account for the frequency of
mindless deciding evident in Langer's and Chaiken's research.
Individual differences were found between university professors (assumed to have
high need for cognition and assembly line workers (assumed to have low need for
cognition). Those high in need for cognition generated more thoughts than those low in
need for cognition. In a group brainstorming task, participants low in need for cognition
generated fewer ideas when they shared responsibility to create a list than when they were
held personally responsible (Petty, Cacioppo, & Kramer, 1985). In further testing of this
construct, need for cognition was found to be unrelated to intelligence in both abstract
reasoning and verbal reasoning (Cacioppo, Petty, & Morris, 1983; Eaglv & Warren. 1976).
In a series of three experiments (Cacioppo, Petty, & Morris, 1983) determining
how need for cognition affects message processing, findings demonstrated that individuals
high in need for cognition were more likely to extract information and think effortfully
about a message than those low in cognition. However, it would be inaccurate to assume
that this individual characteristic is so intransigent that it cannot be overridden by situational
factors. The meaning and implications of a decision will have a strong impact as well as
message presentation and prior knowledge. Need for cognition is neither a necessary nor
sufficient cause of message elaboration.

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Ability
If a person is to carefully evaluate a message using central route processing, the
individual must have the ability to do so. Some persons may have greater ability than
others and certain situations facilitate ability more than others. Distraction, message
repetition, recipient posture, forewarning, argument strength, relevance of message, and
time to consider have all been found to influence message processing ability.
In a series of four experiments, Petty, Wells, and Brock (1976) demonstrated that
distraction made processing more effortful. Unfavorable responses were increased as
distraction increased, but, the number of unfavorable responses increased significantly
more for messages with weak arguments than for those with strong arguments. High
distraction reduced the number of unfavorable thoughts for the weak message but not the
overall message and the number of favorable thoughts for the strong message. Attitudinal
effects were most evident in the low and medium range of distraction Other reolications
(Lammers & Becker, 1980) were consistent in their findings that distraction disrupts the
thoughts that would normally be elicited by a message. Distraction inhibits ability
especially when the motivation is high (Petty & Brock, 1981). Interference during message
presentation decreases elaboration likelihood as well (Petty, Cacioppo, & Heesacker,
1981). Langer's theory states that if deciding is interrupted, a cognitive commitment is not
made.
Repetition: Moderate message repetition theoretically should enhance message
acceptance since it extends the time an individual has to attend to the message required in
any new learning situation. Repetition of verbal stimuli has been shown to increase liking

77
in some studies (McCullough & Ostrom, 1974) and decreasing liking in others (Grush,
1976). Petty and Cacioppo (1979) proposed that message repetition elicits a two-stage
reaction. Repeated presentations provide the recipient with extended opportunity to
evaluate and think about the message during the first stage. Tedium sets in when a person
has exhausted associations to think about and the second stage elicits a negative reaction.
Argument strength was again a factor. Moderate repetition of strong arguments led to a
favorable response; moderate repetition of weak arguments led to more negative attitudes
(Cacioppo & Petty, 1985).
Physical cues: Based on the close association between cognition and body cues,
recipient posture was explored. In a series of experiments (Petty, Wells, Heesacker, Brock,
& Cacioppo, 1983), reclining subjects expressed more agreement than standing subjects.
However, comfort was not the intervening variable since those who were seated reported
being the most comfortable and vet had insignificant message agreement Strop? and weak
arguments were not differentiated by the standing subjects. Other physiological factors
involved in message elaboration are heart rate (Cacioppo, Sandman, & Walker, 1978) and
right brain activity (Cacioppo, Petty, & Quintarar, 1982).
Comprehension: Assessing ability in the absence of motivation is difficult. In one
study (Ratneschwar & Chaiken, 1986), the researchers attempted to manipulate ability to
process systematically (centrally). They manipulated comprehensibility by using a written
description of a novel product with or without an accompanying picture. (The product was
relatively undiscemable without picture.) Subjects in low comprehensibility condition
manifested less comprehension and was more easily influenced by the peripheral cue of the

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inventor is status in rating the usefulness of the product. When the comprehension was
medium or high, participants rated usefulness based on the attributes of the product and
reported more effortful thinking in a debriefing.
Comparisons/Similarities
Extensive similarities exist between the social influence theorists. Petty, Cacioppo,
Chaiken, and Fazio and Langer's theory of mindfulness. Ellen Langer researched decision¬
making processing by focusing on the person making the decisions. The social influence
theorists researched the interaction between people by focusing on particular messages and
their effects on a person's processing. In researching these distinctly different topics, each
has resulted in strikingly similar findings.
Both the processes involved explained by each of these theories and the ensuing
research variables are similar. The semantics are different but the theories support each
other Two routes of processing has been proposed in all these theories. Langer calls these
routes mindfulness and mindlessness; Petty and Cacioppo call them central and peripheral
route processing; Chaiken and Shelley call them heuristic and systematic; Fazio calls them
automatic activation and effortful, deliberate processing. The authors draw find
distinctions between the routes of processing they describe and those of the other theorists,
however, the differences described are a result of the focus of their research rather than
any qualitative difference.
The research variables that may affect processing independently chosen for
exploration by each theorist are also surprisingly similar. The largest body of research on
different variables was conducted on Petty and Cacioppo’s ELM, chosen for use in this

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research. With the exception of relevence and individual differences that may affect
processing, Langer's decision making research and Petty & Cacioppo's social influence
research investigated the identical variables in very different ways, resulting in identical
findings.
An integration of these theories is used for this research in order to draw upon the
strengths of each. The topic under discussion in this research is decision making. The
reason for studying this topic is to understand how a person's decisions about medical
treatment affects coping and the variables which may improve coping. Langer's theory is
provides a decision making theory that has been researched in applied settings with medical
and other physical conditions. Petty and Cacioppo's theory has a demonstrated ability to
both identify and change core attitudinal processes through changing the route of
processing. How a person processes information related to medical conditions and arrives
at a decision may affect his/her ability to cope.
Evidence of a Fourth Decisional Style - Ruminating
Ellen Langer (1994) identified three decisional styles: active, passive, and mindless
deciding. However, she also stated that a person will entertain a message until options
become psychologically different from each other. The decision is made when one of the
avenues to a commitment is accepted as the "best option".
The purpose of making a cognitive commitment is to reduce uncertainty (Langer,
1994). But what happens when a person worries about making the "right" decision?
Although there may be a great deal of effort to discriminate between the options, when
reviewed over and over again, the person still cannot "psychologically discriminate" enough

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to reduce the accompanying anxiety. Engaging in effortful thought might indicate central
route processing but thought alone does not determine route of processing. The
determination is made through the creativity and richness of the thoughts produced. In
central route processing, effortful thought is engaged in only as long as new ideas emerge.
Langer (1994) states that there is a two-part process: generating options and then choosing.
Some people, however, do not generate new options and do not choose, thus making their
effortful thought fruitless.
This inability to choose may be explained by the Yerkes-Dodson curve (Yerkes &
Morgulis, 1988). This theory suggests that with too little anxiety, a person is uninvolved
and lacks the motivation to act; too much anxiety and the person lacks the ability to act. It
is suggested in this research that some people, although a minority, will shift between a few
options and never discriminate enough to come to a cognitive commitment to any options,
thereby indicating peripheral route processing. For example, patients may agree under
pressure to do something, such as enter into chemotherapy treatment, yet they internally
experience tremendous anxiety due to equivocating about the wisdom of their decision.
This category of decisional style is named ruminating style. Persons fitting into this
category would express considerable worry and fear about whether their decision was
correct in spite of having begun to act. They would remain uncertain regardless of new
incoming information and they would continue to put forth a great deal of effort into
thinking the same thoughts repeatedly, ignoring the new information. The ruminating style
fits the definition of peripheral route processing because of it's continual shifting of
opinions. Ruminating style will also be marked by high anxiety.

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Rumination is an intrusive thought process that prevents a cognitive commitment to
a decision. For example, until patients can see a clear choice that radiation is better for
their condition and life situation than surgery, they will not feel certain with either decision.
Rumination is differentiated from active deciding by the options generation process
and by the flexibility of the schema involved. In active deciding, a person's information
gathering and the ensuing association process continues only while new ideas are being
generated. Rumination generates very few options or accepts only the few options
presented without establishing any new associations so that new information is never
entertained. In active deciding, once the options are felt to be exhausted, a decision is
made and the schema that the decision rests upon is altered and allowed to remain flexible.
Rumination becomes an impossible choice between two or a few options that are based on
one or more rigidly-held, unadjustable schemata.
The epistemology' studies of Kruglanski and Webster, especially those dealing with
the need for closure construct support the idea of adding rumination as a decisional style.
Kruglanski asked the question, "How does one attain knowledge?" The construct of the
need for closure emerged from his search to account for the inevitable differences in how
people go about selectively absorbing and processing information. Using the same
definition of need as Petty and Cacioppo (1986), the need for closure was defined by
Kruglanski (1989, p. 14) as "the desire for a definite answer on some topic, any answer as
opposed to confusion and ambiguity." In 1990, Kruglanski discriminated between a need
for specific closure and a need for non-specific closure.

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Individuals may process only a limited amount of information before making a
decision or they may generate numerous hypotheses. They may pay careful attention to
"on-line" details, revising their conceptions as they entertain options or they may base their
decisions on information in memory. They may spend time elaborating on information and
deepening their processing or they may use only the most accessible information.
The foundation for these patterns, Kruglanski stated, was motivation. A specific
type of epistemic motivation is the need for closure. The need for closure is both
dispositional and situational and as such has generated considerable research seeking to
understand the conditions under which the need for closure will be heightened or
diminished outside the normal range for a particular individual.
The need for closure is a continuum with people at the high end exhibiting
impulsivity, rigidity of thought, and reluctance to consider other’s views. People at the low
end, those demonstrating a need to avoid closure, represent the group identified in the new
model as ruminators. These are people who suspend judgement when possible, generate
competing alternatives, and experience doubt and ambivalence. The mid range on the
need for closure continuum would be those people who are more likely to elaborate on an
idea arriving at a well-thought out decision. The descriptions of these categories of people
fit both the depth of processing models and the mindfulness model.
Certain antecedent conditions will affect a person's moving toward increased or
decreased need for closure. Two benefits of closure are predictability and impetus for
action and when either of these is perceived as a need, the person will be motivated to
obtain closure on the issue in question. Time pressure increases the need for closure and

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perceived effort decreases the need for closure. Using ELM'S conceptualization that
effortful thinking is aversive to some people, the need for closure, under some
circumstances, would be enhanced because it is simply easier than elaborating.
In the other direction, the need for closure may be decreased in the face of fear of
invalidity. The need for closure conflicts with the need to determine the right answer.
Kruglanski (unpublished manuscript, p. 10) asserts, "Under heightened need for closure a
person may generate fewer competing hypotheses and/or suppress attention to information
inconsistent with one's hypothesis. Both may result in a sense of valid closure, uncontested
by alternative interpretations or inconsistent evidence." Alternatively, other individuals may
react to a heightened demand for validity by postponing closure or even avoiding it. If a
credible source is added to the equation, the fear of invalidity may increase the tendency to
operate on the source's advice and rather than maintaining openness and continuing to
process centrally, a peripheral route of processing will determine the direction of the
decision.
In a study (Mayseless & Kruglanski, 1987, exp. 2) directing participants to operate
a tachistoscope under conditions to either increase or decrease the need for closure, the
extent of their information search was higher in the need to avoid closure than in the need
for closure condition. In experiment three, participants were shown photographs of
unusual perspectives of common items and asked to create lists of hypotheses about the
identity of the items, and asked to then select one. To establish a need for validity
condition, subjects were told that clear cut opinions correlated with intelligence. When
compared with a neutral condition, participants in the need to avoid closure condition

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generated more hypotheses than those in the neutral condition and, in turn, more than
those in the need for closure condition. Similar to the studies conducted by Petty and
Cacioppo and Langer, participants in this study and others (Webster, 1992; Kruglanski,
Webster, & Klem, 1992; Kruglanski & Webster, 1991) exhibited more confidence in the
need for closure condition than any of the others.
Several studies also point to differences in the type of information sought under the
high or low need for closure conditions. In one study (Trope & Bassok, 1983), diagnostic
information was sought in the need to avoid closure state and more stereotypic information
was sought in the need for closure condition. Petty and Cacioppo would view these results
as reliance on peripheral route processing whereas Langer would see the results as mindless
deciding. Similar to studies on these forms of processing are studies that have
demonstrated identical priming effects (Kruglanski & Freund, 1983, exp. 1). Manipulating
the need for closure also resulted in overestimation of conjunctive events and
underestimation of disjunctive events in a high need for closure condition (Kruglanski &
Freund, 1983, exp. 2). Other situations in which a high need for closure resulted in biased
processing were correspondence bias (Webster, 1993) and overattribution bias (Webster,
1993, exp. 2).
This evidence supports the notion that early "seizing" and "freezing" upon
peripheral cues and subsequent inattention to new relevant information occurs in need for
closure conditions. This end of the continuum constitutes the individual differences in
people who inherently possess a high need for closure. Such people also fit the description
of mindless deciding. Evidence also supports the definition of ruminators as people with a

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high need to avoid closure. These results were consistent across different manipulations of
the need for closure as well as differentiating among people with a dispositional high or low
need for closure.
The need for closure construct and the research supporting it are consistent with
both Langer's theory and the ELM. To understand decisional styles, it may be essential to
include those people who cannot seem to make a decision as well as those who come to
their decisions via different methods of processing.
Methodologic Commentary
The body of research upon which this study stands was conducted by some of the
most highly respected social psychological researchers in the country. The number of high
quality studies making fine discriminations between the variables under consideration were
too numerous to cite. This review purports to give only an overview of the available data.
Still certain concerns about methodology must be addressed.
Generalizability must be questioned. Constraints imposed by the laboratory setting
and the undergraduate student samples diminish the external validity of previously
conducted research. This is particularly true for the attitude change theories and need for
closure studies. After decades of accumulating laboratory evidence, several studies have
been conducted on social influence theories in natural settings, but they are far too few to
rely on with confidence.
Eagly (1987) suggested adopting a wider range of methods to bring the
investigation of social influence theory forward. One contribution of Ellen Langer's
research is demonstrated in her ability to find natural occurrences to use as variable

86
manipulations. For example, the study investigating perceptions of elderly people having
been raised by grandparents at different ages and that using hearing vs. non-hearing people
to determine pre-existing schema. Because of using such naturally occurring events, it is
possible to place greater trust in the external validity of these studies. Overall, the variety
of ways in which these theories were tested and the consistency of the results emanating
from several researchers’ laboratories provides a strong foundation for this study.
Cacioppo and Petty (1987) raised some doubts about the use of self-report
measures in social influence research because of the possibility of their cognitive nature
forcing a cognitive process that biases the results. They suggest that affect could play a
considerably larger role than is evidenced in their studies. Cognitive scales were found to
be more predictive with cognitive passages and less so with affective passages (Crites,
Fabrigar, & Petty, 1994). Many of the scales used have been idiosyncratic to attitude
about a specific item or idea leaving validity and reliability somewhat suspect. They call
for a demonstration of consistently high reliability across objects and comparability across
both affective and cognitive material.
The Decisional Processing Model
The Decisional Processing Model for medical decision-making states that patients
will use two routes of processing, central and peripheral. It further states that the central
route processing will include active decisional style and passive decisional style and that
peripheral route processing will include mindless decisional style and ruminating decisional
style. Earlier arguments on the factors influencing physical response to treatment and

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coping, suggest how a person arrives at a medical decision will determine influence the
direction of these factors. In addition to testing the existence of decisional styles,
Decisional Styles Follow Two Routes of Processing
Social influence theorists, focusing on persuasion, integrated the diverse literature
on attitudes. Their discoveries, led by Richard Petty and John Cacioppo, uncovered two
routes of processing information. The semantic differences are inconsequential. There
exist only subtle differences in that some theories emphasize one route over another in their
exploration. Petty and Cacioppo emphasized the central route because they were looking
for enduring qualities of persuasion. Shelley and Chaiken (Chaiken, 1987) emphasized the
heuristic route. Both acknowledged people's use of the alternative route. Simultaneously,
Ellen Langer began to study the effects of decision making that seemed to occur in the
absence of conscious thought. She coined the term mindlessness for the reactionary way
people had of unthinkingly following cues. She also discovered what Petty and Cacioppo
would have labeled peripheral route processing.
Evidence has been presented in previous sections of this review suggesting a
possible integration of not only the three social influence theories but also the theory of
mindfulness. In a symposium on social influence, Alice Eagly (1987) closed the
conference with a summary of the topics presented along with a review of the history of
research in the social influence arena. She stated, "Progress (to end the confusion) might
have been more continuous had investigators been more skilled at integrating research
findings. The need for insightfl integration and accurate aggregation of findings has been
particularly great for social influence research because of its early popularity" amassing

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large, complex, empirical literature at an early point. It is reasonable to bring these theories
together to support a decision-making model because not one study was found in any of
their research that refutes the ideas incorporated in the model presented in this proposal. It
is also reasonable to state that two routes of processing are used in making medical
decisions among patients with life-threatening illness.
Four Decisional Styles
According to Langer (1994), people using active decisional styles make
discriminations between the current event and pre-existing schema, initiate action to obtain
information, and generate options before they decide. People using passive decisional
styles take information as it is presented to them, think effortfully about that information,
and then make a choice without generating new options. Petty and Cacioppo, along with
the other social influence theorists, describe such behavior as indicative of central route
processing.
Other people make decisions by identifying a few simple cues, matching these cues
with a pre-existing schemata, and arrive at a decision by making a cognitive commitment to
that schemata. Petty and Cacioppo's (1986) research supports the idea that under certain
conditions people process information in the way described by Langer. The term used in
this model, taken from Langer, is mindless decisional style. It represents peripheral route
processing.
The research exploring the conditions under which each route of processing may be
used has been conducted by both Langer and the social influence theorists. Findings were
similar. The presence and availability of a pre-existing schema assists in determining which

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category a person fits. All agree that central route processing requires effortful, substantive
thought. All agree that the route of processing is affected by distractions, the amount of
importance, and the amount of involvement, all of which limit a person's motivation and/or
ability to process.
Petty and Cacioppo stated that a person must make a cognitive response and
Langer states that a decision is made when a person makes a cognitive commitment. In
active, passive, and mindless deciding such a cognitive response (commitment) is made.
The decisional processing model asserts that there is a fourth category in which people fit
who do not make a cognitive commitment to any decision. Based on the evidence of Petty
and Cacioppo, a cognitive response does not occur if either motivation or ability is absent.
The Yerkes-Dodson theory states that when anxiety is too high, the ability to process
information is impaired. The fourth category of decisional style includes people who are
impaired and therefore unable to make a satisfactory decision because of their anxiety. It is
reasonable to assume that a minority of people facing life-threatening illness would fall into
the fourth category of the decisional processing model - ruminating decisional style.
Some Decisional Styles Are More Effective Than Others
Patients who take a more active role in decisions about their treatment have better
health outcomes (Greenfield et al, 1985; 1988). Patients who have a sense of control over
their treatment cope better (Lazarus & Folkman, 1984), report less depression
(Meyerowitz, 1980), and use more cognitive coping strategies (Felton, Revenson, &
Heinrichson, 1984). Decisions made actively are more likely to enhance coping than those
made mindlessly and.

