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Effects of relaxation on symptom distress and personal control experienced by adults with cancer Yearwood-Dance, Linda 1991

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C,2~ -EFFECTS OF RELAXATION ON SYMPTOM DISTRESS AND PERSONAL CONTROL EXPERIENCED BY ADULTS WITH CANCER by LINDA YEARWOOD-DANCE B.S.N., The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES The S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1991 © L i n d a Yearwood-Dance, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ^ \ > , t r s W - C k The University of British Columbia Vancouver, Canada Date W\ocO^ N'fi, V=^\ DE-6 (2/88) ABSTRACT The use o f b e h a v i o r a l t h e r a p i e s , such as r e l a x a t i o n t h e r a p y , i s w e l l documented i n t h e l i t e r a t u r e as an i n t e r v e n t i o n w h i c h may c o n t r o l some o f t h e symptoms and symptom d i s t r e s s a s s o c i a t e d w i t h t h e use o f chemotherapy w i t h i n t h e e x p e r i e n c e o f c a n c e r . However, o v e r 50% o f i n d i v i d u a l s w i t h c a n c e r a r e a l s o t r e a t e d w i t h r a d i a t i o n t h e r a p y , e i t h e r a l o n e o r i n c o m b i n a t i o n w i t h chemotherapy. I n d i v i d u a l s b e i n g t r e a t e d w i t h r a d i a t i o n t h e r a p y e x p e r i e n c e symptoms and r e l a t e d d i s t r e s s s i m i l a r t o t h o s e a s s o c i a t e d w i t h chemotherapy as w e l l as a l o s s o f p e r s o n a l c o n t r o l . The purpose o f t h i s s t u d y was t o d e t e r m i n e t h e e f f e c t o f r e l a x a t i o n t h e r a p y on symptom d i s t r e s s and p e r s o n a l c o n t r o l as p e r c e i v e d by a d u l t s r e c e i v i n g a b d o m i n a l / p e l v i c e x t e r n a l r a d i a t i o n t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . A q u a s i e x p e r i m e n t a l d e s i g n , t h e n o n e q u i v a l e n t c o n t r o l - g r o u p , was used t o a c h i e v e t h e purpose o f t h i s s t u d y . I t was h y p o t h e s i z e d t h a t t h e d a i l y use o f r e l a x a t i o n t h e r a p y by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y would d e c r e a s e t h e amount o f symptom d i s t r e s s and i n c r e a s e t h e amount o f p e r s o n a l c o n t r o l p e r c e i v e d . The sample c o n s i s t e d o f twenty e i g h t i n d i v i d u a l s , f o u r t e e n i n t h e c o n t r o l group and f o u r t e e n i n t h e i n t e r v e n t i o n group. Data were g a t h e r e d by i n t e r v i e w , two i i i s e t s o f q u e s t i o n n a i r e s , and w r i t t e n d i a r i e s . The i n t e r v i e w was done b e f o r e t h e p a r t i c i p a n t s began t h e i r r a d i a t i o n t r e a t m e n t . The q u e s t i o n n a i r e s were a l s o c o m p l e t e d a t t h i s t i m e and t h e n a g a i n t h r e e weeks a f t e r t h e t r e a t m e n t began. A d i a r y was k e p t by t h o s e i n t h e i n t e r v e n t i o n group who were a l s o t a u g h t a s p e c i f i c r e l a x a t i o n t e c h n i q u e and asked t o r e c o r d t h e number o f t i m e s t h e y used t h e t e c h n i q u e and any comments. To answer t h e two h y p o t h e s e s , summary s t a t i s t i c s were used. The r e s u l t s i n d i c a t e d t h a t i n d i v i d u a l s who used r e l a x a t i o n t h e r a p y p e r c e i v e d a d e c r e a s e d amount o f symptom d i s t r e s s t h a n t h o s e i n t h e c o n t r o l group. The Mann-Whitney U T e s t i n d i c a t e d t h a t t h i s d i f f e r e n c e was a t t h e .05 l e v e l o f s i g n i f i c a n c e . On t h i s b a s i s t h e f i r s t h y p o t h e s i s was a c c e p t e d . The r e s u l t s a l s o i n d i c a t e d t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between t h e groups i n t h e amount o f p e r c e i v e d p e r s o n a l c o n t r o l . On t h i s b a s i s , t h e second h y p o t h e s i s was not a c c e p t e d . A recommendation based on t h i s r e s e a r c h s t u d y was f o r n u r s e s t o become knowledgeable i n t h e use o f r e l a x a t i o n t e c h n i q u e s . F u r t h e r r e s e a r c h t o b e t t e r u n d e r s t a n d t h e c a n c e r e x p e r i e n c e i n r e l a t i o n t o p e r s o n a l c o n t r o l was a l s o recommended t o e n a b l e n u r s e s t o p r o v i d e a p p r o p r i a t e and e f f e c t i v e c a r e t o t h e s e i n d i v i d u a l s . i v TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES . . . v i ACKNOWLEDGEMENTS v i i CHAPTER ONE INTRODUCTION 1 C o n t e x t o f t h e Pr o b l e m 1 S i g n i f i c a n c e o f t h e Problem 3 Statement o f t h e Purpose 3 C o n c e p t u a l Framework 4 Symptom D i s t r e s s 5 P e r s o n a l C o n t r o l 6 R e l a x a t i o n Therapy 7 R e s e a r c h Hypotheses 9 D e f i n i t i o n o f Terms 9 Assumpti o n s 11 L i m i t a t i o n s 12 CHAPTER TWO REVIEW OF THE LITERATURE 13 I n t r o d u c t i o n 13 Symptom D i s t r e s s 13 P e r s o n a l C o n t r o l 18 R e l a x a t i o n Therapy 22 Summary 36 CHAPTER THREE METHODOLOGY 38 I n t r o d u c t i o n 38 Sample 38 Data C o l l e c t i o n P r o c e d u r e 39 Data C o l l e c t i o n 40 Data C o l l e c t i o n I n s t r u m e n t s 41 The Symptom D i s t r e s s S c a l e 42 S e l f - C o n t r o l S u b s c a l e 43 I n i t i a l I n t e r v i e w Guide 45 Data A n a l y s i s 45 Human R i g h t s and E t h i c a l C o n s i d e r a t i o n s 4 6 Summary 47 V CHAPTER FOUR PRESENTATION AND DISCUSSION OF FINDINGS ... .48 I n t r o d u c t i o n 48 The Study P a r t i c i p a n t s 48 Age, Sex, E d u c a t i o n and D i a g n o s i s 49 R e l a x a t i o n I n t e r v e n t i o n 52 F i n d i n g s 53 H y p o t h e s i s I 53 D i s c u s s i o n H y p o t h e s i s I 54 H y p o t h e s i s I I 59 D i s c u s s i o n H y p o t h e s i s I I 60 Summary 63 CHAPTER FIVE SUMMARY, RECOMMENDATIONS FOR NURSING EDUCATION, PRACTICE, RESEARCH 65 I n t r o d u c t i o n 65 Summary o f t h e Study 65 Recommendations f o r N u r s i n g E d u c a t i o n and P r a c t i c e 67 Recommendations f o r N u r s i n g R e s e a r c h 69 Summary 72 REFERENCES 7 3 APPENDICES Appendix A INTRODUCTORY LETTER FOR PARTICIPANTS CONTROL GROUP 7 7 Appendix B INTRODUCTORY LETTER FOR PARTICIPANTS INTERVENTION GROUP. 79 Appendix C CONSENT TO PARTICIPATE FORM CONTROL GROUP 81 Appendix D CONSENT TO PARTICIPATE FORM INTERVENTION GROUP 82 Appendix E RELAXATION TECHNIQUE 83 Deep B r e a t h i n g 83 P a s s i v e M u s c l e R e l a x a t i o n 84 App e n d i x F INITIAL INTERVIEW GUIDE 85 App e n d i x G SYMPTOM DISTRESS SCALE 86 Appendix H PERSONAL OPINION SURVEY 91 Appendix I SCORING THE PERSONAL OPINION SURVEY 94 v i LIST OF TABLES Page T a b l e 1 NUMBER OF SUBJECTS PER SITE OF MALIGNANCY 51 T a b l e 2 DISTRIBUTION OF SYMPTOM DISTRESS SCORES/FATIGUE. .57 T a b l e 3 DISTRIBUTION OF SYMPTOM DISTRESS SCORES/BOWEL. . . .58 ACKNOWLEDGEMENTS I would l i k e t o acknowledge t h e a s s i s t a n c e and s u p p o r t o f my T h e s i s Committee, JoAnn P e r r y and F r a n c e B o u t h i l l e t t e , t h r o u g h t h i s c h a l l e n g i n g , b u t v e r y r e w a r d i n g p r o c e s s . I would l i k e t o thank my f r i e n d Jane M i g h t o n who was t h e r e t o d i s c u s s any q u e s t i o n s o r c o n c e r n s I had and t o o f f e r much needed encouragement. I would l i k e t o thank each o f t h e i n d i v i d u a l s and t h e i r f a m i l i e s who agreed t o a s s i s t me t o i n c r e a s e my u n d e r s t a n d i n g o f how we, as n u r s e s , might be a b l e t o o f f e r some a s s i s t a n c e t o i n d i v i d u a l s r e c e i v i n g t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . I would a l s o l i k e t o acknowledge my husband Mark, whose p a t i e n c e and u n d e r s t a n d i n g have been pushed t o t h e utmost o v e r t h e p a s t few y e a r s . H i s c o n s i s t e n t l o v e and s u p p o r t have p r o v i d e d me w i t h an o p p o r t u n i t y t o l e a r n , t o grow ... and t o e a t . 1 CHAPTER ONE Introduction Context of the Problem In Canada, i t i s estimated that over one hundred thousand new cases of cancer were diagnosed i n 1989 and that one i n three Canadians w i l l develop some form of cancer during t h e i r l i f e t i m e (Canadian Cancer S t a t i s t i c s , 1990). Cancer remains one of the most feared diseases despite reports of increased s u r v i v a l rates (Benner & Wrubel, 1989). Radiation therapy i s one method used to t r e a t the disease. Over 50% of i n d i v i d u a l s with a diagnosis of cancer are treated with radiat i o n therapy at some point i n t h e i r i l l n e s s (Yasko, 1982). Many in d i v i d u a l s who receive t h i s type of treatment, p a r t i c u l a r l y to the abdominal/pelvic area, experience symptoms which can i n t e r f e r e with t h e i r d a i l y functioning. Radiation therapy can a f f e c t the a b i l i t y of i n d i v i d u a l s to meet t h e i r basic human needs due to i t s destructive p h y s i o l o g i c a l e f f e c t on both cancer c e l l s and on normal body c e l l s (Yasko, 1982), as well as i t s psychological impact including anxiety, depression, and fear (Barsevick & McCarthy, 1987; Benner & Wrubel, 1989; Peck & Boland, 1977). The intensive demands associated with the side e f f e c t s of r a d i a t i o n therapy may require i n d i v i d u a l s to 2 c o n c e n t r a t e p r i m a r i l y on ways t o manage t h e s e symptoms w h i c h may change t h e i r normal a c t i v i t i e s and remove them from t h e i r u s u a l methods o r p a t t e r n s o f c o p i n g (Benner & Wrubel, 1989). I n d i v i d u a l s who a r e t r e a t e d w i t h r a d i a t i o n t h e r a p y o f t e n a s s o c i a t e t h e e x p e r i e n c e o f b e i n g a l o n e w i t h t h e immense r a d i a t i o n t r e a t m e n t machine w i t h t h e l o n e l i n e s s and i s o l a t i o n o f t h e c a n c e r e x p e r i e n c e i t s e l f ( S t r o h l , 1988). T h i s sense o f i s o l a t i o n from "normal l i f e " i s o f t e n accompanied by t h e f e e l i n g s o f h e l p l e s s n e s s and l o s s o f p e r s o n a l c o n t r o l (Gottesman & L e w i s , 1982; T a y l o r , L i c h t m a n , & Wood, 1984). A l t h o u g h c a n c e r and i t s t r e a t m e n t a r e v a r i a b l e s w h i c h cannot be d i r e c t l y m a n i p u l a t e d by n u r s e s , i n d i v i d u a l s can l e a r n methods w h i c h may e n a b l e them t o cope w i t h b o t h t h e p h y s i c a l and e m o t i o n a l r e a c t i o n s a s s o c i a t e d w i t h t h e d i a g n o s i s and t r e a t m e n t o f c a n c e r . I n r e c e n t y e a r s , t h e r e has been an i n c r e a s i n g i n t e r e s t among h e a l t h p r o f e s s i o n a l s i n t h e use o f r e l a x a t i o n t h e r a p y as a method t o h e l p i n d i v i d u a l s w i t h c a n c e r . R e l a x a t i o n t h e r a p y i s t h e most common b e h a v i o r a l t r a i n i n g method used w i t h a d u l t s w i t h c a n c e r because i t i s : 1) v i r t u a l l y v o i d o f s i d e e f f e c t s ; 2) i n e x p e n s i v e ; 3) easy t o l e a r n ; and 4) u s a b l e i n b o t h h o s p i t a l and home s e t t i n g s ( C o tanch, 1983; Donovan, 1980; Zahourek, 1988). 3 S i g n i f i c a n c e of the Problem R a d i a t i o n t h e r a p y i s p r i m a r i l y g i v e n on an o u t p a t i e n t b a s i s , t h e r e f o r e , i t i s i m p o r t a n t t o i d e n t i f y e f f e c t i v e methods w h i c h w i l l a s s i s t i n d i v i d u a l s r e c e i v i n g t h i s t r e a t m e n t t h e r a p y t o g a i n t h e e f f e c t i v e c o p i n g s k i l l s r e q u i r e d t o manage i n t h e community. I t i s a p p a r e n t i n t h e l i t e r a t u r e t h a t t h e r e i s a l i n k between t h e use o f r e l a x a t i o n t h e r a p y and t h e amount o f symptom d i s t r e s s e x p e r i e n c e d w i t h c a n c e r t r e a t m e n t . However, most o f t h e r e s e a r c h has s t u d i e d t h e e f f e c t o f r e l a x a t i o n t h e r a p y on t h e d i s t r e s s a s s o c i a t e d w i t h t h e s i d e e f f e c t s o f chemotherapy as opposed t o r a d i a t i o n t h e r a p y ( B u r i s h & L y l e s , 1981; Co t a n c h , 1983; S c o t t , Donahue, M a s t r o v i t o & Hakes, 1983). F u r t h e r , any e v i d e n c e w h i c h l i n k s t h e use o f r e l a x a t i o n t h e r a p y t o t h e amount o f p e r s o n a l c o n t r o l p e r c e i v e d by i n d i v i d u a l s w i t h c a n c e r has been p r i m a r i l y a n e c d o t a l and has y e t t o be v a l i d a t e d t h r o u g h r e s e a r c h . Statement of the Purpose The purpose o f t h i s s t u d y was t o d e t e r m i n e t h e e f f e c t o f r e l a x a t i o n t h e r a p y on symptom d i s t r e s s and p e r s o n a l c o n t r o l as p e r c e i v e d by a d u l t s r e c e i v i n g a b d o m i n a l / p e l v i c e x t e r n a l r a d i a t i o n t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . 4 C o n c e p t u a l Framework The f o l l o w i n g c o n c e p t u a l framework has been d e v e l o p e d t o p r e s e n t t h e c o n c e p t s t h a t a r e used i n t h i s s t u d y and t o sug g e s t t h e ways i n w h i c h t h e y a r e r e l a t e d . The purpose o f t h i s framework i s : 1) t o p r o v i d e an o v e r v i e w o f t h e pr o b l e m under i n v e s t i g a t i o n ; and, 2) t o p r o v i d e d i r e c t i o n f o r t h i s s t u d y . A d i a g n o s i s o f c a n c e r and i t s t r e a t m e n t w i t h a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y a r e viewed w i t h i n t h i s c o n c e p t u a l framework as a v e r s i v e e v e n t s a s s o c i a t e d w i t h a number o f p s y c h o l o g i c a l and p h y s i c a l r e a c t i o n s ( K i n g , N a i l , Kreamer, S t r o h l , & Johnson, 1985; Yasko, 1982). The e x p e r i e n c e o f symptom d i s t r e s s and l o s s o f p e r s o n a l c o n t r o l a r e i d e n t i f i e d as common r e a c t i o n s i n i n d i v i d u a l s who r e c e i v e a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r (Gottesman & L e w i s , 1982; M c C o r k l e & Young, 1978; T a y l o r , L i c h t m a n , & Wood, 1984). I n t h e l i t e r a t u r e , r e l a x a t i o n t h e r a p y has been shown b o t h t o d e c r e a s e t h e symptoms and symptom d i s t r e s s a s s o c i a t e d w i t h chemotherapy and t o i n c r e a s e t h e amount o f p e r s o n a l c o n t r o l p e r c e i v e d by i n d i v i d u a l s ( B u r i s h & L y l e s , 1981; C o t a n c h , 1983; S c o t t , Donahue, M a s t r o v i t o & Hakes, 1983). A l t h o u g h s e v e r a l a u t h o r s assume t h a t "symptom d i s t r e s s " i s r e l a t e d t o " p e r s o n a l c o n t r o l " , t h e r e l a t i o n s h i p between t h e s e two v a r i a b l e s has y e t t o be d e f i n e d and i s beyond 5 t h e scope o f t h i s s t u d y . T h e r e f o r e , i n t h i s s t u d y , t h e e f f e c t o f r e l a x a t i o n t h e r a p y on t h e v a r i a b l e s o f symptom d i s t r e s s and p e r s o n a l c o n t r o l was examined s e p a r a t e l y . Symptom D i s t r e s s I n a s t u d y conducted by K i n g , N a i l , Kreamer, S t r o h l & Johnson ( 1 9 8 5 ) , o v e r 50% o f i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y t o t h e a b d o m i n a l / p e l v i c a r e a e x p e r i e n c e d symptoms i n c l u d i n g f a t i g u e , d i a r r h e a , nausea, and a n o r e x i a . Symptoms a r e s u b j e c t i v e r e s p o n s e s t h a t a r e p e r c e i v e d and v e r i f i e d o n l y by t h e i n d i v i d u a l who i s e x p e r i e n c i n g an e v e n t such as r a d i a t i o n t h e r a p y (Rhodes & Watson, 1987). I n some i n d i v i d u a l s , symptoms such as nausea, p a i n , and f a t i g u e w h i c h a r e p e r s i s t e n t a r e commonly a s s o c i a t e d w i t h some degree o f p h y s i c a l o r m e n t a l s u f f e r i n g d e s c r i b e d as d i s t r e s s . Symptom d i s t r e s s , a s s o c i a t e d w i t h a d i s e a s e and/or t h e e f f e c t s o f m e d i c a l t r e a t m e n t , can be d e f i n e d as t h e degree o f m e n t a l , p h y s i c a l , and/or e m o t i o n a l d i s c o m f o r t r e p o r t e d by i n d i v i d u a l s i n r e l a t i o n t o t h e i r p e r c e p t i o n o f t h e symptoms e x p e r i e n c e d (McCorkle & Young, 1978). T h i s s u b j e c t i v e p e r c e p t i o n o f d i s t r e s s c r e a t e s a need w i t h i n i n d i v i d u a l s t o a l t e r t h e i r b e h a v i o r i n r e s p o n s e t o t h e symptoms e x p e r i e n c e d (Rhodes & Watson, 1987). An i n t e r v e n t i o n w h i c h d e c r e a s e s t h e p e r c e i v e d amount o f d i s t r e s s a s s o c i a t e d w i t h a symptom o r a l l o w s t h e 6 i n d i v i d u a l t o s u c c e s s f u l l y cope w i t h t h e d i s t r e s s a s s o c i a t e d w i t h i t w i l l be viewed as l e s s p r o b l e m a t i c t o t h e i n d i v i d u a l ( H o l r o y d , A p p e l & A n d r o s i k , 1983; L e v e n t h a l & Nerenz, 1983; Nerenz, L e v e n t h a l & Love, 1982). P e r s o n a l C o n t r o l I n d i v i d u a l s who a r e t r e a t e d w i t h r a d i a t i o n t h e r a p y a l s o e x p e r i e n c e a l o s s i n t h e amount o f c o n t r o l t h e y p e r c e i v e t h e y have o v e r t h e i r b o d i e s as w e l l as o v e r t h e i r l i v e s i n g e n e r a l ( L e v e n t h a l , 1975). The p e r c e p t i o n o f p e r s o n a l c o n t r o l p r o v i d e s i n d i v i d u a l s w i t h an a s s u r a n c e t h a t t h e y w i l l n o t f a c e an e v e n t t h a t i s beyond t h e i r a b i l i t y t o endure ( M i l l e r , 1979). I n d i v i d u a l s who p e r c e i v e t h e y have c o n t r o l o v e r an a v e r s i v e e v e n t a t t r i b u t e t h i s c o n t r o l t o a s t a b l e i n t e r n a l s o u r c