This is to certify that the: thesis en titled THE EFFECT OF GROUP MUSIC ON COPING, PSYCHOSOC IAL wwwwcggmw OF LIFE FOR WOMEN WIIH BREAST presented by bdARGARE'I‘ FURIOSO h 5 been accepted towards fulfillmen t a of the requirements for MASTER OF MUSI_C_degree in—1‘4-USI~CTLERAPY Wf fl f \— Major prOfessor 25" 9,00 :2. Datew L M S U is an Amflmm've Action/Equal Opportunity Institution 0-7639 M LtBFfifi-y “Mchigantmaua U n Iversity PLACE IN RETURN Box to remove this checkout from your record- TO AVOID FINES return on or before date due. MAY BE RECALLED with earlier due date if requested. L DATE DUE DATE DUE | DATE DUE D913ok " 10am ‘90“ w E3) 9 f1 420% w ‘7 ' VA AUG 2;;11903 o 5 —"T \ —_.. “ *— —-....__ _._._.__.-....—.~ \ SEP'S‘S, gone 5’ 3. 6/01 cycrrue/0mg”.my»p 15 —\ THE EFFECT OF GROUP MUSE THERAPY m 0; LEE ON COPING, PSYCHOSOCIAL ADJUSTMENT, AND QUAL FOR WOMEN WITH BREAST CANCER By Margaret Furioso A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree 0 f MASTER OF MU S IC School of Music 2002 ABSTRACT , QUA FOR WOMEN WITH 3 REAS CAN 1 IF '1‘ (3BR By Mar garet F urioso Bre w m n ast can ' cer 1sth eleadin g form of ' mallgnancy in American 0 e smt'SfiCS 'ndiC t6 ; ‘ 1 a thati ts 0c currence ' contm ' ues to increase (American C ancer Society 2000) M . ’ . usxc thera ' El py Int rv e entions th 0 0 at addr ess psychological rea ti b us to reast c ancer may have impact 0 tic I'CSpons e . 15 research lsease pro a Was gr - . ( ges 33 to to dOCumem ch _ esslon and rognosvs. 74 years) Who parti , anges In five wom P c1 a . . e mu . SIC ther . apy SesSiOfls' Measur- es used we re: (a) Th e Mental Adjustment to C ancel‘ Seal e (MAC) (1) , ) Th6 Perceiv ed Stress Scale (PSS C ntr S HI C Quah oflife Index C ), (c) The Health Locus 0 , ancer Version (QLI-C) T t f o 01 cale( ) ty . - ests reveal , ed A (d) The grou ° Q ps Signiflc d o antly im prove t tal ' quality of life (p% 00 ) d that C Si - 7 an h Calthan d fill) 60= 0 ' 1 9) as m easur HLC ed on the . linical th QLI-C. No difference ‘3 , "n th C emes w ' ° 8 amp}, ere Identlfied and di ere f0 d f scussed of the M . 0‘ ””13 1 SS : and Copyright by MARGARET FURIOSO 2002 TABLE OF CONTENTS ...... vi LIST OF TABLES ............................................................... x CHAPTERI _ .................... 3 REVIEW OF LITERATURE AND RELATED RESEARCH ............................... s Mind-Body medicine ........... . ............................................................. 7 Psychoneuorimmunology and cancer ........................................................ 8 Stress anddlsease ........ 9 Stress and cancer ........................................................................... 1 2 Stress response and gender .................................................................. l 2 Psycho-oncology.................................- .............................. \4 Coping and cancer ................................................................. . . ,...\ 6 Copingstyles ............................................. A8 Psychological adjustrnentto cancer........... - - - . . . 26 Empowermentandgrouptechmque8~~~~~~°""'......... .. 29 Music therapy and cancer - - ----' . . . . ”3‘ Music therapy and breast cancer............... - . ----- ........................ 33 Improvisation ............ . ................................. . .. """"""" 3A Empowermentandmuswtherapy.............-.-...--- - Purposeandresearchquestions.................. -....--" ~ ' CHAPTERz ,...35 METHOD ................................................................................. , ...... Participants ...................................................................... - ‘ W36 Recruitment of participants ................................................... ,_ ‘ 36 Consent and approval .......................................................... . . Procedure ........................................................................ ‘ \W36 Session protocol ....................................................... ~ \ Dependent measures ....................................................... . - . W37 Mental Adjustment to Cancer Scale ................................ . \ . . 37 Perceived Stress Scale ............................................. ‘ ‘ Health Locus of Control Scale ...... . ................................ ‘ . ”"38 Quality of Life Index, Cancer Versron- . ........................... ‘ .--....38 Materials ................................................................... .~-.,39 .............. -..39 CHAPTER3 ------ ..3399 RESULTS ..................................................................... Data analy51s ................... Sociodemographic vanablesgo Mental Adjustmentto CancerScale.............................“Him.................:4g Perceived Stress Scale ..................................................................... 41 Health Locus of Control Scale .................................................... 42 Quality of Life Index, Cancer Version ................................................... 43 Post-study participant interviews .................................................. 43 .................... 44 iv Clinical themes .............................................. ................... , . “”46 CHAPTER 4 DISCUSSION AND CONCLUSIONS - - ............................. Clinical themes ............................................................................ 47 Vitality..................... """""""""""""""" 50 .. Risk-taking ............................................................................ :10 Loss of control ......................................................................... 52 Self-empowerment ....................................................................... 54 L1m1tat10ns$5 Recommendations for future studies .................................................... 57 REFERENCES ...................................................................................... 60 APPENDIX A Recruitment/Informational flyer .......................................................... 72 APPENDIX B Consent Form ............................................................................... 73 APPENDIX C Raw Scores .................................................................................. 75 APPENDIX D Sociodemographic Questionnaire ........................................................ 76 LIST OF TABLES Table 1. Means and standard deviations for Scores on the MAC subscales ..................... 42 Table 2. Means and standard deviations for Scores on the PSS ....................................... 43 Table 3. Means and standard deviations for Scores on the HLC ...................................... 43 Table 4. Means and standard deviations for scores on the QOL ...................................... 44 vi CHAPTER I REVIEW OF LITERATURE AND RELATED RESEARCH Although it is commonly though t Of as 3 singje disease, cancer is a term used to describe over 200 different diseases (DOIInger & Rosenbaum, 1997). There are, however, features common to all types Of cancer, including the uncontrollable grth of cells and the accumulation of abnormal cells (Cancer Facts & Figures, 2001). While normal cells reproduce in accordance with preprogrammed genetic rules in a predictable fashion, cancer cells proliferate in an unpredictable fashion. Cancer cells grow in disorderly ways, divide more rapidly than normal cells and mature in abnormal ways (Kupchella, 1992). Although cancer is typically identified according to organ systems, such as breast, colon or lung cancers, cancer is in reality, a disease of cells (Cooper, 1995). Malignancy refers to the process by which cancer cells accumulate in the body and form tumors (The Bantam Medical Dictionary, 1990). Any abnormal tissue mass that extends beyond the boundaries of normal tissue is called “neoplasm,” a term meaning “new growth.” Malignant neoplasms have the potential to destroy the host. The common term for all malignant neoplasms is “cancer” (Pfeifer, 1997). A malignant tumor invades and destroys the tissue in which it has originated. If the malignant process is not aborted, cancer cells can spread to other parts of the body via the bloodstream and lymphatic system. This spread, or metastasizing, of abnormal cells, can affect vital Organs and body systems and may eventually lead to death (N ezu, Nezu, Friedman, Ffclddis, & Houts, 1998). ’ w According to statistics for 2 00 1 ’ cancer was the second leading cause 0 Pdeatfi 1}] the United States, surpassed only by heart disease (Greenlee, Hill-Hannon, Mun”, & Thun, 2001). One out of every four deaths in the United States is cancer related. In 2001, cancer statistics estimated that 1 :268, 000 new cases of invasive cancer would be diagnosed in the United States (Greenlee etal., 2001 ). Men are statistically at a higher risk for cancer than women and are most commonly diagnosed with prostate cancer, while breast cancer is the leading form of malignancy in women (American Cancer Society, 2000). Among ethnic/minority populations, African Americans have the highest cancer incidence rates and are about 33% more likely to die from cancer than are whites (Bal, 2001). The American Cancer Society estimated that there were approximately 7.4 million Americans living with cancer in 1997 (American Cancer Society, 1997). Some of these survivors were thought to be “cured,” while others continued to exhibit evidence of the disease. There has been an overall improvement in survival rates for those diagnosed with cancer. In the early 20th century, the majority of people with cancer were expected to die. Today, approximately four in ten cancer patients are expected to survive for at least five years following diagnosis (American Cancer Society, 2000). The five - year survival rate is commonly used as the standard for measuring treatment outcome. Currently, the five year relative survival rate for all cancers combined is 60% (Cancer F acts & Figures, 2001). The chances of surviving the second five years are better than Surviving the first five years following diagnosis for most, but not all, cancers (Goldman, 1 997). Cancers are divided into stages as a means of determining how far the disease has pmgressed. Five stages of cancers. delineated 0 - IV, are used to identify the 8D the disease. The higher stages indie ate the more advanced progression. In the earZadOf stages, a cancer Will most likely be small in size and confined to a primary Site. Cancers in advanced stages are larger and may haVe metastasized to other organs. At the time of diagnosis, 3 person with cancer may be at any stage ofthe disease. Prognosis is considered better when diagnosis is at early stages, so the importance of early detection is considered crucial for successful treatment outcome. Screening for cancer and early interventions may be factors that contribute to declining rates of cancer deaths in the United States. If malignancy is detected in early stages, the prognosis for long-term control is more hopeful (Mahon, 1998). The goals for cancer treatment can be identified within three categories: (a) cure, (b) control, and (c) palliation (N ezu et al., 1998). Certain cancers have more successful cure rates, particularly skin, cervical and testicular cancers (Otto, 1997). When it is determined that a cure is impossible, therapy for control or containment of the tumor is implemented. When containment of the tumor becomes impossible and it becomes apparent that treatment is no longer effective, palliative care is directed toward the relief of symptoms, pain control, and the comfort of the patient. There are a number of risk factors involved in the etiology of cancer. The multifactorial etiology of cancer indicates that there are both endogenous and exogenous sources involved (Mahon, 1998). These causes of cancer may interact in ways that continue to impact on the treatment approaches and outcomes. Mind-body medicine Traditionally in Western biomedicine the human body was viewed as a machine. ' ' u ' ” i . When this machine broke down, as n the dlsease Process the biomedical pe , 1‘8 . pact/V6 focused on the repair and restoration or the pans. Usually single, physical 031133.; were sought. The goal of biomedicine concentrated on the identification of a primary cause of disease, so as to isolate and better control it. The mind was usually not identified as a contributing etiological factor in diseaSe and, when considered, was assigned a peripheral role in the generation and progression of pathology (Cunningham, 1995). The role of the mind in the disease process has been increasingly documented (Goleman & Gurin, 1993; Cohen, Tyrell, & Smith, 1991; Antonovsky, 1979; Weiner, 1977). The mind-body connection emphasized a healthy state of mind as intrinsic to a healthy body. The holistic, mind—body approach to healing is related to the maintenance of health as well as to the treatment of disease, particularly in regard to cancer (Miller, 1995). There are three converging areas that explore scientific evidence for the mind’s influence on the body. These areas of research are: (a) physiological research, which explores the biological and biochemical interactions between the brain and the systems of the body; (b) epidemiological research, which explores connections between various psychological factors and specific illnesses; and (c) clinical research, which explores the effectiveness of mind-body approaches in the prevention, alleviation and treatment of diseases (Goleman & Gurin, 1993). Emerging from research on the mind—body connection, the field of medical science known as psychoneuroimmunology (PNT) considered interpersonal and emotional factors that impacted on cancer etiology as well as its progression. P Sychoneuroimmunology concerned itself with the complicated interrelationships among the “gimme system, the central nerV 011s SyStem, the hormonal system, and the th' . Illdto each other. 