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Essentially, decisions are made after discriminating between two or more options.
This requires categorization according to a formerly processed representation (Schwarz &
Bless, 1992; Deifenbach, Leventhal, & Leventhal, 1992). Categorization can occur either
by contrast or assimilation. In contrasting categorization, an individual considers those
ways in which the new object is different from the previous representation. In assimilation,
an individual considers those ways in which the new object is similar to the previous
representation. The danger with assimilation is that in extracting only a few aspects of the
new situation to attend to, subtle differences are ignored. By viewing the new object as the
same, one is more likely to respond in the same manner, thereby aborting any chance of
ongoing adjustment. Decisional styles that do not consider ail the relevant information
deter the reappraisal process necessary to successful adaptation.
On the other hand, an individual who categorizes by contrast, will have to create a
new representation or adjust an old representation. These individuals are more likely to
consider new information and chink about new responses, i.e., adjust. Consideration of
new options is elaborating on an object, detecting differences, generating hypotheses based
on these differences, and constructing a new representation which directs behavior
differently. This is active deciding.
Active deciding and perhaps passive deciding lead a person to become more
personally involved in decisions regarding their treatment and their response to both the
illness and treatment. Greater participation in medical decision-making has been shown to
correspond with improved health outcomes (Greenfield, Kaplan, & Ware, 1985; 1988),

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psychological well-being (Fallowfield, Hall, Maguire, & Baum, 1990; Morris & Royle,
1988), and are more satisfied with their care (Greenfield et al, 1985).
Table 2-1
The Decisional Processing Model
Decisional Category
Route of Processing
Coping Effectiveness
Active Decisional Style
Central Route Processing
Most effective coping
Passive Decisional Style
Central Route Processing
Also effective coping
Mindless Decisional Style
Peripheral Route Processing
Less effective coping
Ruminating Decisional Style
Peripheral Route Processing
Least effective coping
As Table 2-2 shows, this research hypothesized that those people in the active
decisional category are likely to use more effective coping strategies than any other style
because of their ability to differentiate between options, their consideration of how
presented options may affect them differently than other people, and the sense of control
and efficacy required to take such an active role in determining treatment. It was expected
that passive deciding is equally effective in coping, although there may be differences in
self-efficacy when compared with active deciding. Because of employing so little effort in
making the discriminations which render perception of the diagnosis of cancer as requiring
different ways of coping, it was also anticipated that mindless deciding would lead to the
use of less effective coping strategies. However, it is recognized that the denial commonly
seen in people using this style may protect them from high levels of distress, especially in
the short term coping explored in this study. Those patients using ruminating style are

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likely to report the most stress. This perception of high stress in addition to their peripheral
route processing style may lead to the least effective coping.
Summary
The existence of an integrated information system between what is perceived and
how the body functions biochemically has been demonstrated in studies on coping and
surviving a serious illness. Perception is learned within a social context and as such is both
culturally and individually determined. Studies have demonstrated how perceptions can be
changed resulting in changes in coping and survival. However, very few studies exist
investigating how these perceptions evolve into medical decisions or what effect decisional
styles may have on coping.
In order to study decision making and use the results to provide a direction for
designing psychosocial medical interventions, this study integrates the ELM and the theory
of mindfulness. A review of the empirical support for these theories revealed many
parallels. This research evidence is used to build a new model to explain decisional styles.
The decisional processing model states that patients use four decisional styles to
process their decisions regarding treatment and coping. The four categories are active,
passive, mindless, and ruminating. Active and passive decisional styles are processed
centrally and therefore may lead to using more effective strategies. Mindless and
ruminating decisional styles are processed peripherally and may lead to using less effective
strategies. In spite of this commonality of the route of processing, mindless and ruminating
styles are qualitatively opposite, one making immediate reactionary decisions; the other
never settling on any decision.

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Decisional styles can be predicted using the elaboration likelihood model of attitude
change. Research on the constructs of this model, cognitive responding, motivation, and
ability has led to evidence about the circumstances under which a person uses peripheral or
central route processing. Therefore, it should predict whether the patients in the different
decisional style categories are using central or peripheral route processing. In addition to
this prediction, evidence from research on the ELM has also demonstrated ways in which
route of processing can be changed. If evidence accrues that demonstrates central route
processing produces more effective coping with a serious illness, the ELM provides the
tools to change the route of processing information.

CHAPTER THREE
METHODOLOGY
Overview
This inquiry sought to understand how people make decisions about their life-
threatening illnesses and how their decisional styles affect coping. Using the research
supporting the theories of mindfulness and social influence, a decision making model was
created. The study explored the identity of existing categories of decisional styles, how
these decisional styles are predicted by certain variables, and how decisional styles affect
coping. Interviews for this exploratory study were conducted with cancer patients actively
involved in treatment. The Methodology section includes descriptions of the population,
sample, sampling procedures, research design, data analysis, and instrumentation.
Concluding this chapter are the limitations of this research.
Population
The population from which the sample for this research was drawn consists of
cancer patients under treatment at Shands Cancer Treatment Center in Gainesville, Florida.
The Center attracts patients from a geographic area encompassing six southern states, but
the majority of the patients reside in Florida. The population of the State of Florida by
race in 1996 was 84% Caucasian, 10% African-American, 13% Hispanic, and 1% other
(Statistical Abstracts of the United States, 1996). Statistics are not kept on the racial mix
of cancer patients served by Shands. In 1996, 1,359,150 cancer diagnoses were given
94

95
nationwide. Of these, 136,380 were African-Americans, who have a higher incidence of
cancer and higher mortality rates. This is true for other minorities as well. In 1995,
Shands Medical Center treated 1,428 males and 1,108 females for cancer (Tumor
Registry, Shands Medical Center, 1995).
Shands Cancer Treatment Center provides medical services for people from a wide
range of socio-economic levels. The Center treats patients without regard for ability to pay
and consequently draws a significant number of Medicaid patients. The Center also
attracts patients from a wide variety of economic levels who seek state-of-the-art diagnostic
and treatment methods.
Sample And Sampling Procedures
The participants in this study were adults with a diagnosis of any unremitted cancer.
There are two reasons for taking an inclusive approach to the diagnostic categories
explored in this study. First, in studies on coping, findings did not differentiate between
different types of cancer (Cassileth et al, 1984; Pollack, Christian, & Sands, 1990).
Second, certain cancers are more prevalent in particular age groups and some are specific
to gender. Limiting this study to certain cancers would limit the ability to generalize across
genders and age groups. The diagnostic categories are listed in Table 3-1.

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Table 3-1
Frequencies and Types of Diagnoses of Participants
Type of Cancer
# of patients
Lymphomas (Hodgkin's and non-Hodgkin's)
17
Breast cancer (with and without metastasis)
31
Lung cancer (adenocarcinoma, small cell, non-small cell,
& squamous cell
16
Cancer of the head and neck
4
Brain cancers & metastases to the brain
3
Gastro-urinary cancers
12
Ovarian cancer
'•*>
Liver & pancreatic cancer
5
Leukemias
6
Multiple myeloma
3
Vascular sarcomas
2
Carcinoid symdrom with metastasis
1
People with multiple distinct cancers
4
Because cognitive ability is essential in gathering the data in this study, any patients
with an indication of cognitive impairment, either as a symptom of their cancer or their
physician’s estimation, were excluded from participation. The ethnic composition of this
study included 85.8% Caucasians, 10.8% African-Americans, 1.7% Hispanic, 1.7% Asian.

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Three participants, willing to be in the study, had to be excluded due to their limited facility
with the English language (one was Hispanic and two were Asian). In all three cases, the
protocols were attempted using an interpreter, however, this proved to be too difficult to
gather the information as accurately as the other participants in the study and the effort was
abandoned. The gender composition consisted of 64.2% females and 35.8% males.
Patients receiving their initial diagnosis fewer than three weeks prior to this study
were excluded. If persons actively seek information and give careful consideration to the
results of their search, it will take time to do so. It is impossible to know whether persons
in this period of weighing options are ruminating or engaging in effortful thinking. After
the occurrence of traumatic events, people often go through a period of shock lasting from
a few hours to a few weeks (Filipp, 1992). To prevent the results being confounded by the
shock or by not allowing enough time to discriminate, anyone having received their
diagnosis fewer than three weeks prior to assessment were excluded from the study.
Other demographic information about the participants included marital status and
education level. Eighty percent of the participants were married, 3.3% divorced, 12%
widowed, and 5.7% single. Twelve-point-six percent had less than a high school
education, 28.6% completed high school, 33.6% attended some college or vocational
school but did not complete, 8.4% were college graduates, and 16.8% had advanced
degrees. The amount of participants with advanced degrees is unique for this location.
Shands Cancer Center is considered a state of the art clinic with access to new
experimental treatments and knowledge often unavailable in smaller centers. It is seen as a
mecca which draws people for sophisticated treatment and difficult cases and as such is

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likely to drawn a unique population of patients from a greater geographic area. As will be
shown in the results section, the preponderance of such educated people may be the result
of exploration on the part of the patients. In addition, it is located in a town in which the
major employer is a university. Although the sample may be representational of regional
cancer centers' patients when the center is situated in a university setting, it may not
represent that patient population in cities with a lower percentage of highly educated
people. This factor could influence prevalence rates of people in the different decisional
styles categories.
Medically, the patients in this study were quite sick reflecting a skewed population
of people whose treatment may have required such sophisticated or experimental efforts.
Often after the inability to diagnose, or ineffective treatments begun in smaller towns,
patients are referred to a center such as Shands. As a result it is likely the sample contains
many patients with more advanced disease. A full 51% of the patients had stage IV
cancers; 20% had stage III; 16% had stage 2; and only 7% had stage I disease. Prognoses
also were concentrated in the more severe range. Twenty percent had poor prognoses,
23% were fair, 25% were guarded. One physician explained his interpretation of guarded
is a patient who is doing well now but unlikely to live beyond six months. Thirteen percent
were in the good range, and another 13% had very good prognoses. Sixty-four percent of
the patients had no previous cancers; 35.6% were being treated for a recurrence/second
cancer.
Although in the ensuing analysis, continuous data were used, a record of the dates
since the initial diagnosis was obtained. Eleven percent had been diagnosed less than one

99
month, 13% diagnosed less than three months, 26% diagnosed less than six months, 17%
diagnosed less than one year, and 43% diagnosed over one year. However, if the 35%
treated for recurrent disease were subtracted from this figure, only 8% had been diagnosed
with their current cancer over one year.
Sample size was one hundred and twenty participants. In discriminant function
analysis, small samples are subject to bias when calculating the number of persons
accurately categorized. Samples that are too large may result in an overestimation of the
accuracy rate (Huberty, 1975). Huberty recommended the inclusion of three times as
many cases in the smallest group as the number of existing variables, with an additional
one-third to be used as a cross-validation sample. If this formula were to be used, the
current study should include seventy subjects.
By contrast, Kass and Tinsley (1979) recommended ten times the number of
variables which would result in a sample of thirty for this study. Both Brown and Tinsley
(1983) and Tatsuoka (1970) recommended that the smallest group should include no fewer
than the number of variables used. Using this standard, no category in this study would be
likely to result in fewer than three participants. However, by categorizing people on three
predictor variables and four categories, thirty subjects may be too small to detect an effect
size, especially given the exploratory nature of this study.
A third method of calculating the sample size is by multiplying the predictor
variables times ten for each cell and again multiplying by the number of degrees of
freedom in the criterion variable. This study has four predictor variables: Need for
Cognition Scale, Need for Closure Scale, Padua Inventory - Rumination Subscale and

100
Ability To Process Questionnaire. It includes four criterion variables: active deciding,
passive deciding, mindless deciding, and rumination. Therefore a sample size of one
hundred twenty participants was used.
Sampling Procedures
Four locations within the Shands system were used. Fifty-five participants were
interviewed in the clinic, while waiting for their doctor. Fifty-four participants were
interviewed while undergoing chemotherapy in the outpatient chemo room. (Those who
experience nausea during their chemo treatments are typically given atavan. One of the
side effects of atavan is drowsiness. Those participants treated with atavan were eliminated
from participation.) Ten patients were interviewed while undergoing treatment in the
hospital and one was interviewed in the bone marrow transplant unit.
Referrals to the study were obtained through physicians, social workers, nurses, and
physician's assistants. Patients were sometimes approached by a staff member and asked if
they wished to participate but more often a staff member would designate which patients
were appropriate for the study (based on criteria set) and these patients would be
approached by a researcher. The study was explained to the staff at the regularly
scheduled weekly conference.
Five researchers were used to conduct the interviews. The researchers did not
make any decisions and therefore no inter-rater analysis was required at this point. Two
researchers, the investigator and a social worker, conducted one hundred of the interviews.
Both of these women were licensed therapists with over fifteen years experience in
working 'with cancer patients. The remaining three researchers covered the hospital

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participants. They were all mental health counselors with varying levels of experience,
none of which was with cancer patients. A two-hour training session was provided for
each researcher covering the ideas, tasks, and requirements of the study and the interview.
Although the researchers understood how to discriminate between decisional styles, they
did not know the hypotheses.
Confidentiality in this research was protected by the use of coded data packets.
The master list linking names and codes was retained separately by the principal
investigator in a locked file and handled in the same manner as confidentiality with therapy
clients. It was unnecessary for any other sources to be privy to this master list.
Research Procedures
Potential participants who were awaiting treatment or undergoing chemotherapy
treatment were presented with information about the study and asked if they were
interested in hearing more. If they responded affirmatively, the consent form was provided
and read along with the patient. If they consented to the interview, they knew that the
interview would be interrupted when their physician entered the room. The majority of the
clinic interviews were interrupted by medical examinations. Since Shands is a teaching
hospital, medical students and fellows often saw the patients prior to their physician.
Seldom was it necessary for patients to remain in the clinic longer than this process in order
to complete the interview.
One hundred and twenty-three people agreed to be interviewed. Due to language
barriers, three were excluded by the researcher. Eighteen patients refused to be
participants. Six of these people offered no reason, four stated they were too emotionally

102
upset, and eight said they were too sick that day but would be willing another time. Two
patients who were eligible according the study criteria were excluded by the medical staff
because they knew they were about to hear bad news that day. All other patients who fit
the criteria were eligible for the study. The only reason they were not included was if the
researchers were already busy with other participants.
The Interviews
There were two procedural stages in this study. The first was a determination of
which decisional style was employed by the participant in coming to decisions about their
illness. The second stage was the administration of the standardized instruments assessing
the predictor variables. For the first stage of assessment (determination of decisional style),
a multi-method approach was used to assess the category of decisional style which best
represents the participant. In one method, the participant reported his/her identification
with a story and using another method, participants were asked specific questions about
how they arrived at the specific medical decision related to their cancer. The former is
referred to as the vignettes, the latter as the decision tree.
The assumption was made that the process of deciding is relatively accessible to
conscious awareness when attention is so directed. The interview began with a semi-
structured interview in which the researcher asks questions which are framed by a decision
tree leading to the four categories under scrutiny. This was followed by the researcher
having read four vignettes describing the different decisional styles, then asking the
participant which parable was most representational of their way of deciding about their
illness.

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The second procedural stage was a structured interview conducted by the same
researcher at the same time and consisted of the measures of the predictor variables. This
structured interview used the following instruments chosen for this study: 1) Need for
Cognition Scale, short form (Petty, Cacioppo, & Kao, 1982), 2) Need for Closure Scale
(Webster & Kruglanski, 1994), 3) Padua Inventory, Rumination Subscale (Sanavio, 1988),
4) Ability to Process Questionnaire, and 5) Ways of Coping Scale (Lazarus & Folkman,
1984).
Although this interview had been previously timed and found to take forty minutes
if questions were answered without embellishment, the actual interviews took
approximately one hour to an hour and a half. A few interviews took two hours. The
reason for the length was not a lack of understanding the question, but a high need to talk
among this population. Participants sometimes cried, vented their emotions, asked
questions about coping, and frequently offered in-depth details of their journey through
their illness. Many issues came up, such as one wximan who debated about leaving her
husband since he reacted to her cancer by becoming physically abusive to her or the old
southern gentleman who after crying through the interview told the researcher, "I am so
glad to talk with you. I must be strong for my family and can't talk to anyone else."
In addition to the two methods of determining decisional styles and the instruments
assessing the predictor variables and coping, medical data was obtained from the patient's
computerized records to determine differences based on stage, prognosis, type, date of
diagnosis, or recurrence. Stage and prognosis, not available from computerized records,
was determined by their attending oncologist after the patients were interviewed.

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Relevant Variables and Analysis
Types of Analyses
Discriminant function analysis was used to test the model proposed in this research,
Discriminant function analysis is used to predict the category into which a person will fit
based on the predictor variables (Borg & Gall, 1989). This analysis is recommended when
using two or more continuous independent (predictor) variables and one categorical
(criterion) variable (Borg & Gall, 1989). Discriminant function analysis was used to assess
the power of the predictor variables to accurately categorize the participants according to
their decisional styles. This analysis sought to maximize the discrimination between already
existing or defined groups by maximizing the ratio of variance between them. Discriminant
function analysis is a statistical procedure which assigns index numbers to participants who
have been identified as belonging to a certain category in order to determine the power of
the predictor variables to discriminate. The basis for the initial assignment was derived
from the characteristics of the different categories of decision-makers.
Discriminant function analysis is designed to measure the characteristics that are
most important in representing the categories, establish how these dimensions are
described, and designate which variables contribute to these dimensions. The predictor
variables are determined by theory and research and should not be correlated with each
other.
With the exception of need for closure, the predictor variables in this study are well
supported throughout the research conducted on the elaboration likelihood model. The
inclusion of need for closure is supported by the work of Kruglanski (1989, 1990, in press)

105
and Webster & Krugianski (1993, 1994). According to Brown and Tinsley (1983), the
predictor variables should be restricted to a theory-driven few. By measuring participants
on more than one variable, small group differences are weighted and added together to
increase discrimatory power by forcing mathematical distinction (Sanathanan, 1975).
Weights are assigned based on the magnitude of relationship differences. Intercorrelations
are excluded.
Continuous measures for predictor variables are needed for this analysis so that the
discriminations are not artificially constrained to a discrete number of numerical categories
(Carpenter, Deloria, & Morgenstein, 1984). Factors of the elaboration likelihood model
meet this criterion. The criterion variable must be discrete. The category of decision
making satisfy this requirement.
A chi-square analysis was used to determine the probability of the frequency rates
of gender, race, age, type of cancer, stage of cancer, recurrence, and prognosis occurring
by chance. Chi-square designs are used to determine frequency probability between
categorical variables.
In addition to the determination of categories of decisional styles and their
predictors, the relationship between decisional styles and coping was tested. The Ways of
Coping Scale consists of two trigger questions and a scale of questions in which the
participant is asked to respond to their answers to the first two questions. The first
question, categorical in nature, were analyzed using a chi-square. Both the second
question and the scale are continuous measures and their relationship with decisional styles
were therefore analyzed using a one way analysis of variance. The relationship of the

106
individual scales to the decisional styles were tested using a one-way analysis of variance.
The independent variables used in each analysis independently are the Need for Closure
Scale, the Need for Cognition Scale, the Padua Inventory - Rumination Subscale, and the
Ability to Process Questionnaire. The dependent variables are decisional styles: active
deciding, passive deciding, mindless deciding, and ruminating. Anovas are used to
compare three or more independent groups.
Criterion Variable
The criterion variable was decision making style. The categories of decisional
styles were: 1) active deciding (mindfulness; generating options and deciding from among
those options)., 2) passive deciding (deciding among presented options), 3) mindless
deciding (making a premature cognitive commitment without careful thought), and 4)
ruminating (equivocating on a few options without discriminating enough to make a
decision).
Active Deciding
Active deciding is gathering information beyond that which is presented. Using this
decisional style, people combine presented information with self-knowledge to generate
hypotheses about their possible options. From these carefully considered options, active
deciders choose those which they will implement. When they settle on a decision, they
recognize changes, remain open to revising their decision, and demonstrate flexibility of
thought.

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Passive Deciding
Passive deciding involves thinking about choices presented and actively selecting
from among those choices. Although in this style, people engage in effortful thinking,
they do not generate any new options which would allow them to consider
recommendations based on self-knowledge. These people come to know the world as it is
presented to them.
Mindless Deciding
Mindless deciding is making a premature cognitive commitment. In this decisional
style, people make a decision based on either pre-conceived schemata or on peripheral cues
(for example, authority of the doctor) without scrutinizing the information. Decisions are
made quickly and without effortful thinking. After having arrived at a decision, the person
is very certain of the decision and no new information is considered. It requires no
adjustment in their preconceived schemata.
Ruminating
Ruminating is not being committed to any decision. In this style, people remain
unsettled and ruminate about a few options. The time put into this kind of thinking is
unproductive because it results in no new insights or options are being generated. There is
a marked shifting between the same options over and over again. This type of deciding can
occur even when a person is following the course of a decision, for instance, undergoing
chemotherapy without feeling that it was a good decision.

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Predictor Variables
Predictor Variable 1: Need for Cognition Scale (NCS)
Motivation is one of the factors involved in the elaboration likelihood model which
determine whether a person is likely to put effortful thought into a message. Factors
influencing motivation are personal relevance, involvement, personal responsility, multiple
sources and individual need for cognition. People high in the need for cognition engage in
effortful thinking more often than people low in need for cognition. When one's health, if
not life, is at stake, it is reasonable to assume that the personal relevance and involvement is
high. Whether the participant considers multiple sources or not and how much personal
responsibility they feel will be a function of the decisional styles. It is likely that the
participants in this study are motivated by these factors and individual differences will be a
function of their differences on the Need for Cognition Scale.
Predictor variable 2: Need for Closure Scale (NFC)
Need for closure is another construct which affects how much effortful thought will
be entertained prior to making a decision. An important motivation factor consonant with
theories of attitude change is the need for closure (Kruglanski, Webster, & Klem, 1993).
The authors describe the need for closure as a desire for closure rather than a deficit view
of need. The goals of this need are predictability and a basis for action. Need for closure
is the desire to have an answer to end confusion and ambiguity. Need for closure could be
specific (such as the need for an answer that satisfies a particular schema) or unspecific
(the need for any answer), each reducing ambiguity.

