541 Appendix 1a SUBJECT INFORMATION AND CONSENT FORM (Phase 1) We are requesting you to take part in a research project

in the Oncology Department of the Johannesburg Hospital. The project is on the psychological and behavioral response to treatment. The study involves filling in some questionnaires which might take you between one and two hours to complete. If you don't feel 'up to' filling the questionnaire today we can make another appointment to fill it in at your leisure. Obviously this is entirely voluntary and you are you are under no obligation to participate. Your treatment will not be prejudiced or compromised in any way if you decide not to take part. The questionnaires will be filled in with you or given to you by a psychologist from the Department of Psychiatry , not by the Department giving you Chemotherapy . Your name will not be used in any way. The results of the study will be strictly confidential. ............................................................................

I agree/disagree to participate in the research described above. Name: ..................................................................... Signature: ..................................... Witness: ...................................... Hospital Number............................... Date:......................................... Date: .......................................

Thank you for agreeing to participate in this Research.

542 Appendix 1b SUBJECT INFORMATION AND CONSENT FORM (Phase 2) We are requesting you to take part in a research project in the Oncology Department of the Johannesburg Hospital. The project is on the psychological and behavioral response to treatment. The study involves answering a few questions followed by a Medical Trauma Debriefing Session. If you don't feel 'up to' filling the questionnaires today we can fill them in at your leisure. Obviously this is entirely voluntary and you are you are under no obligation to participate. Your treatment will not be prejudiced or compromised in any way if you decide not to take part. The questionnaires will be filled in with you by a psychologist from the Department of Psychiatry , not by the Department treating you medically. Your name will not be used in any way. The results of the study will be strictly confidential. ............................................................................

I agree/disagree to participate in the research described above. Signature: ..................................... Witness .........................................

Date: .......................

543 Appendix 2 THE GENERAL INFORMATION QUESTIONNAIRE CONFIDENTIAL The answers you give to the following questions will be treated in strictly confidential manner. Please try and answer all questions. If, however, you have difficulties over one or two questions, you are at liberty to leave them out and proceed to the next one.

1. 2. 3. 4. 5. 6.

Today's date: Sex: Age:

......................................................... ......................................................... .........................................................

How many years of schooling, college or university have you had ? . . . . . . . . . . Years Are you still studying at present? If so, a) Where . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b) How much further do you intend to study? . . . . . . . . . . . . . . . . . . . . . . . . . . . . years. c) What do you see as your future occupation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes / No

7.

What is your present occupation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes / No Yes /No

8. Are you happy in your work ?

9. If you had a choice, would you prefer to be employed in another form of work ?

If so, what ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Where do you live ? (Check one of these) 1) Central City 5) Farm

544 2) Suburb 3) Town 4) Plot 11. Are you married or in a committed relationship? Yes / No 12. Have you any children? Yes/ No 6) Other

13. Do you feel you were happy as a child? Yes / No Give reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................................................................... 14. As a child, were you closer to your mother or your father? Mother / Father ...........................................................

15. Did you experience any difficulties during adolescence? Yes / No What were these? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..................................................................... 16. Do you tend to have: (Check one of these) 1. A few close friends ? 2. Many friends but none of them very close ? 3. Many friends and a few really close ones ? 4. Not many friends at all ? 17. How much time each week do you spend with your friends? . . . . . . . . . . . . . . . . . . hours. 18. How do you spend your free time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. What kind of books do you read? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

545 20. What kind of music do you like? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21. Do you tend to visit your doctor (or have your doctor visit you ? a. When you are slightly ill ? b. When you are moderately ill ? c. When you are feeling very ill ? 22. Do you have a regular G.P. ? 23. When you are prescribed medication, do you tend to : a. Not fill the prescription ? b. Fill the prescription but take only one or two tablets ? c. Take the tablets now and then and not follow the instructions fully ? d. Follow the instructions fully ? 24. Do you come back follow up appointments even though you are feeling better ? 25. Do you : a. follow the doctor's instructions exactly ? b. follow the instructions more or less ? c. follow the instructions when they make sense to you ? d. not really follow the instructions ? 26. Would you rather go for health diets or alternative medicine rather than follow the advice of a regular doctor ? If you have medicine left over from a previous ailment do you tend to use it again if the same ailment seems to reappear in: a. yourself b. your family

27.

546 28. Have you ever been involved in a serious accident? If so, please give details. ..................................................................... ..................................................................... .....................................................................