30th psychologists and medlcal rfisearchers have accumulated a body of knowledge indicating the human bOdy is aged“ by PSYChological phenomena. This dramatic but incomplete evidence also ascertained that the body’s ability to contra 1 symptoms and survive life-threatening illnesses might be controlled by psychological factors (APA HelpCenter, 1995). One Of the main areas of focus in PM research is the exploration of psychosocial influences on health. Even though PM is a relatively new scientific discipline, it has begun to explain mind-body interactions (Greer, 1999). Within the last 40 years, ongoing research explored the influences of psychosocial and behavioral variables on the immune system (Bovbjerg & Valdimarsdottir, 1998). In early studies, both Solomon & Moos (1964) and Ader & Cohen (1975) indicated that immune response could be conditioned in rats. Engel (1977) outlined the biopsychosocial model of medicine, adding psychological and social processes to the biomedical model. He proposed that states of mind impacted on physiology and interacted with biological processes, resulting in changes in the disease process. According to the biopsychosocial model, various states of mind could impact significantly on physiology. These “stressors” could then contribute to pathological changes in organic disease through interaction with biological processes. A meta- analysis by Herbert & Cohen (1993) found that immune functions in cancer studies were .3" probably altered by a variety of life events. PSychoneuroimmunology and cancer According to the immune surveillance hypothesis of cancer, the immune system ___ . played a role in the prevention Of cancer. This theory suggested that cancer cell continuously forming in the bOd)’, but due t0 the immune system ’s ability to reco;1: foreign material, these potential tumorS are destroyed (Goleman & Gurin, 1993). Some researchers thought that when the nawr a1 killer (NK) cells were suppressed or inactive, an individual may become more susceptible to cancer (Kiecolt-Glaser & Glaser, 1993). It appeared that psychological factors affected immunity, but how they affect cancer remains a question. Some researchers believed that it was not likely that psychological processes played a significant role in all cancers; however, they recommended study of those patients in which hormonal and immunological factors are primary, such as breast cancer (Greer, 1999). Psychoneuroimmunology has generated much skepticism and some immunologists have questioned its entire basis, stating that a direct connection between the immune system and the nervous system is not apparent (Langrnan & Cohn, 1993). The precise role of the immune system’s function is unconfirmed at this time (Greer, 1999). Despite the developments in PNI research, hard evidence to confirm immunological changes as the thread connecting emotions with cancer has yet to be proven. A study indicated no relationship between disease outcome for women with breast cancer and psychological symptoms (Tross, Hendon, & Korzun, 1996). Several randomized trials indicated no differences in survival for cancer patients receiving psychosocial interventions (Cunningham, Edmonds, Jenkins, Pollack, Lockwood, & Wan, 1998; Ilinyckyj, Farber, Cheang, & Weinerman, 1994; Linn, Linn, & Harris, 1982). I)GSpite conflicting evidence, there is general agreement that more research is needed to prove the importance of PNI and that research in this field remains in its infancy (Bovbj erg & Valdimarsdottir, 1998). Stress and Disease Researchers explored the phenomenon of stress in its relationship to general health and its effect on immunological processes of the body (O’Leary, 1990; Kielcolt- Glaser & Glaser, 1992). Although there are varying definitions of stress, there is 90118 ensus that stress is viewed as a negative experience inducing biochemical, Physiological, and behavioral changes (Baum, 1990; O’Leary; 1990; Young, 1980). Despite the conventional view of stress as a negative phenomenon, the arousal that is produced by stress might be considered adaptive if it insti gates coping mechanisms that either eliminate the stressor or mitigate its impact (McCaul, Sandgren, King, O’Donnell, Bran stetter, & Foreman, 1999). The concept of stress was first introduced by Hans Selye (1936). Selye (1974) later suggested that stress could produce both positive and negative responses, depending on individual circumstances and personality factors. According to O’Leary (1990), the phenomenon of stress has increasingly been explored in its relationship to general health and tlle immunological processes of the body. Taché (1986) suggested that arousal pIOduced by stress in the biochemical and physiological processes when maintained for extended periods of time may set the stage for the development of disease. In the meta-analysis by Herbert & Cohen (1993), depression was indicated as a {actor in increased susceptibility to immune-mediated diseases. Herbert & Cohen’s findings indicated reductions in in-vitro measures of cell-mediated immune function, 51,ecifically, proliferative responses to T-cell mitogen and natural killer cell activity (NKCA). Stone and Bovbj erg (1994) reported that humoral activity, or antibody production, was affected by stressors. An author found that repeated activation of the hypothalamic- pituitary-adrenal axis in response to stress produced immunosuppression in human subjects (Spiegel, 1999). Some researchers believed that chronic stress was responsible for impaired immune functioning (van der Pompe, Antoni, Visser, & Garssen, 1996). Despite the strong support for a connection between stressors, emotional distress and Changes in immune function, there are difficulties in claiming causal relationships between stress and compromised immune functioning (Kielcolt-Glaser & Glaser, 1988). Stress and cancer Some research suggested a causal link between stress and vulnerability to diseases, particularly cancer (Werrners, Dasgupta, & Dubey, 1986). Studies found corre I ations between emotional factors and the progression of breast cancer (Greer, Morri s, Pettingale, & Haybittle, 1990; Levy, Herberrnan, Lippman, & D’Angelo, 1987). An author suggested that cancer itself consisted of a series of stressors, including a threat to life, social changes, possible economic hardships, and response to treatment itself (SPie gel, 1999). Other research suggested that the stress responses associated with the diagnosis of cancer may accelerate the progression of the disease (McEwen, 1998). High levels of cortisol, an identified stress hormone, indicated poorer prognosis for Women with breast cancer; specifically, shorter survival times were reported (Audier, \988). Greer (1999) postulated that emotional and psychological factors resulting from W355 might influence homeostatic controls in breast cancer cases. There are contradictory findings in studies of the relationship of stress to the development and progression of cancer (Fox, 1998). Several studies indicated a positive relationship between stress and cancer etiology or progression (Courtney, Longnecker, Theorell, & deVerdier, 1993; Geyer, 1991; Ramirez, Craig, Watson, F entiman, North, & Rubens, 1989). Other studies indicated no relationship, or possibly an inverse relationship, between stress and cancer (Edwards, Cooper, Pearl, deParedes, O’Leary, & Wilhelm, 1990; Priestrnan, Priestrnan, & Bradshaw, 1985). A meta-analysis supported only a modest association between psychosocial factors, including stress, and the development of breast cancer (McKenna, Zevon, Com, & Rounds, 1999). The authors identified connections between certain personality characteristics, psychosocial factors and disease, but cautioned that association is not causation. Other research indicated it was unlikely that psychological factors played an important part in the course of most cancers (Greer, 1999). Greer noted that more research on the multiple variables is needed to identify personality and life events in the devel meent of cancer and that this entire area of study merits further exploration. Stress response and gender Some findings indicated there may be differences in stress responses between males and females. A research team at the University of California at Los Angeles developed a new stress paradigm for women (Taylor, Klein, Lewis, Gruenewald, Gurung, 3‘ Updegraff, 2000). The differences in gender response may be partially due to the more tecent inclusion of women in human stress studies. Before 1995, in laboratory studies of Q‘misiological and neuroendocrine responses to stress, women subjects comprised only 17% of the total populations studied. Since 1995, there has been 5‘ mOvement to redress this imbalance; an effort to address women’s physiological and neuroendocrine responses to stress resulted in a new theory in stress studies. When both animal and human research was performed exclusively on male samples, the accepted response to stress was identified as “fight or flight - ” The new model maintained that although the physiologic reaction to stress remained similar in males and females, the behavioral response differed greatly. The researchers maintained that for women, rather than the fight or flight response, the “tend and befriend” pattern was evident. Tend and befriend response theory proposed that fema 1 es responded to stress by protecting themselves and their young through nurturing behavior (tending), and forming alliances with larger social groups, in particular among other vvomen (befriending). In contrast, males showed less likelihood of tending and befriending and exemplified typical fight or flight responses. Although the researchers acknowledged the basic neuroendocrine core of stress respon ses differed minimally between males and females, they argued that fight or flight response did not account for challenges faced by females. These specific challenges dealt primari ly with maternal investment in offspring. The demands surrounding pregnancy, lactation and care of the young would render fight or flight behavior impractical as well as pOtentially dangerous. If a mother were to engage in fight or flight responses, these behaViors might jeopardize the safety of her offspring. In order to inhibit behavioral tendencies to flee, neuroendocrine mechanisms may have evolved to inhibit such behavior. Stress responses that allowed females to protect both themselves and their Q«wring would be vital. 10 The researchers explored the Possibility of a neuroendocrine basis for such inhibition. Their speculation was that oxytocin and its modulation by estrogen may control stress responses. Oxytocin is a posterior pituitary hormone released in response to a number of stressors and is associated with the parasympathetic system. In animal studies, oxytocin was found to enhance relaxation, reduce anxiety and decrease symp athetic arousal. Some researchers found that oxytocin reduced stress in humans by inhi b iting the release of glucocorticoids (Chiodera, Salvarani, Bacchi-Modena, Spai lanzani, Cigarini, Alboni, Gardini, & Coiro, 1991). They speculated that estrogen may enhance the anxiety-reducing aspects of oxytocin. Not only do human females engage in tend and befi'iend behaviors in response to stre ss , but they are also likely to seek out and receive more support from other females. Contact with other supportive females appeared to down-regulate sympathetic and neuro endocrine responses to stress as well as aid in the recovery fi'om physiological effects of acute stress (Taylor et al., 2000). In the University of California study, the researchers cautioned that the biological underpinnings of behavior should not be interpreted as reductionist or biologically determined. They referred to biology as a central tendency rather than as destiny. They concurred that biology intersects with social, cultural, emotional, and cognitive variables and mat biological and social roles are interwoven in a tangled web. The importance of this research may have implications for interventions for W 0men with breast cancer. Since breast cancer presents an unquestionably stressful situation for women, interventions that modulate the harmful effects of stress may have beneficial applications. The researchers emphasized that “an appropriate and modulated 11 stress response is at the core of SurViVal” (p. 411). In a study of group interventions with women with breast cancer, a healing factor was attributed in part to the giving and receiving of support (Coward, 1998). If the tend and befriend response is activated in women with breast cancer, interventions that provide opportunities to give and receive support, particularly in group settings, may enhance salutary possibilities. Psycho-oncology There is an expanding body of research that identifies psychological, social and behavioral factors effects on the course of cancer (Rowland, 1994). The developing Clill i cal and research field of psycho-oncology (also called psychosocial or behavioral onco logy) has responded to changes in modern oncology settings. Psycho-oncology focus es on two major areas: (a) the impact of social, behavioral and psychological factors on the course of cancer, including onset, detection and progression, and (b) the exploration of the effects of cancer on the physical, psychological, social and spiritual funct i oning of cancer patients, their families, caretakers and care providers (H011 and, 1998). Mind-body interactions are the main focus of interest in psycho- onCOIOgy. These interactions are considered “ . . . a process with continual, mutual interaction and effect that influences coping, psychosocial adjustment, and quality of life” (LCSZcz & Goodwin, 1998, p. 246). Coping and cancer A considerable amount of research in psycho-oncology was concerned with coping styles and affective responses to cancer (Watson & Greer, 1998). Some rasearchers pointed out that it may not be stress itself that is immunosuppressive, but 12 IS opt (Cal 199. inhn: cane Cont thec Ol'ef rather stress combined with poor coping responses (Watson, Pettingale, & Greer, 1985) Greer ( 1 999) surmised that coping style is the psychological factor that most frequently affected cancer outcome. An increasing number of researchers have addressed the problems of coping with life threatening diseases (Folkman, 1999; Greer, 1999; Lazurus & Folkman, 1984). Women with breast cancer who are exposed regularly to stressful situations may mediate the negative consequences by the types of coping styles they employ (Cooper & Faragher 1993 ) - A study of adjustment to breast cancer in early-stage patients indicated that Optimism generally predicated feelings of well being and better coping mechanisms (Carver, Pozo-Kaderman, Harris, Noriega, Scheier, Robinson, Ketcham, Moffat, & Clark, 1994)- Another study concluded that women with breast cancer tended to be emotionally inhib i t ed (Watson, Pettingale & Greer, 1985). This study also indicated that the breast cancer group tended to respond to stress by employing repressive coping styles and anger contro l - In this study, the women with breast cancer were more emotionally labile than the control group; however, they presented clinically as being in control, perhaps even over controlled. Age was also studied in reference to coping styles (Compas, Franken Stoll, Harding Thomsen, Oppedisano, Epping-Jordan, & Krag, 1999). The researchers suggeSted that near the time of diagnosis, younger women tended to respond with poorer adaptiVe coping methods. This study also suggested that the expression of emotion in response to a breast cancer diagnosis was adaptive when it resulted in women’s greater wflation and insight into their illness. This process of catharsis combined with insight i 13 is typically the goal of therapeutic interventions by clinicians. A conclusion of this stud 3» proposed that a coping response