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Motivation to process information carefully will be affected by a person's need for
closure. Responses to a thought-listing technique demonstrated that people with high need
for closure generated fewer discussion-relevant thoughts and more heuristic and systematic
thoughts (Kruglanski et al., 1993). This need for closure is both dispositional and
situational (Webster & Kruglanski, 1994). Therefore both the Need for Closure Scale
(Webster & Kruglanski, 1994) and the Need for Cognition Scale (Petty & Cacioppo,
1986) will be predictor variables for this study.
Predictor Variable 3: Padua Inventory - Rumination Subscale
Decisions are only made when a person makes a cognitive response to a presented
message. It is either directional or neutral. Some individuals do not make a decision.
They shift between a few impoverished choices without entertaining new information of
settling on a course of action. Ellen Langer stated that a decision cannot be made without
discriminating between the choices in a way that is meaningful for the person. If people
have a need to avoid closure, it is likely they will entertain options without discriminating
enough to arrive at a decision. Webster and Kruglanski (1994) described the need to avoid
closure as functionally opposite the need for closure. Although they conceptualized the
process using a cost/benefit analysis, weighing the option of deciding vs. not deciding, there
is no evidence that participants actually evaluated whether to engage in effortful thinking or
not. It is possible that the persons may be continuously ruminating about the choices
because they are mindlessly reacting to the third commitment, the commitment to process,
which Langer (1994) described. The mindlessly made commitment to process is followed
to avoid closing on a choice when there is no way to make such discriminations. For

110
example, a person following a preconceived notion that if the right decision is chosen, the
consequences will be all positive and if the wrong decision is made the consequences will
be all negative, may be too afraid to make a choice.
The Need for Closure Scale is designed to discriminate between those who
demonstrate the need to avoid closure and those who need closure. In addition to the Need
for Closure Scale, the rumination subscale of Padua Inventory (Sanavio, 1988) will be
used to measure rumination. The rumination scale assesses both trait and symptomatic
impairment in mental control over doubts and repetitive thinking.
Predictor Variable 4: Ability to Process Questionnaire (APQ) (Heesacker, 1997)
If a person is to carefully evaluate a message using central route processing, the
individual must have the ability to do so. Ability variables according to the ELM are "those
that affect the extent or direction of message scrutiny without the necessary intervention of
conscious intent" (Petty & Cacioppo, 1986,p. 8). Features of the message itself, the
receiver of the message and the context of the delivery of the message all affect ability.
Ability does not refer to education or intellectual levels but without regards to the depth or
complexity of the thought content, ability refers to whether it is possible for a person to
give time and energy to thinking.
Dependent Variable for Hypothesis Three: Coping
Hypothesis three sought to identify the effect of the categories of deciding, (active,
passive, mindless, ruminating) on coping. Based on the theoretical assumption that coping
is related more closely to the way an individual perceives and reacts to the stressor than the
nature of the stressor alone, the Ways of Coping Questionnaire- Cancer Version (Folkman,

Ill
Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986) was chosen for its theoretical
consistency with the position of this investigation. Additionally, the Ways of Coping Scale
is, by far, the most frequently used instrument for measuring coping in the behavioral
medicine literature. The version adapted for cancer patients changed only seven questions
and has been used in several studies, one of which included 668 cancer patients.
Measurements and instruments
Criterion Variable Measures
Decision Tree
A decision tree was used in a semi-structured interview conducted by the
researchers in order to determine which category participants fit. The researchers were
trained counselors. A two hour training session was conducted for these counselors to
teach the theoretical foundation of the decisional styles. They were instructed to gather
enough information for someone not meeting the participant to be able to categorize them
according to their decisional style related to their cancer.
The decision tree discriminates between the four decisional styles based on how the
styles are characterized and the research supporting the variables. Each item on this
decisional tree is well-supported by research indicating factors affecting decisional styles
and factors describing decisional style, for example, degree of certainty (Langer, 1994) and
type and content of effortful thought (Petty & Cacioppo, 1986). The key features for the
active deciding category are effortful thought, option generation, and flexibility of decisions
made; passive deciding category features are effortful thought, only options presented,
some flexibility of decisions but alterations are based only the same premise of the initial

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decision (for example, if a person make their initial decision from only those options
presented by the doctor and no others, the alteration will only be if the doctor tells them
something is changed); mindless deciding features are no evidence of effortful thought,
responding to cues, decisions made fast, a high degree of certainty, and new information is
denied or rejected; the key features of the ruminating style are a high degree of thought
about a paucity of ideas beyond the point in which new information or ideas are
entertained, either no decision arrived at or if a decision has been made, no commitment is
made to it, frequent worrying.
Questions focus on seven topic areas pertinent to making a discrimination. These
topic areas are: amount of information presented initially, evidence of effortful thought,
whether a decision was made or not, generation of options beyond those presented,
responses to cues, certainty of the decision, and flexibility to change the decisions. The
topic areas for the questions were drawn from the research-supported constructs from
Langer’s mindfulness theory (1989) and Petty and Cacioppo's ELM (1986). By using
topics which enjoy strong empirical support, construct validity is established.
The format was developed according to two sources. The initial question about
what decision were made and which were most serious is based on the format used in
Dunkel-Schetter, Lazarus and Folkman's Ways of Coping Scale - Cancer Version (1992).
In this scale trigger events were used for the follow-up questions that were representational
of events occurring in the person's life. The identical format is used in this study. A list of
choices/decisions typically faced by cancer patients are presented in order to use as a
trigger to orient their answers based on a decision they actually faced.

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The second source used to develop the format was a decision tree explicated by
Heesacker (1993) to integrate two theories during a counseling session. Although the
complexity used in this example is greater than that demanded by this study, it exemplifies
the flow of questioning between several theories.
The principal investigator then read each protocol and made a determination of
which category the person fit according to the information provided on this decision tree.
Inter-rater reliability was established by assigning a random sample of twenty protocols to
two judges. These judges were experienced counselors who were not involved in any
other aspects of the study. They were each trained in the differences between decisional
style categories, then took the protocols home to make their assessments.
Vignettes
A second assessment of which decisional style a participant fits was conducted by
having the researcher read four vignettes describing a person's decision-making process in
making cancer-related decisions. The researcher read the vignette while the participant
followed along reading a copy. Male names are used for male participants and female
names are used for female participants. In every other way the vignettes are identical.
When finished, the researcher asked the participant which vignette character is most like
them. Their answer determined the category.
Construct validity was determined in two ways: first, the constructs assessed were
ones that have been grounded in the theories utilized and well supported in research
devoted to those theories, and second, convergent validity was determined by comparisons
of the two measures, vignettes and decision tree, which are theoretically purported to

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measure the same construct. There were thirteen protocols in which the investigator
decision of category and the participant decision of category were discrepant. In addition
to the twenty protocols used in the reliability study, these thirteen were given to two
additional counselor judges to obtain as accurate an assessment of category as possible. A
Kappa-coefficient was used to determine inter-rater reliability.
Predictor Variable Measures
Need for Cognition Scale (NCS)- short form. (Petty, Cacioppo, & Kao, 1982)
The need for cognition also affects a person’s motivation to think carefully about a
message. Initially, the need for cognition was described by Petty and Cacioppo (1986) as
an intrinsic drive to use effortful thought to reduce the ensuing tension from that drive.
Petty and Cacioppo embraced a modification of this definition and view need for cognition
as an individual’s intrinsic enjoyment of engaging in effortful thought. People with a high
need for cognition will naturally gravitate toward more central route processing than those
with a low need for cognition. The Need for Cognition Scale (Petty & Cacioppo, 1986)
was developed to discriminate between people with an intrinsic motivation to engage in
thoughtful consideration of messages and those intrinsically motivated to avoid effortful
thinking. The Need for Cognition Scale -short form (Petty, Cacioppo, & Kao, 1984) will
be used to measure intrinsic motivation.
The Need for Cognition Scale was developed by Petty and Cacioppo in response
to the need to assess the variance generated as a result of individual differences in people's
enjoyment of effortful thinking. People who enjoyed thinking increased the likelihood of

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engaging in effortful thought without consideration of factors involving message
presentation. This intrinsic motivation is a stable individual characteristic.
Petty and Cacioppo distinguished the need for cognition as a response style
different from a mere avoidance of ambiguity (need for closure), which could be satisfied
by employing heuristics or authoritative consultation. Need for closure is only one
variable affecting a person's willingness to think about an issue. The authors of the ELM
also differentiate need for cognition from self-efficacy since efficacy is a factor in physical
as well as cognitive pursuits. The construct of need for cognition is further described as
intrinsic enjoyment rather than a tension-reducing need.
In their efforts to construct an instrument to assess need for cognition, Petty and
Cacioppo chose questions that "excluded dealing with inner brooding, reverie, mystical or
religious experience, mind wandering, and artistic imaginings" (p. 49). They included
items "describing a variety of situations in which people could choose to gamer
information, analyze available evidence, abstract from the past experiences, or synthesize
ideas” (p.49).
Construct validity was established in several ways: first, by the known groups
method using university faculty and assembly line workers, and second, by university
students, a more homogeneous population. Both samples correlated highly in factor
loadings (r = .72). To simplify administration, a short form was then developed (Petty,
Cacioppo, & Kao, 1984) possessing the same factor structure and correlating highly
(r=.98) with the longer version. Internal consistency and additional support for the stability
of the factor loadings was provided by three studies with undergraduates (Chaiken, 1986)

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and one study with residents in a small town (Furguson, Chung, & Weigold, 1985). The
last study produced a Cronbach's alpha of .86. Internal consistency was reported at .91 by
Heesacker (1985). No gender differences were found in any of these studies. Reading
level was appropriate for adults in various professions and educational backgrounds
(Heesacker, 1985).
Validation of the cognition construct was determined with the presentation of a
boring two level task to 3500 students; one level was simple to perform and the other level
was complex to perform. The NCS effectively discriminated between those students who
preferred the complex task over the simple task, in assessing variant and discriminant
validity, the following correlations were found:
TABLE 3-2
Construct Correlations for the Need for Cognition Scale
Related Measures
Correlations
p value
Field dependence
r = .19
p<05
Close-mindedness
r = -.27 and r = -.23
p<05
Sarason’s measure of test anxiety
r = .02 (ns)
Social desirability
r = .08 (ns)r = .21,
p<05
Measures of curiosity
r = .57 (Olson, Camp, & Fuller, 1984)

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Need for Closure Scale: (Webster & Kruglanski, 1994)
A forty-two item questionnaire was formulated representing five theoretical subsets:
need for order, need for structure, discomfort with ambiguity, desire for predictability, and
close-mindedness. The forty-two items are responded to by the subjects indicating the
extent to which they endorse each item on a 6-point Likert scale. Sixteen of the items were
designed to assess the respondents' need to avoid closure and are reverse scored. These
items were negatively correlated with those on the need for closure subset (r= -.4566, p
< 01). The composite score is determined by summation of all the items after the reverse
scoring is completed.
The NFCS was administered to two standardization samples. The first group
consisted of 281 undergraduates and the second was comprised of 179 adults recruited
from three public libraries. The relatively equivalent gender groups resulted in no
significant differences found for males and females.
On the student population, after modifying the scale for internal consistency, a
Cronbach's alpha = .8405 was calculated. The range for subsets were .62 to .82. Test-
retest reliability (12-13 weeks after initial testing) was .8611. No significant differences
were found in the results for group two, Cronbach's alpha = .8413. The authors concluded
that the NFCS reliably assesses the need for closure construct and is a relatively stable
construct.
In further testing, the authors conducted known groups tests and found that the
Need for Closure Scale did indeed discriminate between people high vs. low in need for
closure and in another test for primacy effects in impression formation. Those scoring high

in need for closure did rely on primacy effects significantly more often than those scoring
low. Correlations were conducted comparing the Need for Closure Scale with other scales
The following table lists the correlations conducted on the NFCS and several other scales
sharing some theoretical characteristics.
TABLE 3-2 Construct Correlations for the Need for Closure Scale
Authoritarianism: Sanford, Adorno, Frenkel-Brunswik, & Levenson, 1950) r = .27
Intolerance of Ambiguity Scale: Eysenck, 1954 r = .36
The Dogmatism Scale: Rokeach, 1960 r = .29
The Modified Bieri REP Test: Kelly, 1955 r = -.30
Personal Need for Structure Scale: Neuberg & Newsom, 1993 r = .24
Fear of Invalidity Scale:Thompson, Naccarato, Parker, & Moscowitz, 1993 r = -.39
Need for Cognition Scale: Cacioppo & Petty, 1982 r = -.29
QT (measure of intelligence): Ammons & Ammons, 1962 r = -. 17
Crowne-Marlowe Social Desirability Scale no correlation
Padua Inventory: Rumination Subscale (Sanavio, 1988)
The Padua Inventory was constructed to improve on previously developed
measures of obsessions and compulsions. Previously constructed questionnaires focused
on behavior traits, not symptoms, (Maudsley Obsessional-Compulsive Questionnaire,
Hodgson and Rachman, 1977; the Self-Rating Obsessional Scale, Sandler and Hazard
1960) and rarely distinguished differences among normal people. Although there is a high
incidence of obsessional rumination and intrusive cognition among obsessive-compulsive

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people, the instrument measuring this important feature used only two questions to assess
rumination. The Padua remedies these above problems by assessing symptoms as well as
traits and distinguishing these behaviors among normal people. It also contains a subscale
solely to assess rumination (Sanavio, 1988).
The statements to which the tester replies were taken from an analysis of twenty-
eight patients who were diagnosed with obsessive-compulsive disorder according to the
DSM-III. The next step in its development was to test its ability to discriminate between
obsessive-compulsive, depressed, and psychosomatic patients. Those statements most
discriminatory were then given to 1,200 normal subjects. A subsequent item analysis left
60 items rated on a 0-4 scale with the higher numbers indicating the most disturbed. The
initial sample and several follow-up samples of the general population (aged 16-70 and
students) were conducted in Northern Italy. Stemberger and Bums (1990) conducted a
study on the Padua with an American population of 701 students. There were no
significant differences between gender on the scores; race was never measured. On the
total scores, the males and females in the youngest two age groups (16-25) in the Italian
sample scored significantly higher than their American counterparts.
Internal consistency for the total PI was .94. Factor loadings resulted in five
subscales. Factor 1, "impaired control over mental activities," is the rumination subscale of
interest for the current study. The twenty items it contains accounted for 23.6% of the
variance. The most representative for this study is an item stating, "I find it difficult to
make decisions even about unimportant matters." Cronbach's alpha was .89 and the
average corrected item-total correlation was -.53.

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Convergent validity was established by correlating the PI with the Maudsley
Obsessional-Compulsive Questionnaire (r = .68, p< 001) and the Symptoms Checklist 90,
obsessive-compulsive subscale (r = .66, p<001) (Stemberger, 1990). Test-retest reliability
was .78 for males and .83 for females at a 30-day interval (Sanavio, 1988).
Ability to Process Questionnaire, (Heesacker, 1997)
The Ability to Process Questionnaire directly asks questions of the respondent
about his/her ability to process the information. Each question is derived from research on
variables affecting ability to process information centrally. It is the body of research on
social influence which provides the construct validity of this questionnaire. Questions
asked refer to the literature on external and internal distractions (Petty & Brock, 1981),
time (Fazio, 1993), involvement (Johnson & Eagly, 1989; Petty & Cacioppo, 1979, 1984,
1990), anxiety or worry (Smith & Petty, 1995) and a straightforward question on whether
the participant perceived that he/she was able to think about the topic.
This questionnaire follows the precedented format of referring the participant to an
actual decision made by asking these questions in response to the decision named by the
participant early in the interview as the most difficult to make related to his/her cancer.
Circumstances will significantly vary a person’s ability to process information. The reason
a referent point is used to trigger thinking about a certain question because ability to
process is not a stable condition across situations, but relevant only to the situation under
question.
Reliability of this instrument follows the same rationale of the coping instruments
used in this study. Lazarus and Folkman's theory delineates a process in which people

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adapt to the stressors in their lives as a stressor moves from being acute to being chronic.
The coping scale developed to measure this process assesses the strategies utilized at the
moment of testing and not necessarily that used over time or in different situations.
Although this approach has been criticized, their coping scale is one of the most used in the
research on coping with medical illness.
Use of this method is justified by it's theoretical consistency with both the Lazarus
and Folkman (1984) perspective on coping, and the theoretical postulates of the ELM.
The rationale is also supported by the face validity that suggests how one may cope with
cancer is not necessarily static over the course of treatment, nor how the same person may
cope with another stressor.
Dependent Variable
Ways of Coping Questionnaire, (Folkman & Lazarus, 1988)
The rationale providing the foundation for the Ways of Coping Scale is the belief
that psychological distress is related more to the way people cope than the type of stressor
involved. A strategy used to cope with one event may not be ideal for another event. The
Ways of Coping Questionnaire provides theoretical consistency with the proposed
research. Both this questionnaire and this study construe the process (decision making or
coping) as a dynamic process involving the person, other people and situations in their
environment, and individual differences. The questions refer the test taker to think about a
particular stressor.
Because of the situation specific nature of the questions, the authors felt that
traditional test-retest reliability is inappropriate and focused on internal consistency. The

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scales range from .61 to .79 Cronbach's alpha. The original structure analysis resulted in
eight factors that were well supported in the population (middle and upper middle-class,
married people) assessed but the findings in studies with other populations raise some
concerns about factor stability. Stability across time using mean autocorrelation was quite
low (.25 to .47). After reporting their results in traditional test construction criteria, the
authors disavow the likelihood that a questionnaire representing "an evolving strategy"
could be held to such standards.
The questionnaire was originally developed in 1977 and in spite of these criticisms,
has been through several stages of refinement with the current version having been
published in 1988. It has been used in a multitude of studies pertaining to adjustment to
illness and was created on the solid research program of Richard Lazarus.
Ways of Coping - Cancer Version (Folkman, Lazarus, Dunkel-Schetter, DeLongis, &
Gruen, 1986)
A form of the WOC was created specifically for research on coping with cancer.
The authors felt that since the original WOC was designed to assess adaptation over
repeated assessments, administering the questionnaire once would reflect an
unrepresentation and inaccurate example of coping for that participant. The instrument is
designed to measure response to a particular stressor. The authors identified specific
cancer-related stressors from previous studies (Dunkel-Schetter, 1982; Revenson & Felton,
1985). These are fear of future recurrences, limitations, pain and symptoms, and
interpersonal problems related to peoples’ reactions to the illness. Respondents choose

whichever ones they find most stressful from a list and assign a valence of 1 to 5(extremely
stressful) to each item they mark as relevant.
Six items from the original scale were dropped because of non-applicability to
cancer diagnosis. Four items which did not load onto the eight factors in the revised
instrument were included because of their determined relevance to cancer. A few items
were reworded slightly and a few items were added to comply with additional coping
behaviors observed in cancer patients (Dunkel-Schetter, 1982).
Medical Data Form (MDF)
A medical data form was constructed from the patient's computerized medical
information to assess factors which could affect differences. Recurrence (Malcame,
Compás, Epping-Jordan, Howell, 1995; Dean & Surtees, 1989; Hilton, 1989, marital
status (Dahlquist, Czyzewski, & Jones, 1996; Yates, Bensley, Lalonde, & Lewis, 1995),
and age (Jacobsen & Butler), have been shown to affect coping. It is not known how these
factors affect decision-making. It is reasonable to believe that a person experiencing a
recurrence of cancer will be more knowledgeable than a person with a first time diagnosis.
It is also anticipated that a person facing a Stage IV cancer with very little chance of
survival may react very differently than the person with a Stage II curable cancer.
Participant's cancer history will be collected from their medical charts.
Another feature of the disease that may prevent participation is diminished
cognitive functioning. Some cancers (Pavol, Meyers, Rexen, & Valentine, 1995; Meyers
& Albruzzese, 1992) affect cognition and may influence a person's ability to gather
relevant data. Participants whose charts reveal cognitive deficits will not be included in the

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study. Although length of time since the diagnosis has been shown to have little effect on
coping (Duukel-Schetter, Feinstein, Taylor & Falke, 1992), it does take time to gather
information and make a thoughtful decision. In order to discriminate between those people
putting active effort into hypothesis testing from those who are ruminating, a sufficient
amount of time since the diagnosis must have passed for the active deciders to have
finished their exploration. Therefore the amount of time since the diagnosis will be
assessed.
TABLE 3-3
Predictor and Criteria Variables for FFypothesis One:
PREDICTOR VARIABLES
CRITERION VARIABLE:
Need for Cognition Scale
DECISIONAL STYLE
Need for Closure Scale
Types:
Padua Inventory - Rumination Subscale
Active Deciding
Ability to Process Questionnaire
Passive Deciding
Mindless Deciding
Ruminating
Hypotheses
1. Participants will both self-select and be selected by the discriminant function analysis
placement into the four decisional styles.
2. H: NFC, NCS, Padua, and Ability to Process will significantly predict decisional style.
3. H:A>P>M=R on Ways of Coping Flo: A>P>M=R on Ways of Coping

4.H: A>P>M=R on Need for Cognition
Ho: A=P=M=R on Need for Cognition
Ho: M=R=A=P on Need for Closure
5. H:M>R=A>P on Need for Closure
6. H:R>A=P>M on Padua Inventory Ho: R=A=P=M on Padua Inventory
7. H:A=P>R>M on Ability Questionaire Ho: A=P=R=M on Ability Questionnaire
Data Analyses
The first hypothesis tests whether people actually use different decisional styles in
making medical decisions. Both the decision tree (information gathered from the semi-
structured interview) and the vignettes (the patient's choice of which pattern of decision fit
their style) were used to determine if patients did exhibit significantly different patterns of
decisional styles. A determination was made by the investigator about which category' a
person fits. Two professional counselors reviewed twenty protocols and chose a category.
Inter-judge reliability was assessed.
The second hypothesis tests the theoretical model proposed in this research. The
criterion variables categorize people according to the decisional style they used in making
an important medical decision when confronted with a life-threatening illness. Differences
on the predictor measures were determined by employing a discriminant function analysis.
One purpose of discriminant function analysis is to classify individuals into predetermined
categories (Nordlund & Nagel, 1991; Tatsuoka, 1988). The predetermined categories in
this study were selected through the multi-method semi-structured interview. After
identifying each individual’s decisional style, the discriminant function analysis tested the
predictive ability of the measures entered: Need for Cognition, Need for Closure, Padua
Inventory, and question about opportunity to elaborate.