547 Appendix 3 MCMI-2: NAME: ................................................... ...........................

AGE: . . . . . . . . . . . . . . . . . . . . . . DATE:

The following pages contain a list of statements that people use to describe themselves. They are printed here to help you to describe your feelings and attitudes. Try to be as honest as possible in filling out the form because the results will be used to help you and others. Dont worry if a few of the statements seem unusual to you. They are included to describe people with many types of problems. When you agree with a statement or decide that it describes you, fill in a T to mark it True. When you disagree with a statement or decide that it does not describe you, fill in an F to mark it False. Try to mark every statement even if you are not sure about your choice. If you have tried your best and still cannot decide, put an F for False. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. __ I always follow my own ideas rather than do what others expect of me. __ Ive always found it more comfortable to do things quietly alone instead of with others. __ Talking to other people has almost always been difficult and painful for me. __ I believe in being strong willed and determined in everything I do. __ In the last few weeks I begin to cry even when the slightest of things goes wrong. __ Some people think of me as a conceited and self-centered person. __ As a teenager I got into lots of trouble because of bad school behavior. __ I always feel I am not wanted in a group. __ I often criticize people strongly if they annoy me. __ I am content to be a follower of others. __ I enjoy so many different things that I cant make up my mind what to do first . __ Sometimes I can be pretty rough and mean in my relations with my family. __ I have little interest in making friends. __ I think I am a very sociable and out-going person. __ I know I am a superior person, so I dont care what people think. __ People have never given me enough recognition for the things I have done. __ I have had a drinking problem that I have tried unsuccessfully to end. __ Lately, I get butterflies in my stomach and break out in cold sweats. __ I have always wanted to stay in the background during social activities. __ I will often do things for no reason other than they might be fun. __ I get very annoyed with people who never seem able to do things right. __ If my family puts pressure on me, Im likely to feel angry and resist doing what they want. __ I often feel I should be punished for the things I have done. __ People make fun of me behind my back, talking about the way I act or look. __ Other people seem more sure than I am of who they are and what they want.

548 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. __ I tend to burst out in tears or in anger for unknown reasons. __ I began to feel lonely and empty about a year or two ago. __ I have a talent to be dramatic. __ I have a hard time keeping my balance when walking. __ I enjoy intense competition. __ When I run into a crisis I quickly look for someone to help me. __ I protect myself from trouble by never letting people know much about me. __ I feel weak and tired much of the time. __ Other people get more angry about bothersome things than I do. __ My drug habits have often gotten me into a good deal of trouble in the past. __ Lately I have found myself crying without any reason. __ I think Im a special person who deserves special attention from others. __ Under no circumstances do I ever let myself be tricked by people who say they need help. __ One sure way to make a peaceful world is by improving peoples morals. __ In the past Ive gotten involved sexually with many people who didnt matter much to me. __ I find it hard to sympathize with people who are always unsure about things. __ I am a very agreeable and submissive person. __ My own bad temper has been a big cause of my troubles. __ I dont mind bullying others to get them to do what I want. __ For the past few years even minor things seem to depress me. __ My wish to get things done just perfectly often slows down my work. __ I am so quiet and withdrawn , most people dont even know I exist. __ I like to flirt with members of the opposite sex. __ I am a quiet and fearful person. __ I am a very erratic person, changing my mind and feelings all the time. __ I feel very tense when I think of the days happenings. __ Drinking alcohol has never caused me any real problems in my work. __ Lately, my strength seems to be draining out of me, even in the morning. __ I began to feel like a failure some years ago. __ I strongly resent big shots who always think they can do things better than I can. __ I have always had a terrible fear that I will lose the love of people I need very much. __ I seem to go out of the way to let people take advantage of me. __ Lately I have begun to feel like smashing things. __ I have given serious thought recently to doing away with myself. __ I am always looking to make new friends and meet new people. __ I keep very close track of my money so I am prepared if a need comes up. __ I was on the front cover of several magazines last year. __ Few people like me. __ If someone criticized me for making a mistake, I would quickly point out some of that persons mistakes.

