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Bibliotherapy for Psychosocial Distress in Lung Transplant Patients and Their Families
Original Research Reports Bibliotherapy for Psychosocial Distress in Lung Transplant Patients and Their Families BRIAN HODGES, M.D., F.R.C.P.c. JOHN CRAVEN, M.D., F.R.C.P.C. CHRISTINE LI1TLEFIELD, PH.D.
Thirty-six lung transplant candidates (n = 16), recipients (n = Jl), and support people (n = 9) were examined for psychological distress, coping style, and orientation to independent learning before and after receiving a self-help book in a program designed to alleviate psychosocial distress and bolster adaptive coping. The subjects rated the book as highly acceptable, and none reported increased psychological distress. Afurther six subjects completed initial psychological measures but elected not to use the book. These subjects were compared with study completers and found to have significantly higher disengagement scores on the Coping Strategies Inventory. Although uncontrolled, significant changes were observed in coping strategies used by the completer group. The relevance of these findings to the use ofbibliotherapy in medically ill populations is discussed. (Psychosomatics 1995; 36:360-368)
O
rgan transplant patients are faced with both a serious medical illness and a major surgical intervention that expose them to a bewildering array of unfamiliar circumstances and challenges to their emotional and physical well-being. I In medical and surgical patients in general, symptoms of emotional distress complicate recovery in one-quarter to one-third. 2 The negative consequences of untreated emotional distress are well described and include increased morbidity 3 and mortality,4.5 decreased compliance with prescribed treatments6 and re-
Received February 9. 1993; revised March 20. 1993; accepted July 13. 1993. From the Clarke Institute ofPsychiatry. University of Toronto; St. Joseph's Health Centre, University of Western Ontario; and The Toronto Hospital. University of Toronto. Address reprint requests to Dr. Hodges. Clarke Institute of Psychiatry. 250 College Street, Toronto. Ontario. Canada M5T IR8. Copyright © 1995 The Academy of Psychosomatic Medicine.
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habilitative programs,7 and impaired functional outcome. 8•9 In transplantation patients, the potential for psychological distress and psychiatric disorder is great. I Increasing attention is being given to the detection and management of psychiatric distress in the medically ill,2 but can be complicated when patients do not recognize or report emotional symptoms to the health care team. Further, misunderstanding of traditional psychological therapies and the stigma of mental illness may contribute to patient reluctance to use counseling or other mental health services. Even when psychosocial distress is recognized in large medical or surgical populations, interventions that require therapist contact can be costly to provide and may overwhelm the availability of professionals. Therefore, it has become increasingly desirable to offer alternate sources of therapeutic information and support either to patients who may be unable or resistant to work with a therapist or as an adjunct to PSYCHOSOMATICS
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traditional methods of counseling and psychotherapy. Bibliotherapy refers to any mass-produced communication medium. be it books. cassettes. or videotapes, which is directed to recipients of health care. with the goal of assisting in the detection, diagnosis. or management of a health problem. 1o A program of bibliotherapy may be self-administered. discussed in groups. or therapist-administered. Written psychoeducational materials have been recommended and produced for a wide variety of health conditions for over a century. I I However. well-designed studies into the use and efficacy of psychoeducational material are sparse. 12 Yet in the area of coping with life events, the publication of selfhelp books is a booming industry.'2 One survey found that specific readings were recommended as an adjunct to counseling and psychotherapy by about three-quarters of mental health practitioners surveyed. but without any evidence of their effectiveness. 13 Few investigators have examined the use and effectiveness of bibliotherapy as a coping aid for medical and surgical patients. The benefit of providing psychoeducational information and instruction through other means has been well documented in both groups. 14-16 Taylor and Clark l7 reviewed 25 studies of the effects of procedural. sensory. or both types of information on coping and adjustment following medical and surgical procedures. The effects of this information was found to have consistent and positive effects on mood, medication need, and patient behavior. A number of authors have suggested that certain persons are more likely to accept and undertake a program of bibliotherapy than others. 1O For example, Scogin et aL's found decreased efficacy of bibliotherapy in mildly and moderately depressed older adults who had fewer years of education, compared with similar patients with higher levels of education. Patients who approach illness-related events with a vigilant or confrontational approach tend to do best with the provision of information. whereas those who tend to have an avoidant or repressive style may benefit less, or fare VOLUME 36. NUMBER 4 • JULY - AUGUST 1995
worse.17.19.20 Two studies have actually suggested increased emotional distress when information was imposed on persons with avoidant coping styles. 20.21 In general, studies examining the clinical effectiveness of bibliotherapy are frequently affected by a high dropout rate,22 but the reasons are seldom explained. Improvements in both the efficacy of bibliotherapy and the degree of subject compliance might be greater if predictors of bibliotherapy use were better appreciated. 'o We undertook this study to determine if lung transplant candidates, recipients, and their families perceive written psychoeducational material as helpful and useful to determine predictors of the use of bibliotherapy and to obtain preliminary information on the effect of bibliotherapy on the level of emotional distress and adaptive coping strategies. Finally, we were interested in detecting any adverse effects that might be associated with use of the book, particularly in relation to individual coping style. METHODS Subjects All patients attending the clinic ofthe Lung Transplantation Program of the Toronto Hospital during the study period (February I through April I, 1992) were asked to participate. Included were subjects who were awaiting lung transplantation, those who had recently received a double-lung transplant, and their support persons. A total of 50 lung transplant candidates, recipients, and their support persons were approached. Forty-two (84%) gave written consent and agreed to participate. Of the eight who declined, four were candidates, two were recipients. and two were support people. Thirty-six subjects (72% of those eligible) participated in a trial of bibliotherapy and completed both the initial and final assessment packages. Of the six who were noncompleters. two were recipients. and four were supports. Of the 36 participants, 16 were candidates, II were recipients, and 9 were support people. 361
Bibliotherapy for Lung Transplant Patients and Families
Procedure The potential subjects were told that their agreement to participate meant that they agreed to complete baseline and follow-up measures and to accept for a 2-week period a personal copy of Surviving Transplantation (see Book Review column in this issue for review, page 413).23 No expectation was placed on the subjects to read the book. Rather it was explained beforehand that the participants were welcome to read none, some, or all of Surviving Transplantation. as their personal preferences dictated. Potential participants were also told at the outset that follow-up measures would not involve any testing of their knowledge of the book's content. The subjects who agreed to participate were seen by a research assistant and an investigator (BH) not involved in their clinical care for the purpose of obtaining consent and distributing a baseline set of self-report measures. Once the baseline measures were completed and returned, each subject was provided with a copy of Surviving Transplantation. Two weeks later, the books were collected, and at that time a followup set of self-report measures was distributed. All subjects were offered an open opportunity (by telephone, in the group, or individually) to discuss any questions or concerns that arose during their reading of the book. The subjects who did not return survey measures or the book were reminded each week until they did so, or they elected to withdraw from the study. Materials
