1. Dissertation - August 2003 Enhanced Benefit Finding in Women with Early Stage Breast Cancer: The Mediational Role of Skill Building and Social Functioning

2. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

3. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

4. Dissertation - August 2003 1.1. Benefit Finding & Breast Cancer Effect maintained at 3-month and 9-month follow-ups Enhanced Benefit Finding Enhanced Benefit Finding Effect of CBSM on Benefit Finding CBSM Intervention Emotional Processing Benefit Finding was related to increased emotional processing (Antoni et al., 2001)

5. Dissertation - August 2003 1.2. Goal 3 Questions: Does the CBSM intervention contribute to generate changes in intrapersonal and interpersonal skills between pre- (T1)and post-intervention (T2) assessments? Does the CBSM intervention contribute to generate changes in intrapersonal and interpersonal skills between pre- (T1)and post-intervention (T2) assessments? Does the change in skills b/w T1 and T2 predict adjustment in social relations at 3-month (T3) and 9- month (T4) follow-ups?Does the change in skills b/w T1 and T2 predict adjustment in social relations at 3-month (T3) and 9- month (T4) follow-ups? Does social relations at T3/T4 mediate the impact of CBSM on Benefit Finding at T4? Does social relations at T3/T4 mediate the impact of CBSM on Benefit Finding at T4?

6. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

7. Dissertation - August 2003 n = 136 (intervention = 60; control = 76) n = 136 (intervention = 60; control = 76) Women with early stage Breast Cancer Women with early stage Breast Cancer Age range = 29 – 79 Age range = 29 – 79 Stage 0 to Stage II Stage 0 to Stage II Self-referral Self-referral Recruited within 1-2 months post-surgery Recruited within 1-2 months post-surgery 2.1. Sample

8. Dissertation - August 2003 2.2. Variables of Interest Intrapersonal Skills Intrapersonal Skills Problem-focused Coping Problem-focused Coping Emotion-focused Coping Emotion-focused Coping Intrapersonal Skills Intrapersonal Skills Seeking support from partner Seeking support from partner Seeking support from friends Seeking support from friends Social Relations Social Relations Social Interpersonal Adjustment Social Interpersonal Adjustment Social Provisions Social Provisions Quality of life (social item) Quality of life (social item) Benefit Finding T1/T4 Benefit Finding T1/T4  EACOPE  SSCOPE  SOCREL  ZBF

9. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

10. Dissertation - August 2003 3.1. Control Variables Failure to randomizationFailure to randomization –Age + Stage of Cancer + Chemotherapy Control variables:Control variables: –Age –Ethnicity (Black vs. non-Black) –Breast Reconstruction (had vs. did not have) –Chemotherapy (had vs. did not have) –Tamoxifen (had vs. did not have)

11. Dissertation - August 2003 3.2. Methodological Choices Primary analyses based on an available- case approach (pairwise omission)Primary analyses based on an available- case approach (pairwise omission) Secondary analyses using a complete- case approach (listwise omission)Secondary analyses using a complete- case approach (listwise omission) Secondary analyses using Support- seeking from friends only (SSCOPE)Secondary analyses using Support- seeking from friends only (SSCOPE) Secondary analyses looking at absolute scores in coping skills at T2Secondary analyses looking at absolute scores in coping skills at T2

12. Dissertation - August 2003 Presentation of Results For each hypothesis: a) Hypotheses tested b) Results c) Discussion d) Future Directions

13. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

14. Dissertation - August 2003 4.a. Did the intervention generate Coping Skills (T2)? (Hyp. 1) Hypothesis 1: Global treatment effect on coping skills post-intervention (T2)Hypothesis 1: Global treatment effect on coping skills post-intervention (T2) Model testedModel tested INTER- PERSONAL SKILLS T1 INTER- PERSONAL SKILLS T2 INTRA- PERSONAL SKILLS T1 INTRA- PERSONAL SKILLS T2 CBSM INTERVENTION CONDITION