549 65. 66. 67. 68. 69. 70. __ Some people say I enjoy suffering. __ I often let my angry feelings out and then feel terribly guilty about it. __ Lately, I feel jumpy and under terrible strain, but I dont know why. __ I very often lose my ability to feel any sensations in parts of my body. __ I believe there are people who use telepathy to influence my life. __ Taking so-called illegal drugs may be unwise, but in the past I found I needed them. 71. __ I feel tired all the time. 72. I cant seem to sleep, and wake up just as tired as when I went to bed. 73. __ Ive done a number of stupid things on impulse that ended up causing me great trouble. 74. __ I never forgive an insult or forget an embarrassment that someone caused me. 75. __ We should respect earlier generations and not think we know better than they. 76. __ I feel terribly depressed and sad much of the time now. 77. __ I am the sort of person that others take advantage of. 78. __ I always try hard to please others even when I dislike them. 79. __ Serious thoughts of suicide have occurred to me for many years. 80. __ I quickly figure out how people are trying to cause me trouble. 81. __ Ive always had less interest in sex than most people do. 82. __ I cant understand it, but I seem to enjoy hurting persons I love. 83. __ A long time ago I decided its best to have little to do with people. 84. __ I am ready to fight to the death before I let anybody take away my selfdetermination. 85. __ Since I was a child I have always had to watch out for people who were trying to cheat me. 86. __ When things get boring, I like to stir up some excitement. 87. __ I have an alcohol problem that has made difficulties for me and my family. 88. __ If a person wants something done that calls for real patience, they should ask me. 89. __ I am probably the most creative thinker among the people I know. 90. __ I have not seen a car in the last ten years. 91. __ I dont see anything wrong with using people to get what I want. 92. __ Punishment never stopped me from doing what I wanted. 93. __ There are many times, when for no reason, I feel very cheerful and full of excitement. 94. __ I ran away from home as a teenager at least once. 95. __ I very often say things quickly that I regret having said. 96. __ In recent weeks I feel worn out for no special reason. 97. __ For some time now Ive been feeling very guilty because I cant do things right anymore. 98. __ Ideas keep turning over and over in my mind and they wont go away. 99. __ Ive become quite discouraged and sad about life in the past year or two. 100. __ Many people have been spying into my private life for years.

550 101. __I dont know why , but I sometimes say cruel things just to make others unhappy. 102. __ I hate or fear most people. 103. __ I speak out my opinions about things no matter what others may think. 104. __ When someone in authority insists that I do something, I am likely to put it off or do it poorly on purpose. 105. __ My habit of abusing drugs has caused me to miss work in the past. 106. __ I am always willing to give in to others just to avoid disagreements. 107. __ I am often cross and grouchy. 108. __ I just dont have the strength to fight back anymore. 109. __ Lately I have to think things over and over again for no good reason. 110. __ I often think I dont deserve the good things that happen to me. 111. __ I use my charm to get the attention of other people . 112. __ When I am alone I often feel the strong presence of someone nearby who cant be seen. 113. __ I feel pretty aimless and dont know where Im going in life. 114. __ Lately, Ive been sweating a great deal and feel very tense. 115. __ Sometimes I feel like I must do something to hurt myself or someone else. 116. __ Ive been unfairly punished by the law for crimes I never committed. 117. __ Ive become very jumpy in the last few weeks. 118. __ I keep having strange thoughts that I wish I could get rid of. 119. __ I have a great deal of trouble trying to control my impulse to drink to excess. 120. __ Most people think that I am a worthless nothing. 121. __ I can get very excited sexually when fighting or arguing with a loved one. 122. __ I have succeeded over the years in keeping my drinking of alcohol to a minimum. 123. __ I have always tested people to find out how much they can be trusted. 124. __ Even when Im awake , I dont seem to notice people who are near me. 125. __ It is very easy for me to make many friends. 126. __ I always make sure that my work is well planned and organized. 127. __ I very often hear things so well that it bothers me. 128. __ My moods seem to change a great deal from one day to the next. 129. __ I dont blame anyone who takes advantage of someone who allows it. 130. __ Ive changed jobs more than three times in the past couple of years. 131. __ I have many ideas that are ahead of the times. 132. __ For some time now I have been feeling sad and blue and cant seem to snap out of it. 133. __ I think it is always best to seek help in what I do. 134. __ I often get angry with people who do things slowly. 135. __ I really get annoyed with people who expect me to do what I dont want to do. 136. __ In the last few years , I have felt so guilty that I may do something terrible to myself. 137. __ I never sit on the sidelines when Im at a party. 138. __ People tell me that Im a very proper and moral person.