characterized by the pure ventilationof emotions may lead to more emotional distress. The researchers emphasized the importance of appropriate interventions designed to assist women toward adaptive coping. This study also recommended age-heterogeneous therapy groups for women, since older women tended to demonstrate better coping skills. Older women may serve as adaptive models for younger women. In a study conducted by Keller (1998), younger women experienced higher levels of distress than older women, indicating that age may be a factor in treatment planning. Coping styles In the past twenty years, coping has gained prominence in the study of stress and illness due to the growing evidence, previously suggested by Lazurus (1982), that coping styles may impact on morbidity and mortality. Adjustment behaviors may be relevant to cancer outcomes, since specific coping styles were significantly associated with optimistic prognoses (Watson & Greer, 1998). In order to identify coping styles, a self-rating questionnaire, the Mental Adjustment to Cancer (MAC), was developed to measure coping styles (Watson, Greer, Young, Inayat, Burgess, & Robertson, 1988). These coping styles were identified in five major categories and have been referred to in many studies in psycho-oncology: (a) fighting spirit, (b) avoidance or denial, (c) fatalism or stoic acceptance, ((1) anxious Preoccupation, and (e) helplessness/hopelessness. Fighting spirit referred to the patient who responded to the diagnosis of cancer in 14 ° ~V an active coping manner, adopting an optimistic outlook on the disease, with determination to fight the disease and to participate in treatment decisions. Several studies were related to longer survival for patients who adopted a fighting spirit (Greer, Morris, & Pettingale, 1979; Greer, Mon'is, Pettingale, & Haybittle, 1990; Hislop, Waxler, Coldman, Elwood, & Kan, 1987; Morris, Pettingale, & Haybittle, 1992; Nelson, Friedman, Baer, Lane, & Smith, 1989; Pettingale, Morris, Greer, & Haybittle, 1985; Thomas, Turner, & Madden, 1988). Avoidance or denial referred to patients who responded to cancer by minimizing the seriousness or avoided thinking about the disease by creating distractions. At times, patients rejected the diagnosis altogether. Several studies indicated significant positive relationships between avoidance and good disease outcome (Dean, & Surtees, 1989; Greer etal., 1979; Greer et al., 1990; Morris et al., 1992; Nelson et al., 1989). F atalism or stoic acceptance referred to patients who responded to cancer by accepting the diagnosis and adopted a fatalistic attitude. This coping style was significantly related to poor disease outcome (Greer et al., 1979; Greer et al., 1990; Morris et al., 1992;Pettinga1e et al., 1985). Anxious preoccupation referred to patients who responded to cancer with fearful vigilance as well as by over-interpreting aches and pains as indicators of disease progression. These patients were often characterized by reassurance-seeking behaviors. This coping style was associated with poor disease outcome (Andrykowski, Brady, & Henslee-Downey, 1994; Greer et al., 1979; Greer et al., 1990; Morris et al., 1992). Helplessness/hopelessness referred to patients who responded to cancer by giving up , becoming overwhelmed by the diagnosis and being unable to see positive options. 15 This coping style was significantly f e13th to poor disease outcome (DiClemcnte & Temoshok, 1985; Greer et al., 1979; Greer et al. 1990; Morris et al., 1992). Psychological adjustment to cancer In addition to coping styles, Barbara Anderson, Ph.D. found a link between psychological interventions and an immune response directly related to fighting breast cancer. In her study, women who participated in a psychological intervention showed lower levels of a stress hormone and higher levels of an antibody that fought breast tumors (APA Monitor Online, 1999a). At four and eight months following surgery, these women showed significantly lower levels of the stress hormone cortisol. In addition, they showed significantly increased levels of an antibody to mucin, a chemical associated with more severe symptoms and faster progression of breast cancer. Cooper & Faragher (1993) found women who are exposed regularly to stressful situations may mediate the negative consequences by the types of coping styles they employ. This study also suggested methods of coping that utilized anger expression and externalizing strategies appeared to help protect women from breast cancer. A study of the effects of psychosocial interventions on psychological and biological functioning of breast cancer patients suggested a link between psychosocial interventions and coping abilities (van der Pompe, Antoni, Visser, & Garssen, 1996). This study also found evidence that psychotherapy could prolong survival. Prolonged Survival time was partially attributed to increases in immune system firnctioning. In a study of women with recently diagnosed breast cancer, attribution of self- blaJne was related to poor psychological adjustment. Self-blame was related to increased ELIlxiety and depression (Glinder & Compas, 1999). A study determined the 16 psychological needs of 275 women With breast cancer; a screening for anxiety and depression revealed they demonstrated significant psychological distress (Payne, Hoffman, Theodoulou, Dosik, & Massie, 1999). Some authors recommended the consideration of psychosocial interventions in the overall treatment plan to enhance immune firnction and improve the quality of life of cancer patients (Ironson, Antoni, & Lutgendorf, 1995). Spiegel (1993) suggested psychosocial support may impact on the rate of cancer progression. The literature on coping styles suggested passive coping (fatalism, anxious preoccupation and helplessness/hope]essness) was associated with poor disease outcome. A study of women with breast cancer concluded poor adjustment to cancer was identified with: (a) problems with the regulation and expression of emotion, (b) passive behaviors, such as avoidance and withdrawal, and (c) hopeless feelings and an external locus of control (Hack & Degner, 1999). Predictably, this study also indicated women with active coping styles preferred to be actively involved in their treatment decisions. Active coping style, particularly fighting spirit, was associated with better prognosis. In a study to determine whether coping styles had an effect on psychological adjustment in advanced breast cancer, researchers found expressing emotion and adopting a fighting spirit resulted in better adjustment. (Classen, Koopman, Angel], & Speigel, 1996). Since the evidence pointed to an association between patients’ coping Style and disease outcome, therapy encouraging active responses and promoting hOpefirlness and internal locus of control may have beneficial impact. After reviewing tI’le literature on the influence of psychological stance and coping, Steven Greer MD, a psychiatrist and cancer specialist, suggested that methods of psychological treatment that 17 would elicit active, fighting-spirit Strategies should be explored (British Journal of Hospital Medicine, 1990). Coping styles may also be associated with the concept of “locus of control.” An external locus of control implied a person was controlled by forces outside his or her power, while an internal locus of control was associated with the belief that a person may shape outcomes (Stein, 1998). Active coping styles may be connected to the internal locus of control concept. Related to loci of control may be what Antonovsky (1987) termed “sense of coherence,” or a certain confidence in the predictability of a person’s internal and external environment. Sense of coherence allows individuals to believe that problems will be worked through to the best conclusion, that basically things will work out for good. Sense of coherence may in part explain how people manage stress, as well as account for differences in health outcomes for those in particularly stressful situations. A study examined the differences in health locus of control in black and white Women with breast cancer (Bourjolly, 1999). The findings indicated both groups of women perceived their loci of control to be external. This research suggested women with breast cancer should be assessed for feelings of powerlessness and if appropriate, be provided with interventions that assist them to gain a sense of control in treatment decisions. This research also discussed empowerment of women as a tool to help them gain control and reduce anxiety. A study indicated women with breast cancer who took a more active role in treatment decisions received preferable treatment than more passive Patients (Tapper, 1999). 18 a...“ Empowerment and group techniqu€5 Since loss of control is so endemic to the cancer experience, empowerment techniques may be beneficial to cancer patients (Gray, Fitch, Davis, & Phillips, 1997). Walker (1999) postulated that, both biologically and psychologically, cancer represented a fundamental breakdown in control mechanisms. In order to gain homeostatis, Walker suggested psychosocial interventions to assist patients in feeling more in control of what was happening both within and around them. In a study of quality of life in cancer patients, the authors supported increasing patients’ input in decision making as a powerful yet simple intervention in coping and adjustment to the disease (Tope, Ahles, & Silberfarb, 1993). In her study of empowerment and women’s health, Stein (1998) stated the major components of empowerrrrent were the ability to control one’s own life and the power to make decisions. The African-American poet, Audre Lorde, who died in 1992, eloquently shared her feelings about taking an active role in her breast cancer journey: “I think now what was most important was not what I chose to do so much as that I was conscious of being able to choose, and having chosen, was empowered fiom having made a decision, done a strike for myself, moved” (1997, p.32). Some authors have identified empowerment techniques for both survival and the enhancement of quality of life: The more patients can feel energized, hopeful, and empowered to act on their own behalf, the more they maintain a healthful life style and the better their subjective sense of well-being, the more effectively they will pursue and tolerate treatment and the better will be their ongoing quality of life. If survival is improved, so much the better. If it is not, the improvement in emotional well-being is still valuable. (Lederberg, Holland, & Massie, 1989, p.2204) 19 V Cunningham & Edmonds (1996) strongly suggested group therapy for patients with cancer. They stated that goals Should be directed toward empowerment, defined as “helping people to help themselves” (p.72). Stein (1998) identified empowerment itself as a group process that could produce positive changes both for individuals and the group. She stated the possible benefits of empowerment for women: Among the potential internal changes are increased sense of control, competence, coherence, confidence and self-esteem. With these changes come greater flexibility and an increased willingness to take initiative. A more optimistic view of the firture is accompanied by a sense of entitlement, and increased personal and community responsibility. The group experience leads to a sense of solidarity, friendship, and community. (p.289) In defining the role of the facilitator in cancer support groups, Cella and Yellen (1993) suggested that group leaders employ empowerment techniques. Other studies suggested the goals of self-help groups should be focused toward participant empowerment and democratic decision-making (Borkrnan, 1990). There has been much discussion of the types of group interventions for cancer patients. The examination of self-disclosure interventions suggested group interventions conducted in a safe environment while encouraging emotional expression resulted in beneficial effects on cancer patients (Ironson et al., 1995). Other studies found supportive group interventions designed for women with breast cancer resulted in improved health outcomes (Braden, Mishel, & Longman, 1995; Samarel & Fawcett, I 992; Stanton & Snider, 1993). Support groups and self-help groups are two types of groups ofien mentioned in the literature; however there may not be clear distinctions between them, depending on the role of the leader and group goals. Generally, support groups are facilitated by a t1‘ained leader, usually a professional, who guides the groups toward identified goals. 20 Self-help groups, as implied by the nam6, are leaderless groups, usually comprised 0f cancer survivors. Cella and Yellen (1993) noted that cancer support groups 335i Sted in Providing the need for mutual aid in coping with cancer. People entered Support groups for multiple reasons, including the pursuit of hope and inspiration for Smival’ as well as for enhanced quality of life. Cella and Yellen alSO diSCOVered that worm?n utilized cancer support groups 75% more than men. A study highlighted the distinction between self-help and Professionally led groups for breast cancer patients (Gray, Fitcb, DaViS, & Phillips’ 1 997) The researchers concluded that self-help groups emphasized empowerment and no1'3lhierarchicat relationships, while professionally led groups relied too heaVily on the leaders, “garage . _ . . x and interventions. However, tn the leaderless groups, conflrctlng member cone ems abO“ either too much negativit and heaviness or too mu erficialit y Ch sup 3’ Were documented. These concerns are areas that might be better negOtiated by a trained gr 0111) 1e Perhaps the consideration of a nonauthoritarian leader would be QDti ader. mal f 01' . . Q groups, so as to not destroy the egalitarran goals of the group (Stein, 199 8 112/1340 Traditional group therapy has also proven to be helpfitl for w omen w. . I cancer. In a widely known and often-cued study, women with Ingram . at1c 0 attended a supportive-expressive group therapy for Over one Year- Stirviv d Ce;- Who 6 tw. 1c when compared to controls (Spiegel, Bloom, Kraemer, & Gottheil, 1989 e as long . . e . study found expressing emotion wrthln the context of a supportive gmu arher D therapy setting assuaged Symptoms of anxiety and depression in women with metastati e ' . _ reast cancer (Spiegel, Blon & Yalom, 1981). Stern (1998) belleved that regardles ’ S 0fthe type of 21 group, the group process may buf f er the negative effects of stress bY increasing resistance, reducing women’s vultlel' ability, and creating or reinforcing supportive resources. Alastair J. Cunningham, Ph.D., foufld that women with breaSt cancer Who benefited from group therapy were a SUbSet Who were more motivated and participated actively. He concluded that the intensity of the participation in the group was the most important factor in the survival of the participants (APA 3’10“thr Online, 1999b). Stein (1998) concurred that active participation is a constituent of the PrOCeSS of empowerment. The therapeutic factors as identified by Yalom (1995) can be identified in cancer support groups, since they do not differ greatly from the curative factors found in traditional psychotherapy groups. One of these factors is catharsis, which was idefli‘fied as the release felt following emotional expression. Cancer stlppOr—t groups provided 3“ environment for shared catharsis (C ella & Yellen, l 993). The cohesiveness that is vital for the group therapeutic proce ess ‘3 gre 8 enhanced by the strong expression of emotion (Y 2110111 1995) Spieg 1 “3’ e (1 999 the suppression of negative emotion tended to reduce the ex erie S p tIce of a1] UggESted positive and negative. Cella and Yellen (1993) discovered that In embers"? ma 10,, both emotion from friends and family but may share feelings in cancer “’15,”? SUPPOI't grou old the need to protect other group members from ChStl'eSS. One of the det Ups w th ”emu“ 11am out S 0f successful groups was that members derived a sense 0f satleaction fr om th . err participation in the groups. With respect to a time frame for cancer support groups, Cella . , Yemen (1993) found that an eight-week, one meetmg per week comrmtment Was effect . Ve. Group siZe 22 for most effective face-to-face inteTaCtion was between 5 and 12 members” Cullningham and Edmonds (1996) recommended 6 to 8 meetings of 90 to 120 minute"ength for cancer support groups. They endorsed grOUps comprised exclusively Of Cancer patients Without family members present, because of increased superficiality resulting from cancer patients’ attempts to protect their families fl‘orn distress. Cunningham and Edmonds (1 996) proposed that since the early stages Ofgroup therapy were aimed at the alleviation 0f psychological dist!