15. Dissertation - August 2003 4.b. Did the intervention generate Coping Skills (T2)? (Results) No effect of the intervention onNo effect of the intervention on –Intrapersonal Skills (EACOPE) at T2 –Interpersonal Skills (SSCOPE) at T2 But effect of the intervention on emotional processing (EAC) at T2, with a greater effect for those with lower EAC scores at T1But effect of the intervention on emotional processing (EAC) at T2, with a greater effect for those with lower EAC scores at T1 Continuous decrease inContinuous decrease in –other coping skills (COPE) from T1 to T4 –Interpersonal Skills (SSCOPE) from T1 to T4

16. Dissertation - August 2003 4.c. Did the intervention generate Coping Skills (T2)? (Discussion) Coping skills at T1 predicted coping skills at T2  Minimal changes from T1 to T2Coping skills at T1 predicted coping skills at T2  Minimal changes from T1 to T2 Measures of the use of coping skillsMeasures of the use of coping skills  Decrease in coping related to decrease in perceived stress?  A shift from problem-focused coping to emotion- focused coping and reflection on existential issues? Use of social support (SS) = only 1 distinctionUse of social support (SS) = only 1 distinction  Intervention effective on other facets of SS (e.g., sources, types and quality of SS)?

17. Dissertation - August 2003 4.d. Did the intervention generate Coping Skills (T2)? (Future Dir.) Use indicators of acquisition of new skillsUse indicators of acquisition of new skills Incorporate a measure of change in perceived stress concurrent to measure of use of coping skillsIncorporate a measure of change in perceived stress concurrent to measure of use of coping skills Select time points with greater variations in stress (e.g., diagnosis vs. post-surgery)Select time points with greater variations in stress (e.g., diagnosis vs. post-surgery) Measure other facets of SS: those targeted in the intervention (e.g. sources, types, quality of social support)Measure other facets of SS: those targeted in the intervention (e.g. sources, types, quality of social support)

18. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

19. Dissertation - August 2003 5.1.a. Did the Intervention Enhance Social Relations? (Hyp. 2) Hypothesis 2: Long-term treatment effect on social relations at T3 and T4Hypothesis 2: Long-term treatment effect on social relations at T3 and T4 SOCIAL RELATIONS T3/T4 SOCIAL RELATIONS T1 CBSM INTERVENTION CONDITION Model testedModel tested

20. Dissertation - August 2003 5.1.b. Did the Intervention Enhance Social Relations? (Results) No effect of the intervention on Social Relations as a whole at any time pointNo effect of the intervention on Social Relations as a whole at any time point  Mediation of a treatment effect via skill building (Hyp. 3) could not be tested T1 reports predicted T3/T4 reports of social relationsT1 reports predicted T3/T4 reports of social relations Increase in social interactions from T1 to T3, in the absence of a treatment effectIncrease in social interactions from T1 to T3, in the absence of a treatment effect

21. Dissertation - August 2003 5.1.c. Did the Intervention Enhance Social Relations? (Discussion) Improvement in social interactions in the absence of a treatment effectImprovement in social interactions in the absence of a treatment effect  one of the benefits arising from the experience of breast cancer?  the change in social relations from T1 to T3 that predicted long-term benefit finding

22. Dissertation - August 2003 5.1.d. Did the Intervention Enhance Social Relations? (Future Dir.) To revisit the construct of social relations; how does it differ from the beneficial outcomes measured in benefit finding?To revisit the construct of social relations; how does it differ from the beneficial outcomes measured in benefit finding? Distinction between quantitative and qualitative measures of social relationsDistinction between quantitative and qualitative measures of social relations –Frequency of social interactions –Quality of relationships with family and friends and quality of social provisions

23. Dissertation - August 2003 5.2.a. Did Change in Skills predict Social Relations? (Hyp. 3 & 4) Hypothesis 3: Mediating effect of skill building on change in social relationsHypothesis 3: Mediating effect of skill building on change in social relations SOCIAL RELATIONS T1 SOCIAL RELATIONS T3/T4 INTRA- PERSONAL SKILLS T1 INTRA- PERSONAL SKILLS T2 INTER- PERSONAL SKILLS T1 INTER- PERSONAL SKILLS T2 CBSM INTERVENTION CONDITION Model testedModel tested

