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Men's Adjustment to Their Partners' Breast Cancer: A Dyadic Coping Perspective. By: Feldman, Barry N.; Broussard, C. Anne. Health & Social Work, May2006, Vol. 31 Issue 2, p117-127, 11p, 3 charts; (AN 21485723)
The American Cancer Society (2003) estimated that there would be 212,600 new breast cancer cases in the United States in 2003. In 2000,182,000 cases were diagnosed, which represents an increase of 30,000 new cases in just three years. With this increase in occurrence, growing numbers of men are likely to experience the impact of breast cancer on their relationships.
In an early article about the psychosocial aspects of the cancer experience, Dyk and Sutherland (1956) suggested, "The spouse is often the key to the patient's success or failure in adapting…to the disability" (p. 138). Nevertheless, until the 1970s partners of breast cancer patients were viewed as passive observers rather than active participants in the cancer experience. In the 1970s and 1980s, descriptive studies documented that men often experienced psychosomatic symptoms and sexuality and intimacy distress (Wellisch, Jamison, & Pasnau, 1978), increased anxiety and depression (Maguire, 1981; Oberst & James, 1985), a general sense of helplessness (Vachon et al., 1977), fear of cancer and its treatment (Gotay, 1984), and concern about their own and their partner's ability to cope with the cancer (Grandstaff, 1975). Despite methodological problems, these studies provided important information about the process of adjusting to breast cancer.
For example, Wellisch and colleagues (1978) surveyed 31 men approximately two years after their wife's mastectomy and found that most men reported good overall adjustment but that close to half of them reported problems with their ability to work and sleep and about a quarter reported symptoms consistent with eating disorders. In addition, more than a third stated that the influence of breast cancer on their sexual relationship was "somewhat bad" or "bad." Not surprising, the higher the men's evaluation of their relationships, the less negative influence they attributed to the mastectomy. Overall, most of the men coped well or denied psychosocial stresses. However, a smaller subgroup was distressed, remained distressed, and reported a downward spiraling in their relationship quality.
In 1981 Maguire assessed husbands' adjustment to breast cancer over time. He included a comparison group of husbands of women with nonmalignant breast disease. Maguire's data revealed increased distress for cancer patients' husbands at three time points: before surgery and at three and 12 months following surgery. More than three quarters of Maguire's sample reported that the time period during the hospitalization and surgery was especially stressful. Although the results showed that anxiety levels of most husbands decreased with time, more than one-third of the husbands reported increased anxiety related to their wives' illness one year after surgery.
Since then, several studies have attempted to quantify the level and length of emotional distress experienced by husbands and to compare the stress levels of spouses by using standardized measurement scales (Baider & Kaplan De-Nour, 1984; Ell, Nishimoto, Mantell, & Hamovitch, 1988; Northouse, 1989; Northouse & Swain, 1987). Findings consistently report high correlations between partners' and patients' adjustment levels.
Sabo and colleagues (1986) examined the efficacy of support group experiences for husbands and found that men most feared that their wives might not survive, but also felt anxious about their own ability to provide their wives enough emotional support. They placed high priority on their wives' adjustment and hid their own feelings. Notably, most participants claimed that the loss of a breast did not matter to them and that their feelings of attraction toward their wives remained unchanged. In a later study, Sabo (1990) found that anxiety reactions, depression, and hypochondriacal preoccupations were common among husbands of breast cancer patients. Again, husbands felt inadequate in their ability to help their wives cope with the cancer diagnosis, and they used denial as the primary defense mechanism to minimize worries and cope with added duties. Similarly, Wilson and Morse (1991) found that many men reported feeling guilty during the treatment phase when they tried to meet basic needs, such as when cooking a meal and worrying that the odors would nauseate their wives. Some husbands believed concealing fears of death was best and used self-control to hide feelings of sadness and fear from their wives.