126
TABLE 3-4
Hypothesis Three: Decisional Styles and Coping
H5: ul> u2 & u3 & u4
u2 > u3 & u4
u3 = u4
H5o: ul = u2 = u3 = u4
Hypothesis three exploring how decisional styles are related to coping were
analyzed using a one-way between subjects ANOVA for unequal cells. The independent
variable was decisional style with four levels and the dependent variable was the Ways of
Coping Scale. Assignment to the groups (four levels of decisional style) was determined
by the participants' responses to the multi-method, semi-structured interview and compared
on the mean scores on coping scale. Significance will be set at alpha = .05.
Because the cells were unequal, there was a possibility that the assumption of
homogeneity may be violated. The F maximum test was performed to test for homogeneity
of variance (Shavelson, 1988).
Hypotheses four through seven were analyzed using a one-way analysis of variance
for unequal cells. The independent variables were, respectively, Need for Closure, Need
for Cognition, Padua Inventory - Rumination Subscale, and Ability to Process
Questionnaire. Each variable was entered independently into an anova calculation with the

127
dependent variable decisional style. Decisional style has four qualitatively different levels,
active, passive, mindless, and ruminating. Significance level was set at alpha = .05.
Because the cells were unequal, there was a possibility of the assumption of
homogeneity being violated (Shavelson, 1988). To be more confident in the results an F-
test Maximum was performed. If the F statistic were too high, it would be an indicator that
it is not a homogeneous sample and the data will be transformed through taking the
logarithm of the scores (Winer, 1971).
In order to determine whether there were differences in decisional styles based on
descriptive data, the following variables: gender, race, age, stage of illness, and prognosis
were tested across the four categories of decision-makers using a chi-square analysis. This
statistical test is used when the research data are in the form of frequency counts. Chi
square analysis is used with categorical data to determine whether frequency distributions
differ between groups (Borg & Gall, 1989). Such non-parametric tests are used to
determine distribution among categories. Both the dependent variables: demographic data
and the independent variables, decision-making categories are discrete categorical variables.
The accuracy of the chi-square statistic is dependent upon each category containing no
fewer than ten participants (Shavelson, 1988). Although it was theoretically consistent to
believe that these criteria will be met, the ruminator category held only four participants.
Limitations
Generalizability limitations
While the sample was drawn from only Shands Cancer Treatment Center, the
Center does attract patients from the entire Southeastern United States and is committed to

128
serving low income patients as well as those choosing Shands for its diagnostic and
treatment expertise. The breadth of its patient population allows the findings of this study
to be generalized to other cancer patients with relative certainty that the sample described is
representational.
There is conflicting evidence in the research whether social and psychological
processes can be compared across diseases. Factors such as age of onset, course of illness
(chronic, acute, remitting), level of disability, and prognosis, and treatment complexity have
been shown to affect the impact of an illness (Holland, 1987). In contrast, several studies
support the notion that impact and coping do not vary significantly across diseases (Pollack
et al, 1990; Cassileth et al, 1984). Application of the results of this study to diseases other
than cancer must be viewed with caution.
A possible sampling bias does exist in the elimination of people with cognitive
impairment. However, when one considers that people in this condition often have their
medical decisions made by family members, it would create a graver error to include them
in the study. This discrimination makes the sample a non-random sample. Another
sampling bias occured with the education level of the participants. This study included an
overabundance of people with advanced degrees when compared to a cross-section of
American citizens.
Another possible source of sampling error is the solicitation of participants from a
regional cancer center rather than several regional cancer centers. Information regarding
these differences are not possible to obtain because Shands does not keep statistics on these
factors.

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A source of sampling bias not controllable is that of using volunteers. Patients may
choose not to volunteer on the basis of a personal or social reason, but they also may
choose not to volunteer because they are too sick to engage in the interview. Certainly,
some people were too sick to engage in an interview; these people may use very different
strategies in their decision-making. Investigation of this factor is beyond the scope of this
study.
It has been demonstrated in both the research of Langer (Langer, Blank, &
Chanowicz, 1978) and that of Petty and Cacioppo that intellect has a negligible if any
effect on the variables considered in this study. Additionally, it has been demonstrated that
differences in coping are unrelated to socio-economic level and education. Information
was collected on education level but not on socio-economic level.
Limitations in assessment
This study includes self-report assessments and therefore is susceptible to
respondent bias. The Padua Inventory contains a lie scale which will be considered in the
analysis. In addition, every effort was made in the research design to account for such
bias. Multi-methods is the use of various means to measure the same trait and is a
recommended means of establishing construct validity (Heppner, Kivlighan, & Wampold,
1992). By using both the semi-structured interview and self-report instruments, this study
employed a multi-method design. Multi-trait refers to various characteristics of people.
Some of the constructs measured in this study are assessed using instruments which tap
different traits related to the same construct. For example, motivation was assessed by
measuring both need for cognition and need for closure. Both have been shown to

130
influence motivation (Petty & Cacioppo, 1986; Kruglanski & Webster, 1996), yet have low
correlation (r= -.2831) demonstrating that they indeed are measuring different traits
involved in the construct motivation (Webster & Kruglanski, 1994).
The relationship between coping and decisional styles studied was the strategies
used for coping since there is significant literature linking certain coping strategies with
long-term physical outcomes. The degree of stress was assessed as an ancillary item with
just one question. The chances of denial (a prevalent defense used among cancer patients)
influencing how a person answered this question is quite high, especially when one
considers the majority of patients in this study have less than one year to live, yet many
stated that having cancer was "somewhat stressful". The dimension of denial and the
degree of stress was not sufficiently measured in this study due to the length of the
protocols.
Limitations in analysis
One limitation of discriminant function analysis occurs when the predictor variables
correlate highly with each other. The first predictor entered will reflect a high discriminant
function coefficient even if the predictors are fairly equal in their predictive capability
(Borg & Gall, 1989). To identify if this problem is occurring in this study, correlations
between the predictor variables were computed. Another possible analysis limitation is
imposed by having unequal cells in the Anovas. This limitation, however, was addressed
by performing an F test and consequent transformation if indicated.

131
Theoretical Limitations
An abundance of research literature exists on the role of emotion in decision¬
making, coping, and the ELM constructs. This study did not consider the role of emotion
because to do so would have been unwieldy both in the design of the research and in the
length of the interviews. If emotions were also considered, it is unlikely that the categories
would be any different but their relationship to the other variables may have been different.
Investigation of how emotion influences decisional styles requires further investigation.
Even with the hypotheses supported, far more investigation between decisional
styles and coping needs to be conducted before these results could be ethically included in
a psycho-educational program.

CHAPTER FOUR
RESULTS OF THE STUDY
The purpose of this study was to explore how people facing a life-threatening
illness make critical decisions about their medical treatment and how their decision making
style affects coping. A research-supported model was created and tested for its viability.
Specifically, this study attempted to answer for the following questions:
1) Do patients use different decisional styles when making medical decisions?
2) Do the variables of motivation, ability, and cognitive responding, delineated by
the elaboration likelihood model, together with a measure of rumination, predict
decisional style?
3) Do these decisional styles influence how effectively patients cope with a life-
threatening illness?
Results of this study are presented in five sections. The first section will address
Hypothesis 1, along with some descriptive information about patients within the decisional
style categories. This section also includes reliability data on the determination of
decisional categories. The second section will address Hypothesis 2, the discriminant
function analysis assessing the ability of the four variables to predict participants' decisional
category membership. The third section addresses the third hypothesis, the relationship
between coping and decisional style. Section four includes the analyses for hypotheses 4
through 7, which explore the relationship between decisional styles and each of the four
132

predictor variables independently - Need for Closure, Need for Cognition, Ability to
Process, and Padua Inventory - Rumination Subscale. Section five covers the ancillary
analyses and conclusions.
Decisional Categories
Hypothesis One:
Hypothesis 1, that people demonstrate four distinct decisional styles in making
medical decisions was supported by every measure. The investigator's category, which was
a composite between the decision tree and the reasons for the patient's choice given on the
vignettes was the variable used in the subsequent analyses. Active decisional style was
used by 32.5% of the participants to decide medical treatment of their cancers. Passive
decisional style was used by 22.5% of the participants. The largest category was the
mindless decisional style, which included 41.7% of the patients. Only 3.3% of the patients
used the ruminator decisional style.
The patients, themselves, selected their category of decisional style by identifying a
vignette that was most like them. Twenty-seven point seven percent of the patients chose
active decisional style, 18.5% chose passive decisional style, 49.6% chose mindless
decisional style, and only 3.4% chose ruminator style.
The decisional tree was a determination made by the investigator based on the
semi-structured interviews in which patients were asked about how they actually made the
medical decision related to their illness. The percentage of active decisional style was
33.3%, passive decisional style was 21.7%, mindless decisional style was 41.7%, and

ruminating style was 3.3%. Table 4-1 contains the proportions of participants in each
decisional style category.
134
Table 4-1
Percentage of Participants in each Decisional Style Category
Decisional Category
Vignette
Decision Tree
Final Investigator
Choice
Active decisional style
27.7
n o n
JJ.J
32.5
Passive decisional style
18.5
21.7
22.5
Mindless decisional style
49.6
41.7
41.7
Ruminating decisional style
3.4
o o
3.3
Comparisons were made between these different methods of placing a person in a
decisional style category using a chi-square. Vignettes and decision tree interview
comparison resulted in a significant chi-square statistic of x2 (12, A— 119)= 193.36,
jfC.OOOl. Comparison of the decision tree and the investigator category was chi-square x2
(9, N= 120) = 338.48, /K.0001. Vignettes and investigator category resulted in a chi-
square x2 (12, N= 119) = 200.36,/K.OOOl. Inspection of the cells suggests significant
consistency between the three methods in identifying the three decisional styles.
Decisional Category Reliability
Any study investigating the function of different categories of decisional styles is
only as strong as the methods used to determine those decisional categories. This study
employed both multiple methods of assessment and an inter-rater reliability study to

135
support the accuracy of the category determination for each participant. The inter-rater
reliability study was conducted using two experienced judges. These judges were both
experienced counselors. Neither of the judges were used for any other part of the study
and they were blind to the hypotheses. Each judge was individually trained about the
categories and how to discriminate between them. Inter-rater agreement for the choice of
category was established if two of three raters (the investigator and the two judges) agreed
on a category.
The reliability study was conducted on twenty protocols out of a total of 120, with
all four decisional styles included. These protocols were randomly selected and given to
two judges to independently identify the decisional style participants most closely fit.
Correspondence between Judge 1 and the investigator was 100% on patient category;
correspondence with Judge 2 was 75%. Correspondence between the two judges was also
75%.
A chi-square was also conducted on the degree of agreement between the patient's
choice of self-descriptive vignettes and the categorization of the participants via the
decision tree interview. A chi square of x2 (12, N-119) = 200.36,p <.0001 revealed
significant agreement. Somewhat higher agreement occurred between the investigator's
determination on the decision tree and the final category in which a participant was placed
was even closer x2 (9, N— 120) = 338.47, p < .0001.
Patients identified which category best described them through identification with
vignettes describing the four decisional styles. The investigator determined which category
the patient fit through the results of the semi-structured interview on the decision tree. The

136
two methods matched in categorizing 103 of the 120 patients. A 2 x 2 contingency
analysis was performed comparing the two assessment methods, resulting in a significant
effect x2 (12, N= 119)= 103.36,/? <0001). This agreement between the investigator, the
judges, and the patients suggest that the patients were well aware of their own decision¬
making process.
Location effects
In order to determine whether the location of the interview was related to
participant decision-making style, a chi square analysis was performed between decision¬
making style and the location. Conventional wisdom suggests that chemotherapy is such an
aversive experience that interviewing participants during chemotherapy may influence their
ability to answer the questions accurately. In this study a few people were indeed sick from
their treatment and were usually given atavan, thus excluding them from the study. The
majority of the people interviewed in the chemotherapy room were undergoing an IV drip
and welcomed the distraction and conversation. Patients were even asking, "When will you
get to me?" when they observed the researcher interviewing other patients. The
participants appeared eager and able.
Because this study was conducted in a teaching facility, where patients typically are
seen by three levels of physicians, physicians in training, and, sometimes, a physician's
assistant, there is often a period of waiting between visitations. In addition, the patients are
often waiting for the results of CT scans and blood counts before the physician can
determine their progress. Many of the participants, therefore, had considerable time during
which they could be interviewed without intrusion. The interviews in clinic, however, were

137
almost always interrupted by the physician visits. A few people were required to remain
later than their normally scheduled visits, in order to complete the interview, and several
others could not stay and never completed their protocols. These incomplete protocols
were dropped from the study.
The hospital people were the sickest. They were hospitalized either because of a
need for stronger, more toxic chemotherapy, a bone marrow transplant, or adverse
reactions to treatment. Many were excluded from this study because they were too sick or
too drugged. The few that were interviewed seemed to welcome the companionship the
interview offered.
In spite of the differences in the interviewing process, no significant differences
were found related to the locations in which these interviews were conducted x2 (6, N=
120) = 12.15,/K.059). However, .059 is close enough to significance to warrant a closer
look at the data.
Table 4-2
Differences in decisional styles based on location of the interview
Clinic
Chemo room
Hospital
Active deciding
22
15
2
Passive deciding
13
14
0
Mindless deciding
17
24
9
Ruminating
o
J
1
0

138
According to the table of results, the majority of people in the hospital were mindlessly
deciding their medical treatment choices. It is important to recall that questioning about
their decisional style was retroactive and questioned their decision making prior to their
hospitalization, which was often months or weeks earlier. Whether the mindless decisional
style was an artifact resulting from being in the hospital or whether mindless deciding
affected the patient's physical state in such a way that they were more likely to be in a
hospital is unknown from this data.
Researcher Effects
Yet another way to examine these data is to determine differences based on
researchers. The majority of protocols were completed by two researchers, one covering
the chemotherapy room and the other covering the clinic. Three other researchers shared
the task of interviewing in the hospital. When comparisons were made between
researchers on every variable in the study, none reached statistical significance except those
related to location. Because were no significant main effects for location either, it was
decided to explore the interactive effects of researcher x location x decisional style.
Significant differences were found x2 (4, N= 120) = 112.46,/K.0001). To increase the
cell size in this analysis, data from the last three researchers were combined. Because
researchers were assigned to cover different locations and no other researcher effects were
significant, results may reflect this assignment. This may indicate that the trend in location
effect indicates that hospitalized people were more likely to use mindless decisional style,
not necessarily a confounding effect of researcher differences. Table 4-3 demonstrates the
researcher coverage of the location of the interviews.

139
Table 4-3
Researcher coverage of interviews
Number of interviews
Location of interviews
Investigator
55
clinic
Researcher #1
48
chemo
Researcher #2
8
hospital
Researcher #3
7
clinic & 1 hospital
Researcher #4
2
hospital
In summary, between these explanations and the reliability studies conducted on
categorizing the data into decisional categories, it is fairly safe to assume a high degree of
accuracy in the decision categories used in the inferential analyses that follow.
Ancillary Analyses Related to Decisional Style Categories
Personal characteristics effects. Two personal variables that correlated with
decisional style were age and education. Education was one of the personal variables
which reached significance x2(12, Af= 119) = 35.31,/? <.0001). There were no
interactive effects for age and education. Another chi-square analysis demonstrated no
relationship between dependent variable, decisional style, and the independent variables,
gender x2 (3, N= 120) = 2.1S,p <.54). Table 4-4 demonstrates the number of participants
in each decisional style based on their education level.

140
Table 4-4
Decisional style by education level (Chi-square 35.312, significant at p > .0001)
Elementary Completed HS Some college College degree Grad degree Total
Active
Deciding 2
Passive
Deciding 5
Mindless
Deciding 8
Ruminating 0
16
15
17
1
2
0
13 32.8%
1 22.7%
6 41.2%
0 3.4%
The relationship between age and decisional style was analyzed using an analysis of
variance resulting in a significant difference. The mean age of active decisional style was
51.8, passive decisional style was 56.2, mindless decisional style was 59.7, and ruminating
style was 56 F (3, 116) = 3.08, p < .03). This finding would lead one to believe that the
younger a person is, the more likely he/she is to be an active decider.
Another two-way analysis of variance was conducted using age x gender as the
independent variable and decisional style as the dependent variable. This anova resulted in
a significant F (7,112) = 2.35, p < .03). Results are demonstrated in the following table.
Far less variation is reflected with women's ages between decisional styles than with men’s
ages between decisional style. To test whether there was a correlation between age and
education level a Pearson Correlation Coefficient was conducted resulting in an
insignificant r = -.05. The results are found in Table 4-5.

141
Table 4-5
Relationship of Age and Gender by Decisional Style F (7,112) = 2.35, p <03)
Category
Males
Females
Age
SD
N
Age
SD
N
Active deciding
53
14.8
14
50
12.4
25
Passive deciding
59
6.4
7
55
11.6
20
Mindless deciding
63
8.4
21
56
13.1
29
Ruminating
69
1
51
15
â– j
J
Medical Data Effects
To determine how the actual medical situation affected participants' decisional style,
chi square analyses were also conducted on each patient's medical data. Stage of cancer
and prognosis were determined by the participant's attending oncologist. Time since the
diagnosis and record of recurrences were gathered from the medical records. No
significant differences were found between patients' decisional styles and (1) Stage of
cancer x2 (9, iV=89) = 15.26,/? <.08), (2) prognosis assessed on a 1 to 6 scale with one
being poor and 6 being excellentx2 (12, N=85 = 11.55,/? <48), ( 3) time since initial
diagnosis x2 (12, tV=1 18) = 8.16,/? <77), (4) or whether the patient's current diagnosis is a
recurrence or not x2 (3,7V== 118) = .56,/? <91). This sample contained seriously ill people
with a mean stage of 3.04 and a mean prognosis of 2.91(2 = fair meaning unlikely to live
three to six months to 3 = guarded, meaning the person is unlikely to live much longer than

142
six months). Diagnosis dates varied considerably with a mean of 1.7 years and a median of
4.4 months. There were two people who previously had cancer over fifteen years prior to
this study. Their dates of diagnoses were dropped as outliers. The means and standard
deviations are reported in Table 4-6.
Table 4-6
Means and Standard Deviations for Medical Data
Mean
Stage of Cancer
3.04*
Prognosis
^ 91**
Date of Initial Diagnosis
1.7 yrs.
Standard Deviation
1.20
1.51
(Median 4.4 mo.) 2
* Stages ranged from 1 meaning non-metastatic and highly probable of a cure to 6 meaning
highly invasive cancer found in multiple sites of the body.
**Prognoses ranged from poor meaning less than three to live to excellent meaning full
remission is anticipated.
Hypothesis Two: Predicting the Decisional Processing Mode!
Hypothesis 2 stated that the Need for Cognition Scale, Need for Closure Scale,
Padua Inventory - Rumination Scale, and Ability to Process Questionnaire will predict
decisional style category. Once it was established that people do have different decisional

143
styles, there remained two other important purposes for this study. The first was to test
whether decisional styles are predicted by the elaboration likelihood model variables.
Hypothesis 2 was tested using a discriminant function analysis to determine the ability of
the predictor variables to determine decisional category. This hypothesis was supported.
Each of the ELM constructs, ability, cognitive responding, and motivation and
rumination were operationalized using four instruments, Need for Cognition Scale, Padua
Inventory - Rumination Subscale, Need for Closure Scale, and Ability to Process
Questionnaire as the predictor variables. A Chi-square test was performed to determine
homogeneity of within covariance matrices. This test resulted in a x2 (30, AM 20) =
77.41,/) <0001.
A discriminant function analysis statistically discriminates on the matrix of scales
between observations (protocols from participants) which determine decisional category.
The analysis then compares this number with the actual categories the participants fit. One
would expect chance alone to accurately categorize people 25% of the time. The
discriminant function resulted in a successful prediction rate of 60%.
Further examination of the success rates reveal differences in prediction rates for
each category of decisional style. The active deciders were predicted with a 72% success
rate, passive deciders were predicted with a 29% success rate; mindless deciders were
predicted with a 61% success rate, and ruminators were predicted with a 100% success
rate.
In three observations, the discriminant function analysis determined inaccurately
placed participants from the mindless decisional styles and placed them in the passive

144
decisional styles. Fourteen participants were removed from the passive decisional style by
the discriminant function. Of these 14 people, 5 went from the passive decisional style into
the active decisional style and 9 went from the passive decisional style into the mindless
decisional style. Theoretically, the only difference between the passive and mindless
decisional styles is the amount of thought engaged in when concerning treatment decisions.
Both mindless and passive decisional styles resulted in choosing the recommendation
provided by the medical system. In the actual data collection, the passive decisional
category was the most difficult to determine.
Eight of the miscategorizations made by the discriminant function analysis were
also the 13 discrepancies which required review by two judges. In these protocols, the self-
assessment by the patient differed from the investigator's assessment of category. In five of
these eight protocols, the judges did not agree on the category. For this group of
participants, categorization proved difficult with every method used.
Hypothesis Three: Relationship Between Decisional Styles and Coping
Effects of decisional style on coping. Hypothesis 3 stated that participants in the
active decisional category use more effective coping strategies than those in the passive
decisional category and these patients, in turn, use more effective coping strategies than
those with mindless decisional styles. Past research findings support that people who use
more coping strategies (Lazarus & Folkman, 1984), more types of coping strategies
(Dunkel-Schetter, Lazarus, & Folkman, 1992), and certain types of coping strategies
(Epping-Jordan et al, 1994; Eysenck, 1993; 1994; Ward, Leventhal & Love, 1988) are
more effective than others in coping with serious illness.