Surviving Transplantation is a book designed to help patients to better understand their personal and emotional reactions to illness, provide situation-specific stress-management and problem-solving techniques, and encourage appropriate help-seeking behavior through education about possible psychiatric complications. The 123-page book uses many clinical case vignettes to illustrate adaptive coping. The clinical material in this book was gathered over several years of experience in counseling and 362
providing psychiatric treatment to transplant patients and their families. It is organized into nine chapters, such as Living With Illness, Waiting for Transplantation, Recovering From Transplantation, Understanding Stress, Dealing With Stress, and When to Ask for Help. Measures Psychological measures with documented reliability and validity in the medically ill were used. Psychological well-being was assessed by using the Beck Depression Inventory (BOI),24 the General Health Questionnaire (GHQ),25 and the Spielberger State-Trait Anxiety Inventory (STAI).26 The Coping Strategies Inventory (CS1)27 was used to gather information about coping style. The Self-Directed Learning Readiness Scale (SDLRS),28 a 58-item self-report questionnaire, was used to gather data on learning preferences and attitudes toward learning. The SDLRS is one of the few instruments identified in the literature for measuring self-direction in adult learning. Although its use has not been validated in medically ill populations, this instrument has been used extensively with other adult populations, and numerous studies attest to its reliability and validity.29 Finally, demographic data, number of support people, and information on reading habits were obtained. In the final assessment package, the patients provided detailed data on their use and satisfaction with the book. This included the amount read, the number of hours spent reading the book, the degree to which they learned something new, and whether they would recommend the book to others. In addition, the subjects were asked to select the degree to which a list of 12 adjectives (helpful, interesting, enjoyable, worthwhile, educational, easy, depressing, useless, worrisome, boring, disturbing, and difficult) described the book. RESULTS Demographic data were compared for the compieters (n =36) and noncompleters (n =6). The completers had a mean age of 43 years, of which PSYCHOSOMATICS
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39% were men. and 61 % were married. The noncompleters had a mean age of 45 years. of which 67% were men, and all were married. Of the completers, II % had only elementary education, half had some high school education, and 36% had postsecondary education. All of the noncompleters had some high school education, and 17% had postsecondary training. The completers reported a mean of six people they could count on for support, whereas the noncompleters reported nine. Reading behaviors were also measured. Of the completer group, 89% said they liked to read, and 72% reported reading greater than 3 hours in the preceding week. For the noncompIeters, 100% liked to read, and 67% had spent greater than 3 hours reading the prior week. In the prior week, 92% of completers had read a newspaper, 92% a magazine, and 71 % a book. For the noncompleters, the corresponding figures were 100%, 100%, and 83%, respectively. By use of chi-squared analysis for categorical variables and t-test for continuous variables, no significant differences were found between these groups for either demographic data or reported reading behaviors. Because of the small sample size in the noncompleters group, the lack of significant differences between the groups may have limited reliability. Table I illustrates the means of the psychological measures taken at baseline on the compIeters and noncompleters. Significantly higher scores were found on the disengagement subscales of the CSI for the group who did not complete the study. The extent to which the subjects found the book useful and acceptable was addressed in several ways. First, Figures I and 2 illustrate the response of subjects to a list of 12 adjectives that they endorsed on a 5-point Likert-type scale, ranging from "not at all" to "completely." A very high proportion of the subjects endorsed the positive adjectives, whereas very few negative ones were applied to the book. Over half of the subjects reported that they found the book very interesting, worthwhile, educational. and easy. None of the subjects described the book as very depressing, useless, worrisome. boring. VOLUME
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disturbing. or difficult. Fifty-six percent of the subjects spent 3 or more hours reading the book. whereas the remainder reported spending beTABLE I.
Means or psychological measures ror compieters and noncompieters at baseline Completer (n = 36)
Noncompleter (n = 61
8.14 47.00 1.93 0.87 35.66 228.11
8.00 56.50 1.92 1.43 44.33 238.50
BDI GHQ CSI engagement CSI disengagement STAI SDLRS
-0.05 0.81 -0.04 2.80 1.46 0.92
.
=
=
Note: BOI Beck Depression Inventory; GHQ General Health Questionnaire; CSI =Coping Strategies Inventory STAI =Spielberger State-Trait Anxiety Inventory; SDLRS = Self-Directed Learning Readiness Scale. Comparisons are two-tailed t-tests.
·P50.01.
FIGURE I.
Mean ratings or use and acceptability
l ....., A l I ' _ (11.36)
Compl.....,
1,----=-------'----'---------------,
'n_ _,..
"..p...
fntoylOl. Worftlmle Eauulonel
E..,
OMcriplors
FI(;URE 2.
Mean ratings or use and acceptability
L.... of Agreenwnll en Com,....., 51 -
v..,MYCh
4
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1,
1
• l6)
I !
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.
---,
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Bibliotherapy for Lung Transplant Patients and Families
tween I and 3 hours. Eighty-nine percent of the subjects reported reading all of the book. 9% read "most." and 3% read half. All subjects said they would recommend the book to others. Using a correlation matrix. subject characteristics were compared with subject responses relevant to the use of Surviving Transplantation and perceived benefit derived (Table 2). The older subjects were more likely to report both having read more of the book and having learned something new. Those who reported a greater number of support people. and those who had higher engagement scores on the CSI spent more time reading the book as well. Level of education was not found to be associated with book use nor were scores on the SDLRS. Group mean scores were compared on the BDl. GHQ. and the subscales of the CSI (Table 3). By use of a two-tailed t-test. significant changes were found in two subscales of the CSI. Subject scores of expression of emotion and social withdrawal both significantly decreased after reading the book. There was no increase in scores measuring psychological distress after reading the book. DISCUSSION Of the 50 persons asked to participate. a sizable majority (84%) agreed. Of the 42 participants. most (86%) completed the study. This rate is higher than generally reported in the literature on the use of self-help-type books. 22 Unfortunately. comparable studies in physically ill samples are not available. The readiness of lung transplant patients and their families to participate likely reflected. in part. their awareness of the role that research plays in the medical advancement and altruistic sentiments that arise in transplant groups. However. it is our impression that this high rate of participation was also influenced by the keen interest in Surviving Transplantation. which was expressed by many patients at the study outset. The life-threatening nature of their clinical predicament. the highly technical atmosphere in which they receive treatment. and the relative novelty of the surgical interventions may have combined to in-
TABLE 2.