Kerson (1985) included breast cancer among those chronic illnesses considered to be most devastating and highest in prevalence. Its ambiguous outcome and unpredictable course pose substantial challenges for couples (Sidell, 1997). Compared with other chronic disorders, such as diabetes, a breast cancer diagnosis invokes images of "death, pain, and horror" (Lewis, Woods, Hough, & Bensley, 1989). Bourjolly and colleagues (1999) observed that the physical and emotional demands of breast cancer affect patients' social roles, social functioning, and functional status. Areas most likely to be affected are household tasks, sexual function, and marital problems (Harwood & O'Connor, 1994; Silberfarb, Maurer, & Crouthamel, 1980). Remission, the "process of adapting, not to terminal disease, but to uncertainty," is the only attainable goal of breast cancer treatment (Nathan, 1990). Men who are partners of breast cancer patients must also learn to live with this uncertainty.
Indeed, coping with chronic and severe illness has become a normative endeavor for many couples (Coyne & Fiske, 1992). Early coping research (see Lazarus, 1966; Lazarus & Folkman, 1984) focused on individual coping patterns and failed to consider the interpersonal and sociocultural domains in which coping takes place (Piening, 1998). However, given the significance of these contextual issues, research has since suggested that chronic illness stressors affect both partners. Dyadic coping constitutes a couple's efforts to cope conjointly with a common or shared stressor.
The limited amount of research conducted from the dyadic coping perspective has identified different types of dyadic coping and depicted situations in which dyadic coping strategies are applied (Kayser, Bodenmann, Piening, & Feldman, 2000). For example, Hannum and colleagues (1991) investigated whether the coping style of one spouse affected the effectiveness of the other spouse's coping. They found that distress reported by wives was linked to the coping of their husbands and that distress reported by husbands was linked to both their own and their wives' coping. There was a degree of symmetry in partners' coping strategies within the couples, such that when wives expressed more stress, husbands expressed increased optimism.
In their study of couples coping with Alzheimer's disease, DeLongis and O'Brien (1990) drew attention to the interpersonal processes of stress and coping and toward perceiving couples coping with chronic illness as "open systems." The researchers identified active engagement (involving both partners in discussions, asking how the partner feels, and other forms of constructive problem solving) and protective buffering (hiding concerns, denying worries, and yielding to partner to avoid arguments) as dyadic coping mechanisms considered instrumental in couples' relationships. The authors suggested that certain communications, such as criticizing, confronting, ignoring, and minimizing contact with others, disrupt social relationships.
In general, despite the current emphasis on breast cancer research and the abundance of accumulated knowledge about the woman's experiences, there remains a paucity of research on the man's experience as he is affected by his partner's disease (Ptacek, Ptacek, & Dodge, 1994). Although dyadic coping and chronic illness studies depict that both partners are affected by each other's coping styles, no research explores the factors that enable some male partners of breast cancer patients to adjust more successfully than others. One important question that remains unanswered is: How does dyadic coping affect men's psychosocial adjustment to their partners' illness? The research presented here addressed this question by exploring the men's experience with their partner's illness using standardized measurement instruments.
Traditional perspectives on coping with stress in individuals have been conceptually within the individualistic transactional model of stress, appraisal, and coping initially espoused by Lazarus (1966) and Lazarus and Folkman (1984). Dyadic coping extends the individualistic model of stress and coping by providing a systemic-transactional approach to perceiving and comprehending coping. Stress is dyadic if it affects both partners and takes into consideration both verbal and nonverbal "stress signals of one partner and the coping reactions of the other partner to these signals" (Bodenmann, 1997,p. 138). When unresolved, the stress of one partner affects the other and both partners have a strong interest in providing mutual support to achieve stability, satisfaction, and well-being in their relationship. Depending on the situation and individual and dyadic appraisals, couples can use various dyadic coping strategies, including positive coping strategies (dyadic stress communication, positive dyadic coping, and common dyadic coping) and negative strategies (hostile dyadic coping and avoidance of dyadic coping).