“ ess, group thel'apy could be appropriate for most cancer patients. They also strongly stated that the biggest deterrent to the instigation of psychological interventions for cancer patients was the “outmoded biomedical model” (p. 77). They believed that the belief in the separation of mind and body made it difficult for biomedically-oriented pro fessiorlals to c:Onsider that emotions could affect something as concrete as cancer. They espoused a mode] acknowleogng mental and physical phenomena as basically two aSpects of the Sarne reality, These authors also suggested that oncology Specialists needed to admowledge “the symbolic means of intervention, such as words, ideas, and imageS . ,. ( 7 DQWCI' 0f Cunningham and Edmonds (1996) were so convinced of the benelgts 8)‘ on s for cancer at' ts the recommended that ps chosocial . gr p p 1en y y IIlOdahties 81) 80.012011 0 offered to all cancer patients, whether or not the patients were in 0b . old 6 VIOuS dis e . _ e spec1f1cally requested assrstance. These authors prOposed that psycho] 38 o OglCa l erapy should be considered with the same seriousness as chemmherapy; they t ought it sh Quid e authors painted out that very few patients would agree to chemotherapy _ 1 f - It was not 23 that as group psychological interventions are accepted as standard adj ufic‘ive t1‘eatment for cancer, it is most likely that specialized facilitators will be apprOPfi ate” t1iained to deal with the particular problems of Cancer Populations. The benefits of leaderless groups and lay leaders were acknoWIBdged, but the importance of pro feSSionaI leadership was stressed. In their study of the state of the art of cancer support groupS, Cella and Yellen (1993) discovered that groups that are more homogeneous, consisting 0f members at common stages of specific cancers may develop cohesiveness sooner than heterogeneous gr CUPS. Another study supported homogeneous groups, but found tllat although it initially created a sense of commonality, it ceased to be important When group members became better acquainted (Cunningham & Edmonds, 1996)- Cella and Yellen (1993) also emphasized the importance of recruiting from underrepresented populations and aCRnowledged the difficulties 0f Starting angel C support groups. They emphasized community outreach and “which I . . a1 sensi Why an d awareness when recruiting group members. In order to reduce psychological distress and possibly affect d' isease s chothera ma be a useful modality to complement the me ‘ p y py y d1 Q31 treatmeq &esslbn cancer (Spiegel et al., 1989). In a study Of breast cancer patients 1.60m. t 01" bre , "Gd (1 . as; year of diagnosis, supportive-expressive psychotherapy resulted in . "8 (be lmpTOV fiI‘St coping and adjustment (Spiegel, Morrow, Classen, Raubertas, St Ott M mood a udali ar, P' Flynn, Heard, & Riggs, 1999). lerce, In a si x week structured PSyChiatric group intervention, Patients W‘ 1th malignant melanoma were assessed for psychological distress and changes in imrn e function at 24 baseline, six weeks and six months following group therapy interventions (Fawa, Cousins, Fawzy, Kemeny, Elashof'f: & Morton, 1990). Significant changes occlll‘red in affective states, coping, and the N14 Unlphoid cell system. How ever, at the S.u‘irvveek follow up, most changes were not y Ct Observable. At the six-month f0 110w up, statistically significant cell changes in the experimental group were clearly evident This finding may Point to increased changes over time and suggeStS follow—up measurements extending over longer time periods. It is also noteworthy that the intervention itself lasted only six weeks, while the results may have prowen beneficial for an extended time. There is a growing body of eVidence to indicate that inhibition of emotion may have negative health consequences. A study encouraged thSiCia‘r‘S to allow their Patients to express feelings and self-disclose surrounding their cal'lcer in order to break through the “conspiracy of silence” often characteristic of the diSease (Keller, 1998' Stein (1998) recommended specialized training for faCilitatQm of empowerment goups. When commenting on exemplar training guides, she stated, “T h . ese materials are particularly focused on conscientization -- on helping women who ha b Ve een t to (or have not been taught to) think abOut their feelings, Who have su Ppress anger, who have often accepted an unjust situation” (13- 45). (be,- r Some evidence suggested that the suppression 0f emotions part' ’ ICUIarI 3’ emotions, was associated with poor psychological adjustment in newly (1' negative 18 cancer patients (Watson, Greer, Rowden, Gorman, Robertson, Bliss & Research documented that the inhibition of negative emotions Was COnn ecled to heightened Physiological arousal with resulting health-related prob] ems (he & rry Pennebaker, 1 993; Hislop, Waxler, Coldmm, Elwood, & Kan, 1987). 25 Berry and Pennebaker (1 993) CXplored both verbal and nonverb 3‘ mod"=111t1es of emotional eXpression and found th em similar in their ability to decrease Phymologleal activity and stress. They pr0posed that Spontaneous nonverbal expr6581on of emOtIOn was related to immediate decreases in autonomic nervous syStem aCtIVIty While the authors acknowledged there was a paucity of research on nonverba1 expressmn, they were convinced of a relationship betVVeen nonverbal expression and health Status, Berry and Pennebaker (1993) also recommended the use Of bOth Verbal and nonverbal therapeutic interventions. Their hypothesis purpOrted that smce nonverbal expression may be effective in immediate reduction in autonOInic arousal, verbal expression may complement beneficial changes, thus enhancing health consequences The expressive arts therapies, including dance, music and art, were hlghhghted as examples of nonverbal interventions- Music therapy and cancer Music therapy may be an appropriate intervention for canQ may address specific roblems related to cancer previo sl outIi p u y “ed These ”681771190 include (a) deleterious effects of stress on immune filnctioning, (b) Inadequ "tea Q6/6018 support, (6) suppression of emotions, ((1) pain and physical symptOmS (6)10 68001;” 05‘s (f) grief and loss 1ssues, and (g) poor adjustment and coping. Music them Con 001 Dy t l of l f these problems, particularly in regard 0 qua 1ty 1 e 1ssues, Accordin R 683 to Ulld (1 99 9,8) “Music therapy has much to offer in regard to quality of life because Strfihgthens Our emotional awareness, installs a sense 0f agency, fosters belongingneSS Cl provides meaning and coherence in life” (949)- 26 A review of the literature on music therapy and cancer indicated a growing awareness of the possible applicati ODS of music in the healing process - Music listening was incorporated as an adjunct to antiemetic therapy with cancer Pati ents undergoing chemotherapy (Ezzonc, Baker, Rosselet, & Terepka, 1998). This study follnd that music listening reduced nausea and vomiting in the experimental group- A music therapy study also indicated reduction in nausea and vomiting, as well as decreased antiCiPatory anxiety for patients receiving chemotherapy (Standley, 1992). The Bonny Method of Guided Imagery and Music (GIM) employed speei fie recorded music to induce imagery (Bonny, 1978). The GIM techniques were SUCCCSSfiJlly implemented to alleviate mood disturbances and improve quality of life in cancer patients (Burns, 200 1). The benefits of the GIM sessions were documented through a six-week follow-up, suggesting salutary effects of the music therapy interventions may continue for extended periods. Group music therapy with adult oncology patients reveal ed int/01 tm both ly improve state scores (Walden, 2001). This study employed music in therapy and inc ”Mod 0 “music-making” and “music-responding” interventions signi ficant structured activities, verbal discussions, and music listenin ; act‘ g “'6 music In O’a’tlt‘v’d improvisation were minimally utilized in this research. 32g and Results of a study with hospitalized cancer patients indicated live ta recorded musie was more effective in reducing tension and enhancin Vigo ther than 1983). Another study addressed the difficulties in engaging hospitaliZed c 1' (Ba11ey, in music therapy interventions (O’Callaghan & Colegrove, 1998), In a Stu:¢::atients Y ancer patients recei Ving bone marrow transplants, results indicated that music lllcreased 27 comfort and relaxation levels (Boldt, 1996). The complementary uses of music therapy and counseling techniques were suggested in a collaborative study of cancer patients (Bunt & Marston-Wyld, 1995). In this StUdy, the expression of feelings and the use of instruments were highlighted as therapeutic agents. Porchet-Munro (1 988) recommended music therapy for cancer patients in all - . - ' ct stages 0f the disease. She suggested that the qualities of musrc that allowed it to impa . . . - 'ate for on the PhySiological, psychological, emotlonal and splntual levels made it aPPmpn the treatment of cancer patients. - . . - - a Another study used song material Wlth cancer patients and their families as . . ted to vehicle for support and change (Bailey, 1984). In this study, songs were implemen assist in processing feelings surrounding grief and death issues. Music therapy has also been used as pain control for cancer patients (Beck, 1 991; Cook. 1 986; Kerkvlier, 1990) At the Bristol Cancer Help Centre in England, music therapy was Offfired as a complementary therapy (Bunt, 1994)- Goals for this program included the exploration of psychological issues surrounding cancer treatment. The majority 0f patients partiCipatin g in music therapy groups identified mUSiC making as the catalyst through WhJ'ch they attained cohesion. As the group progI'eSSEd through several weeks, a Shift occuned in the members away from individual concerns toward a grow identity. There was also a movement from passive to more active behaviors for group members. Group members also reported reductions in anxiety, release of feelings via catharsis and more spontaneity. There was 31 so an indication of temporary pain relief following music therapy sessions, 28 Music therapy and breast cancer Aldridge (1996b) identified the importance of emotional expression for women With breast cancer. The experience of playing and creating music enabled a woman with breast cancer to identify feelings, provided opportunities to gain new intimacy with her bOd)’. and improved intra and interpersonal communication. In this case study, melodic playing was particularly emphasized for breast cancer patients, since melody was COHSldered an important form of musical expression. Analytical music therapy (ATM) is a form of music psychotherapy that may have ben eficial applications for women with breast cancer. The salient agents of therapeutic change in AMT were identified: (a) the expressive aspects of music, (b) musical relationship attained through improvisation, and (c) action modality, during which the patients are engaged at a physical level with mind and body acting simultaneously (SCheiby s 1999). These three agents of change may address the specific needs of women with . . . . . . . breaSt cancer, Since expressmn of emotion, allev1ation of isolation, and empow eI‘nient may contribute to quality of life. Ruud (1998) emphasized the role of music in self-expression. He observed that “0t only does music allow for the experience of emotion, but it also provides the vehicle for the expression of emotion. The ability to experience and express feelings produced What Ruud identified as “vitality,” an important aspect of health. Musical relationship may be connected to the tend/befriend theory of stress r6Spotlse, which highlighted the importance of relationship for women as a miti gator of physiological arousal (Taylor et a1, 2000). Group music therapy sessions may provide the 0I>portunity for women to nurture each other musically while creating alliances and 29 cohesiveness. Since its earliest inception, music therapy authors have acknOWl edged the potency of music in the group setting (Gaston, 1968). The music therapy group experience may offer opportunities for adaptive tend and befi'iend behaviors. Several studies of women with breast cancer revealed the importance of Participants’ active roles in treatment; they also indicated that groups should be structured to create opportunities for empowerment in order to increase internal locus of control (BOUIjOIIy, 1999; Gray, Fitch, Davis, & Phillips, 1997; Stein, 1998). The action method 0f music therapy that employs the entire person in her healing process may increase self— emPCWerment. Active responses to breast cancer were associated with fighting spirit and Ultimately with longer survival times. According to Ruud (1998), “Music empowers us; it gives US a psychological and cultural platform from which to make our own decisions on matters concerning our own lives” (p.62). He also identified a cogent conceptual connecfiol'l between the ability to act and wellness. Relevant to the expressive aspects of music, Berry & Pennebaker (1993) fielmowlé(lged that both verbal and nonverbal modalities of expression may have resultant positive impact on health. Scheiby (1999) suggested that music rivals verbal language in its ability to express emotion. According to Ruud (1998), music therapy is skeptic 3.1 of language and the intellect’s control over reality: “Improvisation is described as being more honest than language because music can express what is feared or hidden by language and intellect” (p. 132). Gaston (1958) argued that music would not exist if verbal communication adequately expressed the human experience. For patients with cancel-2. music therapy may offer the opportunity for self-expression without fear of recnmination (Aldridge, 1996a). 