145
The patients using ruminating styles were again left out of this analysis due to too
few ruminating participants. A one-way analysis of variance using the three remaining
decisional styles as the independent variable and the total Ways of Coping Scale as the
dependent variable resulted in a significant F{2, 113) = 7.54, p < .0008). Mean scores on
coping were (a) active decisional style = 10.79 (SD = 2.03), (b) passive decisional style =
11.24 (SD = 1.90), and (c) mindless decisional style = 9.52 (SD = 2.13). See Table 4-8
for results. This result indicates the patients in the two categories using central route
processing, active and passive, utilized more coping strategies than those in the mindless
category.
The Ways of Coping Scale consists of five subscales: (a) Seek and Use Social
Support, (b) Focus on the Positive, (c) Distancing, (d) Cognitive Escape-Avoidance, and
(e) Behavioral Escape-Avoidance. Both raw and relative scores were computed. Raw
scores allowed for interpretations of both the number of strategies used as well as the
intensities. Relative scores enabled the computation of proportional scores for descriptive
purposes indicating the proportion of each participant's use of a particular strategy relative
to the total strategies used.Means on each subscale of the Ways of Coping Scale are
reported in Table 4-7 for each decisional style.
Differences on the total scale indicate the number of coping strategies employed.
Significant differences occurred between the decisional categories. Examination of the
means reveals that the direction of this difference was partially predicted by hypothesis 3.
Participants using active (mean = 10.79) and passive (mean = 11.24) decisional styles used
more coping strategies than those using using mindless (mean = 9.52) decisional style.

146
Table 4-7
Means for Five Coping Subscales for each Decisional Style*
Category
Support
Positive Focus
Distance
Cognitive
Behavioral
Total
Esc-avoid
Esc-avoid
Active
2.54
2.36
2.34
2.24
1.30
10.79
Passive
2.41
2.46
2.64
2.46
1.25
11.24
Mindless
2.05
1.81
2.41
2.12
1.11
9.52
* (raw scores: five point scale with 0 = never use to 4 = use very often)
Table 4-8
Analysis of Variance for Coping Scales
Scale
df
F value
P
Total scale
2, 113
7.54*
.0008
Seek and use support
2, 113
8.39*
.0004
Focus on the positive
2, 113
8.88*
.0003
Distancing
2, 113
2.51
.08
Cognitive escape-avoidance
2, 113
2.43
.09
Behavioral escape-avoidance
2, 113
1.41
.24

147
To test which differences want statistically significant, /-tests were conducted using
Bonferrrom correction for the number of tests computed. On overall coping strategies
used, there was a significant difference between all three categories. People using passive
decisional styles used significantly more coping strategies than those using active decisional
styles; people using both active and passive decisional styles used more coping strategies
than those using mindless decisional style.
Seeking support and using a positive focus are the specific types of strategies
comprising this significant difference. Support was used most often in active decisional
styles, less in passive decisional styles and least in mindless decisional styles. A positive
focus is used more by participants with passive decisional styles than those with active
decisional styles and active decisional style participants use positive focus considerably
more than participants with mindless decisional styles.
Relative scores were also computed on types of coping strategies and a one-way
analysis of variance, followed by t-tests with a Bonferroni correction was conducted. The
relative coping strategies reveal the proportion of the use of one strategy over the others.
The more types of strategies used, the higher the degree of flexibility in coping (Dunkel-
Schetter, Lazarus, & Folkman, 1992). Remarkable similarity is shown for the proportions
of strategies with one exception; participants with mindless decisional styles used a
significantly larger proportion of distancing than other participants. The difference
between the mindless and the active decisional styles was significant.
Two frames of reference were used to categorize people in decisional categories:
one was Ellen Langer's decisional categories (active, passive, and mindless) and the other,

148
was Petty and Cacioppo's information processing model (central vs. peripheral route
processing). Superimposing Petty and Cacioppo's model upon Langer's model places both
active and passive decisional styles into the category of central route processing and both
mindless and ruminating decisional styles into peripheral route processing.
Additional one way analyses of variance were conducted to determine differences
between people who make their medical decisions using central route processing and those
who use peripheral route processing. Central route processors used significantly more
coping strategies than peripheral route processors F{\, 118) = 11.88, p >.0008). Central
route processors were higher on seeking and using support F(l, 118) = 14.62,p > .0002),
focusing on the positive F(l, 118)= 17.42, p > .0001). When determining the ratio of
coping strategies used, peripheral route processors used significantly more distancing F{ 1,
118) = 8.22, p >.005). Although the means were different it did not reach significance
when using three categories of decisional styles for the analysis on the ratio of strategies
used. When using central and peripheral route processing as the categories, the ratio of
focusing on the positive was significantly higher for central route processors F(l, 118) =
6.95,/? > .009).
Hypothesis 3 stated that patients demonstrating active decisional styles would be
greater than those using passive decisional styles and that patients in both of those
categories would be significantly more effective in coping than either mindless or
ruminating decisional style participants. The Ways of Coping Scale was used to measure
coping in this analysis. The Ways of Coping Scale consists of three parts: First is the issue
the participant found most troubling and the second is the perceived degree of distress

caused by that issue. As described previously, these two questions were used as a testing
strategy so the patient could use a reference point in answering the questions about coping
strategies used. This study sought information related to how patients coped with the most
stressful part of their cancer.
Most Troublesome Part of Cancer
Five choices of issues that cancer patients find troublesome were provided. They
were (a) fear of future due to cancer, (b ) limitations in physical abilities, lifestyle, or
appearance due to cancer, (c) pam or discomfort from illness or treatment, (d) problems
with family or friends due to cancer, and (e) other. The frequency of each problem within
each decisional category is reported in Table 4-10.
Table 4-9
Frequency within Decisional Styles for Most Troublesome Part of Cancer Question
Category
Fear of Future Limitations
Pam and Discomfort
Active deciding
19
11
7
Passive deciding
15
5
4
Mindless deciding
17
16
9
Total
51
32
20
Although many more people l i sted fear of the future as the primary stressor, there
were no significant differences based on decisional style x2 (12, N = 115)= 12.573,/?
<-40. However, sixty percent of the cells had expected counts less than 5, which may

150
render the Chi-square an invalid test. In the initial analysis, the following cells had small
numbers: ruminating category of decisional style and the fourth and fifth choices on the
coping question (problems with family and other). In order to conduct a more valid test,
these categories were eliminated. A Chi-square was then performed on three decisional
styles and the first three choices on the coping question, resulting again in insignificant
findings x2 (4, N= 103) = 3.22, p < .52). According to the results of both tests, there was
no difference in the most troublesome issue related to cancer, based on decisional style.
For all categories, fear of the future was designated by 49.5% of the participants, 31%
identified limitations due to the cancer, and 19.4% identified pain and discomfort as
causing the most distress.
Amount of Stress Generated by the Most Troublesome Part of Cancer
The second aspect of coping was the amount of distress caused by the issue
identified as most troublesome. A one-way analysis of variance resulted in a nonsignificant
relationship between decisional style and the amount of distress reported by the participants
F(2, 117) = .35,/» >.70). On a five-point scale with 1 meaning extremely stressful, patients
using active decisional styles had a mean of 2.25 (SD = 1.04), those using passive
decisional styles had a mean of 2.48 (SD = 1.15), and those using mindless decisional
styles had a mean of 2.56 (SD = 1.05). That places the majority of the participants
between somewhat stressful (3) and stressful (2) regardless of decisional style.
Further investigation into the amount of distress generated by the most troubling
issue led to significant results F(4, 110) = 2.61,/ >.04). Although fear of the future was
the issue most frequently cited as most stressful (n = 53), the mean amount of distress

151
created by this issue was only 2.18 on a 5 point scale. The item identified second most
often as the most troubling, limitations due to cancer, (n= 33) had a mean distress level of
2.72. The highest stress level was reported for "other" which was typically identified as
financial concerns (mean = 3.4).
However, on closer observation, only four participants chose family and friends as
the most troublesome issue and five participants named financial concerns rendering the
fourth and fifth choices for the question of issues about coping with too few people for
statistical analysis. Therefore, another anova was conducted after dropping the last two
categories. This comparison between the interaction of stress level and most troublesome
issue (fear of future, limitations, and pain) was found insignificant F (2, 103) = 2.78,p<
.06). In this study, the issue found most difficult for the participant failed to significantly
influence the level of perceived stress. Neither the issue identified as difficult nor the level
of perceived stress were related to the decisional style of the participant. These factors
remain undetermined for the ruminating category.
Hypotheses 4 through 7: Relationship of Each Scale to Decisional Category
In order to determine the predictability of the overall model it was necessary to test
the predictive ability of each instrument individually. Hypotheses 4 through 7 tested each
instrument independently using a one-way anovas for unequal cells. The continuous
vanables in the four anovas, respectively, were the Need for Cognition, Need for Closure,
Ability to Process, and Padua Inventory, Rumination Subscale. The categorical variable in
the anovas for all four hypotheses was the decisional style categories. Three of the four of
these hypotheses were unsupported, providing evidence of the need for the overall model

152
in order to predict decisional styles. Taken alone, the Need for Cognition Scale, Ability to
Process Questionnaire, and Padua Inventory did not result in a significant relationship with
decisional style. Need for Closure was statistically significant.
These hypotheses tested the relationship between decisional style and each scale
used to operationalize the four predictor variables. The independent variable was
decisional style but, rather than using all four categories, the analysis used only three. The
fourth category, ruminating, was dropped because the cell contained only four participants.
Categories used were active, passive, and mindless deciding. The dependent variables
differed for each hypothesis tested.
Hypothesis 4 - Need for Cognition Scale
Hypothesis four stated that patients with active decisional styles would score higher
than those with passive decisional styles, which would score higher than those using
mindless decisional styles or ruminating on the Need for Cognition Scale. This hypothesis
was not supported. No significant differences were demonstrated between active, passive
and mindless deciders F(2, 113)= 1.77, p < 17). Means and standard deviations for each
category are reported in Table 4-10.
Table 4-10
Means and Standard Deviations on Need for Cognition Scale
Category
N
Mean
Standard Deviation
Active deciding
39
4.10
.88
Passive deciding
27
3.94
.84
Mindless deciding
50
3.74
.92

153
Hypothesis Five - Need for Closure Scale
Hypothesis 5 stated that patients with mindless decisional styles would score higher
on need for closure than those who use ruminating styles, that scores of patients using
ruminating would be equal to those patients with active decisional styles, and that all three
kinds of patients would score higher than those with passive decisional styles on the Need
for Closure Scale. Because the analysis conducted could not include ruminating, the
analysis could actually test only the following hypothesis: those using mindless decisional
styles would score higher than those using active decisional styles and both would score
higher than patients with passive decisional styles on the Need for Closure Scale. This
hypothesis was partially supported. Mean scores of patients with mindless decisional styles
and passive decisional styles did not significantly differ, but significantly differed from
active decisional styles F(2, 92) = 4.47, p < .014). Patients using mindless and passive
decisional styles had a greater demonstrated need for closure than those using active
decisional styles. Table 4-11 contains the means and standard deviations on the Need for
Closure Scale.
Table 4-11
Means and Standard Deviations on Need for Closure Scale
Category
N
Means
Standard Deviation
Active deciding
36
3.95
.42
Passive deciding
21
4.23
.49
Mindless deciding
38
4.23
.44

154
Hypothesis 6 - Padua Inventory - Rumination Subscaie
Hypothesis 6 stated that on the Rumination Subscale, ruminating participants would
score higher than members of any of the other categories. It further stated that active
decisional style and passive decisional style would be equal, and both would score higher
than mindless decisional styles. This hypothesis was not supported by the data F(2,113) =
. 10p < .91). Instead very few differences existed among patients using the three decisional
styles on the rumination subscale. The Padua Rumination Subscale is not predictive of the
three decisional categories analyzed. Means and standard deviations are listed in Table 4-
12.
Table 4-12
Table of Means and Standard Deviations for Rumination Subscale for decisional styles
Category
N
Means
Standard
Deviations
Active deciding
39
.658
.596
Passive deciding
27
.656
.453
Mindless deciding
50
.616
.443
Hypothesis 7 - Ability to Process Questionnaire
The Ability to Process Questionnaire was created for this study by Martin
Heesacker (personal communication, February 5, 1997). Each question was based on
research drawn from literature on central and peripheral processing of information and on
investigation of those factors which interfere with the ability to process information. Each
question tapped a different variable: ability, distraction, time, preoccupation, and emotional

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distress. A factor analysis was conducted on this Ability to Process Questionnaire. A
principle components analysis suggested one factor. Cronbach's Alpha for the scale was
.80, which also supports the single-factor conclusion regarding this scale.
Hypothesis 7 stated that patients with active decisional styles and passive decisional
styles were equal on the Ability to Process Questionnaire and both groups would have
higher mean scores than those patients with ruminating and mindless decisional styles. It
further stated that ruminating style would be greater than mindless decisional style on the
Ability to Process Questionnaire. The hypothesis was unsupported F (2, 113) = .59,p <
.55). Again, very few differences were found between decisional styles indicating that the
Ability to Process Questionnaire is not predictive when used alone. Means and standard
deviations are reported in Table 4-13.
Table 4-13
Means and Standard Deviations for
Ability to Process Qi
lestionnaire for decisional styles
Category
N
Means
Standard Deviation
Active deciding
39
2.04
.64
Passive deciding
27
1.99
.64
Mindless deciding
50
2.16
.74
In summary, consistent with hypothesis 1, the participants in this study did indeed
use different decisional styles. The decisional styles were unrelated to the severity or
prognosis of the illness, amount of time since diagnosis, or whether the cancer was a
reoccurrence. Decisional styles were, however, related to education. Decisional styles

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were assessed using three different methods which resulted in the identical categorization
of 103 of the 120 participants. The categorization of the participants into the four
categories proved to be highly reliable.
The second hypothesis of this study was assessed via the discriminant function
analysis to determine if the elaboration likelihood model variables, together with the Padua
Rumination Scale, would predict decisional styles. This hypothesis was supported. Sixty
percent of the participants were accurately categorized using these predictor variables.
This figure is 35% higher than the 25% if predictions were made by chance.
In support of hypothesis 3, significant differences were found among patients with
different decisional styles on both the amount and type of coping strategies used.
Specifically, active and passive deciders used considerably more coping strategies and more
effective coping strategies than mindless deciders. No analyses were conducted on the
ruminating category because there were too few participants in this category. This study
provides some evidence that patients use different decisional styles and the four categories
in the decisional processing model are valid. Further evidence is provided in this study
suggesting decisional styles and effective coping are related.

CHAPTER FIVE
DISCUSSION OF RESULTS
Chapter Five provides a summary of the results supporting the three main
hypotheses and the decisional processing model. The theoretical implications regarding the
extension of the theory of mindfulness and the elaboration likelihood model into medical
decision making are addressed. Practice implications are also included. The chapter closes
with methodological issues and new research questions generated by the results of this
study.
Medical delivery system is beginning to recognize a general movement toward a
more educated, involved consumer approach by patients (Hodne, 1995). Patients are
assuming a greater role in choosing treatments, including regimens unknown to their
treating physician (Jacobs, 1993). Even major funding sources, such as the National
Institute of Health, are placing quality of life issues on their agenda in anticipation of a
future in which Americans will be facing limitations in their health care (Cynthia Bellar,
personal communication). These indicators suggest that patients wall be considerably more
involved in making their medical decisions.
Research in medical decision making literature focuses primarily on the physician's
decisions whereas only a handful of studies address the patient's role in decision-making.
A few studies suggest that patients do not wish to be involved in their medical decisions
157

158
(Ende, Kazis, & Moskowitz, 1989; Strull, Lo, & Charles, 1984) but other studies conclude
that more patients do wish involvement (Blanchard, Labrecque, Ruckdeschel, &
Blanchard, 1988; Cassileth, Zupkis, Sutton-Smith, & March, 1980; Degner, Kristjanson,
Bowman, Sloan, Carriere, O'Neill, Bilodeau, 1997). Because patient's decisions are
directly related to adherence, outcomes, and coping, it is essential to understand their
decision-making process.
Relationships between personality variables and coping styles have been shown to
affect incidence, progression of disease, and survival. Studies have demonstrated
significant synergistic effects between physical and psychological factors. About half the
variance in predicting cancer is due to personality and coping factors (Eysenck, 1988). in a
review of personality, coping, and cancer, Eysenck (1994) concluded a need for an
integrated model predictive of coping, occurrence, progression, and survival.
Underlying many of the above factors affecting cancer are decisions about such
issues as attribution of causality, self-efficacy, the use of coping strategies, and treatment
regimens. Essential to building a model of personality, coping, and cancer, is a greater
understanding of how these important predictors of cancer are determined. This study
proposed to begin a program of research that leads to a model of decision making that
could be useful in impacting those factors critical to effective coping, limiting disease
progression, and enhancing survival.
Summary of Results
Three main hypotheses were used to test a model of medical decision making and
it's relationship to coping. The results testing the first hypothesis established the existence

159
of four decisional styles. Three of the decisional styles were statistically supported. The
fourth, ruminating, contained few participants but enjoyed perfect agreement between all
methods of measuring. This category could not be included in the empirical testing of the
hypotheses due to the small number of patients. The second hypothesis, testing the ability
of the elaboration likelihood contructs to accurately predict decisional style, was supported.
Hypothesis three, stating that patients using certain decisional styles were more effective
than others in coping was also supported. The Need for Closure variable was the only
ancillary hypothesis that was supported. No relationship was found between any other
variable and decisional style, indicating that the scales by themselves were not
predictive.
Another major finding was that a majority of people engaged in mindless deciding
about an event as serious as a life-threatening illness. How patients made decisions about
their medical treatment was related to decisional style and unrelated to either medical data
or most descriptive variables. The only variables that correlated significantly with
decisional style were education and age.
Theoretical questions were also examined in this study. In building a model of
decisional styles, the elaboration likelihood model of Petty and Cacioppo (1981) and Ellen
Langer's theory of mindfulness were integrated. The integration of these two theories was
supported by the findings of the present study. Evidence was generated that the four
decisional categories indeed fit into two groups, central and peripheral processing routes.