With breast cancer couples, conceptualizing stress as dyadic provides a more accurate understanding of how the stress process systemically affects the couple dyad, whereby the partner shares the stress burden of the patient and vice versa. Adaptation to stress must not be limited to individualized efforts to cope, but also must include the partner's social support (Revenson, 1994). Hence, coping is more appropriately viewed from a dyadic perspective. Thus far, research has not examined men's dyadic coping behaviors in response to their partners' breast cancer.
The sample was taken from a purposive sample of couples recruited for a longitudinal clinical research study to evaluate a psychosocial program called "Partners in Coping" (PIC) for breast cancer patients and their partners (Kayser, 1998). PIC participants had to be diagnosed with primary (first-time), non-metastatic breast cancer within three months; receiving treatment, such as chemotherapy, radiation, surgery, or combinations of treatments; and married or in a partnered relationship. The PIC sample was recruited from two leading cancer treatment facilities in Boston, Massachusetts, between September 2000 and September 2001. Clinical teams that included social workers, physicians, and nurses from the Breast Oncology units at these facilities identified potential recruits. Recruitment materials, including a letter that described the study and invited couples to participate, a study brochure, a decline card, and a stamped return envelope for the decline card, were mailed to potential participants. Researchers made follow-up phone calls to couples who did not return decline cards to ascertain their preference to participate in the study. Questionnaires were mailed to couples upon consent to participate.
The present study, which focused on dyadic coping and partner's adjustment, used the subsample of 71 male partners of breast cancer patients who met the eligibility criteria and completed the preintervention questionnaire for the PIC study. Participants were 89 percent white. They ranged in age from 26 to 78 years, with a mean age of 51 years (SD = 10.9). The majority of couples were married (92 percent). The remaining 8 percent were partnered (unmarried) and resided together. Marriages ranged from one to 54 years in length and averaged 20.7 years (SD = 12.5). Partnered relationships ranged from three to 22 years in length, with an average length of 11.5 years (SD = 6.9). For the total sample of married and partnered couples, relationship length averaged 19.9 years (SD = 12.4). Couples averaged two to three children. Eighty percent of participants had graduated from college, and 61 percent reported annual household incomes of more than $90,000. Finally, more than 22 percent (16 men) had relatives with a mental illness, and slightly more than 14 percent (10 men) reported having received treatment for depression.
Emotional well-being was evaluated by the Quality of Life Spouses Scale (QOL-SP) (Ebbesen, Guyatt, McCartney, & Oldridge, 1990). The QOL-SP consists of 13 items and was initially developed to measure quality of life for cardiac spouses. To determine partner's emotional condition and level of emotional functioning, respondents rate how often within the previous two weeks they felt "sad or depressed," "helpless or insecure," and "frustrated or angry." A higher score on the QOL-SP indicates more optimal functioning. Sample alpha was .92
Illness intrusiveness was measured with the 12-item Illness Intrusiveness Rating Scale (IIRS) (Devins, Hunsley, Mandin, Taub, & Paul, 1998). The IIRS assesses illness-induced lifestyle disruptions that challenge and impede continued patient-family participation in valued interests and activities (Devins et al.). Respondents rate the degree to which their partner's illness and its treatment interfere in various areas of their life, including health, work, financial situation, family relations, and sex. Researchers have used the IIRS in research with breast cancer (Bloom, Stewart, Johnston, & Banks, 1998) and other chronic illnesses (Devins et al.). A higher score indicates more illness intrusiveness. Alpha was .88.