e : t h e i r own r e s p o n s e s ( M i l l e r , 1979; Thompson, 1981). P e r s o n a l c o n t r o l i s d e f i n e d as t h e a b i l i t y t o endure t h e a v e r s i v e n e s s o f an e v e n t t h r o u g h a sense t h a t one a c t i v e l y chooses o r a c h i e v e s m astery o v e r s o m a t i c , a f f e c t i v e , and c o g n i t i v e p r o c e s s e s (Coan & F a i r c h i l d , 1977; M i l l e r , 1979; Thompson, 1981). I t i s a dynamic s e n s a t i o n w i t h i n i n d i v i d u a l s , v a r y i n g a c c o r d i n g t o t h e i n d i v i d u a l ' s p e r c e p t i o n o f a s i t u a t i o n (Coan & F a i r c h i l d , 1977). P e r s o n a l c o n t r o l needs o n l y t o be p e r c e i v e d o r e x p e r i e n c e d by t h e i n d i v i d u a l i n o r d e r t o be e f f e c t i v e , i t 7 does not need t o be o b s e r v a b l e t o o t h e r s (Coan & F a i r c h i l d , 1977; M i l l e r , 1979; Thompson, 1981). R e l a x a t i o n Therapy R e l a x a t i o n t h e r a p y i s i d e n t i f i e d as a c o g n i t i v e -b e h a v i o r a l mode o f t h e r a p y w h i c h a f f e c t s v i s c e r a l f u n c t i o n s , s k e l e t a l muscle a c t i v i t y , and c e r e b r a l a c t i v i t i e s such as t h o u g h t s , p e r c e p t i o n s and e m o t i o n a l s t a t e s and enhances a sense o f p e r s o n a l c o n t r o l ( H i l g a r d , 1969; M a s t r o v i t o , 1989). I t i s easy t o l e a r n and has no documented a d v e r s e s i d e e f f e c t s (Mast, Meyers, U r b a n s k i , 1987; M a s t r o v i t o , 1989). However, i t has been s u g g e s t e d t h a t i n d i v i d u a l s w i t h a h i s t o r y o f s e v e r e d e p r e s s i o n o r p s y c h o s i s s h o u l d have p h y s i c i a n a p p r o v a l p r i o r t o l e a r n i n g t h e s e t e c h n i q u e s as i t may enhance t h e i r symptoms (Donovan, 1980; Mast, Meyers, U r b a n s k i , 1987; M a s t r o v i t o , 1989). R e l a x a t i o n t h e r a p y has been used s u c c e s s f u l l y t o d e c r e a s e b o t h t h e symptoms and p e r c e i v e d symptom d i s t r e s s i n i n d i v i d u a l s r e c e i v i n g chemotherapy ( B u r i s h & L y l e s , 1981; C o t a n c h , 1983; S c o t t , Donahue, M a s t r o v i t o & Hakes, 1983). I t i s s u g g e s t e d i n t h e l i t e r a t u r e t h a t t h e use o f b e h a v i o r a l and c o g n i t i v e t h e r a p i e s , such as r e l a x a t i o n t h e r a p y , may change t h e meaning o f a s i t u a t i o n f o r an i n d i v i d u a l . T h i s change i n meaning a f f e c t s t h e amount o f 8 personal control perceived by the i n d i v i d u a l ( M i l l e r , 1979; Taylor, 1983; Thompson, 1981). Thus, relaxation therapy may change the meaning of a s i t u a t i o n by a l t e r i n g i n d i v i d u a l s ' perception of t h e i r a b i l i t y to endure. A s i t u a t i o n i n i t i a l l y perceived by an i n d i v i d u a l as p o t e n t i a l l y unendurable may be revised and viewed as one that i s within the i n d i v i d u a l ' s a b i l i t i e s to endure. There are a va r i e t y of techniques used i n relaxation therapy including progressive muscle relaxation, passive muscle relaxation, breathing, v i s u a l imagery, and hypnosis (Hilgard, 1969; Mastrovito, 1989; Zahourek, 1988). Although the techniques are d i f f e r e n t , they a l l have a common goal to provide a r e s t f u l , peaceful, and pleasant state c a l l e d relaxation. Relaxation i s a p o s i t i v e l y perceived learned response involving an active and conscious process which re s u l t s i n the r e l i e f of tension or s t r a i n (Sweeney, 1978; Zahourek, 1988). Within t h i s conceptual framework, abdominal/pelvic r a d i a t i o n therapy i s viewed as causing symptom d i s t r e s s and a decrease i n personal control perceived by i n d i v i d u a l s with cancer. Relaxation therapy i s viewed as an intervention used to reduce symptom d i s t r e s s and increase the amount of personal control perceived by these i n d i v i d u a l s receiving radiat i o n therapy. 9 R e s e a r c h Hypotheses 1. I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l e x p e r i e n c e a r e d u c e d amount o f symptom d i s t r e s s as compared w i t h t h o s e who do n o t p r a c t i c e r e l a x a t i o n t h e r a p y . 2. I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l e x p e r i e n c e a h i g h e r l e v e l o f p e r s o n a l c o n t r o l as compared w i t h t h o s e who do n o t p r a c t i c e r e l a x a t i o n t h e r a p y . D e f i n i t i o n o f Terms 1. Symptom D i s t r e s s ; Symptom d i s t r e s s i s d e f i n e d as t h e degree o f m e n t a l , p h y s i c a l , and/or e m o t i o n a l d i s c o m f o r t r e p o r t e d by i n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y i n r e l a t i o n t o t h e i r p e r c e p t i o n o f t h e symptoms e x p e r i e n c e d . The i n d i v i d u a l s r e p o r t on t h e p r e s e n c e and i n t e n s i t y o f nausea, p a i n , i n s o m n i a , f a t i g u e , and cough and, any changes i n bowel p a t t e r n , c o n c e n t r a t i o n , appearance, o u t l o o k , and b r e a t h i n g . Symptom d i s t r e s s i s o p e r a t i o n a l l y d e f i n e d u s i n g t h e Symptom D i s t r e s s S c a l e ( M c C o r k l e & Young, 1978; Appendix G). 2. P e r s o n a l C o n t r o l : P e r s o n a l c o n t r o l i s d e f i n e d as t h e a b i l i t y t o endure t h e a v e r s i v e n e s s o f an e v e n t t h r o u g h a sense t h a t one a c t i v e l y chooses o r a c h i e v e s m a s t e r y o v e r s o m a t i c , a f f e c t i v e , and c o g n i t i v e p r o c e s s e s (Coan & F a i r c h i l d , 1977). P e r s o n a l c o n t r o l i s o p e r a t i o n a l l y d e f i n e d u s i n g t h e S e l f - C o n t r o l S u b s c a l e o f t h e P e r s o n a l O p i n i o n Survey (Coan & F a i r c h i l d , 1977, Appendix H). 3. R e l a x a t i o n t h e r a p y : R e l a x a t i o n t h e r a p y i s d e f i n e d as t h e use o f deep b r e a t h i n g and p r o g r e s s i v e r e l a x a t i o n based on t h e t e c h n i q u e s d e s c r i b e d by Mast, Meyers and U r b a n s k i (1987) (Appendix E ) . a) Deep B r e a t h i n g : Deep b r e a t h i n g i s t h e use o f c o n t r o l l e d and s y s t e m a t i c r e s p i r a t i o n s t h a t can l e a d t o a d e e p l y r e l a x e d and cal m s t a t e (Mast, Meyers & U r b a n s k i , 1987). T h i s t e rm i s o p e r a t i o n a l l y d e f i n e d by a r e c o r d o f t h e number o f t i m e s t h e p a r t i c i p a n t uses t h e t e c h n i q u e o v e r a three-week p e r i o d . b) P r o g r e s s i v e r e l a x a t i o n : P r o g r e s s i v e r e l a x a t i o n i s a p a s s i v e p r o c e d u r e i n v o l v i n g t h e s e q u e n t i a l r e l e a s e o f t e n s i o n o f one body p a r t a t a t i m e , c o n s c i o u s l y a l l o w i n g each p a r t t o become as r e l a x e d as p o s s i b l e (Mast, Meyers, & U r b a n s k i , 1987). T h i s t e r m i s o p e r a t i o n a l l y d e f i n e d by a r e c o r d o f t h e number o f 11 t i m e s t h e p a r t i c i p a n t used t h e t e c h n i q u e o v e r a three-week p e r i o d . 4. E x t e r n a l r a d i a t i o n t r e a t m e n t : E x t e r n a l r a d i a t i o n t r e a t m e n t i s c l a s s i f i e d as t e l e t h e r a p y w h i c h i s t h e use o f i o n i z i n g r a d i a t i o n g i v e n from a s o u r c e a t a d i s t a n c e from t h e body ( H i l d e r l e y , 1987). T h i s t e r m w i l l be o p e r a t i o n a l l y d e f i n e d as t h e a b d o m i n a l / p e l v i c a r e a o f t h e body b e i n g t r e a t e d by r a d i a t i o n t h e r a p y , t h e l e n g t h o f t h e c o u r s e o f t r e a t m e n t , and t h e amount of r a d i a t i o n r e c e i v e d . Assumptions The f o l l o w i n g assumptions have been made i n r e l a t i o n t o t h i s r e s e a r c h s t u d y . 1. The d i a g n o s i s o f c a n c e r i s an une x p e c t e d and a v e r s i v e e v e n t . 2. I n d i v i d u a l s w i t h c a n c e r e x p e r i e n c e some degree o f d i s t r e s s r e l a t e d t o t h e c a n c e r e x p e r i e n c e . 3. P a r t i c i p a n t s i n t h e i n t e r v e n t i o n group w i l l be hon e s t i n r e c o r d i n g t h e number o f t i m e s t h e y use t h e r e l a x a t i o n method. 4. There i s no d i f f e r e n c e between t h e use o f w r i t t e n m a t e r i a l ("hand-outs") and a u d i o t a p e s t o r e i n f o r c e t h e l e a r n i n g p r o c e s s r e l a t e d t o t h e r e l a x a t i o n r e s p o n s e . 12 Limitations Three f a c t o r s l i m i t t h e g e n e r a l i z a b i l i t y o f t h e r e s u l t s o f t h i s s t u d y . F i r s t , a c o n v e n i e n c e method o f s a m p l i n g was used. A t r u l y r e p r e s e n t a t i v e sample o f t h e p o p u l a t i o n may not be o b t a i n e d by t h i s method. Second, t h e e f f e c t w h i c h a s p e c i f i c d i a g n o s i s has i n r e l a t i o n t o t h e amount o f p e r s o n a l c o n t r o l p e r c e i v e d by i n d i v i d u a l s i s an unknown f a c t o r . I n t h i s s t u d y , t h i s v a r i a b l e was not c o n t r o l l e d s i n c e t h e p a r t i c i p a n t s have a v a r i e t y o f d i a g n o s e s o f c a n c e r . T h i r d , t h e v a l i d i t y and r e l i a b i l i t y o f t h e i n s t r u m e n t , The P e r s o n a l O p i n i o n Survey (Coan & F a i r c h i l d , 1977), i s based on s t u d i e s done o n l y w i t h c o l l e g e s t u d e n t s . 13 CHAPTER TWO Review o f R e l a t e d L i t e r a t u r e I n t r o d u c t i o n T h i s l i t e r a t u r e r e v i e w i s o r g a n i z e d t o p r e s e n t what i s known about t h e c o n c e p t s used i n t h i s s t u d y , symptom d i s t r e s s , p e r s o n a l c o n t r o l , and r e l a x a t i o n t h e r a p y i n r e l a t i o n t o i n d i v i d u a l s who a r e r e c e i v i n g t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . Symptom D i s t r e s s V e r y few s t u d i e s have been found w h i c h d e s c r i b e b o t h t h e symptoms e x p e r i e n c e d by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r and t h e d i s t r e s s a s s o c i a t e d w i t h t h e s e symptoms. However, t h e f i n d i n g s i n t h e f o l l o w i n g s t u d i e s s u g g e s t t h a t most i n d i v i d u a l s e x p e r i e n c e an i n c r e a s e i n symptoms and r e l a t e d d i s t r e s s o v e r t h e c o u r s e o f t r e a t m e n t . Peck and B o l a n d (1977) conducted an e x p l o r a t o r y s t u d y t o l e a r n : 1) what i n f o r m a t i o n p a t i e n t s a r e g i v e n when r a d i o t h e r a p y i s p r e s c r i b e d ; 2) p a t i e n t s ' a t t i t u d e s toward t h e t r e a t m e n t ; and, 3) how p a t i e n t s ' a t t i t u d e s a r e a f f e c t e d by t h e e x p e r i e n c e o f r e c e i v i n g r a d i a t i o n t h e r a p y . F i f t y s u b j e c t s w i t h v a r y i n g d i a g n o s e s o f c a n c e r were randomly s e l e c t e d and i n t e r v i e w e d o v e r an 18 month p e r i o d . S t r u c t u r e d i n t e r v i e w s were c o n d u c t e d by a p s y c h i a t r i s t 14 b e f o r e t h e r a d i a t i o n t h e r a p y s t a r t e d and a g a i n w i t h i n one week o f t h e c o m p l e t i o n o f t r e a t m e n t . R e s u l t s showed t h a t w h i l e 60% o f t h e s u b j e c t s were a s s e s s e d as h a v i n g a s i g n i f i c a n t degree o f a n x i e t y p r i o r t o t r e a t m e n t , 80% d i d so by t h e t i m e o f t h e second i n t e r v i e w . The a u t h o r s d e s c r i b e d a " s i g n i f i c a n t degree o f a n x i e t y " (seen i n 33 p a t i e n t s ) as a p r e o c c u p a t i o n w i t h t h e i r d i s e a s e and t h e s i d e e f f e c t s o f t r e a t m e n t , and h a v i n g d o u b t s about t h e r e l i e f o f symptoms and about t h e i r s u r v i v a l . I n a d d i t i o n t o a n x i e t y , a l l b u t one s u b j e c t r e p o r t e d p h y s i c a l s i d e e f f e c t s i n c l u d i n g f a t i g u e , a n o r e x i a , nausea and v o m i t i n g w h i c h began w i t h t h e i r f i r s t t r e a t m e n t and i n c r e a s e d o v e r t h e c o u r s e o f t h e i r t r e a t m e n t . A l l o f t h e s u b j e c t s were aware t h a t t h e y had c a n c e r and were t o r e c e i v e r a d i a t i o n t r e a t m e n t , however most o f them r e p o r t e d t h a t t h e y had r e c e i v e d l i t t l e o r no i n f o r m a t i o n about r a d i a t i o n r e a c t i o n s b e f o r e t h e t r e a t m e n t s t a r t e d . A l t h o u g h t h e v a r i a b l e s o f a n x i e t y and p h y s i c a l symptoms b o t h seemed t o i n c r e a s e o v e r t h e c o u r s e o f r a d i a t i o n t h e r a p y , a p o s s i b l e r e l a t i o n s h i p between t h e two v a r i a b l e s was not a d d r e s s e d . The r e s e a r c h e r s a t t r i b u t e d t h e s u b j e c t s ' a n x i e t y t o t h e l a c k o f i n f o r m a t i o n about t h e i r d i s e a s e and t r e a t m e n t . The r e s u l t s o f t h i s e x p l o r a t o r y s t u d y i n d i c a t e d t h a t i n d i v i d u a l s e x p e r i e n c e d some degree o f a n x i e t y and v a r i o u s 15 p h y s i c a l symptoms r e l a t e d t o r a d i a t i o n t h e r a p y . However, t h e s e r e s u l t s were based on d a t a w h i c h had been s u b j e c t i v e l y i n t e r p r e t e d by a p s y c h i a t r i s t . The i n d i v i d u a l s ' p e r c e p t i o n s o f t h e s e symptoms was n o t a d d r e s s e d . K i n g , N a i l , Kreamer, S t r o h l , and Johnson (1985) c o n d u c t e d a d e s c r i p t i v e s t u d y t o i d e n t i f y and d e s c r i b e symptoms e x p e r i e n c e d by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y . A c o n v e n i e n c e sample o f 96 i n d i v i d u a l s who were t o r e c e i v e r a d i a t i o n t r e a t m e n t was o b t a i n e d . S u b j e c t s were d i v i d e d i n t o f o u r groups based on t h e i r t r e a t m e n t s i t e : c h e s t (n = 15); head and neck (n = 2 5 ) ; male p e l v i s (n = 2 6 ) ; and, female p e l v i s (n = 3 0 ) . Each p a r t i c i p a n t was i n t e r v i e w e d w e e k l y d u r i n g t r e a t m e n t and t h e n m onthly f o r t h r e e months f o l l o w i n g t h e c o m p l e t i o n o f t r e a t m e n t . The Symptom P r o f i l e was d e v e l o p e d by one o f t h e r e s e a r c h e r s t o be used d u r i n g each i n t e r v i e w t o document t h e p r e s e n c e o f symptoms d u r i n g t h e p r e v i o u s week. A l i s t o f t h i r t e e n symptoms was c o m p i l e d o f p o s s i b l e s i d e e f f e c t s e x p e r i e n c e d d u r i n g r a d i a t i o n t h e r a p y . T h i s l i s t i n c l u d e d : s l e e p d i f f i c u l t i e s ; f a t i g u e ; s k i n changes; a n o r e x i a , nausea; v o m i t i n g ; i n d i g e s t i o n ; d i a r r h e a ; c o n s t i p a t i o n ; s o r e t h r o a t ; cough, d i f f i c u l t y s w a l l o w i n g ; changes i n s a l i v a ; and, a m i s c e l l a n e o u s c a t e g o r y f o r o t h e r symptoms r e p o r t e d . T h i s o r i g i n a l l i s t was r e v i s e d a f t e r e x a m i n i n g 16 e a r l y r e s p o n s e s t o t h e " m i s c e l l a n e o u s c a t e g o r y " and two more symptoms were added, p a i n and u r i n a r y f r e q u e n c y . I f any symptoms were r e p o r t e d by t h e p a r t i c i p a n t , i n f o r m a t i o n c o n c e r n i n g t h e t i m e o f o n s e t , f r e q u e n c y , s e v e r i t y , and d u r a t i o n o f each symptom, as w e l l as f a c t o r s t h a t e x a c e r b a t e d o r r e l i e v e d each symptom were c o l l e c t e d . A L i k e r t - t y p e s c a l e was used t o d e t e r m i n e t h e s e v e r i t y o f each r e p o r t e d symptom (not bad; a l i t t l e bad; m o d e r a t e l y bad; q u i t e bad; e x t r e m e l y b a d ) . A p p r o x i m a t e l y 50% o f i n d i v i d u a l s who r e c e i v e d a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y , (male and female p e l v i s groups) r e p o r t e d d i a r r h e a and f a t i g u e . I n b o t h g r o u p s , t h e i n c i d e n c e o f d i a r r h e a i n c r e a s e d o v e r t h e f i r s t two weeks and peaked d u r i n g t h e t h i r d and f o u r t h weeks o f t r e a t m e n t . The i n c i d e n c e o f f a t i g u e a l s o i n c r e a s e d s t e a d i l y t o peak d u r i n g t h e f o u r t h and f i f t h week o f t r e a t m e n t w i t h 65% o f males and 72% o f f e m a l e s r e p o r t i n g t h i s symptom d u r i n g t h i s t i m e p e r i o d . I n b o t h male and female s u b j e c t s , d i a r r h e a and f a t i g u e were r a t e d as a l i t t l e t o m o d e r a t e l y bad d u r i n g t h e t h i r d and subsequent weeks o f t r e a t m e n t . I t i s i m p o r t a n t t o note t h a t t h e s e symptoms were a l s o r e p o r t e d by some o f t h e s u b j e c t s t h r e e months l a t e r , a l t h o u g h t h e s e v e r i t y o f t h e symptoms was n o t r e p o r t e d . 