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Decisional Categories
The use of four decisional styles in the proposed model was supported. Inclusion
of the three decisional styles identified by Langer (1994) received strong support. In
support of Langefs theory, 41% of the participants used the mindless decisional style. The
active and passive decisional styles were used by 32.5% and 22%, respectively. The
ruminating style contained 3.3% of the participants. Although there were very few
participants in the fourth category, there was total agreement among the participants, the
investigator, and the judges about their style of deciding. Furthermore, this style was
perfectly predicted by the discriminant function analysis (100%).
Mindless Decisional Style
In mindless decisional styles people rely on peripheral cues to make a choice.
Many of the participants in this study who used the mindless style made treatment
decisions as serious as whether or not to get a bone marrow transplant within less titan five
minutes and without leaving the doctor's office. They placed their faith in the authority and
reputation of their doctor or the facility. Since most of the interviews took place with a
spouse present, additional conversations occurred revealing that the mindless deciding in
which the patient engaged was often offset by a different style of deciding conducted by
the spouse. Some patients in the mindless category followed their spouses' advice as
unquestioningly as others followed their physicians' advice. They, themselves, still engaged
in no thoughtful decision-making.
Langer's theory postulates that mindless deciding is making a premature cognitive
commitment based on pre-existing schema. It is within the mindless decisional style that

161
evidence of this pre-existing schema is discovered. Decisions have been shown to be
influenced by framing effects (Tversky & Kahneman, 1981) in a study using a hypothetical
life-death story. When presented in the frame of saving lives, the majority choice (72%)
was risk aversive; when presented in the frame of losing lives, the majority (78%) took
risks. Such framing effects were subsequently found to extend to processing operations.
Tversky and Kahneman (1985,1986, 1992) advanced the idea that people engage in two
phases when making risky choices: editing and evaluating. The first operation in this
sequence is coding into a "loss" or a "gain" problem and this coding was affected by
framing.
However, these studies were context independent. In a series of experiments
manipulating context, findings revealed a framing effect when a life and death story was
associated with unidentified people but, when the story was associated with their own
family members, no framing effect was demonstrated (Wang & Johnston, 1995). When
placing their own family in the life and death situation, participants overwhelmingly chose
the riskier decision. The frame of reference was no longer the frame presented to them but
was replaced with their own frame and, in the family context, the frame was unanimously a
"loss". This reference point begins the association with a pre-existing schema and the
schemata operates in framing the decision, ft is this individual coding (meaning) attached
to an event that determines the associations with pre-existing schemata.
The current study provides supportive evidence of such schema. Many of the
patients in the mindless category spoke of their pre-existing schemas, usually the reputation

162
of the facility, as the reason for their decision. They acknowledged that they decided to
take the physician's advice prior to meeting the physician.
Similar to the Wang and Johnston (1995) study in which framing effects
diminished when participants thought of their own family members in the situation, the
decisions in this study were even more highly contextualized and therefore resistant to
external framing effects. Cancer is a silent illness that begins asymptomatic and often
advances considerably before diagnosis occurs. If a patient felt he/she were healthy, as
expressed by those in this study, and was suddenly confronted with cancer, it is very likely
he/she would frame the experience as a loss. Among the mindless deciders, their decisions
were made prior to the physician offering any frame of reference, indicating the framing of
their decisions was their pre-existing schema.
According to the prior research, framing the illness as a loss should have resulted in
a riskier decision when it came to treatment. It is unclear from the current research if
"leaving it to the physician" is considered riskier than more involvement in their treatment
decision. Given that these participants were also the ones who demonstrated a significant
need for closure (hypothesized by Kruglanski as a motivator to reduce anxiety), it is more
likely that they chose the least risky route in order to reduce their distress. There is a
difference between this study using participants whose lives are actually threatened by the
illness and those in the decision-making studies using hypothetical examples. The
difference may lie in the degree of emotional involvement. Although this study suggests
that a more threatening context may influence framing effects, further research is needed to

163
clarify this relationship. If people do use different decisional styles, perhaps the framing
effects vary based on these decisional styles.
As theorized, people in the mindless decisional category made a premature
cognitive commitment to a process. In contrast to decision making literature, these results
did not support the hypothesized framing effects demonstrated in other studies on
contextualization of decisions.
A possible explanation for the large proportion of participants in the mindless
decisional category can be found in the patient-physician communication literature.
Participants in this category reported making their decisions in less than five minutes or, in
the absence of any information, beyond one time-limited conversation with a physician.
Time spent with a physician (more than 19 minutes) (Beisecker & Beisecker, 1990) and
longer acquaintance with a physician (Waitskin, 1985) has been associated with more
information seeking behavior and more active patient participation in decisions. According
to an informal and limited survey of the staff at the facility in which the current study was
conducted, the physicians spend thirty to fourty minutes during the patients initial
appointments. The decisions assessed in the current study were those made at the
beginning of their treatment at this facility. It is likely that only a few patients in this study
had a prior relationship with the oncologist. It is unlikely that patients were categorized in
the mindless decisional style because of either limited time with the treating physician or a
long-standing relationship with the physician.
Langer postulated that neither active nor passive deciding takes place when only
one alternative is provided. In the present study, it was not unusual for the physician to

164
recommend one course of treatment. This lack of options did not inhibit the participants
who chose to go further or to think about whether or not they wanted to be treated. Those
in the active decisional category initiated further information search anyway. However,
many of the patients felt as if they had no choice when presented with one option. For
those participants, follow up questions often surfaced decisions made according to pre¬
existing schema, and they were categorized in the mindless decisional style.
Previous investigations of mindless decisions were conducted under conditions in
which decisions based on commitments made to a pre-existing schema were outside of the
awareness of the participants. The current study, in contrast, demonstrated participants'
use of mindless decision-making under conditions in which they were confronted with
taking a course of action based on their decision. This study extended the generalizability
of research on mindless decisonal styles to include people who were aware of making a
decision. In this sample, under critical conditions, mindless deciding occurred even when
the decision was consciously made and the style of deciding acknowledged.
Active and Passive Decisional Styles
The active decisional category contained 32% and the passive decisional category
contained 22%. Interpreting Langer's writings, this appears to be a higher-than-expected
number of patients, especially in the active decisional category. Active and passive
deciders both engaged in effortful thought but only active deciders sought additional
information. Both groups maintained a sense of control even when they ultimately chose
the physician's recommendations. Patients in another study were found to report a greater
sense of control and improved health when they actively participated in the decisions about

165
their treatment (Brody, Miller, Lerman, Smith, & Caputo, 1989). In other studies, a sense
of control has been identified as affecting adherence to medical regimens (Leidy & Haase,
1996), survival and coping (Epping-Jordan et al, 1994).
Langer theorized a discrimination between active and passive deciding based on the
initiative displayed by the patient in gathering information and the consideration given to
the options generated. This distinction was upheld in the current study. These active
decisional style patients sought information from the internet, the library, the American
Cancer Society information line, and medical journals. They entered self-awareness into
the equation and generated their own opinions. The passive decisional style patients in the
current study gave a great deal of serious consideration to everything presented to them.
They often took notes during appointments with the physician. However, they displayed
no initiative to search beyond what was presented to them. The distinction between active
and passive decisional styles was upheld in the patterns presented by the participants in this
study.
Active decisional styles and mindless decisional styles were readily identified.
Passive decisional style was the most difficult to identify regardless of method used
(decision tree, independent judges or the discriminant function analysis). Similar to this
study, most of the distinctions drawn from research on Langer’s theory have been between
mindlessness and mindfulness (active deciding). In Langer's studies (for example: Langer
& Williams, 1992) passive deciding, if it occurred at all, was not a naturally occurring
event. The present study was conducted under naturalistic conditions. The difficulty'
confronted in identifying the passive decisional category as clearly as the others in the

166
current study may be explained by semantics. Passive deciding is theoretically similar to
active deciding (ie. central route processing) but shares the same outcome with mindless
deciding (Doctor's recommendation). If, when participants are questioned the emphasis is
placed on the outcomes, i.e. "going along with the physician's recommendations", passive
deciding can be confused with mindless deciding. Theoretically, active and passive
decisional styles are more closely related because they both describe a process of effortful
thought and deep consideration. This research clearly supported the distinction between
active and passive decisional categories as Langer theorized.
Although the passive decisional category was statistically significant, it had the most
discrepancies of all the categories. Perhaps the difficulty in drawing a line indicates that,
rather than existing in structured categories in the natural world, decisional styles may
reside on a continuum. Each person may fluctuate in his/her decisional styles within a
certain range, sensitive to the environmental and internal factors empirically demonstrated
to influence routes of processing information. It is possible that there are degrees of active,
passive, and mindless decisional styles.
It is also possible that decisional styles are situation-specific rather than global.
There were two indicators in the data-gathering process indicating this possibility. Men
who had attained positions in life that generally require decisiveness (CEO's of major
corporations, attorneys, university professors, and researchers) were often surprisingly
represented in the mindless category concerning their medical decision-making.
A mediating variable may be operating in determining which style is used for each
situation. One study found that elderly people were more likely than younger people to

167
want decision-making participation (Woodward & Wallston, 1987). The intervening
variable that explained this finding was the difference in the degree of self-efficacy related
to health behaviors. Self-efficacy was not included in this study and more research is
needed to understand the nature of this variable.
Ruminating Decisional Style
Ruminating participants felt that their choice was forced, not by medical
circumstances, but by social circumstances. One woman stated that she was only going
through treatment because her family was badgering her. Another stated that she went
along with the physician recommendations, but she doesn't trust it. The four patients in the
ruminating category were undergoing treatment did not feel committed to the choice. They
expressed high anxiety, low hopefulness, and often anger. Although the people in the
ruminating category were few, they were well known to the staff as "being difficult" and
"making endless demands". Not one patient in any of the other categories was described
by the staff in this manner.
Increased anxiety and distress often lead to increased attentiveness to bodily
sensations and increased misattribution of distress to the illness (Mechanic, 1992). Cancer
treatment is often described as "worse than the disease" because of the uncomfortable and
sometimes serious side effects. Increased attention to bodily sensations and the inherent
discomfort in cancer treatment may lead to labeling the illness as hopeless. Misattribution
increases body scan behavior. Judgement of progress are determined more by perception
of these physical sensations than objective information. Individuals with heightened

168
anxiety and ambiguous symptoms are more likely to engage in misattribution and seek
more medical attention (Cameron, Leventhal, & Leventhal, 1995)
In spite of their small numbers, it may be worthwhile to conduct more research on
the ruminating group if they are using an inordinate amount of staff time and energy. The
numbers were too small to statistically test the ruminating category. It is unlikely that the
people in this category were simply statistical outliers. Participants in the ruminating
category demonstrated a high degree of internal consistency were decidedly different on
the predictor variables in the discriminant function analysis.
Age and decisional style
The interaction of age and gender was one of the personal variables that
significantly correlated with decisional styles. Women did not differ in mean age on
decisional styles. However, significantly more older men were represented in the mindless
decisional category than women or younger men.
Several gender differences noted in the interview process may explain this
difference. More wives than husbands were present for the interviews. Husbands, when
present, rarely involved themselves. The wives were actively involved, contributing
explanations to the researcher, reminding their husbands of past behavior, and intently
listening to the conversation. The traditional of women as care-takers may have precluded
men in the older age group from actively participating in their medical treatment.
The differences found in prior research (Degner, Kristjanson, Bowman, Sloan,
Carriere, O'Neil, & Bilodeau, 1997; Woodward & Wallston, 1987) between younger and
older women in their desire for a more active role in decision making was not supported by

169
this study. Both of the prior studies consisted of patients more than two years post¬
diagnosis. Time since diagnosis was found to be predictive of desire for control in the
Degner study. In contrast, the majority of the participants in the current study had been
diagnosed less than six months. Time since diagnosis had no effect on their decisional
style.
Education and decisional style
Education was also correlated with decisional style. The Need for Cognition Scale
was not correlated with decisional style, ruling out the likelihood that intrinsic motivation
led people to put more effort into their decisions as much as education itself. Examination
of Table 4-2, reveals that people who attended college demonstrate a definite preference
for active and passive deciding (central route processing) in making medical decisions.
Active deciding, defined as taking initiative, is the category containing most of the
college educated participants. Although results do not show reasons for this configuration
of findings, there are several possible explanations for this differentiation. College
attendence may teach a person where and how to utilize resources to gain information.
Another reason may be that the college experience, in teaching students to critically
evaluate material presented, may reduce blind acceptance of "experts". Yet another reason
may be that college attendence improves confidence in one's own abilities, enhancing self-
efficacy.
In the current study, "some college" could mean someone who took academic
courses in a four year institution without completion or attended a vocational technical
school. Vocational colleges seldom teach critical evaluation of academic material, yet

170
frequently, those students gain confidence and pride in their accomplishment. The fact
that this category of education level contains a large number of both passive decisional
styles and mindless decisional styles is consistent with the notion that knowledge about
utilization of academic resources and the ability to critically evaluate important material
may be the reasons driving this decision-making behavior. Resource utilization and
evaluation skills are teachable and could be incorporated into a psychoeducation program
for cancer patients.
In the Degner (1997) study on women with breast cancer, education level was the
best predictor of preferences for involvement in decision making. The Degner sample
included a large number of low education, elderly people, whereas the current study
extended these findings by including an unusually large number of highly educated,
middle-aged people. The Waitzkin study (1985) also reported patients with a higher
education level, a higher socio-economic level, and women demonstrated increased desire
for information and participation.
Race and decisional style
Non-significant results related to race must be viewed with caution. Racial
composition of the study included a small number of African-Americans, Hispanics, and
Asians and therefore they were grouped together as non-whites and then compared with
whites. It is not possible to know if the sample was representative of the population
because statistics are not kept by Shands Cancer Center on the racial make-up of the
population served. In addition, there is growing evidence in the literature that including
people who are culturally different in a statistical analysis in which they are grouped with a

171
another minority, reveals very little about that population. Although efforts were made to
incorporate different races in this study in large enough numbers to be able to conduct
adequate analyses, there simply were not enough non-whites seeking services at the
treatment center during the four weeks in which this study was conducted to do so. To
state, even equivocally, that race is unrelated to decisional styles would be overstating the
results of this study.
A debriefing of the researchers by the principle investigator following the data
collection reached a general consensus that African-Americans who demonstrated a
mindless decisional style put their trust in their religious beliefs, not the physician or the
facility, as was common among the whites. Follow-up studies are needed to determine
decisional styles for people of different cultural experiences.
Medical data and decisional style
The majority of people in the current study were recently diagnosed with pervasive
cancer and given limited life expectancies, yet their decisional styles were unrelated to any
of these factors. Time since diagnosis (mean =3.71 months) in this sample was
considerably less than the time since diagnosis in other studies on decision-making. Degner
et al (1997) with a mean = 4.7 years since diagnosis, reported that women who were closer
to diagnosis were less likely to prefer active roles in decision-making.
Another difference between the current study and previous reseach is the level of
disease in the patients. The mean level of disease was stage 3.04. Women with less
advanced cancers wanted more participation than those with more advanced cancers
(Degner et al, 1997). Less than 10% of the Degner sample was above a stage II meaning

172
that most of their participants were considerably less ill than those in the current study.
The Degner study was conducted on breast cancer patients only, typically more vocal than
any other group of cancer patients. Differences found in the Degner results and these
results may reflect differences in the sample. However, these differences again raise the
question whether decisional styles are situation-specific or global.
Limitations
The sample contained an inordinate number of people with advanced degrees.
Education was a factor in discriminating between decisional styles. It is possible that if this
study were conducted in a geographic location less dominated by a major university, more
people would be categorized in the mindless decisional category.
Elaboration Likelihood Model As Predictive of Decisional Style
Two Routes of Processing
One of the purposes of the current study was to find evidence supporting the
integration of hanger's theory of decision-making (1989) and the social influence theory of
Petty and Cacioppo (1986). Social influence theorists have identified two routes of
processing. Petty and Cacioppo (1986) called these routes, central and peripheral.
According to Petty and Cacioppo (1986), central route processing requires effortful
thought, discrimination between options, an investment of time, and a response. Further
investigation demonstrated that these variables were affected by distraction, amount of
involvement, motivation to process, and emotional state, as well as how the message was
presented. The same description also defines the parameters of hanger's theory. Central

route processing is analogous to Langer's active and passive deciding; peripheral route
processing is analogous to mindless deciding.
The results of the current study supported the proposed integration of theories. In
every method of measuring, participants were found to fall into active, passive, and
mindless decisional categories. Those factors common to both theories were used to
describe decisional styles. It is legitimate to consider both active and passive decisional
styles as central route processing. There were more similarities than differences in the two
styles. Both styles involved effortful thought, considerable time, a continuing search for
more information, an openness to new information, reasonable certainty of the decision,
and devoid of excessive worry. Both active and passive deciding can be considered
central route processing.
On the other hand the participants in this study using mindless deciding,
demonstrated a clear response to cues that triggered a pre-existing schema. This pattern of
deciding describes peripheral route processing.
One discrepancy remains unsettled. Langer's theory suggests that when a cognitive
commitment is made to a pre-existing schema, a person is more certain he/she made the
right decision. Petty and Cacioppo’s theory suggests that when a choice is made through
peripheral route processing, it is subject to change when a different cue presents itself.
This discrepancy may be clarified through the work on availability of cues conducted by
Fazio (1993). Fazio suggests that the strength of the association will determine the
availability of a cue and that a person processing in a peripheral manner will respond to the

174
most available cue. It is possible that the certainty expressed by these patients results from
the strength of the cue that triggered the response.
For example, Joe was told by his family doctor that Shands Cancer Center had the
best medical care. Based on that cue, Joe made a quick decision that, when he went to
Shands, he would accept whatever the (unknown at that point) oncologist recommended.
In an effort to reduce his anxiety about his future (reflecting Kruglanski's theory), Joe
remained closed to any competing information, thereby increasing the availability and
strength of the association and decreasing the likelihood that any other information could
be associated with recovery in his mind. The strength of association and the availability of
the schema may account for the certainty of these decisions in spite of the fact that these
patients exhibited peripheral route processing.
Predictive Ability of ELM
Use of the constructs of the elaboration likelihood model (ELM) to predict
decisional style was supported by this study. With the exception of the need for closure,
none of the variables could independently predict into which category a person would be
placed. The elaboration likelihood model postulates that three factors are necessary and
sufficient to make deep level change by influencing the route of processing.
Ability to process was measured in a straightforward scale assessing those factors
which have been demonstrated in research to interfere with central route processing.
Participants in this study clearly felt they had the ability to make a decision. Even those
participants who reported making their decision in less than five minutes stated that they
had sufficient time.