30 Ruud (1998) also suggested that both nonverbal (musical) and verbal c0mmunication could combine to produce an effective therapeutic intervention. He felt that the arts therapies “ . . . sometimes demand some sort of reflexivity on the client’s behalf afier the therapeutic intervention” (p. 177). In this manner, verbal and nonverbal expression may complement each other. Bruscia (1987) summarized the application of Vel’bal and nonverbal pathways in musical improvisation: When used nonverbally, musical improvisation can replace the need for words, and thereby provide a safe and acceptable way of expressing conflicts and feelings that are difficult to express otherwise. When both nonverbal and verbal channels are employed, the improvisation Serves to intensify, elaborate or stimulate verbal communication, while the verbal communication serves to define, consolidate, and clarify the musical improvisation. (p. 561) A new sense of identity may emerge when a woman achieves the ability to play music ore atively and spontaneously (Aldridge, 1998). Aldridge made a connection between musical performance and active manifestation of self. When music is performed as Self'aetnalization, mood improvement and the amelioration of negative emotion may ensue. Tilis improvement in quality of life, according to the author, would have importance for breast cancer patients and could be associated with the promotion of hOpe. Aldridge (1998) also addressed agency in music making with women with breast cancer - He observed that when women were actively involved in music, they automatically made decisions regarding musical choice: “The patient becomes an active partner in health care rather than putting her into the position of being a passive recipient ofthat care” (p. 221). Aldridge (1998) also indicated that accepting responsibility for musical creations and being able to modify those actions were potential empowering agents. 31 Intprovisation I Musical improvisation may be a most fitting vehicle of expression for Women With breast cancer. Aldridge (1998) proposed that creatively improvising music was an appropriate and beneficial intervention when dealing with a life-threatening illness. He 00mmcnted on the process of improvising music: Improvisation demands the maintenance of a theme that must change to gain liveliness. Our lives are similarly improvised, from the cellular to the cerebral, to maintain our identities intact. In all such processes, listening to each other is a central method for gaining information, negotiating relationship, and maintaining credibility, whether it is cell communicating with cell, person with person, or community with Community. (p. 281) Ruud (1998) suggested that improvisation may allow for the development of a sense of personal agency. In improvisation, a sense of mastery through nonverbal action ay be attained. Ruud also pomted out that mus1c 1mprov18ation treated mu51c as a e - . . . . . p rfonnathe act rather than as an object. The term he gave to describe 1mprov1sation w “ - . , . . as muslcal orality’ (p.15). According to Ruud, another aspect of musrc that enhanced quality Q if life was its relation to identity building. Ruud (1998) highlighted the contribution that musical improvisation may make to the Gale er survivor’s journey: Improvisation can also be seen as creating an opportunity for change, transformation and process to come into focus. In this sense, improvisation means to get not just from one place to another but from one state to another. It means to change one’s relationship with other people, phenomena, and situations -- even one’s relationship with oneself. Therefore, we can see it as a transitional ritual, a way of changing position, framework, status, or states of consciousness.” (p. 118) Aldridge (1996a) proposed that health itself is a creative performance. He identi fied participation as the link between the performance of music and the 32 Performance of health. Aldridge stated, “The means by which we then achieVé health are performed improvisations and therefore susceptible to a creative music therapy” (p.33). Empowerment and music therapy A model of music therapy structured to promote empowerment may be beneficial for WOmen with breast cancer. This model would provide opportunities for women to address issues surrounding the diagnosis of a life-threatening disease. It may also improve these women’s quality of life regardless of its impact on disease progression. Wi thin a model of empowerment, interventions would be structured to encourage active ”Ping methods to induce: fighting spirit, optimism and hope, expression of emotion, including previously sanctioned emotions; adaptive tend/befriend behaviors through muSical aI‘nd interdependent relationships; internal locus of control; and sense of COherenQ e . The music therapy empowerment model could be structured to include: 1 . Group process with emphasis on both process and product, with particular focus 0!) process to encourage spontaneity and heighten self-expression; 2. Opportunities for women to be leaders in the musical setting, since tradltiOnally women’s roles as leaders have been limited; 3. Improvisation, using both instruments and voice to provide for immediate exPression of feelings as well as for active decision making and participation; 4. Opportunities for women to both give and receive support, both verbally, and norlV’erbally in the music media; 5. Opportunities for women to grieve for losses, including emotional and physical 33 losses surrounding breast cancer (for example, symbolically “beating breasts” as a grieving gesture through drumming, employing instruments and voice to “sound”and release strong emotion); 6. Opportunities for women to be seen and heard in the music, since women’s 0L1 ltural roles have ofien rendered them invisible; 7. Opportunities to discover authentic self through self-expression in a safe and accepting environment. PurpOSe; To eXpIOI-e and document the benefits of group music therapy as a complementary interv - - em on for women w1th breast cancer. Questions : 1 - Will group music therapy facilitate improved coping and adjustment for Wom - en v\’1th breast cancer? 2 ~ Will group music therapy sessions reduce stress levels as perceived by women With bre ast cancer? 3 . Will active participation in improvisation-based music therapy groups increase internal locus of control and empower women to take an active role in health decision making? 4. Will self-expression through group music therapy interventions result in imprOVed quality of life for women with breast cancer? 34 CHAPTER II METHOD Participants Five volunteer participants were recruited from the Providence Hospital Cancer C enters in Novi and Southfield, Michigan. These sites were located in the suburban MetrOpolitan Detroit area. The criteria for inclusion stipulated the following: Women of any age, in any stage (0, I, II, III, or IV) of breast cancer. Below is a description of the five stages: 1 - Stage 0 is the earliest type, confined to the ducts (ductal carcinoma in situ) or lobules ( lobular carcinoma in situ); 2 - Stage I indicates a tumor of 2 centimeters or less exists but has not spread mask!" the breast; 3 - Stage 11 indicates that the tumor has grown to more than 2 centimeters but not more than 5 centimeters and may have spread to the axillary lymph nodes; <1. Stage 111 indicates a tumor exists that is more than 5 centimeters in its greatest dimenSion; 5. Stage IV indicates a tumor of any size exists with direct extension to the chest wall Or skin. This stage may include distant metastases, a spread of the carcinoma to a variety of organs. 35 prc Un’ Ho Prc " 9t). Recruitment of participants lunt ° - Vo eers were recruited through the distribution 0 fin format 1 on a 1 flycrs made available in the waiting room areas at the can Cer centers as well as on the inpatient oncology unit in Southfield (See Appendix A for a copy 0f the fl)’er)v providence ° - - - ed of Hospital staff medical oncologists, radiatiml OUCOIOgist and surgeons were inform s liniCS they the study, and they were requested to have Volunt 'lable at the C eer forms aval ‘ practice . . . . t6 served. A medical oncologlst on staff distributed Volunteer forms to her pnva d se . . “agno patients. Volunteer forms were included in packets distributed to all new” d1 breast cancer patients. Volunteer forms were also di stributed at the n10flmw (,6 Wide“ informational seminars attended by cancer survivors and presented b‘} 1" S e Hospital Healing Arts staff The investigator also approached «hag 69 received chemotherapy infiision in Southfield to inform them of the study encourage their participation. Consent and approval Written, informed consent was obtained prior to the comb t encemen 0 r procedures , (Please see Appendix B for a copy of the consent {0%) Th 30} . e M. . . . IQ . Umversrt Committee on Research Involvm Human ' 1 Y g Sub] ems an G the Provid gar; State Hospital md Medical Centers Institutional Review Board and ReS 6120 care}, Co were satisfied that the research would not violate the rights of its arr laces ’Cipant s. Procedure The participants and the investigator, who served as the gmup f 90-minute music therapy sessions, once per week for six weeks. The tator, met for partiCipants , 36 I\ l ~ 5e? and ofsz diSCL flexil: the fa. immed process impact I detenni fl 1 lnCOI'por inten’em Prepare 1 3. ted ues ' ‘ comple q tionnaires one week before the interventions began and one wed, followmg the last music therapy intervention. Telephone interviews were conducted with all the participants within two weeks after the completion of the six 33 s 5 ions. Session protocol Each session was designed in a format that included “freedom within strUCture e and followed the same general outline. Sessions Wer e structured to create an agnospher of safety while allowing for spontaneous self‘expresSiOn, both verbally, i“rough discussion and nonverbal 1y, throngh the music media- Goals for e ac“ sessiofi wet: of flexible and determined by the immediate needs of the group. The format 0096\9‘ the following: sb‘b‘edhe‘ 1. Check-in (10 - 1 5 minutes). In this brief pefiod each group we be‘ we '11) immediate feelings, either verbally 01‘ nonverbally. The check-in served to 1369 process of expression, as well as to alert other members of current i Ssues that m1 gm impact on their participation in the group. This also 21883th the grQup leader in determining appropriate interventions and objectives fol. the sessio 11 2. Relaxation exercise (10 minutes). Abrief, Structured, an id (1 _ 6 image ’3’ incorporating music was implemented following the check-in. The I) ”119056 01‘ ”11:9 intervention was to achieve relaxation of both mind and body. Rel atlbn . _ aISo prepare the participants for the improvisation portion of the session saved to . . . . ypr°VIUIi2 gr ounding techniques for any emotions that might emerge in the co 1‘8 g 6 0f 3. Statement of intention and work of the group (20 minutes) P i . encouraged to determine their own objectives for the sessions t1“ough c 37 ested i ' . was Sllgg n order to Increase assertlveness, encourage group members to 3606p, responsibility for their health choices, and Provide oppo 'ties for decision making- 4. Group work (30 minutes). Group music improvisation based on the you}? ' ' d goals for the sessmn. Members were reminded of the group intention for the sessron an -tberfled encouraged to focus toward those goals. Both themed (referential) and non (nonreferential) improvisations were created. ession . . ex r 5. Reflection and verbal processmg as a Comple cut to non—verbal P (15-20 minutes). . . . act‘s 6. Closmg of group and Opening of ClI’Cle ( 1 O- 1 5 minutes). The $355 . n?»- With the performance of either a pre—composed or spontaneously created so to . - «39 closing song served to remind the group Of Its grow1n g connection as We“ . . S- the ongoing process that continued to unfold in the period b etwe $11 665510“ Dependent measures The Mental Adjustment to Cancer Scale (MAC) (Greer 8:; Watson 1 999 W ' ; 3130!) These adj ustment styles were identified by five scales; (3) fighti 11 3 Spirit (5) c'l’lt‘ts'flhals, preOCCUP ation, (c) fatalism, (d) helpless-hopelessness and (e) poS jt' ' "’6 avoid MAC scales were identified as measures of emotional reaction 51% Ce- 7;) We]! as e co - for cancer patients (Nordin, Berglund, Teije, & Glimeli us, 1999) plug Styles ‘ eMA scales were found to correlate with the Hospital Anxiety and Deb],e Crefined Sstn indicative ' ' b E1 rth ‘ Scale, be' of good concurrent validity (08 01116, SW0 , Kissane B "lg ’ "Ike 1999). ’ & Hopper The Perceived Stress Scale (PSS) (Cohen, Kannarck, & Meme 1 stein, 1983) 13" ”'6 most widely used psychological instrument for the measurement ofthe perception of stress. It measures the degree to which situations in individuals lives are appraised as and stressful. Ten items were designed to determine how unpr edict able, uncontrollable, overloaded life appears to be. & 7728 Health Locus of Control Scale (HLC) (W all ston wallston, Kaplan, is Maides, 1976) measures the degree to which individuals beneve that thelr hea controlled by internal or external factors. The Quality of Life Index, Cancer Version (QLI-C) (Ferrans &Y ti r 921 06 measures both satisfaction and importance of various aspects of life for ca“ be ’t. The instrument also measures satisfaction with those 88pects of 1i fe as «6\ importance of the aspects to the individual. Materials A wide variety of musical instruments were made availab 1e to the parti [5 Clpdlls u PCT 011551011 instruments were used, including Xylophones metall 11 allied Q5 p ones, to],e eclllineS ’ resonator bars, drums of various sizes and timbres, electric pianQ small rhythm instruments, including claves, maracas and tambo.