Dyadic coping was measured by self-report using five subscales of the 61-item Dyadic Coping Scale (DCS) (Bodenmann, 1995; 1997). Although it has never been used with couples coping with chronic illness, the DCS has been validated with more than 1,000 couples in several studies. Three of the five subscales were used to measure positive dyadic coping (dyadic stress communication, common dyadic coping, and positive dyadic coping). The five-item Dyadic stress communication subscale assesses one partner's ability to communicate emotion and problem-focused stress to the other partner, and the extent to which each partner avoids communicating stress. A higher score means better communication of a partner's stress. Alpha was .63. Common dyadic coping (CDC), assessed with 13 items, measures how both partners participate in the coping process in a relatively symmetrical manner to handle a problem or an emotion-focused issue facing the dyad. A higher score indicates more CDC behaviors. Alpha was .84. The third subscale, Positive dyadic coping (PDC) (30 items), examines perceptions of respondent's and partner's use of supportive dyadic coping strategies, such as giving advice, providing practical help, consoling, and being understanding. Positive dyadic coping strategies are used by one partner attempting to assist the other partner during a time when the partner is unable to sustain or restore an adaptive state (Bodenmann, 1997, p. 138). Higher scores indicate the use of more positive coping practices. Alpha was .95. The remaining two subscales (hostile dyadic coping and avoidance dyadic coping) were used to measure negative coping patterns. Partners use Hostile dyadic coping (HDC) (9 items) when the stress signals of one partner generate hostile responses from the other (that is, distancing, ridicule, sarcasm, obvious disinterest or minimizing the level of the partner's stress). Higher scores indicate more hostile coping responses. Alpha was .76 for the study sample. Finally, Avoidance of dyadic coping (ADC) measures coping responses consistent with ambivalence and insignificance. Bodenmann (1997) refers to "ambivalence" as dyadic coping contributions that lack motivation and to "insignificance" as offers of superficial support or the absence of authentic engagement. Higher scores on this subscale indicate the use of more avoidance behavior. Alpha was .73.
Control variables included length of relationship (that is, duration of current marital or nonmarital relationship); number of children; three categorical variables (education level, household income, and religious preference); illness demands; and depression history (that is, "Were you ever treated for depression?"). A subscale of the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) (Cella et al., 1993) was used to measure patients' physical symptoms (illness demands control variable). The wives'/partners' (N = 71) completed the Patient Physical Well-Being (seven items) subscale, which includes items such as: "I have a lack of energy" and "I am bothered by the side effects of treatment." In their study with 466 cancer patients (39 percent with breast cancer) to validate the FACT, Cella and colleagues calculated an alpha of .82. Alpha for the patients' subsample in this study was .89.
Depression history was operationalized with the dichotomous question, "Have you ever been treated for depression?" Earlier research (Gotay, 1984; Maguire, 1981; Oberst & James, 1985) reported that depression can affect a person's psychological makeup and influence personal unhappiness, happiness, or both. Men are less likely to seek treatment for depression; therefore we assume that when men do seek treatment their depression levels are likely to have reached greater severity. That same research (Gotay; Maguire; Oberst & James) has suggested that depression affects an individual's ability to provide or receive support in a relationship. Based on such findings, we expect that men who report having received treatment for depression in their past will report lower levels of emotional well-being, more illness intrusion, and less supportive relationships.
To examine the impact of dyadic coping on men's psychosocial adjustment to their partner's newly diagnosed breast cancer, two hypotheses were examined: ( 1) Male partners of breast cancer patients who report higher levels of positive dyadic coping strategies will report higher levels of adjustment, and ( 2) Male partners of breast cancer patients who report higher levels of negative dyadic coping strategies will report lower levels of adjustment.
Pearson zero-order correlations were calculated using all predictor, outcome, and control variables. A series of multiple regression equations tested the effects of emotional well-being and illness intrusiveness on the various dyadic coping strategies.
Findings from the bivariate analysis yielded a number of significant relationships (Table 1). Patients' physical well-being (illness demands) was associated positively with men's emotional well-being (.29) and negatively with illness intrusiveness level (-.31). At the same time, ill partners' physical well-being was associated negatively with men's negative dyadic coping. Longer relationship length was correlated with less illness intrusiveness, lowered occurrence of depression, and higher levels of partner's physical well-being. Relationship duration was also associated with men's ability to communicate dyadic stress and their use of hostile dyadic coping. There was no association between relationship length and avoidance of dyadic coping. Men who were treated for depression before the breast cancer diagnosis reported lower emotional adjustment and more illness intrusiveness and used fewer positive coping strategies. Finally, men with a history of depression used more hostile (.38) and avoidant (.36) dyadic coping patterns.