175
Motivation is requisite in determining whether a patient will engage in central or
peripheral route processing. The nonsignificant results on the Need for Cognition Scale
suggest that motivation to centrally process treatment information is not based on any
intrinsic need to think more effortfuily. It is altogether plausible that whether a person
enjoys thinking or not would have very little to do with determining whether they put effort
into such a life and death decision as cancer treatment.
To understand motivation in this study, the plight of the cancer patients must be
considered. Need for cognition, while predicting the use of central route processing in
other situations, does not, by itself, influence the decisional style a patient uses to decide
medical treatment and coping. But, situational variables may override global need for
cognition. Some of these situational variables serve to increase the likelihood of central
route processing and others serve to decrease it. Personal relevance increases the
likelihood to use central route processing (Petty & Cacioppo, 1979; Petty, Cacioppo, &
Heesacker, 1981). Unquestionably, motivation to get the best possible treatment for cancer
would certainly be present and so would personal relevance. However, other situational
factors may intervene, reversing the tendency to process centrally.
Increased intensity, as researched by Petty & Cacioppo (1986), was related to
values. Under conditions which threaten one's deep values, people are likely to invoke self
protective schemas, thereby processing peripherally. If self-protection is more important
than thinking effortfuily when values are under attack, it can certainly by used by patients
whose lives are under attack. With increased intensity comes an increased reliance on
normative information, decreasing the likelihood of central processing. In the elevated

176
threat condition that terminal cancer patients face, efforts to reduce the threat most likely
took precedence over need for cognition in directing their decisional style.
Another intervening variable may be efficacy. If a person does not feel efficacious
in making medical decisions in the interest of self-protection, he/she may be more likely to
use peripheral route processing. Although the relationship between route of processing
and efficacy has not been researched, efficacy was found to be a factor in determining
whether a person may wish to be active or passive in making medical decisions (Woodward
& Wal'son, 1987). So, while motivation to process centrally may be present, intrinsically
and situationally, the relationship is complicated by factors that motivate peripheral route
processing as well. Another factor affecting how information is processed and decisions
are made is need for closure.
Kruglanski and Webster (1996) have concluded that need for closure is also a
motivator pertinent to decision-making. Therefore another assessment used to
operationalize motivation was the Need for Closure.
Need for closure was signicantly related to decisional categories. No differences
were found between passive and mindless decisional styles but patients using active
decisional styles had lower need for closure. Kruglanski (in press) stated that in addition to
an individual disposition, situational factors tend to elevate the need for closure. These
factors are 1) when the subjective importance of predictability and action are great and 2)
when the perceived effort to remain open to new ideas is great. Factors which are likely to
decrease the need for closure are fear of invalidity or paying a high price if one's decision is
wrong. When making decisions about cancer treatment, the subjective importance of

177
action is high and predictability is low. If the wrong treatment is chosen, it could have life-
threatening consequences, yet when asked if they were at any time afraid of making the
wrong decision, 71% of the participants answered no or very little. In a person with a
relatively high need for closure, in a situation that is both life-threatening and
unpredictable, the fear of invalidity, rather than operating to prompt avoidance of closure,
may increase the tendency to embrace closure (Kruglanski, in press).
Fear of invalidity in a high cost situation could lead some people to continue an
information search and remain open to continued effortful thinking. Others may respond
to this fear by generating fewer options or suppressing attention to information inconsistent
with their hypotheses. In this manner, the need for closure is manipulated by a situational
variable, diagnosis of cancer, that heightens the necessity for the person to act in an
exaggerated manifestation of his/her characteristic functioning.
The implication of such 'seizing' upon a solution and 'freezing' it in an illusion of
certainty is that judgements made in this manner are highly susceptible to peripheral cues.
All the circumstances related to peripheral route processing are evoked. Patients operating
in this manner rely more on stereotypes, are subject to primacy effects in impression
formation, and resort to pre-existing knowledge (Kruglanski & Webster, 1996).
Cognitive respooding is discriminating between options so that they are seen as
different enough to determine that one is better than another. Cognitive responding was
operationalized by the Padua inventory - Rumination Scale and by a question on the
Decision Tree which asks if respondents had made a decision. An overwhelming majority

178
had. The ability to see certain options as more viable than others is inherent in decision¬
making.
The one category in this study that would not fit the requisite cognitive responding
is ruminating style . Rumination was not addressed in either the research of Ellen Langer
or Petty and Cacioppo. Ruminators do not seem to have the ability to commit to a
cognitive response because they never "settle" on a decision even if they have begun to take
action. Although the sample was too small to analyze, the ruminators demonstrated
dramatic differences in mean scores on ability' to process. Mean score for the total sample
was 12.76 and mean score for those in ruminating category was 18.8. Low scores indicate
high ability to process. Ruminators retain a high degree of uncertainty, wondering if the
other choices may have been better even in the absence of evidence. This constitutes a
lack of cognitive commitment. Cognitive responding was reflective of people in the active,
passive, and mindless decisional styles.
The use of two routes of processing information indicates that both routes may be
used to process salient messages. A message with strong recommendations may also
include salient cues, thus rendering each message equally accessible within the person's
schema. Both routes of processing may be evoked simultaneously, interfering with making
a cognitive commitment to either. The more a person ruminates, the more the rivalry
between options is reinforced rather than either option. When combined with the other
two components of the ELM in a medical decision situation, the motivation would, be high
(especially that affected by fear of invalidity) but the ability to use one mode of processing
over another may be absent. The association between the ELM constructs and a

179
rumination scale found in the current study clarity a process alluded to by Petty and
Cacioppo. They stated, "The ELM, of course, postulates two routes to persuasion and
indicates that attitudes can change in the absence of extended issue-relevant thinking if
salient cues are provided in the persuasion context and people lack the requisite motivation
and/or ability to engage in message scrutiny" (Petty & Cacioppo, 1986, p 181). More
research may be necessary to determine the effects of simultaneously activating both routes
of processing.
Limitations
The style of presentation by the physician may have influenced the decisional styles
used by the patients. Prior research has demonstrated that manipulation of the ELM
variables results in different routes of processing. Whereas the predictive ability of the
ELM constructs provide some evidence that decisional styles may be influenced by how
the message is delivered. The predictive ability of the Need for Closure Scale provides
some evidence that decisional styles are also influenced by individual differences as well.
This question can only be settled with additional research.
The associations between theories, constructs, and specific variables in the current
research are new. The hypotheses tested used these theories in a conceptualization
radically different than their use in past research Using them in this manner was
theoretically valid and supported by the results but the methods for operationalizing their
constructs were created for this study. The study is only as strong as that
conceptualization. Until more research can be conducted on the model, the results,
although significant, must be embraced tentatively.

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Decisiona! Styles and Coping
Decisional styles were correlated with coping. Patients with active decisional styles
used more coping strategies than did patients in other categories. Patients using both active
and passive decisional styles (central route processors) used more strategies to cope than
patients with mindless decisional styles (peripheral route processors). In addition, those
with mindless decisional styles used significantly more of the least effective coping
strategies.
The first two questions about coping asked the participants about the most
distressing part of their cancer. Fear of the future was clearly the most distressing aspect
for all decisional styles. However, those answering fear of the future did not report as
significant a stress level as those reporting the limitations due to cancer. The most
prevalent issue was apparently not the most stressful or the one that evokes the most denial.
Another issue reported as extremely stressful by a low number of participants was the
category "other" which, for these people, meant financial concern. Although financial
concern was not hsted as an item on the scale used, for those participants not insured, it
represented a great deal of stress. Had it been asked as part of the scale, it is likely this
concern would have been reported more frequently.
In addition, patients appeared to be coping more effectively with the fear of the
future than with the other issues. The other issues listed, limitations, pain, and financial
problems tend to confront a person daily, while fear of the future may not. All of these
daily issues may limit a person's ability to utilize the strategies proven most effective.
Support is limited if. for financial or medical reasons, a patient is less able to be with

181
people. Limitations and pain interfere with maintaining normal routines and hope, making
it more difficult to focus on the positive. However, neither the issues identified as stressful
nor the level of perceived stress was related to decisional style.
Significant differences were found in the total strategies used in the different
decisional styles. The hypotheses predicted that more strategies would be used in active
decisional styles than in passive decisional styles. The stress level was also reported higher
(although not significantly) among those using passive decisional styles. In spite of the
stress level differences not reaching significance (passive x = 2.52 as opposed to active x =
2.38), those patients in the passive decisional category may experience more stress and
therefore be more aware of the need to use coping strategies. They also used more
distancing, a less functional strategy of coping than support and positive focus, than any
other category of decisional styles. Patients using passive deciding also had slightly
elevated scores on cognitive escape-avoidance strategies. Having a positive focus and
distancing have both received mixed findings in the coping literature (Felton et al, 1984;
Weisman & Worden, 1976-1977) while cognitive escape-avoidance was found to be
negatively correlated with effective coping (Felton et al, 1984).
Perhaps patients in the active decisional styles who use more effective strategies and
report slightly less perceived stress are simply coping more effectively, in spite of not using
a larger number of strategies. Supporting this possibility arc the significantly more support
activities engaged in by those in the active decisional category. Positive focus was used by
participants with passive decisional styles more often than by those with active decisional
styles but neither of these categories of deciders used positive focus as their primary

182
strategy. Active deciders' primary strategy was seeking support whereas passive and
mindless deciders' primary strategy was distancing. Attempts to distance, labeled threat
minimization, was associated with increased distress (Weisman & Worden, 1976-1977).
However, the difference between the passive and mindless categories on coping is that
patients in the passive category use considerably more strategies along with their distancing.
Therefore the ratio of distancing to total strategies employed is smaller for those people in
the passive decisional category.
The patients using mindless decisional styles reported the most (although
insignificant) perceived stress. The most frequently used strategy was distancing and
cognitive escape-avoidance was second in frequency of use. Positive focus was used
sigr.icantly less frequently than either of the other decisional styles.
in an exploration of patterns of coping with cancer, Christine Dunkel-Schetter,
(1992) posed questions about the antecedents that predispose some cancer patients to use
one coping strategy over other, less effective ones. The current study suggests that
decisional style may be one of those antecedents. In a comparison between her study of
668 cancer patients, the sample in the current study was similar with two exceptions: the
cancer patients in the current study had poorer prognoses and their diagnoses were much
more recent. Interestingly, in spite of these patients being sicker, the mean perceived stress
level was considerably lower than the Dunkei-Schetter group. This finding is even more
surprising when one considers she drew her sample from people much further removed
from treatment than the present sample.

183
The participants in the Dunkel-Schetter study demonstrated little evidence of
coping styles based on demographics and medical variables. Emotional state was
significantly associated with all five patterns of coping. Less emotional distress was
significantly associated with the use of support, focusing on the positive, and distancing.
More distress was associated with using escape-avoidance behavior. Other studies
discriminating between affective and cognitive coping styles have found that cognitive
coping is more effective (Leventhal, 1993).
By assessing patients within different decisional styles and discovering significant
differences in the patterns of coping, the current study extends the findings of prior
research. Consonant with the Dunkel-Schetter study, patients in the current study used
more distancing and support than any other pattern. However, the variation among the
three decisional styles did reflect different patterns.
Coping with distress has also been linked to suppression of emotion and
inappropriate coping mechanisms. The body of research on suppression of emotion as a
component of the cancer-prone individual has been generally accepted as a supported
correlation. The evidence for inappropriate coping mechanisms has shown that there is a
synergistic effect between coping and physical factors. In one classic study, Kissen (1964)
determined that "the poorer the outlet for emotional discharge the less exposure to cigarette
smoke was required to induce lung cancer" (in Eysenck, 1994, p. 172).
One theory of coping, inoculation theory, was tested in a prospective study of
women and breast cancer (Cooper & Faragher, 1993). Women who had an acute, severe
introduction of "problems" in their lives had a significantly higher risk of a malignant

184
diagnosis than women who reported a chronic high number of "problems". The Cooper
and Faragher study provides evidence of a mediating and adaptive coping factor which has
been associated with self-regulation. Self-regulation refers to the ability to remain flexible,
alter behavior according to circumstances, and maintain a sense of control and efficacy
over one's life. In this description it is easy to see the parallels between self-regulation and
active decisional style. Active decisional style necessitates generating options according to
"one's own data base rather than normatively derived options" (Shrank & Langer, 1995)
and leads to enhanced sense of control. Self-regulating types of people were found to be
task-oriented in their coping styles whereas those found to be cancer prone in prospective
studies were more emotion-oriented, avoidance-oriented, and distraction-oriented in coping
styles (Eysenck, 1993).
Life stressors are mediated by coping strategies and certain strategies have been
shown to be more effective than others. The effective strategies are consonant with active
decisional styles and ineffective strategies are consonant with mindless decisional styles.
The current study supports these conclusions.
Limitations
With the exception of the investigation of social support as it affects coping, other
coping patterns have not been well researched. The body of research suggesting that
cognitive strategies and active coping styles are more effective is building but still new
(Cameron, Leventhal, & Leventhal, 1993; Dunkel-Schetter et al, 1992). The current study
did not adequately assess the degree of stress or emotional distress experienced by the
participants. In the one question asked as part of the Ways of Coping Scale, respondents

185
reported less stress than in the Dunkel-Schetter et al study (1992) and far less stress than
one would assume in people with a high probability of a foreshortened future. Denial has
been identified as characteristic of cancer patients (Eysenck, 1994) and utilized as an
effective defense (Cameron et al, 1993). Denial was not measured in this research but
could have been operating in the participants.
Many of the studies documented in coping literature are either conducted on breast
cancer patients or include a disproportionate number of breast cancer patients in their
samples. In spite of breast cancer being one of the most diagnosed forms of cancer,
reported results may not reflect the experience of other people, especially when one
considers how rarely men develop breast cancer. Coping has been shown to be situational
(Lazarus & Folkman, 1984) and various cancers present different problems with which to
cope. The absence of studies with more diverse diagnoses limit the comparative evidence
on coping patterns. The question remains unsettled about the advisability of changing
coping styles to fit particular patterns.
Decisional Processing Model
The reason for building a model using an attitude change theory, along with
hanger's decision-making theory, was to gain an understanding of how to impact decisional
styles if they proved to relate to coping. It is doubtful there would be a reason to actually
use the ELM constructs to predict decisional style but it was assumed that IF the ELM
constructs could predict different styles, they could be used to implement a change in
patients. This is entirely consistent with both the theoretical and empirical literature on the
elaboration likelihood model. The predictive capabilities of these variables were supported.

186
Active decisional style was predicted at a success rate of 72%, passive desicional style at
29%, mindless decisional style at 61%, and ruminating style at 100% success rate. Passive
decisional style was the only one predicted at a success rate only slightly more than chance.
These patients were, by far, the most difficult to categorize (see results in Chapter IV).
Neither the interviewing process nor the instrument assessments found the
distinctions between passive and mindless decisional styles and between active and passive
decisional styles as clear cut as distinctions between the other decisional styles.
Theoretically, patients using both active and passive decisional styles put effortful thought
into their decisions whereas those using mindless decisional styles put forth no discemable
effort. In the current study, effortful thought was operationalized by three questions on the
decision tree. At times participants responded with a mix of answers on these three
questions. If one answer showed definite evidence of effortful thought the patients were
placed in the passive decisional category rather than the mindless category. Passive and
mindless decisional styles could have been confused because both resulted in taking the
choices presented by the medical system. It is possible that the low prediction rates for
passive decisional styles resulted from an initial mis-classification of these participants.
The judges also struggled with placement on some of these participants who, in
fact, may use a mix of styles. In spite of the difficulty in categorizing those with passive
decisional styles, there were definitive differences among these patients on coping. These
differences lead one to believe that we are indeed tapping into a category of people but that
category' is broader in terms of actual behaviors than previously considered. People within

187
the passive decisional style may use behaviors from both active and mindless decisional
styles.
What has been learned from the patients in the passive decisional category is that
decisional styles are either (a) On a continuum with people operating at many different
points, or (b) More fluid with people moving within a range along the continuum. These
are questions requiring more research.
The addition of a category for people who do not "settle" on a decision was
supported in the current study. Ruminating decisional style was identified by the
participants, the investigator, and the judges. The ruminating category was predicted by
the discriminant function analysis 100% of the time as qualitatively different on ELM
constructs and need for closure. Only five of the 120 participants were categorized as
ruminating. However, because of the strength of the identification methods, it is
reasonable to include in the decisional processing model a category of people who do not
make a commitment to a decision and, therefore, do not make a discriminating cognitive
response. Certainly more empirical evidence must be gathered in order to understand this
category and definitively determine it's inclusion.
Implications of the Study
The current research was approached with a theoretical and a practical purpose in
mind. Theoretically, it was designed to build a model of medical decision making that
would integrate and extend Ellen Langer’s theory of mindfulness and Petty and Cacioppo's
elaboration likelihood model. The practical component involved determining the
relationship between the theoretical decisional model and coping with life-threatening

188
illness. Both the integration of theory and the relationship between decisional styles and
coping were supported. Implications for this study will be addressed as the findings relate
to theory, practice, and research.
Four Decisional Styles: Extension of Langer's Theory
Ellen Langer identified three decisional categories: active, passive, and mindless.
She also postulated that when people cannot psychologically discriminate between options,
they cannot arrive at a commitment. This description sounds like rumination. Using the
construct of rumination, a fourth category, consonant with Langer's theory, was added to
the model. It was found that clearly a minority of people use a ruminating style for
deciding medical treatment. Anecdotal reports from the medical staff indicated that
ruminators were well-known to the staff for the considerable staff time and attention they
demanded. The inclusion of this fourth category may provide information for analyzing
costs and benefits. Perhaps in addition to the patient's decisional style affecting how that
person copes, makes decisions, or is personally affected, the medical delivery system itself
is affected by the impact of individuals in this fourth category.
Attempts at applying the popular cognitively-weighted cost-benefit theories to
making medical decisions beyond the realm of prevention for which these theories were
developed have not proven successful. From the number of people in this study who have
made mindless decisions, an implication might be drawn suggesting that under life-
threatening situations, these theories are not applicable. The present study clearly supports
Ellen Langer's conclusions that mindless decisional styles are frequently used in situations
strongly influencing health issues.

189
Using the Elaboration Likelihood Model in Decision-Making - Extension of
Theory
The elaboration likelihood model was developed through the investigation of
attitude change and persuasion. Two routes of processing information were discovered. A
considerable body of laboratory research has been conducted establishing relative certainty
that there is a distinct difference in behavior depending on which route is used. That
research focused predominantly on people's responses to particular messages under
contrived situations. The current study brought the ELM into the field in which the
messages received were not controlled. This study provided greater understanding of how
the ELM operates in a naturally-occurring event.
The study demonstrated that a relationship exists between decision making and
routes of processing. The implication of this relationship is that if ELM factors could be
used to enhance central-route processing and change core attitudes of people in situations
with less immediacy than cancer treatment, could they also be used to change decisional
styles by increasing central-route processing of medical decisions. In other words, it
appears to be possible to use ELM constructs to change decisional styles when it is
important to do so. if central route processing improves such things as medical decision
making and coping, what might it do for quality of life issues, sense of control, efficacy,
and attributions?
Implications for Practice
The literature reporting on the investigation of medical decision making has focused
on the physician's decision making rather than that of the patients. Very little is actually

190
known about how patients process information. Psychological and social factors have been
identified as influencing adherence to medical regimens, level of disability, and coping.
Certain factors have been implicated in progression of disease and survival time. These
psychological factors are decidedly cognitive in nature: attribution of causality, self-
efficacy, appraisal of both illness and coping, and patterns of coping. These are decisions
made by the patients not the physicians. In addition, physicians may offer different
treatment regimens, each carrying differing risks. The regimen to be used becomes the
patient's decision. Information related to any particular illness abounds through many
sources and the patients also decide how many other sources are pursued in addition to the
treatment the physician recommends. Ever}' patient must give informed consent for
treatment which shifts some responsibility for decision-making to the patient.
One positive application for both research and practice would be assistance for
people in understanding how their decisional styles are affecting these important issues.
Another is the possibility of changing medical decision making by increasing central route
processing. Another is to look at the interaction between patient and physician, using the
research on the ELM in order to train physicians to deliver medical information in ways
that enhance central route processing.
Until more definitive studies are conducted on decisional style and its' relationship
with coping, progression, and survival, adventuring into applications would be premature.
Before implications for practice can be fully understood and ethically applied evidence
must be accrued indicating that decisional styles are capable of change and that changes
actually enhance the patient's treatment or subjective experience of the illness.

191
Methodological Issues
The ideas in the current study were built upon the elaboration likelihood model.
Although the constructs postulated in that model are of interestl91, they have not been
operationalized in past research in a manner that allows for generalization to the population
and the situations studied in the current research. Therefore, the predictor variables in this
study were based on understanding the theoretical foundation of the ELM constructs and
seeking instruments and methods which maintained both the spirit and the integrity of the
ELM.
The use of the personal interview increased the strength of this study. Information
was gathered by experienced counselors who consistently make assessments in their
professions. The interview process ferreted out information about which the patients were
unaware. For instance, many patients did not realize that they had made a decision but as
the interview proceded, they began to identify decisions they had made as they revealed
their narratives. If patients had only been asked a simple question about what decisions
they made, many would not have explained the process they described to the interviewer
and, quite possibly, responded negatively.
Even in the structured part of the interviews some questions were misunderstood.
The interview process gave an opportunity for the reseacher to clarify and obtain a truer
meaning of the patient's experience. Using personal interviews rather than questionnaires
was found to be significantly more successful in predicting studies of personality type
(Eysenck, 1990). In a large scale prospective study on personality variables related to

192
different diseases, marked differences in predictive accuracy was found to depend on the
degree of interviewer participation (Grossarth-Maticek, Eysenck, & Barrett, 1993).
Future Research
A number of questions emerge from these findings. The following questions cover
three dimensions: characteristics about decisional styles, effects of changing decisional
styles, and interactions with medical staff and family members based on decisional styles.
Characteristics about decisional styles
1. Are decisional styles global or specific, or global within schema rules? In
Langer’s "process commitment," what are common rules of determining schema
for deciding? Can these schema be changed using the ELM?
2. Are decisional styles changable? Under what conditions do they naturally
change?
3. How are decisional styles developed?
4. What is different about the ruminator category?
5. Are decisional styles more appropriately considered on a continuum?
6. Are there racial/ethnic differences supported by different cultural experiences?
7. What is the role of emotion in decisional style?
8. Is cognitive responding interrupted when both routes of processing are activated
simultaneously?
9. Can an instrument be developed that assesses global or dominant decisional
styles?

193
Effects of changing decisional styles:
1. How do decisional styles affect survival time?
2. Will using the ELM in educational programs change the medical decision
making route of processing? Under what conditions? Which decisional styles
are most amenable?
3. What is the effect of decisional style on quality of life, sense of control, self-
efficacy, attribution of causality, determination of level of disability, and
determination of sick role?
Interactions with others:
1. Do decisional styles "run" in families? How does either a compatible or
complementary decisional style in a spouse affect coping?
2. Would a change in a patient's decisional style threaten the role of the spouse,
especially if the spouse is the medical decision-maker in the family?
3. What is the effect of the physician's decisional style on interactions with patients
having either similar or different decisional styles?
4. How can physicians present information to increase central-route processing in
patients?
5 is there a difference in expenditure of staff resources on patients based on the
patient's decisional style?
6. What is fhe staff response to patients using different decisional styles?