Correlations between subject demographies. baseline psychological measures, and use of the surviving transplantation (n = 36) Amount of Book Read 0.37" -0.04 0.14 -0.12 -0.14 -0.13 -0.12 0.00 0.16
Age Education Suppons CSI engagement CSI disengagement 801 GHQ STAI SDLRS
Time Learned Spent Something New Reading 0.13 0.03 0.39" 0.37' O.QI
-0.11 -0.15 -0.29 -0.27
0.42" -0.17 0.16 -0.02 0.30 -0.02 0.16 0.00 -0.11
Note: CSI = Coping Strategies Inventory; 801 = Beck Depression Inventory; GHQ =General Health Questionnaire; STAI =Spielberger State-Trait Anxiety Inventory; SDLRS Self-Directed Learning Readiness Scale. Comparisons are two-tailed I-tests.
=
"p S 0.05; ..PS 0.01.
TABLE 3.
Baseline and follow-up psychological and coping style measures (n =36) Baseline
Follow-up
8.14 47.00 35.70 1.95 2.27 1.47
7.89 42.56 35.67 2.08 2.14 1.09 1.93 0.75 1.58 0.38 0.63 1.78 0.83
BOI GHQ STAI Problem solving Cognitive restructuring Expressed emotion Social suppon Problem avoidance Wishful thinking Self-criticism Social withdrawal CSI engagement CSI disengagement
2.10
0.83 1.48 0.31 0.98 1.91 0.90
0.42 1.46 0.03 -0.85 1.05 3.77" 1.14
1.02 -o.~7
-0.65
3.34" 1.32 1.05
NOle: BDI = Beck Depression Inventory; GHQ = General Health Questionnaire; STAI =Spielberger State-Trait Anxiety Inventory; CSI =Coping Strategies Inventory. Comparisons are two-tailed I-tests.
"PSO.OI; "P S 0.0001.
crease motivation and participation in this type of study. Many had previously expressed a desire for greater psychoeducational information about the personal and emotional aspects of organ transplantation. PSYCHOSOMATICS
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Equally important, this high level of motivation could lead to an underreporting of distress and overenthusiastic response to the intervention. A study limitation was the lack of a social desirability measure and a reliance on self-report measures. However, every effort was made to ensure that the subjects were aware that study participation did not require them to read the book. Given these considerations, a huge majority of participants (89%) reported that they had read all of the book. Over one-half spent more than 3 hours reading Surviving Transplantation. Positive descriptors (helpful, interesting, enjoyable, worthwhile, educational, easy) were attributed to the book, whereas negative descriptors (depressing. useless, worrisome. boring, disturbing, difficult) were rarely used. In proposing any treatment, it is desirable to be able to not only predict which persons will benefit from treatment. but also to identify those who will be able to comply with treatment recommendations. When the treatment involves a significant amount of new learning, particularly self-directed learning, it has been frequently suggested that certain persons have a readiness for self-directed learning and others do not. 28 .30 It has been suggested that persons who recognize their capacity for self-directed learning realize that they have the power to alter their individual and social environment. 29 We hypothesized that an orientation toward independent learning (as indicated in this study by the SDLRS) would predict successful completion of a self-directed program of treatment. An association between SDLRS scores and performance has been demonstrated in nonmedical samples in the context of nursing education 31 and business and industry.32 However, this measure did not distinguish subjects who read the book from those who did not. The validity of this measure in a medically ill sample may be questioned. Alternatively, it may be suggested that in the medical context. other motivational factors may override this dimension of learning. For example, the need for information in unfamiliar and distressing situation may outweigh any orientation for or against self-directed VOLUME 36. NUMBER 4. JULY - AUGUST 1995
learning. Subjects with an interest in more information may simply be motivated to take whatever form is offered. This phenomenon could also explain why level of education. a variable predictive of use of bibliotherapy in other situations,I8 did not predict reading Surviving Transplantation. Disengagement is a coping style that involves a disinclination to share feelings with others and a tendency to avoid thinking about a stressful situation or to initiate steps to change the situation. 27 Engagement indicates a more confrontational approach to coping with stress. An avoidant style of coping, as measured by the disengagement subscale of the CSI. was more prominent among the subjects who did not complete the study. Similarly, the subjects who approached their situation with a more confrontational style reported greater length of time spent reading the book. Although unanswerable in the context of the current study, it is possible that these associations result from a broad inclination for or against information acquisition about an illness-related situation, rather than a specific attitude toward self-directed reading. It could be hypothesized that persons with an avoidant coping style might do better with an approach that involves a greater degree of therapist contact and support. Alternatively, these persons might be even more disinclined to enroll in such therapy. While an avoidant coping style was associated in this study with a disinclination toward reading a psychoeducational book, it remains possible that the tendency of an avoidant subject to enroll in a more intensive therapeutic milieu (e.g., a support group) could be even greater. Interestingly, older subjects read more of the book and more often reported that they had learned something new. Those with a greater number of support persons spent more time reading the book. We had expected that a higher level of psychological distress would be a motivational factor toward reading Surviving Transplantation. However, measurement of depressive (801) and anxiety symptoms (STAI) and general psychological distress (GHQ) did not correlate with book use. 365
Bibliotherapy for Lung Transplant Patients and Families
Although not a controlled study itself, an additional study objective was to identify beneficial or negative tendencies in subjects for further elucidation in a proposed controlled study of bibliotherapy in the physically ill. No significant changes were found for measures of psychological distress. In fact, baseline levels of emotional distress captured by these measures were fairly low. While nonns for these psychological measures are not available for this specific group, threshold scores quoted in the literature are 15 for the BDI in medically ill populations,33 42/43 for the GHQ,34 and 27 for the STAI 26 in nonnal subjects. Low levels of psychological distress at baseline may have lessened the likelihood of finding an intervention benefit. However, this negative finding is important in documenting that there was no immediate evidence of increased psychological distress during the study period. Reading the book did not have a negative effect on readers' reported level of distress. The lack of a positive effect on distress level may also be an artifact of the short follow-up period. It is possible that any shift in attitude or coping style that might be engendered by the reading of this book would take a greater length of time to result in any potential symptomatic benefit. Two significant changes were observed for coping style. First, the subjects' tendency to cope by releasing emotions dropped significantly. This change is difficult to interpret but might represent a tendency toward a more cognitive method of dealing with distress. This speculation, however, was not reflected in an increase in subscales measuring either cognitive restructuring or problem solving. Second, the subjects reported a lessened tendency to withdraw socially as a way to cope with distress. One subject wrote after the study, "I realize now that I am not alone in what I have experienced." A sense of community with other transplant patients may be encouraged as personal experiences are less likely to be interpreted as idiosyncratic or pathologic, and more likely to be conceptualized as nonnal and common in this extreme of situations. While such a finding was uncontrolled, the suggestion of an 366