Hypothesis 1: Male partners of breast cancer patients who report higher levels of positive dyadic coping strategies will report higher levels of adjustment. Six regression models were used to examine whether higher levels of positive dyadic coping predicted higher levels of men's adjustment (Table 2). None of the models achieved statistical significance for predicting either emotional well-being or illness intrusiveness; however, the control variable for men's history of depression was significant in the three models with emotional well-being as the outcome variable (Model 1: B = -.425,p < .01; Model 3: B = -.393, p < .01; and Model 5: B = -.320,p < .05). Hypothesis 1 was not supported by the data.
Hypothesis 2: Male partners of breast cancer patients who report higher levels of negative dyadic coping strategies will report lower levels of adjustment. Four models tested Hypothesis 2 (Table 3). The first two regression models with hostile dyadic coping and avoidance of dyadic coping levels as predictors of the men's emotional well-being were insignificant. In both equations, the depression control variable attained statistical significance (Model 1: B = -.293, p < .05 and Model 3: B = -.266, p < .01). Model 2, with avoidance of dyadic coping as the predictor and illness intrusiveness as the outcome, was not significant. However, hostile dyadic coping level was a key predictor of illness intrusiveness (B = .312,p < .05). This model accounted for nearly one-third (.329) of the variance in illness intrusiveness. The significant inverse relationship between men's level of hostile dyadic coping and their level of illness intrusiveness provided partial support for Hypothesis 2.
The results showed that increased levels of hostile dyadic coping patterns predicted poorer adjustment in relation to higher illness intrusiveness. As earlier research (Maguire, 1981; Wellisch et al., 1978; Sabo, 1990; Sabo et al., 1986) suggests, men may have been dissatisfied, frustrated, or unhappy with their coping responses to their partners' illness. The impact of coping with their partners' breast cancer negatively affected other aspects of their lives, such as work and sleep, as well as aspects of their relationship, such as their sex lives and relationships with other family members. This finding may reflect a pervasive negativity and helplessness response to the illness by some men (Maguire; Wellisch et al.) that leaves them feeling overwhelmed by their circumstances. These men could likely experience serious physical and emotional difficulties given a combination of negative coping and high illness disruption.
The inverse relationship found between depression and men's decreased use of positive coping behaviors was not surprising. Essentially, two of the positive dyadic coping patterns--common and positive dyadic coping--require a relationship-focused approach to problem solving and when interacting with partners. However, given the challenges of their illness, depressed individuals typically cannot maintain this perspective due to feelings of isolation and disengagement.
A cross-sectional design was used to assess the men's adjustment. Because coping with and adjusting to breast cancer is an ongoing process, adjustment levels can fluctuate even over short periods of time. To best capture men's adjustment, we recommend a longitudinal design that includes several measurements over a longer time period following the patient's diagnosis.
The sample composition--primarily white, middle-class, educated men--is a limitation. To some extent, this homogeneity is related to recruitment methods. Although recruitment sites were chosen with sample diversity in mind, fewer couples from the site that serves the more racially, ethnically, and socioeconomically diverse populations agreed to participate in the study. To increase sample diversity, researchers should consider including a community outreach component that incorporates breast cancer couples from neighborhood centers, churches, and community health centers, with the goal of recruiting more African American, Asian American, and Latino men and more diverse groups of white men.
Another possible selection bias that may have contributed to lack of diversity was that recruitment materials were printed in English. Although interpreters were available, they were not involved in the initial contact phase with potential participants. In addition, using a letter as the initial recruitment tool presupposed that potential participants could read and understand it. Future studies should provide multilingual recruitment materials and provide easier accessibility to interpreters who can assist a broad spectrum of non-English-speaking couples. Allowances should also be made to accommodate potential participants who may be illiterate or otherwise challenged by situations that could hinder their participation.