17 A p p r o x i m a t e l y 50% o f t h e f e males a l s o e x p e r i e n c e d nausea and a n o r e x i a . The i n c i d e n c e o f nausea and a n o r e x i a peaked a t t h e f o u r t h week o f t r e a t m e n t and was r a t e d as m o d e r a t e l y bad. A s h a r p d e c r e a s e i n t h e i n c i d e n c e o f b o t h o f t h e s e symptoms was r e p o r t e d once t r e a t m e n t had ended. Based on t h e l a t t e r f i n d i n g , t h e a u t h o r s s u g g e s t e d t h a t nausea and a n o r e x i a c o u l d have r e s u l t e d from t h e p h y s i c a l e f f e c t s o f r a d i a t i o n t r e a t m e n t o r from p s y c h o l o g i c a l f a c t o r s r e l a t e d t o t h e t r e a t m e n t . P a r t i c i p a n t s were a l s o asked t o i d e n t i f y some o f t h e i n t e r v e n t i o n s t h e y used t o cope w i t h t h e i r symptoms and t h e e f f e c t i v e n e s s o f t h e i n t e r v e n t i o n s t h e y used. I n t e r v e n t i o n s such as m e d i c a t i o n s , low r e s i d u e d i e t , and i n c r e a s e d r e s t were r e p o r t e d . However, t h e d a t a r e l a t e d t o i n t e r v e n t i o n s was a n e c d o t a l and t h e e f f e c t i v e n e s s o f t h e i n t e r v e n t i o n s used by t h e p a r t i c i p a n t s , a l t h o u g h c o l l e c t e d , was n o t e v a l u a t e d . G e n e r a l i z a t i o n o f t h i s s t u d y ' s r e s u l t s i s l i m i t e d p r i m a r i l y due t o t h e l a c k o f any f o r m a l assessment o f t h e r e l i a b i l i t y and v a l i d i t y o f t h e Symptom P r o f i l e i n s t r u m e n t . However, t h i s i s t h e o n l y s t u d y found w h i c h has a t t e m p t e d t o i d e n t i f y symptoms r e l a t e d t o r a d i a t i o n t h e r a p y as w e l l as d e s c r i b e t h e s e v e r i t y o f each symptom as p e r c e i v e d by t h o s e r e c e i v i n g t h e t r e a t m e n t . 18 The f i n d i n g s o f t h e s e two s t u d i e s s u g g e s t t h a t i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r e x p e r i e n c e an i n c r e a s e i n symptoms and r e l a t e d d i s t r e s s o v e r t h e c o u r s e o f t r e a t m e n t . A l t h o u g h some i n t e r v e n t i o n s were i d e n t i f i e d w i t h i n t h e s e s t u d i e s w h i c h may have an e f f e c t on t h e symptoms e x p e r i e n c e d , t h e i r e f f e c t i v e n e s s i s unknown due t o t h e l a c k o f e v a l u a t i v e a n a l y s i s . P e r s o n a l Control R e s u l t s from v a r i o u s s t u d i e s s u g g e s t t h a t a s s i s t i n g i n d i v i d u a l s t o g a i n c o g n i t i v e / b e h a v i o r a l c o n t r o l when f a c e d w i t h t h r e a t e n i n g s i t u a t i o n s w i l l enhance t h e i r p s y c h o l o g i c a l w e l l - b e i n g (Auerbach, M a r t e l l i , M e r c u r i , 1983; Johnson, R i c e , F u l l e r , E n d r e s s , 1978; P a d i l l a , e t a l , 1981). However, few s t u d i e s have been found w h i c h i d e n t i f y and e v a l u a t e t h e s t r a t e g i e s used by i n d i v i d u a l s t o g a i n c o n t r o l d u r i n g t h e c a n c e r e x p e r i e n c e . T a y l o r (1983) c o n d u c t e d a q u a l i t a t i v e s t u d y on t h e e x p e r i e n c e o f women (N = 78) i n r e l a t i o n t o how t h e y coped w i t h t h e d i a g n o s i s and t r e a t m e n t o f b r e a s t c a n c e r . One o f t h e themes t h a t e v o l v e d from t h e d a t a was " g a i n i n g a sense o f m a s t e ry" w h i c h i n v o l v e d g a i n i n g a f e e l i n g o f c o n t r o l o v e r t h e t h r e a t e n i n g e v e n t i n o r d e r t o manage i t o r keep i t from happening a g a i n . 19 In the analysis of the interview data, two-thirds of the women believed they had at least some control over the course of t h e i r cancer or i t s recurrence. Of t h i s group of women, 37% believed they had a l o t of co n t r o l . Some of the remaining one-third believed that although they themselves had no control, t h e i r doctor or the treatment would control the disease. Taylor (1983) concluded that women who either believed i n t h e i r own a b i l i t y to control the disease or those who believed that the doctor or treatment would control the disease tended to be strongly associated with an o v e r a l l p o s i t i v e adjustment although t h i s i s not c l e a r l y indicated from the r e s u l t s of t h i s study. Six d i f f e r e n t methods were i d e n t i f i e d as being used alone or i n various combinations by these women i n order to gain a sense of mastery. Five out of the six methods used by the women involved d i r e c t l y a f f e c t i n g or c o n t r o l l i n g the cancer including: medical treatment; a po s i t i v e attitude; removing the believed i n i t i a l cause ( i . e . s t r e s s ) ; behavioral changes (49% changed d i e t ) ; and, gaining information. The si x t h method involved the use of strategies to control the side e f f e c t s of the treatment or disease. These included imaging, self-hypnosis, d i s t r a c t i o n , and meditation. I t i s important to note that over 90% of women who received chemotherapy treatment used 20 one o r more o f t h e s e s t r a t e g i e s ( i m a g i n g , s e l f - h y p n o s i s , d i s t r a c t i o n , m e d i t a t i o n ) i n an attempt t o c o n t r o l t h e s i d e e f f e c t s . S i m i l a r e f f o r t s were r e p o r t e d by women r e c e i v i n g r a d i a t i o n t r e a t m e n t . T a y l o r (1982) c o n c l u d e d t h a t a sense o f m a s t e r y can be a c h i e v e d by b e l i e v i n g t h a t one can use s t r a t e g i e s t o c o n t r o l t h e c a n c e r o r by assuming c o n t r o l o v e r t h e r e l a t e d e f f e c t s o f t h e d i s e a s e and/or t r e a t m e n t . The e x p e r i e n c e s o f t h e women i n t e r v i e w e d f o r t h i s s t u d y s u g g e s t t h a t s e l f -g e n e r a t e d f e e l i n g s o f c o n t r o l can enhance one's a b i l i t y t o cope w i t h a v e r s i v e e v e n t s . T a y l o r ' s c o n c l u s i o n i s co n g r u e n t w i t h c u r r e n t l i t e r a t u r e ( M i l l e r , 1979; Thompson, 1981). However, i t i s s t i l l unknown as t o w h i c h o f t h e s t r a t e g i e s i d e n t i f i e d i n t h i s s t u d y were most e f f e c t i v e and whether p e r s o n a l c o n t r o l can be i n c r e a s e d by a s s i s t i n g i n d i v i d u a l s t o use t h e s e s t r a t e g i e s . B rockopp, Hayko, Davenport and W i n s c o t t (1989) c o n d u c t e d a c o r r e l a t i o n a l s t u d y t o examine t h e r e l a t i o n s h i p between "the need f o r hope and i n f o r m a t i o n " and " p e r c e i v e d p e r s o n a l c o n t r o l " i n a d u l t s w i t h c a n c e r . A c o n v e n i e n c e sample o f 56 i n d i v i d u a l s a s s e s s e d as e x p e r i e n c i n g t h e m i d d l e phase o f a l i f e - t h r e a t e n i n g d i a g n o s i s o f c a n c e r ( m i d d l e phase = s i x o r more weeks p o s t d i a g n o s i s t o a p o i n t when emphasis on c u r e changes t o an emphasis on p a l l i a t i o n ) were o b t a i n e d . S u b j e c t s were 21 asked to respond to three instruments: a demographic sheet; the Spheres of Control Scale (Paulhus, 1983); and, the items re l a t e d to hope and information from the Needs Assessment Inventory (Brockopp, 1982). Data analysis yielded s t a t i s t i c a l l y s i g n i f i c a n t but weak corr e l a t i o n s between personal control and hoping that pleasurable experiences remained (r = .36, p_ = .004), as well as wanting to share what has been learned during the i l l n e s s with others (r = .25, p_ = .034). Although t h e i r r e s u l t s were s t a t i s t i c a l l y s i g n i f i c a n t , Brockopp, Hayko, Davenport and Winscott (1989) doubted the c l i n i c a l s i g n i f i c a n c e of these r e s u l t s and concluded that an in d i v i d u a l ' s sense of personal control i s not influenced by the needs for hope and information. They stated that the need for personal control i s highly i n d i v i d u a l and must be assessed on an i n d i v i d u a l basis u n t i l association with other psychological constructs are known. Although a t h e o r e t i c a l d e f i n i t i o n for perceived personal control was not provided i n t h i s study, personal control was operationally defined by the Spheres of Control Scale. The Spheres of Control Scale was designed to provide a control p r o f i l e , a pattern of expectancies that an i n d i v i d u a l has i n facing the world. Based on t h i s scale, an i n d i v i d u a l ' s control p r o f i l e i s f a i r l y s t a t i c , i t i s considered a t r a i t of the person (Paulhus, 1983). 22 This d e f i n i t i o n i s i n c o n f l i c t with many of the current d e f i n i t i o n s of personal control i n the l i t e r a t u r e which describe i t as a dynamic sensation (Coan & F a i r c h i l d , 1977; Thompson, 1981). Descriptive accounts by in d i v i d u a l s with cancer support the idea that the concept of personal control has dynamic properties as evidenced by the enhancement i n feelings of personal control through the use of methods such as relaxation therapy (Burish Lyles, 1981; Cotanch, 1983; Scott, Donahue, Mastrovito & Hakes, 1983). In summary, the need for control i n i n d i v i d u a l s with a l i f e - t h r e a t e n i n g i l l n e s s i s acknowledged i n these studies and strategies which may a f f e c t the l e v e l of perceived personal control are discussed. The findings i n these studies also convey the ambiguity surrounding the concept of personal cont r o l . However, i t i s c l e a r that how current interventions used by health care professionals a f f e c t an in d i v i d u a l ' s perception of personal control has yet to be f u l l y investigated. R e l a x a t i o n Therapy This section of the l i t e r a t u r e review explores what i s known about the use of relaxation therapy as i t rela t e s to symptom d i s t r e s s and personal control within the cancer experience. 23 S c o t t , Donahue, M a s t r o v i t o and Hakes (1983) c o n d u c t e d an e x p l o r a t o r y p i l o t s t u d y t o examine t h e c l i n i c a l f e a s i b i l i t y and a n t i e m e t i c e f f e c t o f c l i n i c a l r e l a x a t i o n on p a t i e n t s d i a g n o s e d w i t h o v a r i a n c a n c e r who were r e c e i v i n g a h i g h l y e m e t i c c h e m o t h e r a p e u t i c regimen. T h i s s t u d y was i n i t i a t e d a t t h e r e q u e s t o f c l i n i c i a n s w o r k i n g w i t h t h e s e p a t i e n t s who saw t h e need f o r an e f f e c t i v e , s a f e , and c l i n i c a l l y u s e f u l a n t i e m e t i c b e h a v i o r a l p r o t o c o l . A c o n v e n i e n c e sample o f t e n women were r e c r u i t e d t o r e c e i v e t h e i n t e r v e n t i o n . There was no c o n t r o l group. The r e l a x a t i o n p r o t o c o l i n c l u d e d p r e t r e a t m e n t p a t i e n t e d u c a t i o n and c o u n s e l l i n g , Slow S t r o k e Back Massage, g u i d e d imagery, and p r o g r e s s i v e r e l a x a t i o n . P a r t i c i p a n t s were r e c r u i t e d on t h e day o f h o s p i t a l i z a t i o n , one day p r i o r t o t h e i r chemotherapy t r e a t m e n t . On t h a t same day, p a r t i c i p a n t s r e c e i v e d : p r e t r e a t m e n t c o u n s e l l i n g d e s i g n e d t o i n c r e a s e t h e i r knowledge about chemotherapy; e x p e r i e n c e w i t h g u i d e d imagery and p r o g r e s s i v e r e l a x a t i o n ; and, encouragement t o ask q u e s t i o n s . P a r t i c i p a n t s were t h e n asked t o p r a c t i c e t h e g u i d e d imagery and p r o g r e s s i v e r e l a x a t i o n b e f o r e d i n n e r and a t bedtime. On t h e day o f t r e a t m e n t , p a r t i c i p a n t s were seen p r i o r t o d r u g a d m i n i s t r a t i o n and a g a i n coached t h r o u g h g u i d e d imagery and p r o g r e s s i v e r e l a x a t i o n by t h e i n v e s t i g a t o r . 24 F o l l o w i n g d r u g a d m i n i s t r a t i o n , p a r t i c i p a n t s r e c e i v e d f o u r t o s i x h o u r s o f c o a c h i n g and were a l s o o b s e r v e d . Measures o f f r e q u e n c y and amount o f emesis as w e l l as t h e d u r a t i o n o f a c t i v e e m e t i c r e s p o n s e were n o t e d by t h e i n v e s t i g a t o r d u r i n g t h i s t i m e . A f t e r t h i s t i m e p e r i o d , t h e r e c o r d i n g o f measurements were done by u n i t n u r s i n g s t a f f . I t was n o t s t a t e d how o r i f t h e method o f Slow S t r o k e Back Massage was used. The i n v e s t i g a t o r s s t a t e d t h a t " o v e r a l l " t h e r e s u l t s i n d i c a t e d a r e d u c t i o n i n d u r a t i o n , f r e q u e n c y and i n t e n s i t y o f nausea and v o m i t i n g and a r e d u c t i o n i n t h e volume o f d i a r r h e a . The i n v e s t i g a t o r s a l s o i n t e r v i e w e d t h e p a r t i c i p a n t s t h e day a f t e r t h e i r chemotherapy t r e a t m e n t t o c o l l e c t a n e c d o t a l i n f o r m a t i o n . D u r i n g t h e s e i n t e r v i e w s , p a r t i c i p a n t s s t a t e d t h a t t h e i r f e a r o f t h e t r e a t m e n t was d e c r e a s e d and t h a t t h e y had a g r e a t e r sense o f c o n t r o l o v e r t h e i r body p r o c e s s e s . There a r e t h r e e a r e a s i n t h i s s t u d y w h i c h weaken t h e c o n c l u s i o n s n o t e d by t h e i n v e s t i g a t o r s . F i r s t , i t i s u n c l e a r as t o w h i c h o f t h e f o u r i n t e r v e n t i o n s used i n t h i s s t u d y were e f f e c t i v e . A l l p a r t i c i p a n t s r e c e i v e d e d u c a t i o n and c o u n s e l i n g , c o n t i n u o u s s u p p o r t and a t t e n t i o n o f t h e i n v e s t i g a t o r , g u i d e d imagery, and p r o g r e s s i v e r e l a x a t i o n (and, perhaps a l s o Slow S t r o k e Back Massage). These a r e a l l v e r y d i f f e r e n t i n t e r v e n t i o n s w h i c h makes i t i m p o s s i b l e t o c o n c l u d e t h a t t h e outcomes were r e l a t e d t o t h e r e l a x a t i o n t e c h n i q u e s used. Second, t h e r e i s a q u e s t i o n o f t h e r e l i a b i l i t y o f t h e r e s u l t s . The r e s u l t s o f t h i s s t u d y were dependent on t h e s u b j e c t i v e v i e w o f t h e i n v e s t i g a t o r and t h e u n i t s t a f f n u r s e s who r e c o r d e d t h e d a t a . The q u e s t i o n o f i n t e r - r a t e r r e l i a b i l i t y was n o t a d d r e s s e d n o r were t h e r e any c r i t e r i a mentioned i n o r d e r t o measure t h e v a r i a b l e s s t u d i e d . A f i n a l weakness o f t h i s s t u d y was t h e l i m i t e d amount o f t i m e t h e p a r t i c i p a n t had t o l e a r n t h e i n t e r v e n t i o n . P a r t i c i p a n t s were t a u g h t t h e r e l a x a t i o n t e c h n i q u e s t h e day b e f o r e and were g i v e n t h r e e a d d i t i o n a l o p p o r t u n i t i e s t o p r a c t i c e . However, r e l a x a t i o n i s a l e a r n e d r e s p o n s e (Benson, 1975; Zahourek, 1988). I t i s c u r r e n t l y recommended t h a t r e l a x a t i o n be p r a c t i c e d once d a i l y o v e r a p e r i o d o f a t l e a s t two weeks f o r i t s e f f e c t s t o become known (Zahourek, 1988). A l t h o u g h s e v e r a l weaknesses were n o t e d i n t h e s t u d y by S c o t t , Donahue, M a s t r o v i t o and Hakes (1983), i t appeared t h a t t h e i n t e r v e n t i o n s were s u c c e s s f u l . However t h e need t o know w h i c h i n t e r v e n t i o n s were r e s p o n s i b l e f o r t h e outcomes r e m a i n s . C o tanch (1983) att e m p t e d t o c l a r i f y some o f t h e q u e s t i o n s r a i s e d i n t h e p r e v i o u s s t u d y t h r o u g h an i n i t i a l e x p e r i m e n t a l t e s t o f t h e use o f p r o g r e s s i v e muscle r e l a x a t i o n i n r e d u c i n g nausea and v o m i t i n g and 26 p s y c h o l o g i c a l a v e r s e n e s s a s s o c i a t e d w i t h chemotherapy. Cotanch v i e w e d r e l a x a t i o n b o t h as a r e s p o n s e and as a c o p i n g s k i l l . As a r e s p o n s e , t h e use o f r e l a x a t i o n can d e c r e a s e t h e e f f e c t s o f an a c t i v a t e d f i g h t o r f l i g h t r e a c t i o n . As a c o p i n g s k i l l , r e l a x a t i o n can a f f e c t how an i n d i v i d u a l v i e w s a p o t e n t i a l l y t h r e a t e n i n g s i t u a t i o n . The p a r t i c i p a n t s (N = 12) i n t h i s s t u d y had r e c u r r e n t c a n c e r f o l l o w i n g c o n v e n t i o n a l c a n c e r chemotherapy and were r e c e i v i n g more a g g r e s s i v e , e x p e r i m e n t a l t r e a t m e n t . A l l had e x p e r i e n c e d r e f r a c t o r y nausea and v o m i t i n g d u r i n g t h e i r p r e v i o u s c o u r s e o f chemotherapy as d e f i n e d by t h e Duke's d e s c r i p t i v e s c a l e (Cotanch, 1983). P a r t i c i p a n t s s e r v e d as t h e i r own c o n t r o l . Data c o l l e c t i o n i n v o l v e d : t h e use o f t h e S p e i l b e r g e r ' s s t a t e - t r a i t a n x i e t y i n v e n t o r y ( S T A I ) ; p h y s i o l o g i c a l measurements ( p u l s e , r e s p i r a t i o n s , b l o o d p r e s s u r e ) ; t h e q u a l i t y and q u a n t i t y o f nausea and v o m i t i n g e x p e r i e n c e d u s i n g Duke's d e s c r i p t i v e s c a l e ; and, a c a l o r i e c o u n t (a f o o d d i a r y o f a l l foods and f l u i d s t a k e n by mouth f o r two days f o l l o w i n g chemotherapy). Data were c o l l e c t e d o v e r a c o u r s e o f t h e r a p y w h i c h i n c l u d e d seven t r e a t m e n t s o f chemotherapy, each t r e a t m e n t o c c u r r i n g e v e r y f o u r t o s i x weeks. B a s e l i n e d a t a c o l l e c t e d p r i o r t o each chemotherapy t r e a t m e n t i n c l u d e d t o t a l body w e i g h t , p u l s e , r e s p i r a t i o n s , b l o o d p r e s s u r e , and s t a t e - S T A I . P o s t - t r e a t m e n t d a t a were c o l l e c t e d two 27 days f o l l o w i n g each t r e a t m e n t and c o n s i s t e d o f t h e amount and q u a l i t y o f nausea and v o m i t i n g , o r a l c a l o r i c i n t a k e , t y p e and q u a n t i t y o f a n t i e m e t i c s , and t h e t r a i t - S T A I . Data were c o l l e c t e d d u r i n g t h e f i r s t t r e a t m e n t w i t h o u t t h e use o f t h e i n t e r v e n t i o n , p r o g r e s s i v e muscle r e l a x a t i o n . A l l p a r t i c i p a n t s were t h e n g i v e n p e r s o n a l i n s t r u c t i o n i n t h e use o f p r o g r e s s i v e muscle r e l a x a t i o n by t h e i n v e s t i g a t o r a t some p o i n t between t h e i