‘ hes 61:9 an d Singing and various vocal techniques were incorporated i to the 1 111‘er since the voice is considered an instrument that each participant p0 entlons SSeSS ’ f t t t b 13 865 and”, access readily. Singing is known or 1 s res ora 1ve ene ts, both ay 5’81 01081 Cally as We ell as psychologically; voicework may become an agent 0f empowerme Ht f0 1‘ Women with breaSt Cane er. 39 CHAPTER III RESULTS Data analysis . - the group. Protest and posttest data were analyZed to Compare differences Wlthln . - - 61.611668 Twelve separate t-tests for paired samples were con ducted to determlnc dlfT were between mean pretest and posttest scores using sps S and S AS computer 50 programs. (Please see Appendix C for raw data scores). Sociodemographic variables 6&0‘6 one . - 69 “‘63 All participants (N = 5) completed socrodemo graphic questiofii‘afi .figweae \ study began. (Please see Appendix D for a copy of the queStiOTlna‘ue)‘ “Y were given at the beginning and the end of the Study- A total of five wot“ both pretest and pOSttest measures. The mean age for the partiCipants was 54.6 a With a standaatd deviation 0f1199 The ages ranged fiom 38 to 74. All participants lived within the :Detroit met r . O . area. Three women identified themselves as Afncan- American . Pol/,3” e . themselves as Caucasian. 1701750! At the start of the study, two women were in Stage 1, two and one Woman was in Stage IV of breast cancer. The woman 1‘ metastases to the spine. All the women in the study had undergone surgeries associated w. cancer; four women had received lurnpectomies and one woman had 8 1 their breas x . 1. l , penenceda . mastectom y. Another woman had undergone mu tip e surgenes 3830 3111 c . 40 A‘ ' “we! l spinal metastases. Four women had attended tWO years of college and one woman had received a master’s degree. Three women were menopausal, one woman was pie-menopausal and one woman was post—menopausal. Four women W ere diagnosed within ten mOnths of the beginning of the study, while one woman had been diagnosed three years and ten months before the study began, The range of times since diagnoses was from 4 months to 46 months; the mean was 14.6 months and the standard deviation was 15.81 months. None of the women were receiving radiation treatment. Two women were receiving chemotherapy, one had received chemotherapy in the past, and the reminder had never received chemotherapy (n = 2) Two women were receiving hormonal therapy Two womenwere not participating in any Other healing arts, complementary Prograrns or practices when the study began. Three women Were receiving healing arts or complementary treatments. One woman was in an exercise Program; one woman was receiving massage therapy; and a third “man was inVOIVCd With yoga, Reiki, massage therapy, an exercise program, nutrition counseling, a SUPPOI't group, joumaling, Prayer, art, and meditation practices. Mental Adjustment to Cancer Scale (MA C) The first research question Stated: Will group music therapy faCilitate improved c0ping and adjustment for women W 1th breast cancer? Paired sample t-test scores on the Mental Adjustment to Cancer Scale (MAC) revealed two important findings: 1, The differences on the MAC subscales, helpless/hopeless and anxious 41 preoccupation approached significance (please see Table 1). The statisticaI values were exaCtl)’ the same for both subscales, 2. The values changed in direcfions that indicated decreased helplessness/hopelessness and 1355 anxious Dreoccupation. (Please see Table 1 for complete MAC scores). Table 1 . Means and standard devia tionS for difference Scores on the MAC subscales. Subscale N L df tx‘ P FS 5 (213%) 4 1.863 0.136 H/H 5 (11.332) 4 -2.333 0.080 AP 5 (11.333) 4 -2.333 0.080 F 5 (5(7)?) 4 -0.82 0.458 A 5 23:???) “ A [If . __ \ Note. FS —_— fighting spirit; H/H = helpless/hopeless, AP — anX10us preoccupation- F : fatalism; A = avoidance. Perceived Stress Scale The second research question asked: Will group music therapy Sessions reduce stress levels in women with breast cancer? N0 Significant differences Were found for the pre and POSttest scores on the Perceived Stress Scale (PSS). (Please see Table 2), 42 Table 2— Means and standard deviations for dzfierence Scores or! the p55: Variable N 5% df t p A fl PSS 5 $6532) 4 -137 0.135 Health Locus of Con trol Scale The third research question asked: Will active participation in improvisation- based music therapy groups increase internal locus of control and empower women with breast cancer to take a active roles in health dCClSIOI‘l—maklng? No significant differences were found for the Health Locus Of Control Scale (HLC)- (Please see Table 3). Table 3. Means and standard deviations for difl er ence SCOreS on the HLC. df . N M t N— 4 -0.23 C 5 -O.800 0.829 HL (7.759) Quality of Life Index, Cancer Version The fourth research question 38sz Will self expression through group music therapy interventions result in improved quality 0f life for women with breast cancer? Two significant differences were derived from the scores on the Quality Of Life (QLl-C) measure: 1. There was a significant difference between the pretest and 90811 e st scores on the Health and Functioning subscale. (Please see Table 4), 2, The pretest and posttest scores on the Total Quality of Life measure were also significantly different, (Please see Table 4 for all OLI-C scores). 43 Table 4- Means and standard deviations for dlfl'erence scores 0” Me QLI-C ‘ Variable N M df t P /(§__D_L—\__\ HF 5 g .335 41) 4 _ 3.77 0.019 * 1.243 4 1 76 0.153 SE 5 . (1.578) 5 0.771 4 1.15 0.313 P/S (1.496) F 5 0.285 4 0.34 0.751 (1.879) 5 7.250 4 5.14 0.007 ,, TOTL (3.152) Note. HF = health and metiomng; SE = social and economic; PIS = psychologicaUspir-imai; F = family; TOTL = tot a] Score, “‘ indicates significance. Post-study participant interviews Telephone interviews were conducted With 63011 participant Within tWo weeks of the final session. The interview questions were presented in bOth open and Closed-ended format. The first question was open ended in order to encourage the participants to begin to refocus on their music therapy experience. In a similar manner, the la“ Question was open ended in order to insure that any areas “Gt covered in the Specific interview questions were not neglected- In re sponse to the first question “What has the experience been like for you?” all the women’ 8 responses were worded positively (N = 5). Statements such as “I thoroughly enjoyed all aspects,” ”It Was important to me on many levels’» and “I didn’t know what to expect, but I was pleasantly surprised with the outcome” Were typical 44 responses to the initial question. The answers to the Open-ended initial question were quite gener a1 and vague; however, they served as an “ice-breaker” for the interviews and allowed the women to recall their eXperi ences and begin to put them into words. AS the imCTViews proceeded, the WOmen began to give more specific and personal reactions. For example, in response to the Question “What seemed to be helpful?” responses included: “What was mOSt important for me was that the music therapy process allowed me to revisit my love of music and return to it as a source of a pleasure and comfort during a most stressful time in my life,” “It Was relaxing, like meditation. When we improvised I was not thinking about anything else,” “The mUSic let me express my immediate feelings. When I felt angry, I could hit the drums. When I needed something more uplifting, the light, ethereal quality ofthe tone chimes provided a nice alternative to the heaviness of cancer,” and “The mUSiC shut Off my Worry-buflon.” Some responses to the question “Did your feelings or Opinions about Yourself and your capabilities change at all?” included: “Yes, I began to feel more capable in general,” “ I felt myself becoming more confident and self'assured,” and ”I Was surprised to discover that 1 could actually create music.” All the women voiced a preference for the active music making over the receptive, listening portions of the SCSSionS- All the participants also agreed they felt supported by the other group members, evidenced by statements such as “I benefited from interacting with other women who are in my situation,” “I enjoyed Sharing and exchanging Stories with the other women,” and “It gave me something to look forward to every week.” The meen also concurred that the therapeutic environment felt Safe and 45 accepting (N = 5); one member stated “It felt like a Sanctuary.” When asked abo u; What was uncomfortable, two areas Of di Scomfort were revealed. Due t0 the small gr OllpS size, one woman initially felt awkward and Self‘eonscious; all the women felt discomfort with their early attempts to play the inst! uments due to unfamiliarity with the media. 5 ' . There was consensus on the mo t lInpol'tant benefit of the musrc therapy groups; all participants found the groups to be relax‘hg and a source of stress reduction. The final, open—ended question asked if the participants wanted to add anything that had not been addressed by the interview questlons. Three women answered this question by volunteering to return in the future to share their experiences With newly formed groups in order to encourage participation. Clinical themes Certain themes emerged 1“ the Chhlcal evaluation 0f the sessions. Although numerous issues were supeffioiahy discussed, there were sever al themes that become prominent. Themes were gleaned from pOSl’Study analy sis 0f the sessions and documentation, as well as from the content of the post-study indiVidual interviews Analysis determined that the entire 555510“ processing time (50 minutes) Was spent on these areas; these themes also received disproportionately more discussion time in the post-study intervieWS- These salient themes were: (a) vitality, (b) risk-taking (c) loss of Control, and (d) self-empowerment. Themes were sometimes discussed verbally and then processed nonverbally in the music media. At other times, when themes emerged from the improvisations, they were then processed verb ally through group discussions. 46 CHAPTER IV DISCUS SION AND CONCLUSIONS This StUd)’ produced mixed results, For the Mental Adjustment to Cancer Scale (MAC), there were no statistically Significant differences for effects found; however, the trend pointed in the direction ofless hapelessness and helplessnessi as well as toward less anxious preoccupation (Please see Table I for complete scores). Since some studies have shown the possibility that feelings ofhelplessness and hopelessness can negatively affect disease outcome (Moor ey & Greer, 1989)’ music therapy may PTOVide a deterrent to helpless and hopeless feelings The relatively short length 0f bOth the individual sessions (90 minutCS) and the short overall length of the study (6 weeks) may not have provided enough opportunity for experiences that would significantly decrease helpless and hopeless feelings- Perhaps these trends would have been fortified overtime. The movement of the trend in the right direction may warrant fixture study, There were no differences measured by the Perceived Stress Scale (PS S). Since all the Questions began With “In the last month ' ' ° ’” Perhaps a follow up at a later date would have shown a decreased perception 0f stress. The close PTOXimity of the Winter holiday season may have also deleteriously affected the women’s stress levels. DeSpite the lack of effects for the PSS, all the Women in the group verbalized feeling more relaxed following the study at the final interview conducted two weeks afier the final session. There is a possibility that the anxiolytic effects may have increased over time. Follow up measures at future intervals may have revealed declining “Tess levels- The Health Locus of Control Scale (HLC) did not indicate any Changes for the 47 group Pattietpants. Since locus of control is based on an individual ’5 learned bellbf systems and expectations, it may have been unrealistic to expect a marked change in the short time frame Of this Stud)" Internal and eXtemal locus of control concepts may be ingrained personality tIaits that are esp eCially resistive to change. In addition, the hment has “0t traditionally encouraged patients to take active roles in medical establis their own health care. There is also some controversy in the literature Over the concepts of locus of control (Spiegel, 1991). Overemphasis on gaining control over life situations and ne’s control can result in self-recrimination and guilt illnesses that are C] early beyond 0 Seeman (1991) suggested that in coronary artery disease an unrealistic desire for control may actually suppress irrnnune function. Other researchers discoVet ed that Patients demonstrated poorer adjustment to disease when their wish for c0“tr01 was “0‘ balanced by the yielding of control. They referred to this coping pattern as “positive yielding” (Astin, Anton-Culver, Schwartz, Shapiro, McQuade, Breuer, Taylor, Lee, & Kurosaki, 1999). They discovered that those breast cancer survivors who possessed the high desire to control, combined with the high ability to yield, evidenced the best psychosocial adjustment and quality of life. (A ve yielding will be discussed in reference to clinical example of positi “locus of control” on pp. 53-54). The most important results of this study indicated that there were significant differences in quality of life for the Partieipants as measured on the Quality of Life Index (QLD- The Quality of Life Index was created to measure quality of life in terms of satisfaction With life (FerranS & Powers, 1985)- Total quality Oflife measures included 48 the categories in the areas of health and functioning, social and economic status, % PSYChOtO gical/spiritual aspects, and family. The scores on the health and functioning subscale indicated that there was a significant change in these areas for the women i1Wolved in the study from pretest to posttest. The QLI was also designed to identify the items that were more important to the women and these items had a greater impact on scores than those of lesser importance. The differences in health and functioning scores indicated that the women had become more satisfied with their ability to function as well as with their general health status from pretest to posttest. The highly significant level for the total quality of life scores indicated that the music therapy sessions provided a meaningfiil experience for the women that improved their satisfaction with self-identified important areas of their lives. In cancer research in general, and in breast cancer studies in particular, there is a gowing awareness of the importance of quality of life issues (Rowland, 1994). In addition to improved survival, the United States Food and Drug Administration issued a mandate that quality of life (QOL) is a necessary outcome variable in clinical trials (Johnson & Temple, 1985). The outcome of the Quality of Life Index scores revealed that music therapy groups for women with breast cancer improved their quality of life, which may improve their ultimate survival time. Quality of life may improve disease outcome, regardless of disease progression and tumor size at the time of diagnosis (Coates, Gebski, Signorini, Murray, McNeil, Byme & Forbes, 1992). This may be particularly important in this study, since one of the participants was in an advanced stage of cancer when the study began. 