effect on coping strategy and response to distress warrants further investigation. Conclusions drawn from this study must be interpreted with caution because of the small sample size and the heterogeneous combination of candidates, recipients. and support people. However, the present exploratory study will serve as the basis for a larger controlled study examining the efficacy of bibliotherapy in organ transplant patients. A future study will examine a larger sample of subjects and clearly distinguish between candidates, recipients, and support persons to ascertain the different needs of these groups. A careful detennination of efficacy of the intervention will require the use of a control group. Finally, this study used only self-report measures, and future research might want to examine objective predictors of meaningful benefit, such as increased knowledge and long-tenn behavioral outcomes. Clinically, we feel reassured that patients and their families have found the manual highly acceptable and that they do not become more distressed by reading it. At our center, the book will therefore be used more routinely with future transplant patients and their support persons, possibly including recipients of other organs such as hearts and kidneys, perhaps shortly after candidates are accepted for the program. CONCLUSION The provision of written psychoeducational material for lung transplant patients and their supports resulted in a very high degree of use and acceptability. Bibliotherapy appears to be a safe, well-received means of providing information about emotional distress and coping to patients and their families who face the trials of a life-threatening illness and the potential for disabling consequences. An avoidant coping style may be associated with difficulty undertaking a self-directed approach to therapy in some persons, whereas older age and a tendency to engage may predict greater use of such a program. PSYCHOSOMATICS
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The authors acknowledge the generous support of Dr. Grant Farrow, the Department of Urology, and the Toronto Lung Transplant Program at the University of Toronto. In addi-
tion, we thank Ms. Liza Puckerin and Ms. Anne Rydall for assistance in data collection and statistical analysis, and Ms. Debby Proctor for manuscript preparation.
References I. Craven J. Rodin G: Psychiatric Aspects of Transplantation. Oxford, England. Oxford University Press. 1992 2. Rodin G. Craven J. Littlefield C: Depression in the Medically III. New York. Brunner/Mazel. 1991 3. Mayou R. Hawton K. Feldman E: What happens to medical patients with psychiatric disorder? J Psychosom Res 1988; 32:541-549 4. Davies RK. Quinlan DM. McKegney FP. et al: Organic factors and psychological adjustment in advanced cancer patients. Psychosom Med 1973; 35:464-471 5. Stem MJ, Pascale L, Ackerman A: Life adjustment postmyocardial infarction: determining predictive variables. Arch Intern Med 1977; 137:1680-1685 6. Lustman PJ. Griffith LS. Clouse RE, et al: Psychiatric illness in diabetes mellitus: relationship to symptoms and glucose control. J Nerv Ment Dis 1986; 174:736742 7. Blumenthal JA. Williams RS. Wallace AG. et al: Physiological and psychological variables predict compliance to prescribed therapy in patients recovering from myocardial infarction. Psychosom Med 1982; 44:519527 8. Mayou R. Foster A. Williamson B: The psychological and social effects of myocardial infarction on wives. BMJ 1978; 1:699-701 9. Berrios GE. Samuel C: Affective disorder in the neurological patient. J Nerv Ment Dis 1987; 175: 173-176 10. Craighead LW. McNamara K. HoranJJ: Perspectives on self-help and bibliotherapy: you are what you read. in The Handbook of Counselling Psychology. edited by Brown SD. Lent RW. New York. Wiley. 1984 II. Moody MT. Limper HK: Bibliotherapy methods and materials. Chicago. IL. American Library Association. 1971 12. Starker S: Oracle at the Supermarket: Exploring the American Obsession With Self-Help Books. New Brunswick. NJ. Transaction Books. 1988 13. Starker S: Do-it-yourself therapy: the prescription of self-help books by psychologists. Psychotherapy 1988; 25:142-146 14. Anderson KO. Masur FT: Psychological preparation for invasive medical and dental procedures. J Behav Med 1983; 6: 1-40 15. Johnson JE: Psychological interventions and coping with surgery. in Handbook of Psychology and Health. Vol IV. Social Psychological Aspects of Health. edited by Baum A. Taylor SE. Singer JE. Hillsdale. NJ. Lawrence Erlbaum. 1984 16. Ludwick-Rosenthal R. Neufeld RWJ: Stress manage-
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ment during noxious medical procedures: an evaluative review of outcome studies. Psychol Bull 1988; 104: 326342 17. Taylor SE. Clark LF: Does information improve adjustmentto noxious events? in Advances in Applied Social Psychology. Vol 3. edited by Saks MJ. Saxe L. Hillsdale. NJ. Lawrence Erlbaum. 1986 18. Scogin F. Jamison C. Gocchneaur K: Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. J Consult Clin PsychoI1989;57:403-407 19. Shipley RH. BUll JH. Horwitz EA: Preparation to reexperience a stressful medical examination: effect of repetitious videotape exposure and coping style. J Consult Clin Psychol 1979; 47:48~92 20. Miller SM, Mangan CE: Interaction effects of information and coping style in adapting to gynaecologic stress: should the doctor tell all? J Pers Soc Psychol 1983; 45:223-236 21. Langer EJ. Janis IL. Wolfer JA: Reduction of psychological stress in surgical patients. Journal of Experimental Social Psychology 1975; 11:155-165 22. Glasgow RE. Rosen GM: Behavioral bibliotherapy: a review of self-help behavior therapy manuals. Psychol Bull 1978; 85:1-23 23. Craven J. Farrow S: Surviving Transplantation: A Personal Guide for Organ Transplant Patients. Their Families. Friends. and Caregivers. Toronto. Ontario. University of Toronto Press. 1993 24. Beck AT. Ward CH. Mendelson M. et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:53"'()3 25. Goldberg DP: Manual of the General Health Questionnaire. Windsor. England. NFER Publishing Company. 1978 26. Spielberger CD. Gorsuch RL. Lushene RE: Manual for the State-Trait Anxiety Inventory (Self-Evaluation Questionnaire). Palo Alto. CA. Consulting Psychologic Press. 1970 27. Tobin DL. Holroy KA. Ross VC: Users' Manual forthe Coping Strategies Inventory. Department of Psychology. Ohio University. 1984 28. Guglielmino LM: Development of the self-directed learning readiness scale. University of Georgia. Dissertation Abstracts International 1977; 38:6467A 29. Brookfield S: Self-directed adult learning: a critical paradigm. Adult Education Quarterly 1984; 35:59-71 30. Torrence EP. Mourad S: Some creativity and style of learning and thinking correlates of Guglielmino's self-