Because our health care system will likely continue to relocate the burden of health care to partners and families of breast cancer patients, social workers and other practitioners must develop increased understanding of how to work effectively to assist patients' partners. Our findings emphasize the need to work with patients and partners conjointly to increase positive couple coping strategies. First, such interventions can help men and their ill partners identify existing positive and negative coping patterns within their relationships. Once identified, evaluation of the effectiveness or harmfulness of negative coping patterns can be addressed, leading to elimination of negative coping patterns. Finally, interventions could allow couples to experiment with positive coping styles within the protection of the therapeutic environment before implementing them in their personal lives. As Kayser, Feldman, and colleagues (2000) suggested, a conjoint approach in interventions with breast cancer couples can enhance their dyadic coping and also enhance men's adjustment.
Social workers should also design interventions to help couples in younger relationships who have not had the opportunity to develop and grow their relationships over time. The impact of breast cancer can be more severe for these couples who may also be younger in age and thus in the earlier childrearing years. Such couples may also need to develop more relationship-building skills and may be more overwhelmed by the demands of breast cancer. There is little research that addresses breast cancer issues for younger couples.
The results depicting increased hostile coping as a forecaster of increased illness intrusiveness indicate that practitioners should develop interventions that target middle-age and older couples. Middle-age and older couples expect to be in transitional phases of life that include the launching of children and retirement. Re-evaluation of personal and relationship goals by each partner during these transitions can evoke expectations of increased leisure activities. However, the demands of breast cancer may cause some men to feel "cheated" when plans (for example, travel or relocation) must be delayed or abandoned (Rolland, 1994b). Unhappiness and bitterness related to the disease may be reflected in their hostile coping patterns and poor adjustment levels.
We encourage practitioners to develop interventions that recognize the needs of unmarried couples. Coping with breast cancer presents different issues and challenges to unmarried men and their partners. For example, concerns about relationship commitment may be heightened, thus increasing anxiety and stress for both partners individually and conjointly. Also, unmarried couples may feel and actually be stigmatized by health care professionals who make moral assumptions about lifestyles based on a couple's marital status.
The findings indicating men's tendencies to inflate their adjustment levels suggest that couples' support groups that focus on the meaning of the cancer experience could benefit men and their ill partners. Findings also highlight the importance of developing interventions for men who become depressed while trying to cope with their partner's breast cancer diagnosis. As Sabo and colleagues (1986) noted, some men minimize or deny their symptoms of depression, and others might be reluctant to report such symptoms. They found that groups could facilitate examination of the denial process and its roots in social patterns that perpetuate the provider-protector role of husbands. In group sessions, men and their spouses were better able to discuss how men's denying and hiding fears precipitated anxiety and sadness for themselves, while simultaneously triggering anger and disappointment in their wives. In general, the many therapeutic functions provided by the group experience have the potential to stimulate and enhance illness-related communication. For men reluctant to participate in couples counseling, the group format provides a viable alternative or could serve as an additional means of support in conjunction with other modes of therapy.
Overall, coping with breast cancer is a family task, and men need help adjusting to their partners' illness. As improved diagnostic capabilities and treatment advances are bringing more couples into the world of breast cancer, social workers must play a vital role in the enhancement of their well-being. Given the meaning of this study's findings for practitioners, the significance of social workers' abilities to deliver specialized assistance and care to breast cancer couples and the patients' partners cannot be understated. Clearly, social workers have long been key providers of mental health services to chronically ill patients and their families (Society for Social Work and Research, 2000). The biopsychosocial focus embodied by the profession promotes recognition of the significance of a partner's support in the adjustment and well-being of a woman suffering from breast cancer. The dyadic perspective allows social workers to acknowledge the potential influence of dyadic coping on men's adjustment.
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Coordinating Author/Instructor: Tracy Appleton, LCSW, MEd
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