r f i r s t and second chemotherapy t r e a t m e n t . I t i s u n c l e a r as t o when t h i s i n s t r u c t i o n o c c u r r e d . P a r t i c i p a n t s were t o l d t h a t r e l a x a t i o n was a s k i l l t h a t needed t o be l e a r n e d and c o u l d o n l y be l e a r n e d t h r o u g h p r a c t i c e . They were each g i v e n a b o o k l e t and an a u d i o t a p e as r e i n f o r c e m e n t o f t h e i n s t r u c t i o n and t o l d t o p r a c t i c e t w i c e a day as w e l l as d u r i n g t h e i r subsequent chemotherapy t r e a t m e n t s . A w e e k l y s c h e d u l e c a r d was p r o v i d e d t o r e c o r d t h e i r p r a c t i c e s e s s i o n s . D ata a n a l y s i s was o b t a i n e d by m e asuring a s t r a i g h t p e r c e n t change comparing t h e b a s e l i n e d a t a c o l l e c t i o n t o subsequent d a t a c o l l e c t i o n . A f t e r t h e second c o u r s e o f t r e a t m e n t , a d e c r e a s e i n t h e amount o f nausea and v o m i t i n g was e x p e r i e n c e d i n n i n e out o f t w e l v e p a r t i c i p a n t s based on t h e Duke's d e s c r i p t i v e s c a l e and remained f a i r l y s t a b l e a f t e r subsequent t r e a t m e n t s . There was a l s o a s i g n i f i c a n t d e c r e a s e i n t h e t o t a l t r a i t - S T A I (X = 20%) b u t n o t i n t h e 28 s t a t e - S T A I . A l l p a r t i c i p a n t s improved i n c a l o r i c i n t a k e d u r i n g t h e 48 hours f o l l o w i n g t r e a t m e n t . C a l o r i c i n t a k e i n c r e a s e d from 950 c a l o r i e s a f t e r t h e i n i t i a l t r e a t m e n t t o 1700 c a l o r i e s a f t e r t h e s e v e n t h t r e a t m e n t . P h y s i o l o g i c a l measurements showed a s i g n i f i c a n t d e c r e a s e i n p u l s e r a t e (3f = 14%) and r e s p i r a t i o n r a t e (3T = 2 0 % ) . S y s t o l i c and d i a s t o l i c b l o o d p r e s s u r e d i d not change s i g n i f i c a n t l y . A n e c d o t a l l y , a l l p a t i e n t s v e r b a l l y r e p o r t e d t h a t t h e r e l a x a t i o n t r a i n i n g i n c r e a s e d t h e i r f e e l i n g s o f " c o m f o r t " and o f " b e i n g i n c o n t r o l " . A l t h o u g h t h e r e s u l t s o f t h i s s t u d y s u g g e s t e d t h a t t h e use o f r e l a x a t i o n was e f f e c t i v e , i t i s u n c l e a r as t o whether t h e a n x i e t y was d e c r e a s e d due t o r e l a x a t i o n o r because t h e p a r t i c i p a n t s , h a v i n g been t h r o u g h t h e f i r s t t r e a t m e n t , w i t h what was d e s c r i b e d as e x p e r i m e n t a l and a g g r e s s i v e m e d i c a t i o n s , were now aware o f what t h e e x p e r i e n c e o f t h i s t r e a t m e n t i n v o l v e d . I n o r d e r t o a v o i d t h i s v a r i a b l e , B u r i s h and L y l e s (1981) c o n d u c t e d an e x p e r i m e n t a l s t u d y u s i n g p a t i e n t s who were a l r e a d y r e c e i v i n g chemotherapy t r e a t m e n t s and had e x h i b i t e d a n t i c i p a t o r y a n x i e t y , nausea, and/or v o m i t i n g d u r i n g t h e s e t r e a t m e n t s t o s t u d y t h e use o f p r o g r e s s i v e muscle r e l a x a t i o n f o l l o w e d by g u i d e d imagery i n r e d u c i n g t h e s e a d v e r s e r e a c t i o n s t o chemotherapy. 29 A c o n v e n i e n c e sample was r e c r u i t e d , w i t h s i x t e e n p a t i e n t s randomly a s s i g n e d t o e i t h e r an i n t e r v e n t i o n o r t o a c o n t r o l group. Each p a t i e n t p a r t i c i p a t e d i n f i v e c o n s e c u t i v e s e s s i o n s : one p r e t r a i n i n g , two t r a i n i n g , and two p o s t t r a i n i n g s e s s i o n s w h i c h c o r r e s p o n d e d w i t h t h e i r s c h e d u l e d chemotherapy t r e a t m e n t s . The average l e n g t h o f t i m e between t r e a t m e n t s was 15 days. The p r e t r a i n i n g s e s s i o n was t h e same f o r a l l p a t i e n t s . I t s purpose was t o o b t a i n b a s e l i n e i n f o r m a t i o n b e f o r e and a f t e r one chemotherapy t r e a t m e n t . The i n f o r m a t i o n c o l l e c t e d by t h e i n v e s t i g a t o r b e f o r e t h e s e s s i o n i n c l u d e d p h y s i o l o g i c a l measures o f a r o u s a l ( b l o o d p r e s s u r e and p u l s e r a t e ) and t h e p a t i e n t ' s f e e l i n g s o f a n x i e t y , anger o r h o s t i l i t y , and d e p r e s s i o n o b t a i n e d t h r o u g h t h e use o f t h e M u l t i p l e A f f e c t A d j e c t i v e Check L i s t . The chemotherapy t r e a t m e n t was t h e n g i v e n by a n u r s e . A f t e r t h e s e s s i o n , t h e s e measurements were r e p e a t e d . P o s t - t r e a t m e n t r a t i n g s c a l e s were a l s o a d m i n i s t e r e d t o a s s e s s t h e e x t e n t w h i c h p a t i e n t s f e l t a n x i o u s o r n a u s e a t e d d u r i n g t r e a t m e n t . The p o s t t r e a t m e n t r a t i n g s c a l e s measured a n x i e t y and nausea and were 7 - p o i n t r a t i n g s c a l e s r a n g i n g from "not a t a l l " t o " e x t r e m e l y " w h i c h b o t h t h e p a t i e n t and t h e n u r s e c o m p l e t e d . There was no r e p o r t on t h e v a l i d i t y and r e l i a b i l i t y o f any o f t h e 30 measures used. No o t h e r i n t e r v e n t i o n s o c c u r r e d d u r i n g t h e p r e t r a i n i n g s e s s i o n . The two t r a i n i n g s e s s i o n s f o r t h e r e l a x a t i o n group c o n s i s t e d o f t h e i n v e s t i g a t o r : c o l l e c t i n g p r e t r e a t m e n t d a t a ; a s s i s t i n g p a t i e n t s i n t h e r e l a x a t i o n group i n t h e use o f p r o g r e s s i v e muscle r e l a x a t i o n and g u i d e d imagery w h i l e chemotherapy was b e i n g a d m i n i s t e r e d by a n u r s e ; and, c o l l e c t i n g p o s t t r e a t m e n t d a t a . A p p r o x i m a t e l y 45 m i n u t e s b e f o r e t h e chemotherapy was s c h e d u l e d t o b e g i n , each p a t i e n t i n t h e i n t e r v e n t i o n group was s e a t e d i n a r e c l i n e r c h a i r . Data were c o l l e c t e d w h i c h i n c l u d e d p h y s i o l o g i c a l measurements and t h e p a t i e n t ' s f e e l i n g s o f a n x i e t y , anger o r h o s t i l i t y , and d e p r e s s i o n t h r o u g h t h e use o f t h e M u l t i p l e A f f e c t A d j e c t i v e Check L i s t . The i n v e s t i g a t o r t h e n e x p l a i n e d t h e i n t e r v e n t i o n and a s s i s t e d t h e p a t i e n t t h r o u g h t h e p r o g r e s s i v e muscle r e l a x a t i o n e x e r c i s e and t h e n g u i d e d imagery. S h o r t l y a f t e r t h e g u i d e d imagery i n s t r u c t i o n s began, t h e n u rse began t h e chemotherapy. The i n v e s t i g a t o r c o n t i n u e d t h e g u i d e d imagery f o r t h e d u r a t i o n o f t h e t r e a t m e n t and t h e n f o r about f i v e m i n u t es a f t e r t h e chemotherapy was c o m p l e t e d . P h y s i o l o g i c a l measures were a g a i n c o l l e c t e d as w e l l as t h e s e l f - r e p o r t measures ( M u l t i p l e A f f e c t A d j e c t i v e Check L i s t and t h e two r a t i n g s c a l e s w h i c h measured a n x i e t y and n a u s e a ) . Each p a t i e n t was g i v e n w r i t t e n i n s t r u c t i o n s on how t o do t h e e x e r c i s e s 31 a t home and asked t o p r a c t i c e once a day. A l t h o u g h w r i t t e n r e c o r d s were n o t k e p t , most p a t i e n t s r e p o r t e d p r a c t i c i n g f o u r t o f i v e t i m e s a week. D u r i n g t h e two p o s t t r a i n i n g s e s s i o n s , p a t i e n t s i n t h e r e l a x a t i o n group were asked t o r e l a x on t h e i r own by a p p l y i n g t h e p r o c e d u r e s t h e i n v e s t i g a t o r had a s s i s t e d them w i t h d u r i n g t h e two p r e v i o u s s e s s i o n s . The f o r m a t f o r t h e s e s e s s i o n s was i d e n t i c a l t o t h e t r a i n i n g s e s s i o n s e x c e p t t h a t t h e i n v e s t i g a t o r was not p r e s e n t t o a s s i s t t h e p a t i e n t s . D u r i n g t h e f o u r s e s s i o n s a f t e r t h e p r e t r a i n i n g s e s s i o n , t h e p a t i e n t s i n t h e c o n t r o l group were a l s o b r o u g h t i n t o t h e t r e a t m e n t room a p p r o x i m a t e l y 45 minutes p r i o r t o t h e i r chemotherapy t r e a t m e n t . D u r i n g t h i s t i m e p e r i o d , t h e i r p u l s e and b l o o d p r e s s u r e s were r e c o r d e d by t h e i n v e s t i g a t o r , t h e y completed t h e M u l t i p l e A f f e c t A d j e c t i v e Check L i s t , and t h e n were asked t o r e l a x and r e s t q u i e t l y u n t i l t h e i r t r e a t m e n t began. They t h e n c o m p l e t e d t h e same measures a f t e r t h e i r t r e a t m e n t as d i d t h e i n t e r v e n t i o n group. The r e s u l t s o b t a i n e d d u r i n g t h e p r e t r a i n i n g s e s s i o n s u g g e s t e d no d i f f e r e n c e s e x i s t e d between t h e r e l a x a t i o n group and t h e c o n t r o l group. The r e s u l t s o b t a i n e d d u r i n g t h e t r a i n i n g s e s s i o n s showed p a t i e n t s i n t h e r e l a x a t i o n 32 group as f e e l i n g s i g n i f i c a n t l y l e s s a n x i o u s ( 2 = .003), angry ( 2 = .02), and d e p r e s s e d (p_ < .03) t h a n p a t i e n t s i n t h e c o n t r o l group as measured by t h e M u l t i p l e A f f e c t A d j e c t i v e Check L i s t . Based on t h e p a t i e n t and n u r s e r a t i n g s c a l e s , p a t i e n t s r e p o r t e d f e e l i n g l e s s a n x i o u s ( 2 = .003) and n a u s e a t e d ( 2 = .006) and t h e n u r s e s s u b j e c t i v e l y r e p o r t e d s i m i l a r f i n d i n g s . The a n a l y s i s o f t h e n u r s e s ' r e c o r d i n g o f v o m i t i n g d u r i n g chemotherapy i n d i c a t e d t h a t o n l y two p a t i e n t s i n each c o n d i t i o n v o m i t e d d u r i n g one o r b o t h o f t h e t r a i n i n g s e s s i o n s , r e s u l t i n g i n a n o n s i g n i f i c a n t d i f f e r e n c e (X*< 1.0). The p h y s i o l o g i c a l measures showed v e r y l i t t l e d i f f e r e n c e t h r o u g h o u t t h e s t u d y . The r e s u l t s o b t a i n e d d u r i n g t h e p o s t t r a i n i n g s e s s i o n s showed p a t i e n t s i n t h e r e l a x a t i o n group as f e e l i n g s i g n i f i c a n t l y l e s s a n x i o u s ( 2 = .001), angry ( 2 < .02), and d e p r e s s e d ( 2 < .02) t h a n p a t i e n t s i n t h e c o n t r o l group as measured by t h e M u l t i p l e A f f e c t A d j e c t i v e Check L i s t . Based on t h e p a t i e n t and n u r s e r a t i n g s c a l e s , p a t i e n t s r e p o r t e d f e e l i n g l e s s a n x i o u s ( 2 < .04) and n a u s e a t e d ( 2 = .006) and t h e n u r s e s s u b j e c t i v e l y r e p o r t e d s i m i l a r f i n d i n g s . The a n a l y s i s o f t h e n u r s e s ' r e c o r d i n g o f v o m i t i n g d u r i n g chemotherapy was s i m i l a r t o t h e t r a i n i n g s e s s i o n s . 33 B u r i s h and L y l e s (1981) r e p o r t e d t h a t t h e i r s u b j e c t s showed an i n c r e a s e d improvement i n t h e s e measurements o v e r t h e c o u r s e o f t h e s t u d y a l t h o u g h t h e i r r e p o r t e d r e s u l t s do n o t r e f l e c t t h i s f i n d i n g . B o t h t h e r e l a x a t i o n group and t h e c o n t r o l group r e p o r t e d f a i r l y s t a b l e r a t i n g s o f a n x i e t y and nausea o v e r t h e c o u r s e o f t h e f i v e t r e a t m e n t s . The a u t h o r s f u r t h e r s u g g e s t e d t h a t t h e improvement o f t h e p a t i e n t s o v e r t i m e may have been due t o i n c r e a s e d f e e l i n g s o f s e l f - s u f f i c i e n c y and p e r s o n a l c o n t r o l many o f t h e p a t i e n t s appeared t o have d e v e l o p e d o v e r t h e c o u r s e o f t h e s t u d y as compared w i t h t h e c o n t r o l group. However, t h e v a r i a b l e s o f s e l f - s u f f i c i e n c y and p e r s o n a l c o n t r o l were n e i t h e r d e f i n e d n or measured i n t h i s s t u d y . The r e s u l t s from t h e above t h r e e s t u d i e s s u p p o r t t h e b e l i e f t h a t r e l a x a t i o n t h e r a p y may be an e f f e c t i v e a d j u n c t i v e t r e a t m e n t i n managing t h e ad v e r s e e m o t i o n a l and p h y s i c a l s i d e e f f e c t s a s s o c i a t e d w i t h chemotherapy t r e a t m e n t . The f o l l o w i n g s t u d y p r o v i d e s i n f o r m a t i o n on t h e use o f r e l a x a t i o n t h e r a p y i n i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r . B r i d g e , Benson, P i e t r o n i and P r i e s t (1988) c o n d u c t e d a c o n t r o l l e d randomized t r i a l o f women w i t h b r e a s t c a n c e r (N = 154) b e i n g t r e a t e d w i t h r a d i a t i o n t h e r a p y on an o u t p a t i e n t b a s i s . The purpose o f t h i s s t u d y was t o d e t e r m i n e whether s t r e s s c o u l d be a l l e v i a t e d i n t h e s e 34 women. S t r e s s was o p e r a t i o n a l l y d e f i n e d by t h e Leeds g e n e r a l s c a l e s and t h e P r o f i l e o f Moods S t a t e s . The Leeds g e n e r a l s c a l e s measure t h e s e v e r i t y o f d e p r e s s i v e and a n x i e t y symptoms. The P r o f i l e o f Moods S t a t e s y i e l d s s c o r e s f o r t e n s i o n , d e p r e s s i o n , v i g o u r , f a t i g u e , anger, and c o n f u s i o n . The t o t a l s c o r e on t h i s s c a l e i n d i c a t e s t h e i n d i v i d u a l ' s o v e r a l l l e v e l o f mood d i s t u r b a n c e , a h i g h s c o r e i n d i c a t e s a h i g h l e v e l o f mood d i s t u r b a n c e . The sample was d i v i d e d i n t o t h r e e g r o u p s : a c o u n s e l l i n g group who were encouraged t o t a l k about t h e m s e l v e s ; a r e l a x a t i o n group who r e c e i v e d p a s s i v e muscle r e l a x a t i o n ; and, a second r e l a x a t i o n group who r e c e i v e d p a s s i v e muscle r e l a x a t i o n and g u i d e d imagery. P a r t i c i p a n t s i n b o t h r e l a x a t i o n groups were t a u g h t a b r e a t h i n g e x e r c i s e and t h e i r s p e c i f i c r e l a x a t i o n t e c h n i q u e d u r i n g an i n i t i a l t h i r t y minute s e s s i o n a f t e r h a v i n g r e c e i v e d a t l e a s t one s e s s i o n o f r a d i a t i o n t h e r a p y . P a r t i c i p a n t s were a l s o g i v e n an a u d i o t a p e w h i c h r e p e a t e d t h e b r e a t h i n g i n s t r u c t i o n s and t h e p a s s i v e muscle r e l a x a t i o n o r p a s s i v e muscle r e l a x a t i o n and i m a g i n g e x e r c i s e and were asked t o p r a c t i c e i t a t home f o r a t l e a s t 15 m i n u t e s p e r day d u r i n g t h e s i x weeks on t h e s t u d y . B o t h measurement t o o l s were completed a t t h i s t i m e by a l l t h r e e groups and a g a i n i n s i x weeks. 35 The i n i t i a l and six week scores on the Leeds general scales and the P r o f i l e of Moods States were compared by-analysis of covariance ( c o n t r o l l i n g for the i n i t i a l scores) to t e s t for the e f f e c t s of the interventions. The Leeds general scores showed no s i g n i f i c a n t differences (p_ < .05) i n any of the three groups. The subscales of the P r o f i l e of Moods States also did not show any s t a t i s t i c a l l y s i g n i f i c a n t differences among the three groups. However, the t o t a l mood disturbance, measured by the t o t a l score of the P r o f i l e of Moods States, d i f f e r e d s i g n i f i c a n t l y i n the predicted way (r> < .036). At the end of the treatment period, the intervention groups had improved i n t o t a l mood disturbance, r e f l e c t e d by a decrease i n t h e i r t o t a l score, where as the counselling group, o v e r a l l , had become worse. The researchers also looked at the single item "relaxed" which i s part of the subscale for tension i n the P r o f i l e of Moods States. An ANCOVA based on t h i s single item was done. At the end of three weeks, the women trained i n passive muscle relaxation plus guided imagery were more relaxed than those i n the passive muscle relaxation only group who were noted to be more relaxed than the women i n the counselling group (p < .025). In t h i s study, there are three areas of concern. F i r s t , although the counselling group was regarded by the 36 i n v e s t i g a t o r s as t h e c o n t r o l group, c o u n s e l l i n g i s an i n t e r v e n t i o n . T h e r e f o r e , t h e r e s u l t s r e f l e c t d i f f e r e n c e s between t h e i n t e r v e n t i o n s used i n t h i s s t u d y w h i c h may be one o f t h e r e a s o n s f o r t h e n o n s i g n i f i c a n t r e s u l t s o b t a i n e d . Second, t h e use o f a s i n g l e i t e m from a s u b s c a l e o f t h e P r o f i l e o f Mood S t a t e s t o c o n c l u d e t h a t p a t i e n t s were more r e l a x e d i s i n a d e q u a t e . The c o n c e p t " r e l a x e d " i s one o f s e v e r a l i n t e r r e l a t e d c o n c e p t s w h i c h d e f i n e t e n s i o n w i t h i n t h e P r o f i l e o f Moods S c a l e s . I t i s n o t a c o n c e p t w h i c h has been d e f i n e d w i t h i n t h i s s t u d y and, t h e r e f o r e , i s not measurable. T h i r d , s t r e s s was n o t c l e a r l y d e f i n e d and, j u d g i n g by t h e r e s u l t s , t h e measurement t o o l s used t o o p e r a t i o n a l l y d e f i n e s t r e s s d i d n o t p r o ve s u f f i c i e n t . A l t h o u g h t h e c o n c e p t s o f t e n s i o n , d e p r e s s i o n , v i g o u r , f a t i g u e , anger, c o n f u s i o n , and a n x i e t y may be m a n i f e s t a t i o n s o f s t r e s s , t h e y do n o t n e c e s s a r i l y d e f i n e s t r e s s . The r e s u l t s s u g g e s t t h a t t h e p a r t i c i p a n t s i n t h i s s t u d y may have been e x p e r i e n c i n g something o t h e r t h a n s t r e s s . Summary T h i s l i t e r a t u r e r e v i e w has e x p l o r e d what i s known about t h e c o n c e p t s used i n t h i s s t u d y , symptom d i s t r e s s , p e r s o n a l c o n t r o l , and r e l a x a t i o n t h e r a p y i n r e l a t i o n t o i n d i v i d u a l s who a r e r e c e i v i n g t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . A l t h o u g h t h e m a j o r i t y o f t h e l i t e r a t u r e 37 d e s c r i b e d i n t h i s r e v i e w f o c u s e d on i n d i v i d u a l s w i t h c a n c e r r e c e i v i n g chemotherapy, i t i s a p p a r e n t t h a t r a d i a t i o n t h e r a p y causes s i m i l a r r e a c t i o n s i n c l u d i n g symptoms d i s t r e s s and a l o s s o f c o n t r o l . I t i s a l s o a p p a r e n t from t h i s r e v i e w t h a t i n d i v i d u a l s w i t h c a n c e r use s e v e r a l s t r a t e g i e s t o cope w i t h t h e r e a c t i o n s r e l a t e d t o t h e i r d i s e a s e and t h e t r e a t m e n t . R e l a x a t i o n t h e r a p y has been w i d e l y r e c o g n i z e d by h e a l t h c a r e p r o f e s s i o n a l s as a s t r a t e g y used by i n d i v i d u a l s w i t h c a n c e r (Donovan 1980; Mast, Meyers, & U r b a n s k i , 1987; M a s t r o v i t o , 1989; T a y l o r , 1985). The s t u d i e s d i s c u s s e d i n t h i s l i t e r a t u r e r e v i e w s u p p o r t t h e b e l i e f t h a t r e l a x a t i o n t h e r a p y may be an e f f e c t i v e a d j u n c t i v e t r e a t m e n t i n managing t h e a d v e r s e e m o t i o n a l and p h y s i c a l s i d e e f f e c t s a s s o c i a t e d w i t h chemotherapy t r e a t m e n t . A l t h o u g h a n e c d o t a l i n f o r m a t i o n e x i s t s , t h e r e i s a n o t i c e a b l e absence o f s t u d i e s u s i n g r e l a x a t i o n t h e r a p y i n i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y and i t s e f f e c t on p e r s o n a l c o n t r o l and symptom d i s t r e s s . T h i s s t u d y was d e s i g n e d t o add t o t h e c u r r e n t knowledge o f t h e e f f e c t s o f r e l a x a t i o n t h e r a p y i n i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r . 