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directed learning readiness scale. Psychol Rep 1978; 43:1167-1171 31. Savoie M: Continuing education for nurses: predictions of success in courses requiring a degree of learner selfdirection (University of Toronto). Dissenation Abstracts International 1979; 40: 12A 32. Guglielmino PJ. Guglielmino LM. Long HB: Self-directed learning readiness and performance in the
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workplace. Higher Education 1987; 16:303-317 33. Craven JL. Rodin GM. Linlefield CH: The Beck Depression Inventory as a screening device for major depression in renal dialysis patients. Int J Psychiatry Med 1988; 18:373-382 34. Benjamin S: Community screening for mental illness: a validation study oflhe General Health Questionnaire. Br J Psychiatry 1980; 140:174-180
PSYCHOSOMATICS
Thirty-six lung transplant candidates (n = 16), recipients (n = Jl), and support people (n = 9) were examined for psychological distress, coping style, and orientation to independent learning before and after receiving a self-help book in a program designed to alleviate psychosocial distress and bolster adaptive coping. The subjects rated the book as highly acceptable, and none reported increased psychological distress. Afurther six subjects completed initial psychological measures but elected not to use the book. These subjects were compared with study completers and found to have significantly higher disengagement scores on the Coping Strategies Inventory. Although uncontrolled, significant changes were observed in coping strategies used by the completer group. The relevance of these findings to the use ofbibliotherapy in medically ill populations is discussed. (Psychosomatics 1995; 36:360-368)
O
rgan transplant patients are faced with both a serious medical illness and a major surgical intervention that expose them to a bewildering array of unfamiliar circumstances and challenges to their emotional and physical well-being. I In medical and surgical patients in general, symptoms of emotional distress complicate recovery in one-quarter to one-third. 2 The negative consequences of untreated emotional distress are well described and include increased morbidity 3 and mortality,4.5 decreased compliance with prescribed treatments6 and re-
Received February 9. 1993; revised March 20. 1993; accepted July 13. 1993. From the Clarke Institute ofPsychiatry. University of Toronto; St. Joseph's Health Centre, University of Western Ontario; and The Toronto Hospital. University of Toronto. Address reprint requests to Dr. Hodges. Clarke Institute of Psychiatry. 250 College Street, Toronto. Ontario. Canada M5T IR8. Copyright © 1995 The Academy of Psychosomatic Medicine.
360
habilitative programs,7 and impaired functional outcome. 8•9 In transplantation patients, the potential for psychological distress and psychiatric disorder is great. I Increasing attention is being given to the detection and management of psychiatric distress in the medically ill,2 but can be complicated when patients do not recognize or report emotional symptoms to the health care team. Further, misunderstanding of traditional psychological therapies and the stigma of mental illness may contribute to patient reluctance to use counseling or other mental health services. Even when psychosocial distress is recognized in large medical or surgical populations, interventions that require therapist contact can be costly to provide and may overwhelm the availability of professionals. Therefore, it has become increasingly desirable to offer alternate sources of therapeutic information and support either to patients who may be unable or resistant to work with a therapist or as an adjunct to PSYCHOSOMATICS
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traditional methods of counseling and psychotherapy. Bibliotherapy refers to any mass-produced communication medium. be it books. cassettes. or videotapes, which is directed to recipients of health care. with the goal of assisting in the detection, diagnosis. or management of a health problem. 1o A program of bibliotherapy may be self-administered. discussed in groups. or therapist-administered. Written psychoeducational materials have been recommended and produced for a wide variety of health conditions for over a century. I I However. well-designed studies into the use and efficacy of psychoeducational material are sparse. 12 Yet in the area of coping with life events, the publication of selfhelp books is a booming industry.'2 One survey found that specific readings were recommended as an adjunct to counseling and psychotherapy by about three-quarters of mental health practitioners surveyed. but without any evidence of their effectiveness. 13 Few investigators have examined the use and effectiveness of bibliotherapy as a coping aid for medical and surgical patients. The benefit of providing psychoeducational information and instruction through other means has been well documented in both groups. 14-16 Taylor and Clark l7 reviewed 25 studies of the effects of procedural. sensory. or both types of information on coping and adjustment following medical and surgical procedures. The effects of this information was found to have consistent and positive effects on mood, medication need, and patient behavior. A number of authors have suggested that certain persons are more likely to accept and undertake a program of bibliotherapy than others. 1O For example, Scogin et aL's found decreased efficacy of bibliotherapy in mildly and moderately depressed older adults who had fewer years of education, compared with similar patients with higher levels of education. Patients who approach illness-related events with a vigilant or confrontational approach tend to do best with the provision of information. whereas those who tend to have an avoidant or repressive style may benefit less, or fare VOLUME 36. NUMBER 4 • JULY - AUGUST 1995
worse.17.19.20 Two studies have actually suggested increased emotional distress when information was imposed on persons with avoidant coping styles. 20.21 In general, studies examining the clinical effectiveness of bibliotherapy are frequently affected by a high dropout rate,22 but the reasons are seldom explained. Improvements in both the efficacy of bibliotherapy and the degree of subject compliance might be greater if predictors of bibliotherapy use were better appreciated. 'o We undertook this study to determine if lung transplant candidates, recipients, and their families perceive written psychoeducational material as helpful and useful to determine predictors of the use of bibliotherapy and to obtain preliminary information on the effect of bibliotherapy on the level of emotional distress and adaptive coping strategies. Finally, we were interested in detecting any adverse effects that might be associated with use of the book, particularly in relation to individual coping style. METHODS Subjects All patients attending the clinic ofthe Lung Transplantation Program of the Toronto Hospital during the study period (February I through April I, 1992) were asked to participate. Included were subjects who were awaiting lung transplantation, those who had recently received a double-lung transplant, and their support persons. A total of 50 lung transplant candidates, recipients, and their support persons were approached. Forty-two (84%) gave written consent and agreed to participate. Of the eight who declined, four were candidates, two were recipients. and two were support people. Thirty-six subjects (72% of those eligible) participated in a trial of bibliotherapy and completed both the initial and final assessment packages. Of the six who were noncompleters. two were recipients. and four were supports. Of the 36 participants, 16 were candidates, II were recipients, and 9 were support people. 361