551 139. __ I sometimes get confused and feel upset when people are kind to me. 140. __ My use of so called illegal drugs has led to family arguments. 141. __ I am very ill-at-ease with members of the opposite sex. 142. __ There are members of my family who say Im selfish and think only of myself. 143. __ I dont mind that people are not interested in me. 144. __ Frankly, I lie quite often to get out of trouble. 145. __ People can easily change my ideas, even if I thought my mind was made up. 146. __ Others have tried to do me in, but I have the will power to overcome them. 147. __ My parents often told me that I was no good. 148. __ I often make people angry by bossing them. 149. __ I have great respect for those in authority over me. 150. __ I have almost no close ties with other people . 151. __ People have said in the past that I became too interested and too excited about too many things. 152. __ I have flown across the Atlantic thirty times in the last year. 153. __ I believe in saying early to bed and early to rise..... 154. __ I deserve the suffering Ive gone through in life. 155. __ My feelings toward important people in my life often swing from loving them to hating them. 156. __ My parents always disagreed with each other. 157. __ On occasion I have had as many as ten or more drinks without becoming drunk. 158. __ In social groups I am almost always very self-conscious and tense. 159. __ I think highly of rules because they are a good guide to follow. 160. __ Ever since I was a child , I have been losing touch with the real world. 161. __ I rarely feel anything strongly. 162. __ I used to be really restless, traveling around from place to place with no idea of where I would end up. 163. __ I cant stand people who are late for appointments. 164. __ Sneaky people often try to get the credit for things I have done or thought of. 165. __ I get very irritated if someone demands that I do things that his way rather than my own. 166. __ I have the ability to be successful in almost anything I do. 167. __ Lately, I have gone all to pieces. 168. __ I seem to encourage the people I love to hurt me. 169. __ There has never been any hair on either my head or my body. 170. __ When I am with others I like to be the center of attention. 171. __ People who I admired greatly at first have often become real disappointments to me later. 172. __ Im the kind of person who can walk up to anyone and tell him or her off. 173. __ I prefer to be with people who will be protective of me. 174. __ Ive had many periods in my life when I was so cheerful and used up so much energy that I fell into a low mood.

552 175. __ I have had difficulties in the past stopping myself from over-using drugs or alcohol.

553 Appendix 4 (THE DYSFUNCTIONAL ATTITUDES SCALE) PLEASE ANSWER "TRUE" OR "FALSE (T or F) True False 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. It is difficult to be happy unless one is good looking. intelligent, rich and creative. (T) People will probably think less of me if I make a mistake. If I do not do as well as other people, it means I am an inferior human being. If I do not do well all the time, people will not respect me. If other people know what you are really like, they will think less of you. My value as a person depends greatly on what others think of me. I cannot be happy unless most people I know admire me. It is possible to gain another person's respect without being especially talented at anything. I can be happy even if I miss out on many of the good things in life. If others dislike you, you cannot be happy. My happiness depends more on other people than it does on me. If you don't have other people to lean on, you are bound to be sad. I am nothing if a person I love doesn't love me. I do not need the approval of other people in order to be happy. (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

554 15. 16. 17. To be a good, moral, worthwhile person, I must help everyone who needs it. If you cannot do something well, there is little point in doing it at all. People should have a reasonable likelihood of success before undertaking anything. I cannot trust other people because they might be cruel to me. If a person avoids problems, the problems tend to go away. I should be upset if I make a mistake. Taking even a small risk is foolish because the loss is likely to be a disaster. What other people think about me is very important. It is awful to be disapproved of by people important to you. Being isolated from others is bound to lead to unhappiness. If I fail at work, then I am a failure as a person. (T) (T) (T) (T) (T) (T) (T) (T) (T) (F) (F) (T) (F) (F) (F) (F) (F) (F) (T) (F) (F) (F)

18. 19. 20. 21. 22. 23. 24. 25.

555 Appendix 5

BHS
Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Age: . . . . . . . . . Marital Status: . . . . . . . . . . . . . . . . . . . . . . . . . Sex: . . . . . . . . . . . . . . . Occupation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Education: . . . . . . . . . . . . . . . . . . . . . . . . . The questionnaire consists of 20 statements. Please read the statements carefully one by one. If the statement describes your attitude for the past week including today, darken the circle with a 'T' indicating TRUE in the column next to the statement. If the statement does not describe your attitude, darken the circle with an 'F' indicating FALSE in the column next to the statement. Please be sure to read each statement carefully. True False 1. 2. 3. 4. 5. 6. 7. 8. 9. I look forward to the future with hope and enthusiasm. I might as well give up because there is nothing I can do about making things better for myself. When things are going badly, I am helped by knowing that they cannot stay that way forever. I can't imagine what my life would be like in ten years. I have enough time to accomplish the things I want to do. In the future, I expect to succeed in what concerns me most. My future looks dark to me. I happen to be particularly lucky, and I expect to get more of the good things in life than the average person. I just can't get the breaks, and there's no reason I will in the future. (T) (T) (T) (T) (T) (T) (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F)