38 CHAPTER THREE Methodology I n t r o d u c t i o n A q u a s i e x p e r i m e n t a l d e s i g n , t h e n o n e q u i v a l e n t c o n t r o l -group, was used i n t h i s s t u d y . The r e s e a r c h h y p o t h e s e s g u i d i n g t h e s t u d y methodology were: 1) I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l e x p e r i e n c e a re d u c e d amount o f symptom d i s t r e s s as compared w i t h t h o s e who do n o t p r a c t i c e r e l a x a t i o n t h e r a p y ; 2) I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l e x p e r i e n c e a h i g h e r l e v e l o f p e r s o n a l c o n t r o l as compared w i t h t h o s e who do not p r a c t i c e r e l a x a t i o n t h e r a p y . T h i s c h a p t e r w i l l d i s c u s s t h e p r o c e s s u t i l i z e d f o r o b t a i n i n g s t u d y p a r t i c i p a n t s , t h e i n s t r u m e n t s used i n t h e s t u d y , and t h e methods o f d a t a a n a l y s i s . E t h i c a l c o n s i d e r a t i o n s and t h e methods used t o p r o t e c t human r i g h t s w i l l a l s o be p r e s e n t e d . Sample T h i r t y a d u l t s who met t h e f o l l o w i n g c r i t e r i a c o m p r i s e d t h e c o n v e n i e n c e sample f o r t h i s s t u d y . T h i s sample s i z e was chosen f o r m a n a g e a b i l i t y r e a s o n s a t t h i s l e v e l o f r e s e a r c h . The p a r t i c i p a n t s were r e c r u i t e d from a l o c a l c a n c e r agency. The f i r s t 15 p a r t i c i p a n t s c o m p r i s e d 39 t h e c o n t r o l group. The r e m a i n i n g 15 p a r t i c i p a n t s r e c e i v e d t h e i n t e r v e n t i o n o f r e l a x a t i o n t h e r a p y . The c r i t e r i a f o r p a r t i c i p a n t s e l e c t i o n i n c l u d e d men and women who were: 1) between 25 and 75 y e a r s o f age; 2) r e c e i v i n g a b d o m i n a l / p e l v i c e x t e r n a l r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r ; 3) r e c e i v i n g a t o t a l r a d i a t i o n dose between 3000 and 5000 r a d s ; 4) n o t r e c e i v i n g c o n c u r r e n t chemotherapy f o r a d i a g n o s i s o f c a n c e r ; 5) f r e e from c o g n i t i v e d e f i c i t s s e c o n d a r y t o t h e i r d i s e a s e o r t r e a t m e n t ; 6) a b l e t o r e a d and speak E n g l i s h ; 7) n o t r e c e i v i n g p s y c h o t r o p i c m e d i c a t i o n s ; and, 8) r e s i d i n g i n t h e l o c a l a r e a d u r i n g t h e i r c o u r s e o f t r e a t m e n t . Data C o l l e c t i o n P r o c e d u r e I n i t i a l c o n t a c t w i t h p o t e n t i a l p a r t i c i p a n t s was made t h r o u g h t h e agency where c l i e n t s r e c e i v e d r a d i a t i o n t h e r a p y . S u i t a b l e c a n d i d a t e s f o r t h e s t u d y were i d e n t i f i e d by t h e r e s e a r c h e r w i t h a s s i s t a n c e from agency s t a f f , s p e c i f i c a l l y t h e R a d i a t i o n T e c h n o l o g i s t s . A f t e r t h e s t a f f had g a i n e d c o n s e n t from t h e s e i n d i v i d u a l s f o r t h e r e s e a r c h e r t o approach them, p o t e n t i a l s u b j e c t s were g i v e n a v e r b a l and a w r i t t e n e x p l a n a t i o n o f t h e s t u d y (Appendix A o r B) by t h e r e s e a r c h e r . Those who w i s h e d t o 40 p a r t i c i p a t e s i g n e d a Consent t o P a r t i c i p a t e form a t t h i s t i m e (Appendix C o r D). Once c o n s e n t was g i v e n , a copy o f t h e c o n s e n t w i t h t h e r e s e a r c h e r ' s name and number was g i v e n t o each p a r t i c i p a n t i n t h e ev e n t o f f u r t h e r q u e s t i o n s . Data C o l l e c t i o n Data were c o l l e c t e d on two o c c a s i o n s from each o f t h e p a r t i c i p a n t s : b e f o r e t h e s t a r t o f t h e i r c o u r s e o f r a d i a t i o n t h e r a p y , and a t t h e end o f a t h r e e week p e r i o d d u r i n g w h i c h t h e y were r e c e i v i n g r a d i a t i o n t h e r a p y . The methods o f d a t a c o l l e c t i o n i n c l u d e d f a c e - t o - f a c e i n t e r v i e w s t o g a t h e r demographic and c u r r e n t t r e a t m e n t d a t a (Appendix F ) , and t h e c o m p l e t i o n o f two paper and p e n c i l s c a l e s f o r t h e measurement o f symptom d i s t r e s s and p e r s o n a l c o n t r o l . The i n t e r v e n t i o n group a l s o k e p t a d i a r y t o r e c o r d t h e number o f t i m e s t h e y used t h e r e l a x a t i o n t h e r a p y and any comments t h e y w i s h e d t o make. D u r i n g t h e second i n t e r v i e w , t h e r e s e a r c h e r a l s o asked p a r t i c i p a n t s i n t h e c o n t r o l group i f t h e y had used any t y p e o f r e l a x a t i o n t e c h n i q u e d u r i n g t h e p a s t t h r e e weeks. I n t h e i n t e r v e n t i o n group, t h e r e s e a r c h e r g u i d e d each p a r t i c i p a n t t h r o u g h t h e r e l a x a t i o n t h e r a p y , as d e f i n e d i n t h i s s t u d y . Each p a r t i c i p a n t was t h e n g i v e n a w r i t t e n d e s c r i p t i o n and/or an a u d i o t a p e o f t h e r e l a x a t i o n t h e r a p y 41 t o use as a r e m i n d e r t o p e r f o r m t h e e x e r c i s e s (Appendix E ) . A w e e k l y s c h e d u l e ( d i a r y ) was p r o v i d e d t o each p a r t i c i p a n t t o r e c o r d t h e number o f t i m e s t h e method was used each day. I t was r e i n f o r c e d t h a t i t was n e c e s s a r y f o r t h e p a r t i c i p a n t s t o r e c o r d o n l y t h e number o f t i m e s t h e y used t h e method. I t was acknowledged t h a t t h e y might n o t use i t e v e r y day and t h a t t h i s was i m p o r t a n t i n f o r m a t i o n t o c o l l e c t . The p a r t i c i p a n t s were a l s o asked t o r e c o r d any comments t h e y had about how t h e y f e l t o r about t h e t e c h n i q u e i t s e l f . A t i m e was s e t f o r t h e r e s e a r c h e r t o c o n t a c t t h e p a r t i c i p a n t s a t t h e c l i n i c once a week f o r t h e f o l l o w i n g two weeks t o a s s i s t p a r t i c i p a n t s w i t h any problems o r c o n c e r n s t h e y had i n u s i n g t h e method o r i n k e e p i n g t h e d i a r y . Data C o l l e c t i o n I n s t r u m e n t s There were two q u e s t i o n n a i r e s and an i n t e r v i e w used i n t h i s s t u d y . The i n t e r v i e w p r o v i d e d an o p p o r t u n i t y t o c o l l e c t demographic d a t a , an o n c o l o g i c a l h i s t o r y , t h e t y p e and l e n g t h o f r a d i a t i o n t h e r a p y p r e s c r i b e d , and t h e p a r t i c i p a n t ' s c u r r e n t methods o f c o p i n g and use o f r e l a x a t i o n t h e r a p y . The f i r s t q u e s t i o n n a i r e c o l l e c t e d d a t a on symptom d i s t r e s s and t h e second q u e s t i o n n a i r e c o l l e c t e d d a t a on p e r s o n a l c o n t r o l . 42 The Symptom Distress Scale To measure symptom d i s t r e s s , the Symptom Distress Scale (SDS) designed by McCorkle & Young (1978) was used (Appendix G). This scale measures the degree of discomfort experienced by i n d i v i d u a l s with cancer i n r e l a t i o n to t h e i r perception of the symptom being experienced. I t takes approximately f i v e to ten minutes to complete. Higher scores indicate greater l e v e l s of symptom d i s t r e s s . Internal consistency was established i n a study of i n d i v i d u a l s with a chronic i l l n e s s (N = 60). McCorkle and Young (1978) found that the Cronbach's alpha was .82. In another study, s t a b i l i t y of the scale was established with a t e s t - r e t e s t (three months between testing) c o r r e l a t i o n of .78 (McCorkle & Quint-Benoliel, 1983). Content and face v a l i d i t y were established during a p i l o t study where the major concerns of cancer patients (N = 26) receiving chemotherapy and r a d i a t i o n therapy were i d e n t i f i e d (McCorkle & Young, 1978). The types of symptoms i d e n t i f i e d i n t h e i r study were congruent with those reported i n the l i t e r a t u r e (Schneider, 1976). However, i t was noted that newly diagnosed cancer patients were more concerned with problems related to the acceptance of t h e i r disease and anxiety of the future. Long term cancer patients were more concerned with 43 p h y s i c a l d i s c o m f o r t s t h a t i n t e r f e r e d w i t h t h e i r d a i l y l i v i n g ( M c C o r k l e & Young, 1978). Convergent v a l i d i t y was e s t a b l i s h e d by t h e c o r r e l a t i o n o f .90 o b t a i n e d between Ware's h e a l t h p e r c e p t i o n q u e s t i o n n a i r e and t h e SDS ( M c C o r k l e , 1987). A l t h o u g h t h i s e v i d e n c e s u p p o r t s t h e v a l i d i t y o f t h e t o o l , f u r t h e r r e s e a r c h i s needed t o e s t a b l i s h c o n s t r u c t v a l i d i t y w h i c h i s d i r e c t l y c o n c e r n e d w i t h what a t o o l a c t u a l l y measures ( F r a n k - S t r o m b e r g , 1988). S e l f - C o n t r o l S u b s c a l e To measure p e r s o n a l c o n t r o l , t h e S e l f - C o n t r o l (SC) S u b s c a l e o f t h e P e r s o n a l O p i n i o n Survey (POS) d e s i g n e d by Coan & F a i r c h i l d (1977) was used (Appendix H). The P e r s o n a l O p i n i o n Survey i s a m u l t i d i m e n s i o n a l s c a l e d e s i g n e d t o a s s e s s seven major components o f t h e e x p e r i e n c e o f c o n t r o l . The S e l f - C o n t r o l s u b s c a l e c o n s i s t s o f 19 s t a t e m e n t s used t o measure how much c o n t r o l i n d i v i d u a l s p e r c e i v e t h e y have o v e r t h e i r i n t e r n a l p r o c e s s e s w h i c h i n c l u d e s o m a t i c , a f f e c t i v e , and c o g n i t i v e p r o c e s s e s . The d a t a a r e c o l l e c t e d as e i t h e r " t r u e " o r " f a l s e " and a key p r o v i d e d by t h e a u t h o r (Appendix I ) i s used t o q u a n t i f y t h e d a t a . Data i s c o l l e c t e d a t a r a n k l e v e l . A h i g h s c o r e i n d i c a t e s a h i g h e r r a n k on t h e s e l f -c o n t r o l s c a l e . The o r i g i n a l s t u d y p o p u l a t i o n f o r t h i s s c a l e i n c l u d e d 525 c o l l e g e s t u d e n t s . The r e s u l t s from 44 that study supported the hypothesis that there i s not a general control dimension (Rotter, 1966) but that the experience of control i s multidimensional. Coan & F a i r c h i l d (1977) conducted r e l i a b i l i t y tests on the present revised scale. To measure s t a b i l i t y , a t e s t - r e t e s t was done. Subjects (N = 105) completed the questionnaire at three d i f f e r e n t times over a three month period r e s u l t i n g i n correlations ranging from .61 to .87 with the SC subscale at .75. Factor analysis yielded an i n t e r n a l consistency within each subscale with Kuder-Richardson c o e f f i c i e n t s ranging from .67 to .83 with the SC subscale at .73 i n d i c a t i n g moderate to high c o r r e l a t i o n s . These r e s u l t s for r e l i a b i l i t y are at an acceptable l e v e l for a t o o l i n the early stages of development (Frank-Stromberg, 1988). Content v a l i d i t y was obtained through the use of the l i t e r a t u r e i n an attempt to capture more of the v a r i a t i o n i n the way i n d i v i d u a l s experience control or the lack of control (Coan & F a i r c h i l d , 1977). In a study of psychologists (N = 90), the POS and the Sixteen Personality Factor Questionnaire were used to e s t a b l i s h convergent v a l i d i t y . The authors summarized t h e i r findings by suggesting that "there i s a tendency f o r factors of experienced control to be p o s i t i v e l y associated with variables that involve emotional control and 45 n e g a t i v e l y a s s o c i a t e d w i t h v a r i a b l e s t h a t s u g g e s t a n x i e t y , d i s t r e s s , o r e m o t i o n a l s e n s i t i v i t y " (Coan & F a i r c h i l d , 1977, p. 4 ) . I n i t i a l I n t e r v i e w Guide The i n t e r v i e w g u i d e d i r e c t e d t h e c o l l e c t i o n o f demographic, o n c o l o g i c a l h i s t o r y , t h e t y p e and l e n g t h o f r a d i a t i o n t h e r a p y p r e s c r i b e d , and t h e p a r t i c i p a n t ' s c u r r e n t c o p i n g methods and use o f r e l a x a t i o n t h e r a p y (Appendix F ) . Data A n a l y s i s The demographic and c u r r e n t t r e a t m e n t d a t a g a t h e r e d f rom t h e i n t e r v i e w s were used t o d e s c r i b e t h e c h a r a c t e r i s t i c s o f t h e sample. F o r b o t h h y p o t h e s e s , t h e S e l f - C o n t r o l S u b s c a l e and t h e Symptom D i s t r e s s S c a l e were c a l c u l a t e d and examined f o r f r e q u e n c y d i s t r i b u t i o n , and measures o f c e n t r a l tendency and v a r i a b i l i t y . The Symptom D i s t r e s s S c a l e and t h e P e r s o n a l O p i n i o n Survey y i e l d s c o r e s a t an o r d i n a l l e v e l . T h e r e f o r e , n o n p a r a m e t r i c t e s t s were used i n t h e a n a l y s i s . The Mann-Whitney U T e s t was a p p l i e d t o t h e b a s e l i n e s c o r e s o b t a i n e d on b o t h q u e s t i o n n a i r e s t o d e t e r m i n e t h a t no d i f f e r e n c e s e x i s t e d between t h e c o n t r o l group and t h e i n t e r v e n t i o n group. The Mann-Whitney U T e s t was a l s o used t o t e s t f o r any d i f f e r e n c e between symptom d i s t r e s s s c o r e s 46 and p e r s o n a l c o n t r o l s c o r e s o f t h e i n t e r v e n t i o n group as compared w i t h t h e c o n t r o l group. Human R i g h t s and E t h i c a l C o n s i d e r a t i o n s The r i g h t s o f p a r t i c i p a n t s were p r o t e c t e d i n t h e f o l l o w i n g manner: 1. C o n f i d e n t i a l i t y was m a i n t a i n e d . Each p a r t i c i p a n t was g i v e n a code number wh i c h was t h e n used i n t h e a n a l y s i s . The l i s t w i t h t h e names and codes were d e s t r o y e d once d a t a c o l l e c t i o n was co m p l e t e d . Data were r e v i e w e d o n l y by t h e i n v e s t i g a t o r and members o f t h e t h e s i s committee. 2. Informed c o n s e n t was o b t a i n e d p r i o r t o d a t a c o l l e c t i o n . The l e t t e r o f i n f o r m a t i o n d e s c r i b e d t h e s t u d y and t h e p a r t i c i p a n t ' s r o l e i n t h e s t u d y . The s t u d y p a r t i c i p a n t was g i v e n t h e o p p o r t u n i t y t o q u e s t i o n t h e r e s e a r c h e r about t h e s t u d y . 3. I f a t anytime t h e p a r t i c i p a n t w i s h e d t o w i t h d r a w from t h e s t u d y , she o r he c o u l d do so. The s u b j e c t was reminded t h a t t h i s would n ot j e o p a r d i z e any h e a l t h c a r e b e i n g r e c e i v e d a t t h e t i m e o r i n t h e f u t u r e 47 Summary The methodology used i n t h i s q u a s i - e x p e r i m e n t a l s t u d y i n v o l v e d two d a t a c o l l e c t i o n i n s t r u m e n t s and t h e use o f an i n i t i a l i n t e r v i e w . The d a t a c o l l e c t e d was a n a l y z e d a c c o r d i n g t o t h e s t a t i s t i c a l methods d e s c r i b e d . E t h i c a l c o n s i d e r a t i o n s and t h e methods used t o p r o t e c t human r i g h t s were a l s o p r e s e n t e d . CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n o f the F i n d i n g s I n t r o d u c t i o n T h i s c hapter i s d i v i d e d i n t o f o u r s e c t i o n s . The f i r s t s e c t i o n d e s c r i b e s the c h a r a c t e r i s t i c s of the study p a r t i c i p a n t s . The next two s e c t i o n s p r e s e n t an a n a l y s i s of the d a t a r e l a t e d t o the two r e s e a r c h hypotheses. The f i n a l s e c t i o n d i s c u s s e s the f i n d i n g s . The Study P a r t i c i p a n t s The sample c o n s i s t e d of 30 i n d i v i d u a l s w i t h a d i a g n o s i s o f cancer being t r e a t e d w i t h a b d o m i n a l / p e l v i c r a d i a t i o n therapy. A t o t a l of 30 i n d i v i d u a l s i n i t i a l l y agreed t o p a r t i c i p a t e i n the study. Of these t h i r t y i n d i v i d u a l s , one i n d i v i d u a l i n the c o n t r o l group used s p e c i f i c r e l a x a t i o n techniques d u r i n g the time o f p a r t i c i p a t i o n i n t h i s study and, t h e r e f o r e , was excluded from the a n a l y s i s . One i n d i v i d u a l withdrew from the i n t e r v e n t i o n group a f t e r completing the i n i t i a l q u e s t i o n n a i r e s and u s i n g the r e l a x a t i o n method f o r t h r e e days. He s t a t e d t h a t he was unable t o breathe d u r i n g the e x e r c i s e which made him more anxious than he had been p r e v i o u s l y . T h e r e f o r e , the a n a l y s i s i s based on the da t a c o l l e c t e d from 28 s u b j e c t s , 14 s u b j e c t s i n the c o n t r o l group and 14 s u b j e c t s i n the i n t e r v e n t i o n group. 