Bibliotherapy for Lung Transplant Patients and Families
Procedure The potential subjects were told that their agreement to participate meant that they agreed to complete baseline and follow-up measures and to accept for a 2-week period a personal copy of Surviving Transplantation (see Book Review column in this issue for review, page 413).23 No expectation was placed on the subjects to read the book. Rather it was explained beforehand that the participants were welcome to read none, some, or all of Surviving Transplantation. as their personal preferences dictated. Potential participants were also told at the outset that follow-up measures would not involve any testing of their knowledge of the book's content. The subjects who agreed to participate were seen by a research assistant and an investigator (BH) not involved in their clinical care for the purpose of obtaining consent and distributing a baseline set of self-report measures. Once the baseline measures were completed and returned, each subject was provided with a copy of Surviving Transplantation. Two weeks later, the books were collected, and at that time a followup set of self-report measures was distributed. All subjects were offered an open opportunity (by telephone, in the group, or individually) to discuss any questions or concerns that arose during their reading of the book. The subjects who did not return survey measures or the book were reminded each week until they did so, or they elected to withdraw from the study. Materials
Surviving Transplantation is a book designed to help patients to better understand their personal and emotional reactions to illness, provide situation-specific stress-management and problem-solving techniques, and encourage appropriate help-seeking behavior through education about possible psychiatric complications. The 123-page book uses many clinical case vignettes to illustrate adaptive coping. The clinical material in this book was gathered over several years of experience in counseling and 362
providing psychiatric treatment to transplant patients and their families. It is organized into nine chapters, such as Living With Illness, Waiting for Transplantation, Recovering From Transplantation, Understanding Stress, Dealing With Stress, and When to Ask for Help. Measures Psychological measures with documented reliability and validity in the medically ill were used. Psychological well-being was assessed by using the Beck Depression Inventory (BOI),24 the General Health Questionnaire (GHQ),25 and the Spielberger State-Trait Anxiety Inventory (STAI).26 The Coping Strategies Inventory (CS1)27 was used to gather information about coping style. The Self-Directed Learning Readiness Scale (SDLRS),28 a 58-item self-report questionnaire, was used to gather data on learning preferences and attitudes toward learning. The SDLRS is one of the few instruments identified in the literature for measuring self-direction in adult learning. Although its use has not been validated in medically ill populations, this instrument has been used extensively with other adult populations, and numerous studies attest to its reliability and validity.29 Finally, demographic data, number of support people, and information on reading habits were obtained. In the final assessment package, the patients provided detailed data on their use and satisfaction with the book. This included the amount read, the number of hours spent reading the book, the degree to which they learned something new, and whether they would recommend the book to others. In addition, the subjects were asked to select the degree to which a list of 12 adjectives (helpful, interesting, enjoyable, worthwhile, educational, easy, depressing, useless, worrisome, boring, disturbing, and difficult) described the book. RESULTS Demographic data were compared for the compieters (n =36) and noncompleters (n =6). The completers had a mean age of 43 years, of which PSYCHOSOMATICS
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39% were men. and 61 % were married. The noncompleters had a mean age of 45 years. of which 67% were men, and all were married. Of the completers, II % had only elementary education, half had some high school education, and 36% had postsecondary education. All of the noncompleters had some high school education, and 17% had postsecondary training. The completers reported a mean of six people they could count on for support, whereas the noncompleters reported nine. Reading behaviors were also measured. Of the completer group, 89% said they liked to read, and 72% reported reading greater than 3 hours in the preceding week. For the noncompIeters, 100% liked to read, and 67% had spent greater than 3 hours reading the prior week. In the prior week, 92% of completers had read a newspaper, 92% a magazine, and 71 % a book. For the noncompleters, the corresponding figures were 100%, 100%, and 83%, respectively. By use of chi-squared analysis for categorical variables and t-test for continuous variables, no significant differences were found between these groups for either demographic data or reported reading behaviors. Because of the small sample size in the noncompleters group, the lack of significant differences between the groups may have limited reliability. Table I illustrates the means of the psychological measures taken at baseline on the compIeters and noncompleters. Significantly higher scores were found on the disengagement subscales of the CSI for the group who did not complete the study. The extent to which the subjects found the book useful and acceptable was addressed in several ways. First, Figures I and 2 illustrate the response of subjects to a list of 12 adjectives that they endorsed on a 5-point Likert-type scale, ranging from "not at all" to "completely." A very high proportion of the subjects endorsed the positive adjectives, whereas very few negative ones were applied to the book. Over half of the subjects reported that they found the book very interesting, worthwhile, educational. and easy. None of the subjects described the book as very depressing, useless, worrisome. boring. VOLUME
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disturbing. or difficult. Fifty-six percent of the subjects spent 3 or more hours reading the book. whereas the remainder reported spending beTABLE I.
Means or psychological measures ror compieters and noncompieters at baseline Completer (n = 36)
Noncompleter (n = 61
8.14 47.00 1.93 0.87 35.66 228.11
8.00 56.50 1.92 1.43 44.33 238.50
BDI GHQ CSI engagement CSI disengagement STAI SDLRS
-0.05 0.81 -0.04 2.80 1.46 0.92
.
=
=
Note: BOI Beck Depression Inventory; GHQ General Health Questionnaire; CSI =Coping Strategies Inventory STAI =Spielberger State-Trait Anxiety Inventory; SDLRS = Self-Directed Learning Readiness Scale. Comparisons are two-tailed t-tests.
·P50.01.
FIGURE I.
Mean ratings or use and acceptability
l ....., A l I ' _ (11.36)
Compl.....,
1,----=-------'----'---------------,
'n_ _,..
"..p...
fntoylOl. Worftlmle Eauulonel
E..,
OMcriplors
FI(;URE 2.
Mean ratings or use and acceptability
L.... of Agreenwnll en Com,....., 51 -
v..,MYCh
4
Som_h'l
1,
1
• l6)
I !
- - --
.
---,
,1 _ _ Not At All
O....M"V
U.....