49 Aldridge (1996a) emphasized that the creative arts could have l.ml’t’rtttrlt benefits t“ SWtVors in the area of quality of life. He indicated that quality of life measures could demonstrate improved status despite the deterioration of physical factors in disease Processes; this would appear to apply in this study. The instillation of hope is a crucial element closely associated with quality of life. Yalom (1995) identified hope as an essential therapeutic factor in the group therapy 1? :rocess. Indications of hope in the breast cancer group were exemplified by statements swch as “It gave me something to look forward to every week,” “I enjoyed the interaction Wi 1h other women. I realized that I was not alone,” and “I look forward to the future.” Clinical themes Vitality. Low energy levels and lack of vigor were the most common complaints of the group. Whether undergoing active treatment or in post-treatment stages, all the women were frustrated by a loss of vitality. They also noted fluctuations in energy levels, with more periods of fatigue and inertia than high vitality levels. This lack of energy and vigor is consistent with other findings in cancer research studies (Fawzy, Kemeny, Fawzy, Elashoff, Morton, Cousins, & F ahey, 1990). Lack of vigor was often apparent in the musical content of group improvisations. Unthemed improvisations in the early group stage were characterized by soft, delicate, monotonous patterns, minimal changes in rhythm or dynamics, and aimless musical wandering. The women acknowledged listening carefully to each other; they were hesitant to dominate or stand out in the music and seemed to be waiting for another group member to initiate change or to experiment with contrasting material. There may be both physical and psychological reasons for the low energy levels. 50 Since it is recognized that the suppresSion of strong emotion can reSUIt in 139k 0f vitality, unaccessed feelings could account for low energy levels. It is also well known that the tntenSity and invasiveness of cancer treatment can have devastating physical effects that reSult in exhaustion. One woman differentiated between the physical and psychological components 0 f v itality. She stated in the post-study interview, “My mental energy has increased, it cowever, my physical energy has remained the same.” Involvement in music making piecesses may have allowed the woman to express feelings nonverbally and increase her mental and psychological vitality without impacting on her physical vigor. Future regearchers may wish to discriminate between physical and emotional energy in order to determine the effects of music therapy interventions. It was common for the women to spontaneously remark following improvisations that the experience felt relaxing. This may have indicated that the since the music making incorporated physical body functions as well as cognitive and emotional capacities, the act of improvisation may have had an anxiolytic effect upon the women. Risk taking. The women in the study acknowledged a desire to engage in new, more life-enhancing behaviors. Facing their illnesses had allowed them to refi'ame many aspects of their lives and to reevaluate old behavior patterns. In an attempt to live their lives as fully as possible, they found themselves more amenable to taking risks. A new appreciation for the gift of life and a realization of its fi'agility gave them courage to stretch beyond past comfortable but restrictive boundaries. The desire to live more fully also motivated them to take risks in the context of the music therapy sessions. All of the women agreed that it felt uncomfortable and 51 threatening to initially engage in the music-making activities. HOWEVER their desire to experience new healing methods allowed them to overcome their fears and make the att‘fll'lpt. The courage of the participants in this study should not be underestimated. Their willingness to engage in aprocess that was new and unfamiliar to them during a time of so many uncertainties was commendable. One woman carried over her risk-taking behavior outside the group. She decided to parasail on a brief vacation between sessions. She shared with the group that before l/Ier illness she had wanted to parasail, but could not find the courage to follow through. Since her diagnosis she decided that some risks were worth taking. She compared parasailing to some aspects of her cancer journey; she had experienced the rewards of facing threatening circumstances and fears, making decisions for herself, and following through on her desires. She found her parasailing experience exhilarating and it also served to strengthen her desire to continue to engage in life—enhancing opportunities. Perhaps the women in this study are representative of a category of women with breast cancer who particularly benefit from group interventions. Cunningham (APA Monitor Online, 1999b) identified a subset of women who survived twice as long as predicted by oncologists. These women, who were participants in a psychosocial intervention, were identified as more motivated for treatment and engaged actively in the group process. Cunningham believed that high motivation and active participation were the predictors of extended survival times. He suggested that researchers examine the intensity of participation as a predictor of increased survival times. Loss of control. Coping with a life-threatening disease shattered any illusions of being in control for the women in the study. For some of the women, the most difficult 52 aspect of the disease was in giving up control, facing losses associated with the diagnosis, and being placed in the position to rely upon others. Since these women were usually in the Position to give support to others, they were unprepared for being on the receiving end of relationships. For these women, being caretakers and nurturers was highly correlated with their self-concept. They acknowledged that it was most difficult for them to ask for help, and when given no other option but to ask, they felt guilty and embarrassed. Some important group work occurred around the issue of asking for and receiving help. A musical activity was designed to allow each woman to take on the role of group I: ader, with the other women supporting and accompanying her in the music. This activity proved most difficult for a few of the women, who did not want to either ask for help or give direction to the other women. When the women realized that this activity did not require one woman’s needs to be met at the expense of the others, the reticent women became more assertive both in expressing their needs and in receiving group support. This experience served as metaphor for patterns in all the women’s lives. Some women were able to make connections from the musical experience that helped to reframe their relationships with family and friends. An indication of becoming more comfortable with requesting help became apparent when one group member needed to relinquish her usual holiday obligations due to her weakened physical and financial state. Requesting help became the focus of this session and she received much support and encouragement for making decisions that would be in her best interests. Eventually this woman was able to gracefully bow out of responsibilities without losing self-esteem. The relinquishment of control may represent the positive yielding pattern associated with 53 better Psychosocial adjustment and quality of life in other research findings (Astin et al., W99} Her reliance on the group support and her ability to relinquish control were factors in making healthy decisions. The mutual caring and empathy that was characteristic of this group may also be indicative of the tend and befi'iend behaviors referenced in the literature (Taylor et al., 2000). Tend and befriend behaviors were correlated with positive and life enhancing responses to stress. The women progressively became more comfortable both giving and r’eceiving support. They also found that the common bond of living with breast cancer helped strengthen their cohesiveness. Self -empowerment. Self-empowerment components were represented in all the clinical themes. Definitions of empowerment always contain aspects of taking action and assuming responsibility for decisions (Stein, 1998). Since the music therapy interventions were structured as action methods, they may have provided opportunities for the women to both decide and then actively pursue behaviors that impacted positively on their sense of competence. Evidence of the study’s empowering effect upon the women may be evidenced in their stated preference for the active aspects of the interventions. Following an activity where the women together played a gathering drum while chanting healing phrases, one woman spontaneously remarked “That felt empowering.” There had previously been no mention of or reference to goals of empowerment for this group. Also, the women’s desire to share their experience with others in order to encourage future participants may be viewed as a result of their own empowerment. This desire to encourage firture participation in music therapy groups could be an indication of 54 the women’s reaching out to the public domain as well as a testimonial to the “few" eness of the group for them. This extension of care beyond the group can be imm‘pl’eted as an indication of the results of empowerment. The act of volunteering and the Willingness to become more visible to others could also be construed as an outgrth of empowerment. The group’s desire to reach out to others was evidenced in the final moments of t the study. Some of the women had observed other cancer patients in the waiting area of tJIe facility, and expressed a desire to invite them in for a final combined musical eXperience. When all the women agreed, five patients in the waiting area were invited to jo in the group in a song and to accompany themselves with the tone chimes. It seemed a most fitting way to end the group and a symbolic “torch passing” to future participants. Limitations There were several important limitations to this study. Caution should be taken in reference to the interpretation of the study’s results and conclusions. As in any research project, internal validity may be precarious due to many unforeseen and uncontrollable variables. It is impossible to control every variable and it may be possible that other factors that were invisible to the investigator may have accounted for the changes observed. One of the group members was involved in multiple complementary therapy practices; it would be difficult to sort out which interventions impacted most powerfully. The most obvious limitation of the study was the small sample size. Recruiting participants proved to be the most difficult task of the research. Several factors may have been at play in the recruitment process. Cancer researchers have acknowledged that 55 recruiting research participants for cancer studies was particularly difficult due to a Vafie‘y 0f physical, psychological and practical reasons (Cella & Yellen, 1993), Upon being invited to join the research study, several women receiving adjuvant treatment complained that the treatment was extremely debilitating and had resulted in Serious depletion of their strength, motivation, and energy levels. These women had no desire to attend yet another treatment that they were not convinced would help them. other women were less skeptical of the possible benefits of music therapy, but still found Chcmselves exhausted after chemotherapy and did not wish to add another commitment to til eir schedules. Another element that may have affected the low participant numbers must be mentioned. The terrorist attack of September 11, 2001 on the United States coincided with the original starting time of the study. Following the September 11 date, several potential participants decided to withdraw before the study began. Despite the Implementation of an extensive outreach program, only five women were willing to join the group. It is difficult to ascertain the impact of the terrorist attack upon the recruitment outcome. It may be possible that since cancer is often viewed as an attack upon the individual, the attack upon the country may have been even more intensely felt by these women. Withdrawal and the wish to remain close to home and familiar surroundings may have been defensive responses to feelings of vulnerability. Perhaps the combination of the commonplace problems of recruiting cancer patients combined with the threat to national security contributed to the poor response to recruitment attempts. It may be interesting to compare this recruitment endeavor with other research studies commencing at this important historical time to discover if a 56 common thread or trends are revealed, Statistics were also affected by the small sample size. Since it is typically ple size obviotlsly recommended that sample size be no less than N = 30, the small Sam ere had violated this nonn. The paired t-tests would have prov en more meaningful if th been increased numbers of research Participants; however, they did indicate strong significance on the quality of life Scales. Due to the Small sample Size, it is imPOSSible to generalize the results outside Of thi 5 study. A control Eton? would have better determined that the improved scores were due to the treatment variables. Another limitation concemCd the acoustics in the physical space where the interventions occurred. Although the setting was aesthetically pleasing to me with walls Partic'lpams, the hard surfaces 0f the building materials, including a stone floor and ceiling made entirely of glass, produced poor so und quality. When the instruments were played, the echo effect of the overly “live” room made it difficult for participants to hear each other and at times, to even hear the insnutrients they were playing- Understanding Speech was also troublesome frustrating at timeS, particularly when participants Were requested to repe and _ Stateme several times. Future research Should carefully evaluate the acoustical 6011) nts P onents ofthe Ad - equate a cousncal Draper-ti es of the room should take precedence over aesthetic Vi sual aspec ts research setting that impact on both verbal and musical communication. whe - n SEIecting a research site- Reco’hmendations f‘or future studies It is hoped that this research will serve as a catalyst for future - m1131c therapy resea ' l‘ch for women With breast cancer. Ihe extant musrc therapy resear h l' c iteratur e 57 . . . erS contains I'Clatively few references to breast cancer and to cancers 