49 Age, Sex, Education and Diagnosis The ages of the subjects ranged from 25 to 75 years of age. The median age i n the control group was 58 years and i n the intervention group was 51 years. In the control group, 29% of the subjects were male and 71% were female. In the intervention group, 71% of the subjects were male and 29% were female. As can be seen i n Table 1, the high percentage of females i n the control group accounts for the higher number of gynecological malignancies. S i m i l a r l y , the high percentage of males i n the intervention group accounts for the higher number of genito-urinary malignancies i n t h i s group. In the control group, three (21%) subjects had completed an undergraduate degree and seven (50%) had either completed or attended high-school. Four (29%) of the subjects had attended grade school. In the intervention group, six (43%) had completed eith e r graduate or undergraduate degrees, seven (50%) had eith e r completed or attended high-school, and one (7%) had attended grade school. A l l subjects had a diagnosis of cancer for which ra d i a t i o n treatment to the abdominal/pelvic area was given (see Table 1). Twenty-three subjects were treated for a primary malignancy with the intent to cure. Four subjects had l o c a l recurrent disease following previous surgery and 50 were a l s o t r e a t e d w i t h t h e i n t e n t t o c u r e . O n l y one s u b j e c t i n t h e i n t e r v e n t i o n group r e c e i v e d p a l l i a t i v e r a d i a t i o n t r e a t m e n t f o r t h e c o n t r o l o f h e r r e c u r r e n t d i s e a s e . The t o t a l dose o f r a d i a t i o n r e c e i v e d ranged between 3000 and 5000 r a d s o v e r t h r e e t o s i x weeks. A Mann-Whitney U T e s t performed on t h e p r e - s c o r e s o b t a i n e d f rom b o t h t h e measurement t o o l s used i n t h i s s t u d y s u g g e s t e d t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e c o n t r o l group and t h e i n t e r v e n t i o n group i n r e l a t i o n t o t h e above v a r i a b l e s (age, s e x , e d u c a t i o n and d i a g n o s i s . 51 T a b l e 1 Number o f S u b j e c t s P e r S i t e o f M a l i g n a n c y C o n t r o l I n t e r v e n t i o n G a s t r o - I n t e s t i n a l M a l i g n a n c i e s C o l o n 1 4 R e c t a l 2 1 G e n i t o - U r i n a r y M a l i g n a n c i e s B l a d d e r 0 2 T e s t i c u l a r (seminoma) 1 2 P r o s t a t e 2 3 G y n e c o l o g i c a l M a l i g n a n c i e s C e r v i x 1 1 Endometrium 5 0 O v a r i a n 1 0 Non-Hodgkins Lymphoma 1 1 T o t a l 14 14 52 R e l a x a t i o n I n t e r v e n t i o n A l l s u b j e c t s i n t h e i n t e r v e n t i o n group were t a u g h t how t o use t h e r e l a x a t i o n t e c h n i q u e and g i v e n t h e c h o i c e o f h a v i n g w r i t t e n i n s t r u c t i o n s and/or an a u d i o t a p e t o r e i n f o r c e t h e i r l e a r n i n g . A l l s u b j e c t s chose t h e a u d i o t a p e . A l l b u t two s u b j e c t s s t a t e d t h e y used t h e t a p e each t i m e t h e y p r a c t i c e d r e l a x a t i o n . The two s u b j e c t s who d i d n o t used t h e tap e each t i m e s t a t e d t h a t by t h e t h i r d week t h e y knew t h e t e c h n i q u e and were a b l e t o use i t "whenever t h e y began t o f e e l t e n s e o r u p s e t " . S u b j e c t s i n t h e i n t e r v e n t i o n group were a l s o asked t o p r a c t i c e t h e r e l a x a t i o n t e c h n i q u e once a day w h i l e r e c e i v i n g r a d i a t i o n t h e r a p y and t o r e c o r d t h e number o f t i m e s t h e y used t h e t e c h n i q u e and any a d d i t i o n a l comments i n a d i a r y p r o v i d e d by t h e r e s e a r c h e r . The range o f t i m e s t h e t e c h n i q u e was used by t h e s e s u b j e c t s o v e r t h e t h r e e week p e r i o d was 15 t o 60, w i t h a median o f 22 and a mean of 26. A p p r o x i m a t e l y s i x t y - f o u r p e r c e n t ( n i n e ) o f t h e s u b j e c t s used t h e r e l a x a t i o n t e c h n i q u e once p e r day. Twenty-one p e r c e n t ( t h r e e ) o f t h e s u b j e c t s used i t l e s s t h a n once p e r day and f o u r t e e n p e r c e n t (two) used i t t w i c e a day o r more. 53 F i n d i n g s H y p o t h e s i s 1; I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c  r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l  e x p e r i e n c e a r e d u c e d amount o f symptom d i s t r e s s as  compared w i t h t h o s e who do not p r a c t i c e r e l a x a t i o n  t h e r a p y . To d e t e r m i n e t h e degree o f symptom d i s t r e s s e x p e r i e n c e d by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y , t h e Symptom D i s t r e s s S c a l e d e s i g n e d by M c C o r k l e & Young (1978) was used. A l l s u b j e c t s were asked t o complete t h i s q u e s t i o n n a i r e b e f o r e t h e s t a r t o f t h e i r c o u r s e o f r a d i a t i o n t h e r a p y and a g a i n a t t h e end o f a t h r e e week p e r i o d d u r i n g w h i c h t h e y were r e c e i v i n g r a d i a t i o n t h e r a p y . D e s c r i p t i v e s t a t i s t i c s were used t o examine t h e r e s u l t i n g s c o r e s . These s c o r e s were a measurement o f symptom d i s t r e s s p e r c e i v e d by t h e s u b j e c t s b e f o r e s t a r t i n g r a d i a t i o n t r e a t m e n t and t h e n t h r e e weeks a f t e r s t a r t i n g r a d i a t i o n t r e a t m e n t . Symptom d i s t r e s s s c o r e s o b t a i n e d b e f o r e t h e r a d i a t i o n t r e a t m e n t began ranged from 13 t o 34 (Md = 20, M = 20.9, SD = 7.0) i n t h e c o n t r o l group and from 14 t o 41 (Md = 25, M = 23.9, SD = 15.21) i n t h e i n t e r v e n t i o n group. The symptom d i s t r e s s s c o r e s o b t a i n e d t h r e e weeks a f t e r t h e r a d i a t i o n t r e a t m e n t had s t a r t e d ranged from 15 t o 47 (Md = 24, M = 27, SD = 10.2) i n the c o n t r o l group and from 15 t o 40 (Md = 21.5, M = 22.2, SD = 11.4) i n the i n t e r v e n t i o n group. The lowest score o b t a i n a b l e was 13, and the h i g h e s t score a t t a i n a b l e was 65. Using the Mann-Whitney U T e s t , a s i g n i f i c a n t d i f f e r e n c e was found i n the d i f f e r e n c e i n the symptom d i s t r e s s s c o r e s between the two time i n t e r v a l s i n the c o n t r o l group compared wi t h the i n t e r v e n t i o n group (U = 154; p_ < .05). Based on t h i s r e s u l t , the f i r s t h y p o t h e s i s was accepted. D i s c u s s i o n The above r e s u l t s support the r e s e a r c h i n the l i t e r a t u r e r e l a t e d t o symptom d i s t r e s s d u r i n g r a d i a t i o n treatment (King, N a i l , Kreamer, S t r o h l , and Johnson, 1985; Peck & Boland, 1977). The symptoms which were r e p o r t e d most f r e q u e n t l y by the s u b j e c t s were: d i a r r h e a , f a t i g u e , nausea and a n o r e x i a . Approximately 50% of i n d i v i d u a l s i n t h i s study who r e c e i v e d a b d o m i n a l / p e l v i c r a d i a t i o n treatment r e p o r t e d d i a r r h e a and f a t i g u e , s i m i l a r t o the r e s u l t s from the study done by King, N a i l , Kreamer, S t r o h l , and Johnson (1985). Nausea (25%) and a n o r e x i a (32%) were r e p o r t e d l e s s f r e q u e n t l y by both male and female s u b j e c t s . The o t h e r nine symptoms l i s t e d i n the Symptom D i s t r e s s S c a l e were mentioned as having o c c u r r e d or b eing i n t e r f e r e d w i t h , but w i t h much l e s s frequency. 55 U n f o r t u n a t e l y , a l i m i t a t i o n n o t e d w i t h t h i s s c a l e i s t h a t i t does n o t i n c l u d e an a b s o l u t e number f o r "no d i s t r e s s " r e l a t e d t o each symptom w h i c h f o r c e s s u b j e c t s t o choose "1" w h i c h c o u l d mean "no d i s t r e s s " o r a " l i t t l e d i s t r e s s " . T h e r e f o r e , i t i s i m p o s s i b l e t o d e t e r m i n e w h i c h symptoms may not have been p e r c e i v e d as h a v i n g any amount o f d i s t r e s s a s s o c i a t e d w i t h them. The i n t e r v e n t i o n o f r e l a x a t i o n t h e r a p y d i d appear t o d e c r e a s e t h e o v e r a l l symptom d i s t r e s s e x p e r i e n c e d by t h e s u b j e c t s who used i t when compared w i t h t h o s e i n t h e c o n t r o l group. Of t h e f o u r t e e n s u b j e c t s i n t h e i n t e r v e n t i o n group, 50% wrote i n t h e i r d i a r i e s t h a t t h e y used t h e r e l a x a t i o n t e c h n i q u e t o h e l p them t o s l e e p w i t h some degree o f a s s i s t a n c e . One s u b j e c t s t a t e d t h a t "sometimes t h e t a p e h e l p e d me t o s l e e p and sometimes i t d i d n ' t . But t h e t i m e s when i t made me f e e l warm a l l o v e r were w o n d e r f u l , and I was o f f t o s l e e p " . A c c o r d i n g t o M c C o r k l e and Young (1978), e x p e r i e n c e s o f symptom d i s t r e s s can be grouped i n t o t h r e e c a t e g o r i e s : Low ( s c o r e 1 o r 2 ) ; Medium ( s c o r e 3 ) ; o r , H i g h ( s c o r e 4 o r 5 ) . T a b l e 2 uses t h e s e c a t e g o r i e s t o i l l u s t r a t e how r e l a x a t i o n t h e r a p y had an impact on t h e d i s t r e s s a s s o c i a t e d w i t h t h e l e v e l o f f a t i g u e e x p e r i e n c e d by t h e s u b j e c t s . T a b l e 3 uses t h e s e same c a t e g o r i e s t o i l l u s t r a t e the d i s t r e s s associated with the changes i n bowel function experienced by the subjects. The r e s u l t s from several studies i n the l i t e r a t u r e support the p o s i t i v e e f f e c t s of using relaxation therapy i n managing the adverse physical side e f f e c t s associated with chemotherapy treatment (Burish & Lyles, 1981; Cotanch, 1983; Scott, Donahue, Mastrovito & Hakes, 1983). The r e s u l t s from t h i s study add to the current knowledge of the p o s i t i v e e f f e c t s of relaxation therapy i n i n d i v i d u a l s receiving r a d i a t i o n treatment for a diagnosis of cancer. T a b l e 2 D i s t r i b u t i o n o f Symptom D i s t r e s s S c o r e s ( F a t i g u e and  Bowel) P r i o r t o R a d i a t i o n Treatment and 3 weeks l a t e r F a t i g u e S core F i r s t S c o re Second S c o r e F r e q u e n c y / P e r c e n t F r e q u e n c y / P e r c e n t C o n t r o l group (n = 14) Low 12/86 2/14 Medium 1/7 5/36 H i g h 1/5 7/50 I n t e r v e n t i o n group (n = 14) Low 8/57 8/57 Medium 5/36 3/21.5 H i g h 1/7 3/21.5 Note. Minimum s c o r e = 13. Maximum s c o r e = 65. T a b l e 3 D i s t r i b u t i o n of Symptom Distress Scores (Fatigue and Bowel) P r i o r to Radiation Treatment and 3 weeks l a t e r Bowel Score F i r s t Score Second Score Frequency/Percent Frequency/Percent Control group (n = 14) Low 13/93 5/36 Medium 0/0 0/0 High 1/7 9/64 Intervention group (n = 14) Low 10/72 7/50 Medium 3/21 4/29 High 1/7 3/21 Note. Minimum score = 13. Maximum score = 65. 59 H y p o t h e s i s 2; I n d i v i d u a l s r e c e i v i n g a b d o m i n a l / p e l v i c  r a d i a t i o n t h e r a p y who p r a c t i c e r e l a x a t i o n t h e r a p y w i l l  e x p e r i e n c e a h i g h e r l e v e l o f p e r s o n a l c o n t r o l as compared  w i t h t h o s e who do n o t p r a c t i c e r e l a x a t i o n t h e r a p y . To d e t e r m i n e t h e l e v e l o f p e r s o n a l c o n t r o l e x p e r i e n c e d by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y , t h e S e l f - C o n t r o l S u b s c a l e o f t h e P e r s o n a l O p i n i o n S u r v e y d e s i g n e d by Coan & F a i r c h i l d (1977) was used. A l l s u b j e c t s were asked t o complete t h i s q u e s t i o n n a i r e b e f o r e t h e s t a r t o f t h e i r c o u r s e o f r a d i a t i o n t h e r a p y and a g a i n a t t h e end o f a t h r e e week p e r i o d d u r i n g w h i c h t h e y were r e c e i v i n g r a d i a t i o n . D e s c r i p t i v e s t a t i s t i c s were used t o examine t h e r e s u l t i n g s c o r e s a t two p o i n t s i n t i m e . The f i r s t s c o r e r e s u l t s were a measurement o f t h e l e v e l o f c o n t r o l p e r c e i v e d by t h e s u b j e c t b e f o r e s t a r t i n g r a d i a t i o n t h e r a p y . The second s c o r e r e p r e s e n t s t h e l e v e l o f p e r s o n a l c o n t r o l p e r c e i v e d t h r e e weeks a f t e r s t a r t i n g t r e a t m e n t . P e r s o n a l c o n t r o l s c o r e s o b t a i n e d b e f o r e t h e r a d i a t i o n t r e a t m e n t ranged from 6 t o 18 (Md = 12.5, M = 12.1, SD = 3.4) i n t h e c o n t r o l group and from 2 t o 19 (Md = 13.5, M = 13.1, SD = 4.5) i n t h e i n t e r v e n t i o n group. The p e r s o n a l c o n t r o l s c o r e s o b t a i n e d t h r e e weeks a f t e r t h e r a d i a t i o n t r e a t m e n t had begun ranged from 10 t o 19 (Md = 14, M = 14.4, SD = 2.9) 60 i n t h e c o n t r o l group and from 3 t o 19 (Md = 17, M = 14.8, SD = 4.6) i n t h e i n t e r v e n t i o n group. The l o w e s t s c o r e o b t a i n a b l e was 0, and t h e h i g h e s t s c o r e a t t a i n a b l e was 19. U s i n g t h e Mann-Whitney U T e s t , no s i g n i f i c a n t d i f f e r e n c e was found between t h e two t i m e i n t e r v a l s i n t h e c o n t r o l group when compared w i t h t h e i n t e r v e n t i o n group (U = 189). Based on t h i s r e s u l t , t h e second h y p o t h e s i s was n o t a c c e p t e d . D i s c u s s i o n The above r e s u l t s f a i l t o s u p p o r t t h e a n e c d o t a l f i n d i n g s c i t e d i n t h e l i t e r a t u r e w h i c h propose t h a t t h e use o f r e l a x a t i o n t e c h n i q u e s i n c r e a s e s one's p e r c e p t i o n o f p e r s o n a l c o n t r o l ( B u r i s h & L y l e s , 1981; C o t a n c h , 1983; S c o t t , Donahue, M a s t r o v i t o & Hakes, 1983; T a y l o r , 1983). P o s s i b l e e x p l a n a t i o n s f o r t h e n o n s i g n i f i c a n t r e s u l t i n c l u d e t h e s m a l l sample s i z e and t h e use o f a c o n v e n i e n c e sample. However, t h i s a u t h o r would argue t h a t t h e r e a r e two o t h e r p o s s i b l e r e a s o n s f o r t h i s r e s u l t . F i r s t , t h e t o o l used t o measure p e r s o n a l c o n t r o l was i n v a l i d f o r i n d i v i d u a l s w i t h c a n c e r , h a v i n g o n l y been used on h e a l t h y c o l l e g e s t u d e n t s . Second, t h e con c e p t o f p e r s o n a l c o n t r o l has y e t t o be a d e q u a t e l y d e f i n e d . Comments w r i t t e n i n t h e d i a r i e s o f a few o f t h e s u b j e c t s s t a t e d t h a t t h e y f e l t " b e t t e r " a t t h e end o f t h e s t u d y . F o u r o f t h e s u b j e c t s i n t h e i n t e r v e n t i o n 61 group (29%) s t a t e d t h a t t h e y t h o u g h t t h e y were r e l a x e d p r i o r t o u s i n g r e l a x a t i o n t h e r a p y . One s u b j e c t s t a t e d " A l t h o u g h I f e e l I can u s u a l l y r e l a x , t h e t a p e seemed t o h e l p me e v e r more". A t t h e end o f t h e t h r e e weeks, t h i s s u b j e c t f e l t t h e t e c h n i q u e had d e f i n i t e l y made i t e a s i e r f o r him " t o r i d m y s e l f o f my t e n s i o n s " . I n d i v i d u a l s who may not appear a n x i o u s o r f e e l any t e n s i o n o f t e n r e c o g n i z e p r e v i o u s l y u n i d e n t i f i e d t e n s i o n s once t h e y b e g i n t o use r e l a x a t i o n t h e r a p y (Donovan, 1980; Zahourek, 1988). However, t h e a b i l i t y t o i d e n t i f y one's t e n s i o n and t h e n t o r e l a x and, p e r c e i v i n g o n e s e l f as h a v i n g p e r s o n a l c o n t r o l , a r e n o t n e c e s s a r i l y r e l a t e d . O n l y one s u b j e c t ' s i m p r e s s i o n o f how t h e r e l a x a t i o n t e c h n i q u e s had h e l p e d h e r seemed t o s u p p o r t t h i s s t u d y ' s d e f i n i t i o n o f p e r s o n a l c o n t r o l : " I ne v e r knew I was t e n s e u n t i l I began t h e s e e x e r c i s e s . Now, i f I g e t annoyed and I t e n s e up, I j u s t b e g i n t o b r e a t h e q u i e t l y and t h i n k about t h e e x e r c i s e and I r e l a x . I can d e a l w i t h a s i t u a t i o n t h a t b e f o r e would have j u s t made me u p s e t " . A l t h o u g h t h i s s u b j e c t was n o t r e f e r r i n g s p e c i f i c a l l y t o her r a d i a t i o n t h e r a p y b u t t o e v e n t s d u r i n g h e r normal day, use o f t h e e x e r c i s e s seemed t o be an e f f e c t i v e c o p i n g s k i l l . A c c o r d i n g t o Thompson (1981), an a v e r s i v e e v e n t t h a t i s a s s o c i a t e d w i t h a h i g h l y d e s i r e d outcome w i l l be l e s s 62 p a i n f u l and/or l e s s s t r e s s f u l . A l t h o u g h a d i a g n o s i