556 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. My past experiences have prepared me well for the future. All I can see ahead of me is unpleasantness rather than pleasantness. I don't expect to get what I really want. (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

When I look ahead to the future I expect I will be happier than I am now. (T) Things just don't work out the way I want them to. I have great faith in the future. I never get what I want, so it's foolish to want anything. It's very unlikely that I will get any real satisfaction in the future. The future seems vague and uncertain to me. I can look forward to more good times than bad times. There's no use in really trying to get anything I want because I probably won't get it. (T) (T) (T) (T) (T) (T) (T)

557 Appendix 6 THE SOCIAL READJUSTMENT RATING SCALE LIFE CHANGE STRESS INDEX Complete the Questionnaire below. Tick only those events that have affected you personally in the past 12 months, and ignore the others. EVENT ( ) Death of a spouse ( ) Divorce ( ) Marital separation ( ) Jail term ( ) Death of a close family member ( ) Personal injury or illness ( ) Marriage ( ) Fired at work ( ) Marital reconciliation ( ) Retirement ( ) Deterioration in health of a close family member. ( ) Pregnancy ( ) Sexual difficulties ( ) Gain of a new family member

558 ( ) Business readjustments ( ) Deterioration in financial state ( ) Death of a close friend ( ) Change to different line of work ( ) Increased number of arguments with spouse ( ) Mortgage more than double your annual income ( ) Foreclosure of mortgage or loan ( ) Change in responsibility at work ( ) Son or daughter leaving home ( ) Trouble with in-laws ( ) Outstanding personal achievement ( ) Spouse begins or stops work ( ) Beginning or completing school ( ) Change in living conditions ( ) Revision of personal habits ( ) Trouble with boss ( ) Change in work hours or conditions ( ) Change in residence ( ) Change in schools ( ) Change in recreation ( ) Change in church activities ( ) Change in social activities

559 ( ) Mortgage or loan less than twice your annual income ( ) Change in sleeping habits ( ) Change in number of family get-togethers ( ) Change in eating habits ( ) Vacation ( ) Minor violations of the law

560 Appendix 7

The Buss-Durkee Scale of Aggression

Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date: . . . . . . . . . . . . . . . .

Please answer 'true' or 'false' to the following questions, by placing an X in the appropriate column. True False 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Once in a while I cannot control my urge to hurt others. I sometimes spread gossip about people I don't like. I lose my temper easily but get over it quickly. Unless somebody asks me in a nice way, I won't do what they want. I don't seem to get what's coming to me. I know that people tend to talk about me behind my back. When I disapprove of my friends' behaviour, I let them know it. The few times I have cheated, I have suffered unbearable feelings of remorse. I can think of no good reason for ever hitting anyone. I never get mad enough to throw things. I am always patient with others. When someone makes a rule I don't like, I am tempted to break it. Other people always seem to get the breaks. (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

561 14. 15. 16. 17. 18. 19. 20. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. I tend to be on my guard with people who are somewhat more friendly than I expected. I often find myself disagreeing with people. I sometimes have bad thoughts which make me feel ashamed of myself. If somebody hits me first, I let him have it. When I am mad I sometimes slam doors. I am irritated a great deal more than people are aware of. When someone is bossy, I do the opposite of what he asks. There are a number of people who seem to dislike me very much. I can't help getting into arguments when people disagree with me. People who shirk on the job must feel very guilty. Whoever insults me or my family is asking for a fight. I never play practical jokes. It makes my blood boil to have somebody make fun of me. When people are bossy, I take my time just to show them. Almost every week I see someone I dislike. There are a number of people who seem to be jealous of me. I demand that people respect my rights. It depresses me that I cannot do more for my parents. People who continually pester you are asking for a punch on the nose. When I am angry, I sometimes sulk. (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T)

(T) (T) (T) (T) (T) (T)