1n general. All 03110 . rates combined are the second leadln g Cause of death in the United States; breast cancer continued to increase between 1 988 and 1996. In 2001, the total number of recordec1 deaths from all cancers also continued to increase (Greenlee et al., 2001). Treatments that address quality of life for cancer patients are becoming increasingly important, One of the Mexican Cancer Society Board of Directors, priorities was to discover methods 0f trefitment that measurably improved the quality Of life for cancer survivors (“New DiIeCtions for CA,” 2001)- Since this study revealed improvement in quality of life for its pafilcipants, further study is encouraged to idcntify music therapy interventions that cancer survivors. Studies with larger samples WOUId produce more help inclusion of a control group would also increase the internal validity . Homogeneous-stage groups may reveal aspects of therapy that are more relevant to specific cancer stages. ProtOCOIS for music therapy groups for women with bfeaSl Cancer might be developed to address the particular treatment issues enco . unwed in the Various disease stages. Follow-up measures t aken at later times might also reveal either ekt ended Or delayed benefits, Longer rescafCh periods, for example 8 to 10 weeks ma also im , . . . . Prove research outcomes- this study indicated that mltlal anxrety when playing i sub 'd , - h hStruments may 31 e over time ed exposure may Increaset e comfort] t evel . . and repea Qf partlcnpants. Qualitative music therapy studies may uncover more SUbstantia] informat’ 1011 about the evolutionary process that emerges in groups. Since creativity is so e’Ssential to t/ze Improvisational process, qualitative research may provide Valuable insights th at are 58 overlooked or invisible in quantitative studies. Music therapy research that identifies patients’ degrees of involvement in the Process needs to be developed. Designs that distinguish the select participants who are more motivated and work more intensely should be explored. The positive effects for these individuals may be diluted out in an overall group mean. This may be particularly important in light of the literature that identified this subset as correlated with an especially positive prognosis. Music therapy groups for women with breast cancer may prove to be effective sources of comfort and healing both in addressing physical and psychological problems associated with the disease. Breast cancer is a multifaceted disease, both in its etiology, treatment, and prognosis. This study does not venture to simplify such a complicated disease although it does propose that music’s potential for healing may generate new life- enhancing possibilities. This research is a rudirnentary attempt to identify interventions that may provide direction as research in this area expands and evolves. Music’s advantage over other treatment applications may be in its ability to nurture and SUStain hope in the darkest of times. 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Giza/”8’00! aspects Weiner, H. (1977). psychobiolOgy and Human Disease. New York H " onand. Wermers, G.W., Dasgupta, J .D., & Dubey, DP. (1986). Stress, the i system, and cancer. In S.B. Day (Ed.), Cancer, Stress, and Death (pp 3 3 8 line Plenum. ' - O)' New York: Y alom, 1. (1 995), The theory and practice of group psychoth Basic Books. erapy, New York; 70 YOun A 1980 l 'b ' kn g, . ( ). e discourse owledge. Social Science & Medicine, £338??? :md the reproduction of , _ 46. COHVentional 71 APPENDIX A RECRUIIW7INFORb1ATIONM. mm . .b kn! MUSIC THERAPY 7% GROUP5 FOR WOMEN WITH BREAST CANCER You are -i nvlted to particlpate in an excitlng research project designed exclusively for women with mean Cancer. This study will take place at Providence Hospital, both at the SOUthfleld and Novi locations. Groups of women With breast cancer Wt“ meet to explore the benefits of music by llstening.creatlng and enjoying the beauty of music. Groups will meet once a week for six weeks for 90 Minutes. No previous musical experience is required or necessary for you to join. The groups will be led by an experienced muslc'theraPiSt Who works in the Healing Arts Program at Providence Hospital.The"e ‘5 no charge for thtS- service. Music: has been assOCiated with healing in several ways: - Music may lower stress leVels and improve Immune function ,, - Muslc may reduce nausea sometimes associated with chemotherapy ' - Music may reduce ten5i0n and enhance vigor - Music may help control pain - Music can provide an eth’eSStVe outlet for strong feelings - Music can provide a Meals“t experien cc and a diversion from negative thoughts - Music groups can provide a support system for coping with breast cancer IF You Am; imnssft-SD IN THE BENEi-Trs OF MUSIC, THERE WILL BE AN ' INFORMA-nONAL “germs AT THE FOLLOWING LOCATIONs: IN NOV]: AT THE ASSARIAN CANCER CENTER ON TUESDAY, OCTOBER 30. 2001 AT 3:00 P.M. iN THE CONFERENCE ROOM ON THE SECOND FLOOR. i I» IN SOUTHFIELD= AT THE PROVIDENCE MAIN HOSPITAL CHAPEL LOCATED NEAR THE MAIN HOSPITAL ENTRANCE, ON MONDAY, OCTOBER 29, 2001AT 7:00 P.M. . : .. OR Tl _ :- -FOR MoRE lNFQRMATlON CALL: '4 ' MARGARET FURIOSO MI-BC ’ 734/ 98 l 2977 72. APPENDIX B You are being invited to participate in a research f the H . Project conducted by Margaret Furioso, a graduate student and staff I‘neflii"?r ° , .eaimg Arts Program at the Assarian Cancer Center Of Providence Hospital. This prOj ect ls COnducted under the supervision of Michigan State University Depal'im"mt 0f MuSic Therapy and the Healing Arts Program of Providence Hospital. You are invited to participate in a research to discover the effects of music on women with breast cancer. The project W1“ focus on improving coping skills through self- empowerment, decreasing stress IBVels, and improving overall quality of life for participants. If you are a member of the contI'OI, no-music group, you will be asked to complete questionnaires and the beginning and the end of the project (if you are a member of the control group. you may skip to the Second paragraph on the next page). If you a member of the experimental group, you will be aSked to attend 6 music therapy group sessions comprised of women with breast cancer. These sessions will last for 90 minutes and will meet once per Week. The sessions will take place either in Southfield at the main hospital or in Novi at the Assarian Cancer Center. Times for the sesstpn will be structured around availability 0f the PaniCiPants and will be determined folloWIng communication with potential PartiCIPahiS- The seSSiOnS will be facilitated by an exPe‘iethd, board certified music therapist who has expertise in working with both Physwai and emotional illnesses. The: scSSiOHS Will be conducted in compliance with standards 0f practicc of the American Music Therapy Association and the policies and procedures 0i: Providence Hospital. The sessions will use music as an active agent for change and Will employ the use ofa vari ety 0f musical and PCfCllSSive instruments, including xylophones, metallophones, drums of all sizes, bells and chimes, keyboards, and rhythm instruments of various sizes and timbres. Group experiences will include relaxation techniques Incorporating music, group improvisation using all music media as well as reflCCtion on the experience in the form of group discussion or personal verbal sharing folloWing the musical engagement. The sessions are designed as “ficeedom-within-SWCWC” format in order to encourage full participation by all. The focus is on spontaneous eacpression of emotion and the creative use of both werbal and nonverbal methods of self-expression. You will be asked to complete questionnaires at the beginning and at the end of the project that may take from 15 to 20 minutes. The project leader will also Conduct a brief intCI'ViCW t0 PFOVide the Opportunity for you to express your thoughts and feelings about the sessions. In addition, counseling ra sources and referrals will be made available for all research participants in order to Mint process materi a1, if desired. Sessions and interVIews may be audio and/or videotaped for exclusive review by the project leader. 73 There are no known risks associated With PmiCiPating in this study. The PrOject ma benefit you in several waySI you may,red“°§= Stress and release tension , providing y relaxation and its associated benefits, mclmlmg improved sleep, lessening of worries and preoccupation with intruSive thoughts’ p918 Slble (yet unproven) benefits to your immune system; improve your coping With your 1 bless rt t o i Provide support for you as well provide the opportunity for you to give SuPPO o the:- Women in the same situation; provide and outlet for your creativity and pro"lde you wlth a pleasurable experience that is known to be healing; and teach you skills {hat you may find helpfiil to use as you continue your cancerjourney when the project 15 completed. If you decide to participate in this project, Please understand that your participation is VOIHDWY and you have the right to Wlthdraw your consent or discontinue participation at any time. You have the right to refuse to answer any question(s) for any reason. In addition, Your individual privacy will be maintained in all published and written data resulting from this study. The Q9111) sessions will maintain the privacy of all members and questionnaires will be coded In order to insure confidentiality, Your privacy .Wlii be protected to the maximum extent allowable by law. During the period of the preject all questionnaires and interview material will be kept in a secured place, accesmble only to the project leader. At the completion of the project, all information associated With the project will remain private and Confidenti al. A Signed copy of this corisetlt f0“? Will be provided to you before the music therapy sessions begin. If you have questions about this study, please contact Margaret. Funoso, MT-BC, at the PIOVidence Cancer Institute (248-465-3000). If you have questions about your rights as a human subj ect ofresearch, you may contact Ashir Kumar, chall‘person of the University Committee on Research Involving Human Subjects at Michigan State University (517-355-2180). I have read the above information 811d voluntarily consent to participate the research project entitled “The Effect of GrouP Mus“? Therapy for Women with Breast Cancer on Coping, Psychosocial Adjustment and Quality Of Life” Signature of Participant: Date: Signature of Witness: Date: 74 APPENDIX c RAW SCDRES subled MA(75"80 mcsrs1 mcsuo “ism MACSAPO MACSAP1 MACSFO MACSH MACSAO MACSA1 1 46 44 1o 7 26 24 16 14 4 i 2 2 59 52 7 6 25 24 14 18 2 1 3 43 49 a 6 19 19 19 17 2 1 4 58 31 6 7 26 26 16 15 2 4 5 57 59 1o 32 29 23 18 2 1 5”“ Control!) ,Coflflo'1 Subject Strasso Stresst ' 1“ 14 25 1 25 1‘ 2 34 i 31 2 15 13 3 34 31 3 20 19 4 27 18 4 15 10 5 39 38 5 27 26 QOLHFO QOLHF1 001.550 001.851 OOLPSO QOLPS1 oou=o ecu-'1 QOLTotIO 001.7081 1 9.923 17.153 16285 19.785 16.285 16.285 25.2 26.4 67.693 79.623 2 21.73 22.961 18.928 19.571 24.428 24.428 27.6 28.8 92.686 95.76 3 1532-, 25291 28.011 27.571 25.714 25.714 28 26.625 98.512 105201 4 23.423 2723 23.571 24 23.571 24 25.2 27.6 95.765 102.83 5 5.076 9 20.357 22.5 13.714 17.142 24 22 63-147 70.642 Note. 0 - etest° 1 s posttest; WEST-‘3 - gal Adjustment to Cancer, Fighting Spirit Subscale. MACS” - Mental Adjustment to Cancer, Helplessness/ [-bpelessness Subscale MACSAP - Mental Adjustment t0 Cancer, Anxious Preoccupation Subscale "AC3!" -- Mentai Adjustment to Cancer» Fatausm Subscale MCSA 8 Mental Adjustment to Cancer, Avoidance Subscale Control .- Health locus of Control Scale Stress . Per-C m Stress Scale - Q1613): of Life Index, Health and Functioning Subscale QJUIF QISE - 11 of Life Index, Social and Economic Subscale QOLPS - 32113: of Life Index, Psychologicall Spiritua1 Subscale mLTotl "' Quality of Life IndeX, Total Score 75 APPENDDto Music Therapy Groups for Women with Breast Cancer '" m w“ Demographic Questionnaire 1. Date of birthzi I \_ 2. Ethnicity: African-American 0 ASian‘Anmrican a Caucasian a Hispanic 0 Native American 0 Other 0 3- Approximately, how tall are you? 4. APPmfimately,how mucth you weigh? . 5. What is the highest level of education yo“ have completed? (Check 0116): High school CI Some college: years Associates degree 0 Bachelor’s degree 0 Master’s dew Cl Doctoral degree a 6. Doyouhfive any children? If so, how many? 7 . Are you may menopausal? Yes a No CI 8. Are you receiving hortnOnal l‘eplalcerruent therapy (HRT)? Yes D No D a) If 50, please answer the following Name brand (if known) IA Dosagev A Frequency_ ‘ 9. Currentlyjnwhat stage ofbreast cancerare you? 10. When Were youfirst diagnosed? 11. Are you currently undergoing chemotherapy? Yes D No 0 a) If so, please complete the {allowing Name brand ‘ Dosage Frequency Ages? #— v ‘ '7 v ‘— 76 a) What side efi‘ects do you commonly experience afier receiving chemotherapy? I ‘ \ l 3. Are you currently undergoing radiation therapy? Yes a No D a) What Side efiects do you commonly experience after radiation therapy? \ \ ‘4. Are you may undergoing hormonal therapy? Yes D No D a) Ifso, please answer the follOWing, Name brand (ifknown) Dosage_ Frequency . b) What side efi'ects do you experience associated with hormomal therapy? A v A A I A 15. Have you undergone sugar associated with your breast cancer? Yes D No D 8) Ifso, When? I Date($) b) What was the nature ofthe surgery? Check all that apply; Lmnpectomy U Masmctomy D Reconstl'u‘ifion D Other Cl (explain) ‘ 16. Are you my taking antibiotics? Yes D No 0 l7. AreyoucmrenflytaldngsterOids? YesD N00 18. Areyou currentlymldnganfideptessantS? Yes D No U 19. Doyouhave a historyofdiabetes?YesU NOD ‘a)Ifso.areyou taidnginsuinbyinjecdonvres :1 No a 20. How many hours of restful sleep did you have in each of the past 3 nights? a) Last night ‘A_b) Night before last '0) 3 nights ago 77 21. Dming the past week, how many ““95 0f 003:: or tea have you consumed per day? 2% During the past week. how “my ““5 °f soda have you consmned per day? a)Whatbtand ofsodadoyouusmn” d'h‘k?_ 23- HOW many alcoholic beverages have you Consumed per week during the last month? (Usethcfollovvingsystem: I beveragca 1.502. liquor, lZozeanofbea,and80z.giassof wine.) 24.1nthepast 2 weenhowmamcimmeshaveyousmokedperday? 25. Pleaselist allpresetiptionflledicafionsyoumcurrenflytaking: ”- p __f I 26. Please IiSt all over-the—Oom (nmaiption) medications, such as aspirin, laxatives. sleeping Pills. and pain medications that you have regularly taken in the past 2 weeks: A I A I l ———f v I 7 I 27. Areyoucmmflyparficipafinginm healhgaxtsoroomplemonm mmmpmcfices, eitheratpmvidenoenospitalorclscwhm7Yaa Not! 10380. please check as many ‘5 apply: YogaCl Remit! MassageCJ ExerciseCI NutritionU SapportGroupsD 10mg mmcficlcfl ArtCI Ceramicsa Meditation D MusicU OthetU _ v flank Yaw! ' 78