s o f c a n c e r and r e c e i v i n g t r e a t m e n t w i t h r a d i a t i o n may be a v e r s i v e e v e n t s , a l l b u t one s u b j e c t i n t h i s s t u d y ' s sample were b e i n g t r e a t e d w i t h t h e i n t e n t t o c u r e . T h e r e f o r e , t h e r e s u l t s o f t h i s s t u d y s u p p o r t t h i s a s s u m p t i o n . The one s u b j e c t who r e c e i v e d p a l l i a t i v e t r e a t m e n t a l s o r e c e i v e d i n s t r u c t i o n i n t h e r e l a x a t i o n t e c h n i q u e . I t i s i n t e r e s t i n g t o note t h a t not o n l y d i d she have t h e h i g h e s t o v e r a l l symptom d i s t r e s s s c o r e (40; maximum s c o r e = 65) o f t h e e n t i r e sample a t t h e end o f t h e t h r e e week p e r i o d b u t h e r p e r s o n a l c o n t r o l s c o r e had a l s o i n c r e a s e d by t h r e e p o i n t s from h e r i n i t i a l s c o r e . T h i s s u b j e c t f e l t and was v e r y i l l a t t h e end o f h e r t r e a t m e n t : " I am n o t s u r e I made t h e r i g h t d e c i s i o n t o t r y t h e r a d i a t i o n . I f e e l so a w f u l . N o t h i n g seems t o h e l p and I c a n ' t do a n y t h i n g b u t s l e e p , i t ' s v e r y f r u s t r a t i n g " . Which l e a d s t h i s d i s c u s s i o n back t o t h e q u e s t i o n o f t h e v a l i d i t y o f t h e t o o l used t o measure p e r s o n a l c o n t r o l , s p e c i f i c a l l y c o n t e n t v a l i d i t y . I t i s u n c l e a r as t o whether t h i s t o o l i s a c t u a l l y m e a s u r i n g p e r s o n a l c o n t r o l g i v e n t h e r e s u l t s o f t h i s s t u d y . N o r r i s (1982) s t a t e d t h a t h a b i t makes i t d i f f i c u l t t o c r i t i c a l l y examine c o n c e p t s used i n n u r s i n g and t o d e f i n e them f o r use i n s c i e n t i f i c work. Y e t , i f c r i t i c a l 63 a n a l y s i s i s i g n o r e d , n u r s i n g w i l l c o n t i n u e t o use c o n c e p t s , such as p e r s o n a l c o n t r o l , w i t h o u t knowing e x a c t l y what t h e y mean. T h i s has i m p l i c a t i o n s f o r a l l phases o f t h e n u r s i n g p r o c e s s as w e l l as n u r s i n g r e s e a r c h . The r e s u l t s from t h i s s t u d y s u g g e s t t h a t t h o s e s u b j e c t s who were b e i n g t r e a t e d f o r t h e i r c a n c e r w i t h t h e i n t e n t t o c u r e d i d not have any change i n t h e i r p e r c e p t i o n o f p e r s o n a l c o n t r o l o v e r t h e c o u r s e o f t r e a t m e n t , e i t h e r p o s i t i v e l y o r n e g a t i v e l y . The r e s u l t s a l s o s u g g e s t t h a t r e l a x a t i o n t h e r a p y d i d n o t a f f e c t t h e l e v e l o f p e r c e i v e d c o n t r o l i n t h e i n t e r v e n t i o n group. However, based on t h i s d i s c u s s i o n , t h e r e s u l t s from t h i s s t u d y can a l s o be i n t e r p r e t e d t o s u g g e s t t h a t t h e r e i s a need f o r f u r t h e r a n a l y s i s r e l a t e d t o t h e c o n c e p t o f c o n t r o l as i t a p p l i e s t o s i t u a t i o n s e n c o u n t e r e d w i t h i n t h e p r a c t i c e o f n u r s i n g . T h i s a n a l y s i s would t h e n g i v e d i r e c t i o n f o r t h e development o f a measurement t o o l w h i c h would p r o v i d e r e s u l t s t o f u r t h e r d i r e c t n u r s i n g p r a c t i c e i n t h e a r e a o f p e r s o n a l c o n t r o l . Summary T h i s c h a p t e r began w i t h a d e s c r i p t i o n o f t h e s t u d y p o p u l a t i o n . There were twenty e i g h t i n d i v i d u a l s who were b e i n g t r e a t e d w i t h a b d o m i n a l / p e l v i c r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r . F o u r t e e n i n d i v i d u a l s c o m p r i s e d t h e c o n t r o l group and t h e r e s t were i n t h e i n t e r v e n t i o n group. 64 The i n t e r v e n t i o n group used a d e f i n e d r e l a x a t i o n t e c h n i q u e f o r t h r e e weeks d u r i n g t h e i r t r e a t m e n t . The f i r s t h y p o t h e s i s r e l a t e d t o t h e e f f e c t o f r e l a x a t i o n t h e r a p y on t h e amount o f symptom d i s t r e s s e x p e r i e n c e d . I t was found t h a t t h e r e was a s i g n i f i c a n t d i f f e r e n c e i n t h e amount o f symptom d i s t r e s s e x p e r i e n c e d between t h e two groups. The i n t e r v e n t i o n group e x p e r i e n c e d a l o w e r o v e r a l l amount o f symptom d i s t r e s s compared w i t h t h e c o n t r o l group. T h i s r e s u l t was comparable w i t h o t h e r s t u d i e s done w i t h i n d i v i d u a l s r e c e i v i n g chemotherapy f o r a d i a g n o s i s o f c a n c e r . The second h y p o t h e s i s r e l a t e d t o t h e e f f e c t o f a r e l a x a t i o n t e c h n i q u e on t h e amount o f p e r s o n a l c o n t r o l e x p e r i e n c e d . I t was found t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n t h e amount o f p e r s o n a l c o n t r o l e x p e r i e n c e d between t h e c o n t r o l and i n t e r v e n t i o n group. A l t h o u g h t h i s r e s u l t does n o t s u p p o r t t h e l i t e r a t u r e , t h e v a l i d i t y o f t h e t o o l used t o measure p e r s o n a l c o n t r o l and t h e need f o r a c l e a r and measurable d e f i n i t i o n o f t h i s c o n c e p t w i t h i n n u r s i n g was d i s c u s s e d . 65 CHAPTER FIVE Summary, Recommendations for Nursing Education, Practice, and Research Introduction T h i s c h a p t e r c o n c l u d e s t h e p r e s e n t a t i o n o f t h i s s t u d y . A summary o f th e s t u d y and i t s f i n d i n g s b e g i n t h e c h a p t e r . Recommendations f o r n u r s i n g e d u c a t i o n and p r a c t i c e f o l l o w . F i n a l l y , recommendations f o r n u r s i n g r e s e a r c h a r e made. Summary of the Study T h i s q u a s i e x p e r i m e n t a l s t u d y was d e s i g n e d t o de t e r m i n e t h e e f f e c t o f r e l a x a t i o n t h e r a p y on symptom d i s t r e s s and p e r s o n a l c o n t r o l as p e r c e i v e d by a d u l t s r e c e i v i n g a b d o m i n a l / p e l v i c e x t e r n a l r a d i a t i o n t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r . The sample c o n s i s t e d o f twe n t y e i g h t i n d i v i d u a l s , f o u r t e e n i n t h e c o n t r o l group and f o u r t e e n i n t h e i n t e r v e n t i o n group. The sample p a r t i c i p a n t s were i n i t i a l l y approached by s t a f f members i n th e r a d i a t i o n department o f a l o c a l c a n c e r agency t o o b t a i n t h e i r c o n s e n t t o p a r t i c i p a t e . A l l p a r t i c i p a n t s were asked t o complete a t o t a l o f f o u r q u e s t i o n n a i r e s . Those i n d i v i d u a l s i n t h e i n t e r v e n t i o n group were a l s o t a u g h t a s p e c i f i e d r e l a x a t i o n t e c h n i q u e and asked t o p r a c t i c e i t a t l e a s t once a day w h i l e on th e s t u d y . The 66 number o f t i m e s t h e t e c h n i q u e was used and any comments were r e c o r d e d i n a d i a r y p r o v i d e d by t h e r e s e a r c h e r . I t was i d e n t i f i e d i n t h e l i t e r a t u r e t h a t i n d i v i d u a l s b e i n g t r e a t e d w i t h r a d i a t i o n t h e r a p y n o t o n l y e x p e r i e n c e p h y s i o l o g i c a l and p s y c h o l o g i c a l s i d e e f f e c t s b u t a l s o f e e l i n g s o f h e l p l e s s n e s s and a l o s s o f p e r s o n a l c o n t r o l . R e l a x a t i o n t h e r a p y was i d e n t i f i e d as t h e i n d e p e n d e n t v a r i a b l e i n t h i s s t u d y w h i c h a f f e c t s t h e dependent v a r i a b l e s o f symptom d i s t r e s s and p e r s o n a l c o n t r o l . I t was h y p o t h e s i z e d t h a t t h e d a i l y use o f r e l a x a t i o n t h e r a p y by i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y would d e c r e a s e t h e amount o f symptom d i s t r e s s and i n c r e a s e t h e amount o f p e r s o n a l c o n t r o l p e r c e i v e d . Data were g a t h e r e d by i n t e r v i e w , two s e t s o f q u e s t i o n n a i r e s and w r i t t e n d i a r i e s . The i n t e r v i e w was com p l e t e d b e f o r e t h e p a r t i c i p a n t s began t h e i r r a d i a t i o n t r e a t m e n t . The q u e s t i o n n a i r e s were a l s o c o m p l e t e d a t t h i s t i m e and t h e n a g a i n t h r e e weeks a f t e r t h e t r e a t m e n t began. A d i a r y was k e p t by t h o s e i n t h e i n t e r v e n t i o n group t o r e c o r d t h e number o f t i m e s r e l a x a t i o n was used and any comments. To answer t h e two h y p o t h e s e s , summary s t a t i s t i c s were used. The r e s u l t s i n d i c a t e d t h a t i n d i v i d u a l s who used r e l a x a t i o n t h e r a p y p e r c e i v e d a d e c r e a s e d amount o f symptom d i s t r e s s t h a n t h o s e i n t h e c o n t r o l group. The Mann-Whitney U T e s t i n d i c a t e d t h a t t h i s d i f f e r e n c e was a t t h e p_ < .05 l e v e l o f s i g n i f i c a n c e . On t h i s b a s i s t h e h y p o t h e s i s was a c c e p t e d . The r e s u l t s o f t h e second h y p o t h e s i s i n d i c a t e t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between t h e groups i n t h e amount o f p e r c e i v e d p e r s o n a l c o n t r o l . On t h i s b a s i s t h e h y p o t h e s i s was n o t a c c e p t e d . Recommendations f o r Nursing E d u c a t i o n and P r a c t i c e As s t a t e d e a r l i e r , i t i s e s t i m a t e d t h a t one i n t h r e e C anadians d e v e l o p some form o f c a n c e r d u r i n g t h e i r l i f e t i m e (Canadian Cancer S t a t i s t i c s , 1990). Over 50% o f t h e s e i n d i v i d u a l s a r e t r e a t e d w i t h r a d i a t i o n t h e r a p y , p r i m a r i l y on an o u t p a t i e n t b a s i s , a t some p o i n t i n t h e i r i l l n e s s (Yasko, 1982). Many o f t h e s e i n d i v i d u a l s e x p e r i e n c e b o t h p s y c h o l o g i c a l and p h y s i o l o g i c a l s i d e e f f e c t s d e s p i t e m e d i c a l i n t e r v e n t i o n s . The r e s u l t s o f t h i s s t u d y can d i r e c t n u r s i n g e d u c a t i o n and n u r s i n g p r a c t i c e i n t h i s a r e a . Based on t h i s s t u d y , t h e recommendation f o r n u r s i n g e d u c a t i o n i s t o i n c o r p o r a t e t h e use o f r e l a x a t i o n t e c h n i q u e s as a n u r s i n g i n t e r v e n t i o n i n c a r i n g f o r i n d i v i d u a l s r e c e i v i n g t r e a t m e n t f o r a d i a g n o s i s o f c a n c e r w i t h i n t h e b a s i c n u r s i n g e d u c a t i o n c u r r i c u l u m . S t u d e n t s 68 should l e a r n t o use i n t e r v e n t i o n s such as p a s s i v e muscle r e l a x a t i o n and b r e a t h i n g techniques w i t h i n t h e i r p r a c t i c e . N u r s i n g students would begin by l e a r n i n g the t h e o r y r e l a t e d t o the e f f e c t i v e n e s s of r e l a x a t i o n therapy. They would then l e a r n how t o use b a s i c r e l a x a t i o n t e c h n i q u e s , u t i l i z i n g the the o r y w i t h i n t h e i r p r a c t i c e . The methods used t o te a c h the students would i n c l u d e those t h a t would then be used by the students t o teach t h e i r p a t i e n t s . W i t h i n t h e i r assessment, n u r s i n g students must be taught t o be aware of how the p a t i e n t p e r c e i v e s r e l a x a t i o n . Some of the i n d i v i d u a l s who r e f u s e d t o p a r t i c i p a t e i n t h i s study s t a t e d they d i d not b e l i e v e i t would h e l p them. They f e l t t h a t the d o c t o r would be ab l e t o h e lp should they develop any s i d e e f f e c t s . Nurses need t o o f f e r i n d i v i d u a l s the c h o i c e of whether they wish t o l e a r n the use of r e l a x a t i o n therapy. Although the i m p l i c a t i o n i s not d e r i v e d s p e c i f i c a l l y from t h i s study, the n u r s i n g students must a l s o know of those circumstances where i t may be i n a p p r o p r i a t e t o use r e l a x a t i o n therapy. I n d i v i d u a l s who have a severe d e p r e s s i o n o r p s y c h o s i s should be assessed by a p h y s i c i a n p r i o r t o the use of r e l a x a t i o n (Donovan, 1980; Mast, Meyers, U r b a n s k i , 1987; M a s t r o v i t o , 1989). The recommendation f o r n u r s i n g p r a c t i c e i s t o apply the knowledge and s k i l l s i n r e l a x a t i o n therapy a c q u i r e d 69 w i t h i n n u r s i n g e d u c a t i o n t o p r e v e n t o r d e c r e a s e t h e amount o f symptom d i s t r e s s e x p e r i e n c e d . The r e s u l t s f r om t h i s s t u d y n o t o n l y s u p p o r t p r e v i o u s s t u d i e s w h i c h i n d i c a t e t h a t symptom d i s t r e s s e x p e r i e n c e d by i n d i v i d u a l s i n c r e a s e s o v e r t h e t r e a t m e n t c o u r s e o f r a d i a t i o n ( K i n g , N a i l , Kreamer, S t r o h l , Johnson, 1985, Peck & B o l a n d , 1977), b u t a l s o s u g g e s t t h a t t h e use o f r e l a x a t i o n t h e r a p y d e c r e a s e s t h e d i s t r e s s a s s o c i a t e d w i t h t h e s i d e e f f e c t s o f t h e t r e a t m e n t . As p r e v i o u s l y s t a t e d , t h e m a j o r i t y o f i n d i v i d u a l s r e c e i v e t h e i r r a d i a t i o n t r e a t m e n t s as o u t p a t i e n t s and, t h e r e f o r e , a r e seen by n u r s e s w i t h i n t h e c a n c e r agency, a t home, o r i n a community h o s p i t a l . Nurses a r e i n an i d e a l p o s i t i o n t o use i n t e r v e n t i o n s , such as r e l a x a t i o n t h e r a p y , t o d e c r e a s e t h e symptom d i s t r e s s a s s o c i a t e d w i t h t h e t r e a t m e n t and/or t h e d i s e a s e . Recommendations f o r N u r s i n g R e s e a r c h A l t h o u g h t h e r e s u l t s o f t h i s s t u d y d i d show t h a t t h e use o f r e l a x a t i o n t h e r a p y d e c r e a s e d p e r c e i v e d symptom d i s t r e s s w i t h i n a s p e c i f i c group o f i n d i v i d u a l s , t h e g e n e r a l i z a b i l i t y o f t h e s e r e s u l t s i s l i m i t e d due t o a number o f f a c t o r s . S p e c i f i c a l l y , t h e number o f s t u d y p a r t i c i p a n t s i n t h i s s t u d y was s m a l l and s u b j e c t s were r e c r u i t e d by a c o n v e n i e n c e s a m p l i n g . A d d i t i o n a l l y , n o t a l l c a n c e r s i t e s were r e p r e s e n t e d . I n c r e a s i n g t h e number o f p a r t i c i p a n t s and t h e v a r i e t y o f t h e i r d i a g n o s e s o f 70 cancer would provide a stronger argument as to the s i g n i f i c a n c e of the r e s u l t s . If symptom d i s t r e s s was again s i g n i f i c a n t l y decreased i n such a study, i t would be i n t e r e s t i n g to note i f there were any differences between male and female subjects and i f there were any differences between in d i v i d u a l s being treated for d i f f e r e n t types of cancers. King, N a i l Kreamer, Strohl, and Johnson (1985) noted that more than 30% of the subjects i n t h e i r study (n = 96) who were receiving rad i a t i o n treatments to the chest, head and neck, and p e l v i s experienced the persistence of at l e a s t one symptom through the t h i r d month a f t e r treatment was completed. A longitudinal study could be done to determine i f symptom d i s t r e s s was also decreased over time. As previously stated, the need for control i n i n d i v i d u a l s with a l i f e - t h r e a t e n i n g i l l n e s s i s acknowledged i n the l i t e r a t u r e . However, very few studies have been found which attempt to describe the concept of personal c o n t r o l . The majority of studies found i n the l i t e r a t u r e p r i m a r i l y involve laboratory experiments ( M i l l e r , 1979; Thompson, 1981). How in d i v i d u a l s perceive control and how i t d i f f e r s given c e r t a i n conditions need to be determined to provide relevant information to guide health care professionals. Qualitative research would be 71 a p p r o p r i a t e and u s e f u l t o answer q u e s t i o n s such a s : What does h a v i n g c o n t r o l mean? I s p e r s o n a l c o n t r o l p e r c e i v e d d i f f e r e n t l y f o r i n d i v i d u a l s who a r e f r e e from d i s e a s e t h a n f o r t h o s e who have c a n c e r ? I s p e r s o n a l c o n t r o l p e r c e i v e d d i f f e r e n t l y by i n d i v i d u a l s w i t h c a n c e r who a r e b e i n g t r e a t e d w i t h t h e i n t e n t t o c u r e v e r s u s t h o s e who were i n a p a l l i a t i v e s i t u a t i o n ? A l t h o u g h t h e r e s u l t s from t h i s s t u d y i n d i c a t e d t h a t t h e use o f one r e l a x a t i o n t e c h n i q u e was i n e f f e c t i v e i n r e l a t i o n t o p e r s o n a l c o n t r o l , t h e need t o l o o k a t t h e e f f e c t i v e n e s s o f o t h e r t e c h n i q u e s i s n e c e s s a r y . A t t h i s t i m e , i t i s n o t c l e a r i f one r e l a x a t i o n t e c h n i q u e may be more e f f e c t i v e t h a n a n o t h e r . F u r t h e r , t h e r e i s l i t t l e d i r e c t i o n w i t h i n t h e l i t e r a t u r e as t o w h i c h t e c h n i q u e may be most e f f e c t i v e i n c e r t a i n s i t u a t i o n s o r w i t h c e r t a i n c o n d i t i o n s . A c c o r d i n g t o t h e l i t e r a t u r e , i n d i v i d u a l s who are e x p e r i e n c i n g f a t i g u e may n o t b e n e f i t from p r o g r e s s i v e muscle r e l a x a t i o n o r from g u i d e d imagery as t h e y may be v e r y t i r i n g (Kaempfer, 1982; M c C a f f e r y & Beebe, 1989). A l t h o u g h t h i s may be t r u e , t h e r e i s no r e s e a r c h t o c o n f i r m t h i s o b s e r v a t i o n n or t o suggest a l t e r n a t i v e t e c h n i q u e s w h i c h may be used i n t h e s e s i t u a t i o n s . F i n a l l y , i t i s u n c l e a r as t o w h i c h i n d i v i d u a l s b e n e f i t t h e most from t h i s t y p e o f i n t e r v e n t i o n and i n what ways. I t i s s t a t e d i n t h e l i t e r a t u r e t h a t 72 i n d i v i d u a l s who have s l e e p d i s t u r b a n c e s o r a r e aware t h a t t h e y need t o r e l a x b e n e f i t more t h a n t h o s e who a r e e x t r e m e l y a n x i o u s ( M c C a f f e r y & Beebe, 1989). However, t h e r e i s no r e s e a r c h t o s u p p o r t t h e s e c l a i m s nor i s how i n d i v i d u a l s " b e n e f i t " from r e l a x a t i o n t h e r a p y d e s c r i b e d . Summary I n d i v i d u a l s who r e c e i v e a b d o m i n a l / p e l v i c r a d i a t i o n t r e a t m e n t e x p e r i e n c e symptom d i s t r e s s r e l a t e d t o t h e s i d e e f f e c t s o f t h e t r e a t m e n t . To enhance t h e n u r s i n g c a r e p r o v i d e d t o t h e s e i n d i v i d u a l s , n u r s e s s h o u l d become knowledgeable i n t h e use o f r e l a x a t i o n t e c h n i q u e s w h i c h may be used by t h e s e i n d i v i d u a l s i n o r d e r t o d e c r e a s e p e r c e i v e d symptom d i s t r e s s . F u r t h e r r e s e a r c h t o b e t t e r u n d e r s t a n d t h i s e x p e r i e n c e i n r e l a t i o n t o p e r s o n a l c o n t r o l i s r e q u i r e d t o e n a b l e n u r s e s t o p r o v i d e a p p r o p r i a t e and e f f e c t i v e c a r e t o t h e s e i n d i v i d u a l s . 