(F) (F) (F) (F) (F) (F) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

562 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. If someone doesn't treat me right I don't let it annoy me. Occasionally when I am mad at someone I give him the "silent treatment". I sometimes have the feeling that others are laughing at me. Although I don't show it, I am sometimes eaten up with jealousy. Even when my anger is aroused, I don't use 'strong language'. I am concerned about being forgiven for my sins. I seldom strike back, even if someone hits me first. I sometimes pout when I don't get my own way. Sometimes people bother me just by being around. I don't know any people that I downright hate. My motto is "Never trust strangers". If somebody annoys me, I am apt to tell them what I think of them. I do many things that make me feel remorseful afterwards. When I really lose my temper, I am capable of slapping someone. Since the age of ten, I have never had a temper tantrum. I often feel like a powder keg ready to explode. If I let people see the way I feel, I'd be considered a hard person to get along with. I commonly wonder what hidden reason another person may have for doing something nice for me. When people yell at me I yell back. Failure gives me a feeling of remorse. I get into fights about as often as the next person. (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

563 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. I can remember being so angry that I picked up the nearest thing and broke it. I sometimes carry a chip on my shoulder. At times I feel I get a raw deal out of life. (T) (T) (T) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F) (F)

I used to think that most people told the truth but now I know otherwise. (T) When I get mad I say nasty things. When I do wrong, my conscience punishes me severely. If I have to resort to physical violence to defend my rights, I will. I sometimes show my anger by banging on the table. I can't help being a little rude to people I don't like. I have no enemies who really wish to harm me. I could not put someone in his place even if he needed it. I often feel that I have not lived the right kind of life. I have known people who pushed me so far that we came to blows. I don't let a lot of unimportant things irritate me. I seldom feel that people are trying to anger or insult me. Lately, I have been somewhat grouchy. When arguing, I tend to raise my voice. I generally cover up my poor opinion of others. I would rather concede a point than get into an argument about it. (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T) (T)

564

565 Appendix 8 THE ROTTER INTERNAL - EXTERNAL LOCUS OF CONTROL

This is a questionnaire to find out the way in which certain important events in our society affect different people. Each item consists of a pair of alternatives letteres 'a' or 'b'. Please select the one statement of each pair (and only one) which you more strongly BELIEVE to be the case as far as you are concerned. Be sure to select the one you think you should choose or the one you would like to be true. This is a measure of personal belief; obviously there are no right or wrong answers. Your answer, either 'a' or 'b' to each question on this inventory, is to be reported beside the question. Please answer these items CAREFULLY but do not spend too much time on any one item. Be sure to find an answer for EVERY choice. For each numbered question make an 'X' on the line beside either the 'a' or 'b', whichever you choose as the statement most true. In some instances you may discover that you believe both statements or neither one. In such cases you are to select the one you most strongly believe to be the case as far as you are concerned. Also try to respond to each item INDEPENDENTLY when making your choice. Do not be influenced by your previous choices.

566 Select and cross that alternative which YOU PERSONALLY BELIEVE TO BE MORE TRUE. I MORE STRONGLY BELIEVE THAT : 1. a. b. Children get into trouble because their parents punish them too much. The trouble with most children nowadays is that their parents are too easy with them. Many of the unhappy things in people's lives are partly due to bad luck. People's misfortunes result from the mistakes they make. One of the major reasons why we have wars is because people don't take enough interest in politics. There will always be wars, no matter how hard people try to prevent them. In the long run, people get the respect they deserve in this world. Unfortunately, an individual's worth often passes unrecognised, no matter how hard he tries. The idea that teachers are unfair to students is nonsense. Most students don't realise the extent to which their grades are influenced by accidental happenings. Without the right breaks one cannot be an effective leader. Capable people who fail to become leaders have not taken advantage of their opportunities.

2.

a. b.

3.

a. b.

4.

a. b.

5.

a. b.

6.

a. b.

567 7. a. b. No matter how hard you try, some people just don't like you. People who can't get others to like them don't understand how to get along with others. Heredity plays the major role in determining one's personality. It is one's experiences in life which determine what one is like. I have often found that what is going to happen will happen. Trusting to fate has never turned out as well for me as making a decision to take a definite course of action. In the case of the well prepared student there is rarely if ever such a thing as an unfair test. Many times exam questions tend to be so unrelated to course work that studying is really useless. Becoming a success is a matter of hard work. Luck has little or nothing to do with it. Getting a good job depends mainly on being in the right place at the right time. The average citizen can have an influence on government decisions. This world is run by the few people in power, and there is not much the little guy can do about it. When I make plans, I am almost certain that I can make them work. It is not always wise to plan too far ahead because many things turn out to be a matter of good or bad fortune anyhow. There are certain people who are just no good.