194
Conclusion
Within the last few years, there has been "increasing emphasis on bridging the
multiple dimensions of human development and behavior (biological, psychological, and
cultural) and efforts to combine the strengths" of individual theories (Kelly, 1997). The
current study tested the integration of Langer's theory of mindfulness with Petty and
Cacioppo's elaboration likelihood model. The integration resulted in a clearer
understanding of the cognitive processing employed by patients making serious medical
decisions. The Decisional Processing Model utilizing the ELM constructs of motivation,
ability', and cognitive responding was predictive of decisional style. The theory of
mindfulness was supported and expanded to include a fourth decisional category, the
ruminating style.
Coping is significantly affected by the decisional style used. A patient facing a life-
threatening illness makes many decisions about issues as important as self-efficacy,
appraisal, coping strategies, and attribution. There is an abundance of research literature
indicating the importance of these factors (decisions) in influencing health.
Utilization of the ELM in designing psychoeducational programs that enhance
central route processing in the making of medical decisions may influence the factors
shown in research to impact severity, progression, and survival time in people with serious
illness. Educational programs may inspire questioning of patient's pre-existing schemas for
their validity. Such programs may increase a patient's skills in finding additional
informative resources and thereby increase self-efficacy when participating in their medical

194
decisions. Unconscious attributions and expectations may surface for reconsideration and
a more mindful approach to the application of coping strategies might be elicited.
The major purpose of the current study was to test the viability of the Decisional
Processing Model. Using three categories of decisional styles from Langer's research on
mindfulness and adding a fourth decisional style, ruminating, the decisional processing
model was created. The model was tested to determine if it accurately described the styles
of medical decision-making used by cancer patients and was supported by the data. The
decisional processing model appears to be a viable model to use in the investigation of
medical decision-making.

APPENDIX
ASSESSMENT INSTRUMENTS
PARTICIPANT NUMBER
DESCRIPTIVE DATA:
1. Gender: Male Female
2. Race: ________
3. Age:
4. Marital Status:
5. Education level:
195

MEDICAL DATA FORM
PARTICIPANT NUMBER
TYPE OF CANCER
STAGE OF CANCER
PROGNOSIS ’
DATE OF FIRST CANCER DIAGNOSIS
RECURRENCES OF CANCER: TYPES AND DATES
TYPE DATE
COGNITIVE DEFICITS NOTED: YES NO

197
DECISION TREE
1.What decisions did you have to make relating to your illness (Check all that apply)
Choices of treatment
Choices about living arrangements '
Choices about jobs
Choices about financial plans
Choices about how treatment may affect your physically
Choices about what things you needed to do to cope
Other physical care choices (such as where to put a port for chemo)
What other choices can you remember having to decide _____
197
2.Of all of these which decision was the most serious to you?
NOW KEEPING THAT DECISION IN MIND, I'D LIKE TO ASK YOU A FEW
QUESTIONS RELATED TO HOW YOU THOUGHT ABOUT THE CHOICE.
3.What choices for treatment were provided by your doctor?
4.What other things were told to you by the medical staff?
5.What were your thoughts when you heard ? (Anything else? Repeat until
participant
answers no.)
6.How much time did you think about these before you decided9
dwelled on it
considerable time
some time
very' little

198
practically none
7.How much effort do you feel you put into thinking about what to do?
8.On a scale of 1 to 10, with 1 being "putting it out of your mind almost all the time" and
being "thinking about it almost all the time", how would you rate the effort you put in?
9. Did you make a decision? Yes No
10. If you made a decision, how certain did you feel that you made the right decision9
Very certain __
Fairly certain
Had some doubts
Still doubting it
11. Did you think of other things to do?
12.if yes, were these other things you thought about considered in your decision-making?
13. Did you actively seek information anywhere else? Yes No
14. What kinds of information? Where?
15.How much consideration did you give these other suggestions?

199
16.How did you decide which options you would try?
17.After making a decision, how certain did you feel?
18.After making a decision, did you continue to look for more information?
19 What did you find? How did you learn about that?
20. What were your thoughts in response to the new information?
21. Did you change anything based on the new information?
22. After thinking about your choices for awhile, did you get to the point when it became
too tiresome to think about it anymore?
Yes Yes, but I still persisted No
23. How soon after you knew you had cancer did you get to that point?
24. How much do you continue to worry about whether you made the right decision?
25. Were you afraid of making the wrong decision? If so, what did you do as a result of
this fear?

200
VIGNETTES
I AM GOING TO READ TO YOU FOUR STORIES ABOUT PEOPLE AND HOW
THEY THOUGHT ABOUT THINGS RELATED TO THEIR CANCER
ID WOULD LIKE YOU TO LISTEN TO THESE STORIES AND WHEN I AM
FINISHED LET ME KNOW WHICH ONE IS MOST LIKE YOU AND WHICH ONE
IS LEAST LIKE YOU.
IF YOU WANT ME TO READ ANY OR ALL OF THEM A SECOND TIME, I'LL BE
HAPPY TO DO SO. YOU CAN FOLLOW ALONG WITH ME USING THIS CARD
IF YOU LIKE.
STORY 1 - JOE (KATHY)
When Joe (Kathy) was told he had cancer, he had many decisions to make. He had to
choose how he would get his treatment, he had to decide what to do about his job, and
how his family would manage while he was tired from treatment. On his way home from
the doctor's office, he thought, "The doctor knows what he is doing. I'll tell the doctor to
do whatever treatment he suggests." When he arrived home, he called his boss to discuss
his job. His boss told him how to handle the times he needed to be out of work. Joe
(Kathy) felt relieved and put it out of his mind. Within a short time, he simply thought,
"Well, we'll all manage somehow." and didn't think about it much. Joe (Kathy) is glad he
decided quickly and feels mostly comfortable with his decision.
STORY 2-BILL (SADIE)
When Bill (Sadie)was told he had cancer, he also had decisions to make. He had to decide
how his family will be cared for, when he would take treatment, and how they’d manage
financially. On his way home, thought a lot about what the doctor had said. He discussed
with his family for many days what the doctor said about his treatment choices. He pretty
much stayed with what the doctor and medical staff told him and wasn't really interested in
seeking out additional information on his own. When the Cancer Society offered to send
information, he accepted but really considered only what the doctor and his nurses told
him. After thinking for awhile about all the doctor had said, he chose one of the options
the doctor had given him. It took Bill (SADIE) several weeks to decide all these things.
He also feels mostly comfortable with his decisions.

201
STORY 3 - MDCE (JANE)
When Mike (Jane) was told he had cancer, the decisions he had to make were about
treatment, supporting his family financially, and how he and his family would cope. On his
way home, Mike (Jane)gave a lot of thought to what the doctor told him. He also thought
about where else he would turn for more information. He called the Cancer Society, read
some pamphlets that were given to him, went to the county library and spoke to an uncle of
his who had cancer a few years ago. He thought a lot about whether his situation was
similar to his uncle's. He thought about what kind of person he was and what fit for him.
It took him a few weeks to gather a lot of information, think long and hard about his life,
and then make his decisions. Mike (Jane)still thinks about new ideas but feels mostly
comfortable with his choices.
STORY 4 - PAUL (PAULA)
Decisions do not come easy for Paul (Paula), especially important ones. When Paul
(Paula) was told he had cancer, he remembered precisely what the doctor told him and
repeated those things over and over again in his mind. He first spoke to his wife about
what to do about work. Paul (Paula) asked quite a few people about their opinions,
although he does not accept other people's opinions readily. Paul (Paula) spends a lot of
time thinking about his options. He likes being very careful about important things and is
very concerned about making the wrong decision. After thinking almost constantly about
his options and after going over and over in his mind what the doctor said, Paul (Paula) is
never really settled on a decision he's comfortable with. He keeps turning over the options
in his mind. Paul (Paula) is currently taking treatment, but often wonders if he did the right
thing.
WHICH ONE OF THESE PEOPLE ARE MOST LIKE YOU? WHY?
WHICH ONE IS LEAST LIKE YOU? WHY?

202
NEED FOR COGNITION SCALE: Please respond to the following questions
indicating whether you agree or disagree that the statement is characteristic of you.
1. I would prefer complex to simple problems.
2. I like to have the responsbility of handling a situation that requires a lot of thinking.
3. Thinking is not my idea of fun.*
4.1 would rather do something that requires little thought than something that is sure to
challenge my thinking abilities.*
5. 1 try to anticipate and avoid situations where there is likely chance I will have to think in
depth about something.*
6. I find satisfaction in deliberating hard and for long hours.
7.1 only think as hard as I have to.*
8.1 prefer to think about small, daily projects to long-term ones.*
9. I like tasks that require little thought once I've learned them *
10. The idea of relying on thought to make my way to the top appeals to me.
11.1 really enjoy a task that involves coming up with new solutions to problems.
12. Learning new ways to think doesn't excite me very much.*
13.1 prefer my life to be filled with puzzles that I must solve.
14. The notion of thinking abstractly is appealing to me.
15. I would prefer a task that is intellectual, difficult, and important to one that is somewhat
important but does not require much thought.
16. I feel relief rather than satisfaction after completing a task that required a lot of mental
effort. *

203
17. It's enough for me that something gets the job done; I don't care how or why it works.*
18. I usually end up deliberating about issues even when they do not affect me personally.

204
PADUA
Instructions: The following statements refer to thoughts and behaviors which may occur in
everyone in everyday life. For each statement, choose the reply which best seems to fit
you and the degree of disturbance which such thoughts or behaviors may create. Rate
your replies as follows:
0 = Not at all
1= a little
2 = quite a lot
3 = a lot
4 = very much
I. After doing something carefully, I still have the impression I have either done it badly or
not finished it.
2.1 have the impression that I will never be able to explain things clearly, especially when
talking about important matters.
3.1 invent doubts and problems about most of the things I do.
4. Unpleasant thoughts come into my mind against my will and 1 cannot get rid of them.
5.1 find it difficult to make decisions, even about important matters.
6. Sometimes I am not sure I have done things which in fact 1 know I have done.
7.1 imagine catastrophic consequences as a result of absent-mindedness or minor error
which I make.
8. My brain constantly goes its own way, and I find it difficult to attend to what is
happening around me.
9. When I talk, I tend to repeat the same things and the same sentence several times.
10. In certain situations, I am afraid of losing my self-control and doing embarrassing
things.
II. When I read I have the feeling I have missed something important and must go back
and reread the passage at least two or three times.
12. I think or worry at length about having hurt someone without knowing it.
13. When I start thinking of certain things 1 become obsessed with them.

205
14. When I hear about suicide or crime, I am upset for a long time and find it difficult to
stop thinking about it.
15. Iam sometimes late because I keep doing certain things more often than necessary.
16. When a thought or doubt comes into my mind, 1 have to examine it from all points of
view and cannot stop until 1 have done it.
17. I worry about remembering completely unimportant things and make an effort not to
forget them.
18. In certain situations, I feel an impulse to eat too much, even if I am ill.
19. When doubts and worries come to my mind, I cannot rest until I have talked them over
with a reassuring person.
20. 1 tend to ask people to repeat the same things to me several times consecutively even
though I did understand what they said the first time.
21.1 check and recheck gas and water taps and light switches after turning them off.
22. I keep on checking forms, documents, checks, etc. in detail to make sure I have filled
them in correctly.
23. I return home to check doors, windows, drawers, etc. to make sure they are properly
shut.
24.1 keep on going back to see that matches, cigarettes, etc. are properly extinguished.
25. I check letters carefully many times before posting them.
26. 1 tend to keep on checking things more often than necessary.
27. When I handle money I count and recount it several times.
28. Before going to sleep 1 have to do certain things in a certain order.
29. Before going to sleep 1 have to do certain things in a certain order.
30. I have to do things several times before I think they are properly done.
31.1 feel obliged to follow a particular order in dressing, undressing, and washing myself.

206
ABILITY TO PROCESS QUESTIONNAIRE
Please answer the following questions by focusing only on the decision that you just
identified as the most serious one for you.
1.1 really was able to think about the topic of that decision.
strongly agree neutral disagree strongly
agree disagree
*2. So much was going on in my life at the time of the decision that 1 found it really
difficult to concentrate.
strongly
agree
agree
neutral
disagree
3.1 had sufficient time to give that decision careful thought.
strongly agree neutral disagree
agree
strongly
disagree
strongly
disagree
*4. My mind was blank during much of the time that I was making that serious decision,
agree neutral disagree
strongly
agree
strongly
disagree
5. My world was free enough of distractions that 1 was able to really think through that
decision.
strongly
agree
agree
neutral
disagree
strongly
disagree
*6. Worries of mine made it very difficult to think carefully about that serious decision,
agree neutral disagree
strongly
agree
strongly
disagree
* These questions are reverse scored.

207
ATTITUDE, BELIEF AND EXPERIENCE SURVEY
Read each of the following statements and decide how much you agree with each
according to your beliefs and experiences. Please respond according to the following scale.
1. Strongly disagree
2. Moderately disagree
3. Slightly disagree
4. slightly agree
5. moderately agree
6. strongly agree
1. 1 think that having clear rules and order at work is essential for success.
2. Even after I've made up my mind about something, I am always eager to consider a
different opinion.
3. I don't like situations that are uncertain.
4. I dislike questions which could be answered in many different ways.
5. I like to have friends who are unpredictable.
6. I find that a well-ordered life with regular hours suits my temperment.
7. 1 enjoy the uncertainty of going into a new situation without knowing what might
happen.
8. When dining out, I like to go to places where I have been before so that 1 know what to
expect.
9. I feel uncomfortable when I don't understand the reason why an event occured in my
life.
10.1 feel irritated when one person disagrees with what everyone else in a group believes.
11.1 hate to change my plans at the last minute.
12.1 would describe myself as indecisive.
13. When I go shopping, I have difficulty deciding exactly what it is that 1 want.

208
14. When faced with a problem I usually see the one best solution very quickly.
15. When I am confused about an important issue, I feel very upset.
16. I tend to put off making important decisions until the last possible moment.
17.1 usually make important decisions quickly and confidently.
18.1 have never been late for an appointment or work.
19.1 think it is fun to change my plans at the last moment.
20. My personal space is usually messy and disorganized.
21. In most social conflicts, I can easily see which side is right and which is wrong.
22. I have never known someone that I did not like.
23. I tend to struggle with most decisions.
24. I believe that orderliness and organization are among the most important characteristics
of a good worker.
25. When considering most conflict situations, I can usually see how both sides could be
right.
26. I don't like to be with people who are capable of unexpected actions.
27.1 prefer to socialize with familiar friends because I know what to expect from them.
28.1 think that I would learn best in a class that lacks clearly stated objectives and
requirements.
29. When thinking about a problem, I consider as many different opinions on the issue as
possible.
30.1 don't like to go into a situation without knowing what 1 can expect from it.
31.1 like to know what people are thinking all the time.

209
32. I dislike it when a person's statement could mean many different things.
33. It's annoying to listen to someone who cannot seem to make up his or her mind.
34.1 find that establishing a consistent routine enables me to enjoy life more.
35.1 enjoy having a clear and structured mode of life.
36. 1 prefer interacting with people who's opinions are very different from my own.
37. I like to have a place for everything and everything in its place.
38. 1 feel uncomfortable when someone's meaning or intention is unclear to me.
39. I believe that one should never engage in leisure activities.
40. When trying to solve a problem 1 often see so many possible options that it's confusing.
41.1 always see many possible solutions to problems I face.
42. I'd rather know bad news than stay in a state of uncertainty.
43. 1 feel that there is no such thing as an honest mistake.
44. I do not usually consult many different opinions before forming my own view.
45. I dislike unpredictable situations.
46. I have never hurt another person's feelings.
47. I dislike the routine aspects of my work (studies).

210
WAYS OF COPING - CANCER VERSION
1.Cancer is generally a difficult or troubling experience for those who have it. The
following are some possible problems associated with cancer. Please indicate which one
has been the most difficult or troubling for you in the past six months by circling the
appropriate number.
1 Fear and uncertainty about the future due to cancer.
2 Limitation in physical abilities, appearance, or lifestyle due to cancer.
3 Pain, symptoms, or discomfort from illness or treatment.
4 Problems with family or friends related to cancer.
5 Other (please specify)
2.How stressful has this problem been for you in the last six months?
1 Extremely stressful
2 Stressful
3 Somewhat stressful
4 Slightly stressful
5 Not stressful
When we experience stress in our lives, we usually try to manage it by trying out different
ways of thinking or behaving. These can be called ways of coping. Sometimes our
attempts are successful in helping us solve a problem or feel better and other times they are
not. The next set of items is on the ways of coping you may have used in trying to manage
the most stressful part of your cancer. Please read each item below and indicate how often
you have tried this in the past six months in attempting to cope with the specific problem
circled above. It is important that you answer every item as best you can.
How often have you tried this in the past 6 months to manage the problem circled above?
Does not Rarely Sometimes Often Very
Apply often
1. Concentrated on what I had to do next
the next step ? 0 12 3 4
2. Felt that time would make a difference
_the only to do was to wait 0 1 2 3 4
3. Did something which I didn't think would work,
but at least I was doing something.... 0 12 3 4
4. Talked to someone to find out more about the
situation 0 12 3 4
2
5. Criticized for lectured myself.
0
1
4

6. Tried nto close off my options, but leave things
open somewhat 0
7. Hoped a miracle would happen.... 0
8. Went along with fate; sometimes 1 just have
bad luck... 0
9. Went on as if nothing were happening 0
10. Tried to keep my feelings to myself.... 0
11. Looked for the silver lining, so to speak; tried to
look on the bright side of things.... 0
12. Slept more than usual.... 0
13. Looked for sympathy and understanding from
someone 0
14. Was inspired to do something creative... 0
15. Tried to forget the whole thing.... 0
16. Tried to get professional help 0
17. Changed or grew as a person in a good way... 0
18. Waited to see what would happen before doing
anything.... 0
19. Made a plan of action and followed it ... 0
20. Let my feelings out somehow.... 0
21. Came out of the experience better than when I
went in 0
22. Talked to someone who could do something
concrete about the problem 0
23. Tried to make myself feel better by eating,
drinking, smoking or using drugs.... 0
24. Took a big chance or did something risky.... 0

212
25. Tried not to act too hastily or follow my
first hunch...
0
1
2
j
4
26. Found new faith...
0
1
2
3
4
27. Rediscovered what is important in life....
0
1
2
3
4
28. Changed something so things would turn
out all right..
0
1
2
->
4
29. Avoided being with people in general...
0
1
2
3
4
30. Didn't let it get to me; refused to think about
it too much. ..
0
1
2
3
4
31. Asked a relative or friend 1 respect for advice....
0
1
2
3
4
32. Kept others from knowing how bad things were.
..0
1
2
3
4
33. Made light of the situation; refused to get too
serious about it
0
1
2
-»
4
34. Talked to someone about how I was feeling....
0
1
2
3
4
35. Took it out on other people
0
1
2
â– *>
4
36. Drew on my past experiences; 1 was in a similar
experience before....
0
1
2
3
4
37. Knew what had to be done, so redoubled my
efforts to make things work....
0
1
2
4
38. Refused to believe it would happen....
0
1
2
J
4
39. Came up with a couple of different solutions to
the problem ...
0
1
2
n
J
4
40. Tried to keep my feelings from interfering with
other things too much
0
1
2
3
4
41. Changed something about myself.....
0
1
2
3
4
42. Wished that the situation would go away or

213
somehow be over with 0 1
43. Had fantasies or wishes about how things might
turn out 0 1
44. Prayed.... 0 1
45. Prepared myself for the worst.... 0 1
46. Went over in my mind what 1 would say or do 0 1
47. Thought of how a person I admire would handle
this situation and used that as a model 0 1
48. Reminded myself how much worse things
could be.. 0 1
49. Tried to find out as much as I could about cancer
and my own case 0 1
50. Treated the illness as a challenge or battle
to be won... 0 1
51. Depended mostly on others to handle things or
tell me what to do 0 1
52. Lived one day at a time or took one step
at a time.... 0 1
53.Tried something entirely different from any
of the above. Please describe
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4
2 3 4

214
PHYSICIAN ASSESSMENT OF PATIENT PROGNOSIS
The following patients were interviewed in my study, "Towards a decisional
processing model for medical decision-making among cancer patients."
I would greatly appreciate your providing information on the prognosis of the
following patients of yours according to the scale below. If the stage is not identified
on this form, please state the stage of illness at initial diagnosis at Shands.
Prognosis Scale
Poor =1 Fair= 2 Gaurded= 3 Good= 4 Very Good=5 Excellent^ 6
Name
Patient number
Prognosis
Stage

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