I Worn..,._
Borino
Di.Ublne
Dillcult
~ll~
Bibliotherapy for Lung Transplant Patients and Families
tween I and 3 hours. Eighty-nine percent of the subjects reported reading all of the book. 9% read "most." and 3% read half. All subjects said they would recommend the book to others. Using a correlation matrix. subject characteristics were compared with subject responses relevant to the use of Surviving Transplantation and perceived benefit derived (Table 2). The older subjects were more likely to report both having read more of the book and having learned something new. Those who reported a greater number of support people. and those who had higher engagement scores on the CSI spent more time reading the book as well. Level of education was not found to be associated with book use nor were scores on the SDLRS. Group mean scores were compared on the BDl. GHQ. and the subscales of the CSI (Table 3). By use of a two-tailed t-test. significant changes were found in two subscales of the CSI. Subject scores of expression of emotion and social withdrawal both significantly decreased after reading the book. There was no increase in scores measuring psychological distress after reading the book. DISCUSSION Of the 50 persons asked to participate. a sizable majority (84%) agreed. Of the 42 participants. most (86%) completed the study. This rate is higher than generally reported in the literature on the use of self-help-type books. 22 Unfortunately. comparable studies in physically ill samples are not available. The readiness of lung transplant patients and their families to participate likely reflected. in part. their awareness of the role that research plays in the medical advancement and altruistic sentiments that arise in transplant groups. However. it is our impression that this high rate of participation was also influenced by the keen interest in Surviving Transplantation. which was expressed by many patients at the study outset. The life-threatening nature of their clinical predicament. the highly technical atmosphere in which they receive treatment. and the relative novelty of the surgical interventions may have combined to in-
TABLE 2.
Correlations between subject demographies. baseline psychological measures, and use of the surviving transplantation (n = 36) Amount of Book Read 0.37" -0.04 0.14 -0.12 -0.14 -0.13 -0.12 0.00 0.16
Age Education Suppons CSI engagement CSI disengagement 801 GHQ STAI SDLRS
Time Learned Spent Something New Reading 0.13 0.03 0.39" 0.37' O.QI
-0.11 -0.15 -0.29 -0.27
0.42" -0.17 0.16 -0.02 0.30 -0.02 0.16 0.00 -0.11
Note: CSI = Coping Strategies Inventory; 801 = Beck Depression Inventory; GHQ =General Health Questionnaire; STAI =Spielberger State-Trait Anxiety Inventory; SDLRS Self-Directed Learning Readiness Scale. Comparisons are two-tailed I-tests.
=
"p S 0.05; ..PS 0.01.
TABLE 3.
Baseline and follow-up psychological and coping style measures (n =36) Baseline
Follow-up
8.14 47.00 35.70 1.95 2.27 1.47
7.89 42.56 35.67 2.08 2.14 1.09 1.93 0.75 1.58 0.38 0.63 1.78 0.83
BOI GHQ STAI Problem solving Cognitive restructuring Expressed emotion Social suppon Problem avoidance Wishful thinking Self-criticism Social withdrawal CSI engagement CSI disengagement
2.10
0.83 1.48 0.31 0.98 1.91 0.90
0.42 1.46 0.03 -0.85 1.05 3.77" 1.14
1.02 -o.~7
-0.65
3.34" 1.32 1.05
NOle: BDI = Beck Depression Inventory; GHQ = General Health Questionnaire; STAI =Spielberger State-Trait Anxiety Inventory; CSI =Coping Strategies Inventory. Comparisons are two-tailed I-tests.
"PSO.OI; "P S 0.0001.
crease motivation and participation in this type of study. Many had previously expressed a desire for greater psychoeducational information about the personal and emotional aspects of organ transplantation. PSYCHOSOMATICS
Hodges et al.
Equally important, this high level of motivation could lead to an underreporting of distress and overenthusiastic response to the intervention. A study limitation was the lack of a social desirability measure and a reliance on self-report measures. However, every effort was made to ensure that the subjects were aware that study participation did not require them to read the book. Given these considerations, a huge majority of participants (89%) reported that they had read all of the book. Over one-half spent more than 3 hours reading Surviving Transplantation. Positive descriptors (helpful, interesting, enjoyable, worthwhile, educational, easy) were attributed to the book, whereas negative descriptors (depressing. useless, worrisome. boring, disturbing, difficult) were rarely used. In proposing any treatment, it is desirable to be able to not only predict which persons will benefit from treatment. but also to identify those who will be able to comply with treatment recommendations. When the treatment involves a significant amount of new learning, particularly self-directed learning, it has been frequently suggested that certain persons have a readiness for self-directed learning and others do not. 28 .30 It has been suggested that persons who recognize their capacity for self-directed learning realize that they have the power to alter their individual and social environment. 29 We hypothesized that an orientation toward independent learning (as indicated in this study by the SDLRS) would predict successful completion of a self-directed program of treatment. An association between SDLRS scores and performance has been demonstrated in nonmedical samples in the context of nursing education 31 and business and industry.32 However, this measure did not distinguish subjects who read the book from those who did not. The validity of this measure in a medically ill sample may be questioned. Alternatively, it may be suggested that in the medical context. other motivational factors may override this dimension of learning. For example, the need for information in unfamiliar and distressing situation may outweigh any orientation for or against self-directed VOLUME 36. NUMBER 4. JULY - AUGUST 1995
learning. Subjects with an interest in more information may simply be motivated to take whatever form is offered. This phenomenon could also explain why level of education. a variable predictive of use of bibliotherapy in other situations,I8 did not predict reading Surviving Transplantation. Disengagement is a coping style that involves a disinclination to share feelings with others and a tendency to avoid thinking about a stressful situation or to initiate steps to change the situation. 27 Engagement indicates a more confrontational approach to coping with stress. An avoidant style of coping, as measured by the disengagement subscale of the CSI. was more prominent among the subjects who did not complete the study. Similarly, the subjects who approached their situation with a more confrontational style reported greater length of time spent reading the book. Although unanswerable in the context of the current study, it is possible that these associations result from a broad inclination for or against information acquisition about an illness-related situation, rather than a specific attitude toward self-directed reading. It could be hypothesized that persons with an avoidant coping style might do better with an approach that involves a greater degree of therapist contact and support. Alternatively, these persons might be even more disinclined to enroll in such therapy. While an avoidant coping style was associated in this study with a disinclination toward reading a psychoeducational book, it remains possible that the tendency of an avoidant subject to enroll in a more intensive therapeutic milieu (e.g., a support group) could be even greater. Interestingly, older subjects read more of the book and more often reported that they had learned something new. Those with a greater number of support persons spent more time reading the book. We had expected that a higher level of psychological distress would be a motivational factor toward reading Surviving Transplantation. However, measurement of depressive (801) and anxiety symptoms (STAI) and general psychological distress (GHQ) did not correlate with book use. 365