8.

a. b.

9.

a. b.

10.

a. b.

11.

a. b.

12.

a. b.

13.

a. b.

14.

a.

568 b. 15. a. b. 16. a. b. 17. a. b. 18. a. b. 19. a. b. 20. a. b. 21. a. b. 22. a. b. 23. a. b. There is some good in everybody. In my case, getting what I want has little or nothing to do with luck. Many times we might just as well decide what to do by flipping a coin. Who gets to be the boss often depends on who was lucky enough to be in the right place first. Getting people to do the right thing depends upon ability. Luck has little or nothing to do with it. As far as world affairs are concerned, most of us are the victims of forces we can neither understand nor control. By taking an active part in political and social affairs, the people can control world events. Most people can't realise the extent to which their lives are controlled by accidental happenings. There really is no such thing as 'luck'. One should always be willing to admit his mistakes. It is usually best to cover up one's mistakes. It is hard to know whether or not a person really likes you. How many friends you have depends upon how nice a person you are. In the long run the bad things that happen to us are balanced by the good ones. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three. With enough effort we can wipe out political corruption. It is difficult for people to have much control over the things politicians do in office. Sometimes I can't understand how teachers arrive at the grades they give. There is a direct connection between how hard I study and the grades I get.

569

24.

a. b.

A good leader expects people to decide for themselves what they should do. A good leader makes it clear to everybody what their jobs are. Many times I feel that I have little influence over the things that happen to me. It is impossible for me to believe that chance or luck plays an important role in my life. People are lonely because they don't try to be friendly. There's not much use in trying too hard to please people. If they like you, they like you. There is too much emphasis on athletics in high school. Team sports are an excellent way to build character. What happens to me is my own doing. Sometimes I feel that I don't have enough control over the direction my life is taking. Most of the time I can't understand why politicians behave the way they do. In the long run the people are responsible for bad government on a national as well as on a local level.

25.

a. b.

26.

a. b.

27.

a. b.

28.

a. b.

29.

a. b.

570 Appendix 9 FORMAT OF PSYCHOTHERAPEUTIC INTERVENTION USED IN PHASE 2 A HYBRID ADAPTATION OF THE WITS TRAUMA DEBRIEFING MODEL (Eagle,1998) 1. TELLING THE STORY

This involves detailed description of the experience of cancer in sequence including facts, feelings, cognition and sensations. Fantasized and imagined aspects are also solicited as well as cancer misconceptions and cognitive distortions around the illness and treatment as applied to themselves. The person is encouraged to recall in detail everything he can and the therapist is present as a witness to this process through active listening , empathic reflection and appropriate questioning. This therapeutic space becomes a transitional space (Winnicott) in which the experience is relived in the realm of the symbolic rather than the actual. This exposure technique can also reduce anxiety (desentization). The patient's story telling can allow him/her to create some cognitive structure around the event, thus facilitating the process of assimilation and accommodation into existing cognitive frameworks. Telling the story with reference to details, physical details is helpful in facilitating access to emotion. A description of the worst moment can be asked for. A person goes back over the (the events) and relives the feelings of key moments and is then able to bring into his awareness and sometimes reevaluate what went on and what messages he has been carrying around in his subconscious ever since. Certain unblocking techniques can be used, such as : "Think of the change-room looked like as you were waiting for the x-rays or scans. What did the gown they gave you to wear look like, the pictures on the office wall, the secretary, the surgeon etc. Once a place is visualised in its detail, then the emotions and fears can often be recalled and situations can be relived. The person can tell and retell the story until he/she feels that everything has been told and experienced. Where it becomes obvious that the person has been through previous medical trauma the patient is encouraged to describe this as well. Telling the story leads to a catharsis which clears the way for a cognitive reappraisal of what in reality happened and the strength of its impact.

571 2. NORMALIZING THE SYMPTOMS The patient is encouraged to discuss the similar impact of trauma on others and not only on him/her self . In this way the realization comes that this is shared with people undergoing similar treatment. The experience in not simply shared with the therapist but the individual realises that the symptoms s/he is experiencing are common. The individual might have felt that her/his reactions were unusual or pathological. It brings a certain relief to know others have experienced this. The patient would be given a description and education of PTSD symptoms as well as other reactions such as depression, guilt and shame. Many patients believe that their symptoms mean they are going crazy or cannot take care of themselves. Providing accurate information about these symptoms helps to alleviate these concerns. They need reassurance about the normality of their symptoms and reactions, and the need for trauma debriefing. "Everyone feels the 'death imprint'." (Lifton 1993) and this, too, is discussed in the context of the association of cancer and death.