73 REFERENCES Auerbach, S., M a r t e l l i , M., M e r c u r i , L. (1983). A n x i e t y , i n f o r m a t i o n , i n t e r p e r s o n a l i m p a c t s , and a d j u s t m e n t t o a s t r e s s f u l h e a l t h c a r e s i t u a t i o n . J o u r n a l o f  P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 44, 1284-1296. B a r s e v i c k , A. 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A complex answer to a simple question. Psychological B u l l e t i n , 90, (1), 89-101. Yasko, J . M. (1982). Care of the c l i e n t r e ceiving external r a d i a t i o n therapy. V i r g i n i a : P r e n t i c e - H a l l . Zahourek, R. P. (1988). Relaxation & imagery: Tools for  therapeutic communication and intervention. Toronto: W. B. Saunders. 77 Appendix A I n t r o d u c t o r y L e t t e r f o r P a r t i c i p a n t s i n C o n t r o l Group U n i v e r s i t y o f B r i t i s h C olumbia My name i s L i n d a Yearwood and I am a R e g i s t e r e d Nurse c u r r e n t l y c o m p l e t i n g my M a s t e r o f S c i e n c e i n N u r s i n g Degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . I am d o i n g a s t u d y t o f i n d o u t more about t h e e f f e c t a c o p i n g t e c h n i q u e has on t h e e x p e r i e n c e o f i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r . P a r t i c i p a t i n g i n t h i s s t u d y i n c l u d e s c o m p l e t i n g f o u r q u e s t i o n n a i r e s : two a t t h e b e g i n n i n g and two a t t h e end of a t h r e e week p e r i o d d u r i n g w h i c h you a r e r e c e i v i n g t r e a t m e n t . A l t h o u g h you w i l l n o t l e a r n t h e t e c h n i q u e a t t h e t i m e o f t h e s t u d y , t h e i n f o r m a t i o n g a i n e d from y o u r p a r t i c i p a t i o n w i l l a s s i s t n u r s e s t o h e l p i n d i v i d u a l s cope w i t h r a d i a t i o n t h e r a p y i n t h e f u t u r e . F u r t h e r , you w i l l have t h e o p p o r t u n i t y t o l e a r n t h e t e c h n i q u e d u r i n g a 30 -minute t e a c h i n g s e s s i o n a t t h e end o f y o u r p a r t i c i p a t i o n i n t h e s t u d y . A t a t i m e c o n v e n i e n t f o r you, I w i l l v i s i t you, have you complete t h e q u e s t i o n n a i r e s and answer a few q u e s t i o n s r e l a t e d t o y o u r t r e a t m e n t . A t t h i s t i m e , I w i l l a r r a n g e a d a t e and a t i m e f o r a second m e e t i n g i n t h r e e weeks t o have you complete t h e same two q u e s t i o n n a i r e s a g a i n . Each v i s i t s h o u l d t a k e no l o n g e r t h a n 30 m i n u t e s . 79 Appendix B I n t r o d u c t o r y L e t t e r f o r P a r t i c i p a n t s E f f e c t s o f R e l a x a t i o n Therapy on Symptom D i s t r e s s and  P e r s o n a l C o n t r o l Experienced by A d u l t s w i t h Cancer My name i s L i n d a Yearwood and I am a R e g i s t e r e d Nurse c u r r e n t l y c o m p l e t i n g my M a s t e r o f S c i e n c e i n N u r s i n g Degree a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a . I am d o i n g a s t u d y t o f i n d o ut more about t h e use o f r e l a x a t i o n t h e r a p y on t h e e x p e r i e n c e o f i n d i v i d u a l s r e c e i v i n g r a d i a t i o n t h e r a p y f o r a d i a g n o s i s o f c a n c e r . P a r t i c i p a t i n g i n t h i s s t u d y i n c l u d e s c o m p l e t i n g f o u r q u e s t i o n n a i r e s : two a t t h e b e g i n n i n g and two a t t h e end o f a t h r e e week p e r i o d d u r i n g w h i c h you a r e r e c e i v i n g t r e a t m e n t as w e l l as u s i n g a s t r u c t u r e d method o f r e l a x a t i o n t h e r a p y on a d a i l y b a s i s d u r i n g t h i s t i m e . T h i s method s h o u l d t a k e no l o n g e r t h a n 10 m i n u t e s p e r day t o do. I w i l l p r o v i d e you w i t h a d i a r y i n w h i c h I w i l l ask you t o r e c o r d t h e number o f t i m e s you used t h i s method each day. A t a t i m e c o n v e n i e n t f o r you, I w i l l v i s i t you, have you complete t h e q u e s t i o n n a i r e s and answer a few q u e s t i o n s r e l a t e d y o u r t r e a t m e n t . A t t h i s t i m e , I w i l l a l s o be t e a c h i n g you how t o use a method o f r e l a x a t i o n t h e r a p y . T h i s v i s i t s h o u l d t a k e no l o n g e r t h a n 60 m i n u t e s . I w i l l 83 Appendix E R e l a x a t i o n Technique Deep B r e a t h i n g 1. C l o s e y o u r eyes o r p i c k a p o i n t on t h e c e i l i n g t o l o o k a t w h i l e you r e l a x . Remember t h a t r e l a x a t i o n i s n ' t so much something t h a t you do, as i t i s a s t a t e o f "not d o i n g " . D u r i n g t h i s e x e r c i s e you w i l l p a s s i v e l y r e l a x y o u r m u s c l e s , g i v i n g away y o u r t e n s i o n o r a r e a s o f p a i n as you b r e a t h e . Scan y o u r body f o r a r e a s o f t e n s i o n and r e l a x q u i e t l y , l e t t h e c h a i r s u p p o r t y o u r body c o m f o r t a b l y as you r e l a x y o u r m u s c l e s . 2. I n h a l e s l o w l y and d e e p l y t h r o u g h y o u r nose ... and e x h a l e t h r o u g h y o u r mouth, b l o w i n g t h e b r e a t h o u t e a s i l y ... ( R e p e a t ) . C o n t i n u e t o i n h a l e d e e p l y and p e a c e f u l l y ... and as you e x h a l e , t h i n k " r e l a x " ... ( R e p e a t ) . L e t y o u r l u n g s f i l l q u i e t l y and c o m p l e t e l y ... and t h e n blow t h e a i r out e a s i l y . 3. As you i n h a l e , i magine t h a t you a r e s e n d i n g h e a l i n g a i r t o t h e p a r t s o f your body t h a t you f e e l a r e t e n s e o r p a i n f u l ... and b l o w i n g away t h e p a i n o r t e n s i o n as you e x h a l e q u i e t l y and t h i n k " r e l a x " . I n h a l e d e e p l y , s e n d i n g h e a l i n g a i r t h r o u g h your body ... and b l o w i n g away t h e t e n s i o n as you e x h a l e q u i e t l y . 4. As you i n h a l e , t h e muscles i n y o u r s h o u l d e r s and neck u n c l e n c h ... and as you e x h a l e you a l l o w t h e s e muscles t o r e l a x . The muscles i n t h e a r e a s you f e e l t e n s i o n o r d i s c o m f o r t become i n c r e a s i n g l y more c o m f o r t a b l e as you b r e a t h e q u i e t l y and p e a c e f u l l y . 5. As you c o n t i n u e t o b r e a t h e q u i e t l y and c a l m l y , you can f e e l y o u r body becoming warm and c o m f o r t a b l e . 6. N o t i c e how c a l m and r e l a x e d you have become. C o n t i n u e t o b r e a t h e c a l m l y and q u i e t l y . R e f e r e n c e : Mast, D., Meyers, J . & U r b a n s k i , A. (1987). R e l a x a t i o n t e c h n i q u e s : A s e l f - l e a r n i n g module f o r n u r s e s : U n i t I I I . Cancer N u r s i n g , 10, ( 5 ) , 279-285. 84 P a s s i v e M u s c l e R e l a x a t i o n 1. B r e a t h e c a l m l y and e v e n l y as you t h i n k about y o u r muscles one by one. B e g i n w i t h t h e muscles i n y o u r f o r e h e a d and s c a l p , l e t t i n g t h e t e n s i o n f l o w away ... Now t h i n k about t h e muscles around y o u r eyes ... R e l a x th e m u s c l e s around y o u r eyes so t h e y l i e q u i e t l y c l o s e d ... T h i n k about t h e muscles i n y o u r f a c e and jaw .. i n y o u r mouth and tongue ... l e t y o u r m u s c l e s go as you b e g i n t o r e l a x deeper and deeper ... 2. N o t i c e any t e n s i o n i n t h e muscles i n y o u r neck and r e l a x t h e muscles i n your neck, l e t t i n g t h e t e n s i o n f l o w away ... 3. Now t h i n k about t h e muscles i n y o u r s h o u l d e r s and upper back. L e t t h e t e n s i o n f l o w away as you r e l a x deeper and deeper ... Moving down t o y o u r arms, r e l a x t h e m u s c l e s i n your arms ... T h i n k about y o u r hands, a l l o w i n g f e e l i n g s o f r e l a x a t i o n t o f l o w down y o u r arms t o y o u r hands, l e a v i n g them c o m p l e t e l y r e l a x e d .. L e t th e t e n s i o n f l o w out t h r o u g h your f i n g e r t i p s , l i k e sand t h r o u g h an h o u r g l a s s as you t h i n k " r e l a x " . 4. N o t i c e any t e n s i o n o r t i g h t n e s s i n y o u r c h e s t and i n h a l e c a l m l y , r e l a x i n g t h e muscles i n y o u r c h e s t ... and blow t h e t e n s i o n away as y o u r e x h a l e ... T h i n k about t h e muscles i n your stomach ... l e t them go ... 5. R e l a x t h e muscles o f your l o w e r back, a l l o w i n g y o u r l o w e r back t o r e s t more c o m f o r t a b l y a g a i n s t t h e bed .. Your b r e a t h i n g i s p e a c e f u l and r e l a x e d as you f o c u s on t h e m u s c l e s i n your b u t t o c k s and y o u r l e g s ... r e l a x y o u r t h i g h s ... y o u r c a l v e s ... and y o u r f e e t , as f e e l i n g s o f warmth and c o m f o r t f l o w r i g h t down t o your t o e s ... Your body i s warm and c a l m and r e l a x e d ... Your b r e a t h i n g i s c a l m and easy ... Mast, D., Meyers, J . & U r b a n s k i , A. (1987). R e l a x a t i o n t e c h n i q u e s : A s e l f - l e a r n i n g module f o r n u r s e s : U n i t I I I . Cancer N u r s i n g , 10, ( 5 ) , 279-285. 85 Appendix F I n i t i a l I n t e r v i e w Guide Coding Date Demographic and H e a l t h Data 1. Age: 2. Sex: 3. E d u c a t i o n : 1. grade s c h o o l completed 2. h i g h s c h o o l completed 3. p o s t secondary e d u c a t i o n 4. u n i v e r s i t y e d u c a t i o n 4. Oncology H i s t o r y : a. I n i t i a l d i a g n o s i s : b. Date o f i n i t i a l d i a g n o s i s : c. Any r e c u r r e n c e s : Yes No I f y e s , when and where? 5. C u r r e n t H i s t o r y : a. P r e s e n t d i a g n o s i s : b. Treatment p l a n : 6. What a r e y o u r c u r r e n t methods o f c o p i n g w i t h y o u r d i a g n o s i s and t h e t r e a t m e n t ? 7. A r e you c u r r e n t l y u s i n g any method o f r e l a x a t i o n ? 86 Appendix G Questionnaire Symptom Distress Scale (McCorkle & Young, 1978) Coding Date SYMPTOM DISTRESS QUESTIONNAIRE Each o f t h e f o l l o w i n g s e c t i o n s l i s t s 5 d i f f e r e n t numbered s t a t e m e n t s . T h i n k about what each s t a t e m e n t s a y s , t h e n p l a c e a c i r c l e around t h e one st a t e m e n t t h a t most c l o s e l y i n d i c a t e s how you have been f e e l i n g d u r i n g t h e p a s t week i n c l u d i n g t o d a y . The s t a t e m e n t s under each s e c t i o n a r e ran k e d from 1 t o 5, where number 1 i n d i c a t e s no pro b l e m and number 5 i n d i c a t e s t h e maximum amount o f pr o b l e m s . Numbers 2 t h r o u g h 4 i n d i c a t e you f e e l somewhere i n between t h e s e two extremes. P l e a s e c i r c l e one number under each s e c t i o n . 1. NAUSEA (1) I seldom feel I am nauseous I am often I am usually I suffer from any nausea i f once in a nauseous nauseous nausea almost at a l l while continually 2 . NAUSEA ( 2 ) 1 when I do have nausea, i t i s very mild 2 When I do have nausea, i t i s mildly distressing 3 When I have nausea, I feel pretty sick 4 When I have nausea, I feel very sick 5 When I have nausea, I am as sick as I could possibly be 3. APPETITE 1 I have my normal appetite 2 My appetite i s usually, but not always, pretty good 3 I don't really enjoy my food like I used to 4 I have to force myself to eat my food 5 I cannot stand the thought of food 4. INSOMNIA 1 I sleep as well as I always have 2 I have occasional spells of sleeplessness 3 I frequently have trouble getting to sleep and staying asleep 4 I have d i f f i c u l t y sleeping almost every night 5 It i s almost impossible for me to get a decent night's sleep 5. PAIN (1) 1 I almost never have pain 2 I have pain once in a while 3 I frequently have p a i n — several times a week 4 I am usually in some degree of pain 5 I am in some degree of pain almost constantly 6. PAIN (2) When I do have pain, i t is very mild when I do have pain, i t is mildly distressing The pain I do have is usually f a i r l y intense The pain I have is usually very intense The pain I have is almost unbearable 7. FATIGUE I usually am not tired at a l l I am occasionally rather tired There are frequently periods when I am quite tired I am usually very tired Most of the time, I feel exhausted 8. BOWEL 1 I have my normal bowel pattern 2 My bowel pattern occasionally causes me some discomfort 3 I frequently have discomfort from my present bowel pattern 4 I am usually in discomfort because of my present bowel pattern 5 My present bowel pattern has drastically changed from what was normal for me 9. CONCENTRATION 1 I have my normal a b i l i t y to concentrate 2 i occasionally have trouble concentrating 3 I often have trouble concentrating 4 I usually have at least come d i f f i c u l t y concentrating 5 I just cannot seem to concentrate at a l l 10. APPEARANCE 1 My appearance has basically not changed 2 My appearance has gotten a l i t t l e worse 3 My appearance is definitely worse than i t used to be, but I am not greatly concerned about i t 4 My appearance is definitely worse than i t used to be, and I am concerned about i t 5 My appearance has changed drastically from what i t was 11. BREATHING I usually breathe normally occasionally have trouble breathing I often have trouble breathing I can hardly ever breathe as easily as I want I almost always have severe trouble with my breathing 12. OUTLOOK I am not fearful or worried I am a l i t t l e worried about things I am quite worried, but not afraid I am worried and a l i t t l e frightened about things I am worried an scared about things 13. COUGH I seldom cough I have an occasional cough I often cough I often cough, and occasionally have severe coughing spells I often have persistent and severe coughing spells Appendix H Q u e s t i o n n a i r e The P e r s o n a l Opinion Survey S e l f - C o n t r o l Subscale (Coan & F a i r c h i l d , 1977) 92 C o d i n g Date PERSONAL OPINION SURVEY SELF-CONTROL SUBSCALE Theses 19 s t a t e m e n t s a r e about your own f e e l i n g s about y o u r s e l f , o r m a t t e r s o f h e a l t h . There a r e no a b s o l u t e l y " r i g h t " o r "wrong" answer. T h i n k about what each s t a t e m e n t s a y s , t h e n p l a c e a c i r c l e around t h e answer t h a t i n d i c a t e s how you have been f e e l i n g d u r i n g t h e p a s t week i n c l u d i n g t o d a y . F o r each i t e m , c i r c l e one o f t h e c h o i c e s . I f t h e i t e m i s t r u e , c i r c l e t h e T. I f t h e i t e m i s f a l s e , c i r c l e t h e F. T F 1. I a l m o s t always u n d e r s t a n d why I f e e l and r e a c t as I do. T F 2 . 1 have sometimes f e l t t h a t d i f f i c u l t i e s were p i l i n g up so h i g h t h a t I c o u l d n o t overcome them. T F 3 . 1 seldom c r y . T F 4 . 1 sometimes have t r o u b l e w i t h my muscle s t w i t c h i n g o r t i g h t e n i n g up. T F 5 . 1 can h i d e my f e e l i n g s v e r y w e l l . T F 6. A t t i m e s , I have been so angry t h a t I j u s t c o u l d n ' t h e l p d o i n g o r s a y i n g t h i n g s I wou l d n ' t o r d i n a r i l y do o r say. T F 7 . 1 don't l e t t h i n g s b o t h e r me t h e way some p e o p l e do. T F 8. Sometimes an i d e a r u n s t h r o u g h my mind and I c a n ' t s t o p t h i n k i n g about i t no m a t t e r how h a r d I t r y . T F 9 . 1 a l m o s t always keep c o n t r o l o f my e m o t i o n s . T F 10. My moods swing back and f o r t h a l o t from h i g h t o low. T F 11. I seldom have t r o u b l e w i t h muscle spasms o r cramps. T F 12. I o f t e n have t r o u b l e g e t t i n g t o s l e e p a t n i g h t . 93 T F 13. I am seldom bothered by headaches. T F 14. Sometimes I worry about something that i s not r e a l l y important. T F 15. I t takes a l o t to hurt my fe e l i n g s . T F 16. I don't l i k e to waste time f e e l i n g sorry for myself. T F 17. I know how to relax for a few minutes when I'm getting tense and then go back to what I was doing. T F 18. I seldom have nightmares. T F 19. When I'm upset over something, I usually know why and what to do about i t . Appendix I S c o r i n g the P e r s o n a l Opinion Survey Q u e s t i o n n a i r e The raw s c o r e on each s c a l e i s s i m p l y t h e number o f r e s p o n s e s t h a t agree w i t h t h e f o l l o w i n g key. F a c t o r 5: I n t e r n a l S e l f - C o n t r o l S c a l e 1. T 10. F 2. F 11. T 3. T 12. F 4. F 13. T 5. T 14. T 6. F 15. T 7. T 16. T 8. F 17. T 9. T 18. T 

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