Bibliotherapy for Lung Transplant Patients and Families
Although not a controlled study itself, an additional study objective was to identify beneficial or negative tendencies in subjects for further elucidation in a proposed controlled study of bibliotherapy in the physically ill. No significant changes were found for measures of psychological distress. In fact, baseline levels of emotional distress captured by these measures were fairly low. While nonns for these psychological measures are not available for this specific group, threshold scores quoted in the literature are 15 for the BDI in medically ill populations,33 42/43 for the GHQ,34 and 27 for the STAI 26 in nonnal subjects. Low levels of psychological distress at baseline may have lessened the likelihood of finding an intervention benefit. However, this negative finding is important in documenting that there was no immediate evidence of increased psychological distress during the study period. Reading the book did not have a negative effect on readers' reported level of distress. The lack of a positive effect on distress level may also be an artifact of the short follow-up period. It is possible that any shift in attitude or coping style that might be engendered by the reading of this book would take a greater length of time to result in any potential symptomatic benefit. Two significant changes were observed for coping style. First, the subjects' tendency to cope by releasing emotions dropped significantly. This change is difficult to interpret but might represent a tendency toward a more cognitive method of dealing with distress. This speculation, however, was not reflected in an increase in subscales measuring either cognitive restructuring or problem solving. Second, the subjects reported a lessened tendency to withdraw socially as a way to cope with distress. One subject wrote after the study, "I realize now that I am not alone in what I have experienced." A sense of community with other transplant patients may be encouraged as personal experiences are less likely to be interpreted as idiosyncratic or pathologic, and more likely to be conceptualized as nonnal and common in this extreme of situations. While such a finding was uncontrolled, the suggestion of an 366
effect on coping strategy and response to distress warrants further investigation. Conclusions drawn from this study must be interpreted with caution because of the small sample size and the heterogeneous combination of candidates, recipients. and support people. However, the present exploratory study will serve as the basis for a larger controlled study examining the efficacy of bibliotherapy in organ transplant patients. A future study will examine a larger sample of subjects and clearly distinguish between candidates, recipients, and support persons to ascertain the different needs of these groups. A careful detennination of efficacy of the intervention will require the use of a control group. Finally, this study used only self-report measures, and future research might want to examine objective predictors of meaningful benefit, such as increased knowledge and long-tenn behavioral outcomes. Clinically, we feel reassured that patients and their families have found the manual highly acceptable and that they do not become more distressed by reading it. At our center, the book will therefore be used more routinely with future transplant patients and their support persons, possibly including recipients of other organs such as hearts and kidneys, perhaps shortly after candidates are accepted for the program. CONCLUSION The provision of written psychoeducational material for lung transplant patients and their supports resulted in a very high degree of use and acceptability. Bibliotherapy appears to be a safe, well-received means of providing information about emotional distress and coping to patients and their families who face the trials of a life-threatening illness and the potential for disabling consequences. An avoidant coping style may be associated with difficulty undertaking a self-directed approach to therapy in some persons, whereas older age and a tendency to engage may predict greater use of such a program. PSYCHOSOMATICS
Hodges et aJ.
The authors acknowledge the generous support of Dr. Grant Farrow, the Department of Urology, and the Toronto Lung Transplant Program at the University of Toronto. In addi-
tion, we thank Ms. Liza Puckerin and Ms. Anne Rydall for assistance in data collection and statistical analysis, and Ms. Debby Proctor for manuscript preparation.
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VOLUME 36. NUMBER 4. JULY - AUGUST 1995
ment during noxious medical procedures: an evaluative review of outcome studies. Psychol Bull 1988; 104: 326342 17. Taylor SE. Clark LF: Does information improve adjustmentto noxious events? in Advances in Applied Social Psychology. Vol 3. edited by Saks MJ. Saxe L. Hillsdale. NJ. Lawrence Erlbaum. 1986 18. Scogin F. Jamison C. Gocchneaur K: Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. J Consult Clin PsychoI1989;57:403-407 19. Shipley RH. BUll JH. Horwitz EA: Preparation to reexperience a stressful medical examination: effect of repetitious videotape exposure and coping style. J Consult Clin Psychol 1979; 47:48~92 20. Miller SM, Mangan CE: Interaction effects of information and coping style in adapting to gynaecologic stress: should the doctor tell all? J Pers Soc Psychol 1983; 45:223-236 21. Langer EJ. Janis IL. Wolfer JA: Reduction of psychological stress in surgical patients. Journal of Experimental Social Psychology 1975; 11:155-165 22. Glasgow RE. Rosen GM: Behavioral bibliotherapy: a review of self-help behavior therapy manuals. Psychol Bull 1978; 85:1-23 23. Craven J. Farrow S: Surviving Transplantation: A Personal Guide for Organ Transplant Patients. Their Families. Friends. and Caregivers. Toronto. Ontario. University of Toronto Press. 1993 24. Beck AT. Ward CH. Mendelson M. et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:53"'()3 25. Goldberg DP: Manual of the General Health Questionnaire. Windsor. England. NFER Publishing Company. 1978 26. Spielberger CD. Gorsuch RL. Lushene RE: Manual for the State-Trait Anxiety Inventory (Self-Evaluation Questionnaire). Palo Alto. CA. Consulting Psychologic Press. 1970 27. Tobin DL. Holroy KA. Ross VC: Users' Manual forthe Coping Strategies Inventory. Department of Psychology. Ohio University. 1984 28. Guglielmino LM: Development of the self-directed learning readiness scale. University of Georgia. Dissertation Abstracts International 1977; 38:6467A 29. Brookfield S: Self-directed adult learning: a critical paradigm. Adult Education Quarterly 1984; 35:59-71 30. Torrence EP. Mourad S: Some creativity and style of learning and thinking correlates of Guglielmino's self-
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directed learning readiness scale. Psychol Rep 1978; 43:1167-1171 31. Savoie M: Continuing education for nurses: predictions of success in courses requiring a degree of learner selfdirection (University of Toronto). Dissenation Abstracts International 1979; 40: 12A 32. Guglielmino PJ. Guglielmino LM. Long HB: Self-directed learning readiness and performance in the
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