572 3. ADDRESSING SELF BLAME OR SURVIVOR GUILT

Patients have many cognitive distortions about themselves, their abilities and their reactions and are often filled with self blame, spurred on by their punishing superegos. Subjectively, all the distortions dominate and the person has difficulty in seeing past them. When the person can step back and be objective and perhaps evaluate his or herself as he would another person; he can be far kinder more tolerant and understanding and be able to see things more clearly. The person often feels she/he has, through the illness and treatment, behaved in a way which is incongruent with his or her self image. Certain messages and distortions have taken hold of their thinking, some of them having been present since the patient was a child , and now more strongly reactivated. In this part of the session, patients are taught to identify their dysfunctional automatic thoughts. They then learn to gather evidence used to evaluate the validity of the thoughts. Using this evidence, erroneous or unhelpful thoughts are being challenged and the replaced with more functional or rational thoughts. There can also be cognitive reframing and reassurance from the therapist.

573 4. PROMOTING MASTERY

The patient would be taught to replace negative , debilitating cognitions with positive, self enhancing thoughts and actions. This is based on the patients unique, cognitive deficits, stresses, problems and accompanying negative self talk. There will, of course, also be a certain amount of REFRAMING during this procedure. Work would be continued on personal distortions and general oncology myths and distortions and distortions about their illness, as well as chemotherapy, its implications and side effects. Efforts would be made to desensitize the person to the fear of Chemotherapy. This would be used in conjunction with MENTAL AND EMOTIVE IMAGERY to substitute the 'bad, destructive' images of chemotherapy to the investigative and healing aspects of chemotherapy. For those who understand something about computers it would be given over as something of a Virus Guard which investigates the hard drive and automatically cleans infected files. The 'Pacman' imagery could also be given. The patient would be encouraged to see him/herself as a partner with the doctor in his/her treatment (Holland 1999) and not see the doctor as an authority which he can rebel against. He should have an active participation in the development of treatment programs and involvement in his own treatment programs. Follow-up visits can be seen as 'well visits' rather than 'sick visits.' Talking about traumatic stress seems to affirm and validate to person. It also validates the trauma and the suffering. It is important to see that the person's identity is not defined by the cancer. Support systems will be assessed and mobilised. The person can be asked to score themselves out of 100 as to they are managing things and how they did as they went through the traumatic events. When they do that honestly they often become aware of how well they have actually done. If they can't score themselves they might be able to score someone else in a similar situation and work from there. It is important for the patient to see and acknowledge that they have done well.

574 5. FACILITATING THE CREATION OF MEANING

The patient will be asked "What good did you learn from this and can you learn from this. Often the patient brings this in and one can facilitate it, going into the concept of Post Traumatic Growth, and trying to facilitate this. The person's belief system is engaged and he/she is encouraged to look for meaning beyond him/herself. It is important to encourage the person to see meaning within the whole cancer situation. Goals, even short term ones can be defined. Certain perceptions can be changed and reframed, such as the difference between the cancer VICTIM and the cancer SURVIVOR.

575 Appendix 10 TABLE 15 THIS TABLE LISTS THE TYPE OF CANCER AND THE CHANGE IN BEHAVIOR AFTER THE INTERVENTION. PATIENT A B C D TYPE OF CANCER Leukaemia Testicular Cancer Melanoma Breast cancer TYPE OF COMPLIANCE Did not comply with follow up apps. Complied with follow up appointments Complied fairly well with follow up appointments Complied with treatment, follow up, and had breast reconstruction. Complied with treatment and follow up appointments. Complied fairly well with follow up appointments. Returned for follow up and colonoscopy Compliance with treatment and follow up. Went for treatment by surgery and follow up Complied with follow ups. returned to treatment and follow ups.

E F G H I J K

Lymphoma Lymphoma Malignant Caecum polyp. Breast Cancer Basal Carcinoma of the ear Testicular Cancer Lymphoma

Patient J died between follow up sessions from a disease (COPD) not related to the Cancer. Up till this time he complied following the trauma debriefing. Patient K died during a course of Chemotherapy by haemorrhage. Up to this time he complied following the trauma debriefing.

576 Appendix 11 Ethics Clearance Certificate