24. Dissertation - August 2003 5.2.a. Did Change in Skills predict Social Relations? (Hyp. 3 & 4) Hypothesis 4: Moderating effect of skill building on social relationsHypothesis 4: Moderating effect of skill building on social relations Model tested: Model tested: Outcome variable = SOCREL T3/T4 Predictors: 1) SOCREL T1 2)  (T2 – T1) EACOPE / SSCOPE 3) SOCREL T1 * Condition

25. Dissertation - August 2003 5.2.b. Did Change in Skills predict Social Relations? (Results -1) Skill building did not predict (change in) social relations at T3 and T4Skill building did not predict (change in) social relations at T3 and T4 Mediation of a treatment effect via skill building could not be testedMediation of a treatment effect via skill building could not be tested No moderating effect of skill building on T1 levels of social relations as a predictor of later social relationsNo moderating effect of skill building on T1 levels of social relations as a predictor of later social relations

26. Dissertation - August 2003 5.2.b. Did Change in Skills predict Social Relations? (Results-2) T2 interpersonal skills predicted social relations at T3, with a greater effect for those who reported lower levels of social relations at baselineT2 interpersonal skills predicted social relations at T3, with a greater effect for those who reported lower levels of social relations at baseline T2 intrapersonal skills and SS from friends only predicted social relations at T4, with a positive effect for those reporting lower levels of social relations at T1 and a negative effect for those with higher levels of social relations at T1T2 intrapersonal skills and SS from friends only predicted social relations at T4, with a positive effect for those reporting lower levels of social relations at T1 and a negative effect for those with higher levels of social relations at T1

27. Dissertation - August 2003 5.2.c. Did Skill Building predict Social Relations? (Discussion) Using coping skills (target of the intervention) at T2 should result in better social relations later on (beneficial outcome)Using coping skills (target of the intervention) at T2 should result in better social relations later on (beneficial outcome)  T2 skills predicted frequency of social interactions and perceived quality of support T1 and T2 skills were highly correlated (r =.50)T1 and T2 skills were highly correlated (r =.50)  Change in coping skills did not predict later social relations (low effect size) Benefits to those “who need it the most”Benefits to those “who need it the most”  What about the other participants?

28. Dissertation - August 2003 5.2.d. Did Skill Building predict Social Relations? (Future Dir.) Further explore the negative effects of the use of intrapersonal skills on those who reported higher levels of social relations at T1Further explore the negative effects of the use of intrapersonal skills on those who reported higher levels of social relations at T1

29. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Changes in Coping Skills 5. Changes in Social Relations 6. Predictors of Benefit Finding 7. Conclusion

30. Dissertation - August 2003 6.1.a. Did the Intervention Enhance Benefit Finding ? (Hyp. 5) Hypothesis 5: Long-term global treatment effect on benefit finding (BF) at T3 and T4Hypothesis 5: Long-term global treatment effect on benefit finding (BF) at T3 and T4 Model Tested: Model Tested: BENEFIT FINDING T3/T4 BENEFIT FINDING T1 CBSM INTERVENTION CONDITION

31. Dissertation - August 2003 6.1.b. Did the Intervention Enhance Benefit Finding ? (Results) Effect of the intervention on benefit finding at T3, not at T4Effect of the intervention on benefit finding at T3, not at T4  Long-term effect of CBSM intervention Greater positive effect for those who started with lower levels of benefit finding at baselineGreater positive effect for those who started with lower levels of benefit finding at baseline  Positive effect on the participants “who needed it the most”

32. Dissertation - August 2003 6.2.a. Did Skill Building predict Benefit Finding ? (Hyp. 6 & 7) Hypothesis 6: Long-term effect of skill building on benefit finding at T3 and T4Hypothesis 6: Long-term effect of skill building on benefit finding at T3 and T4 Model tested: Model tested: INTRA- PERSONAL SKILLS T2 INTRA- PERSONAL SKILLS T1 BENEFIT FINDING T1 BENEFIT FINDING T3/T4 INTER- PERSONAL SKILLS T2 INTER- PERSONAL SKILLS T1

33. Dissertation - August 2003 6.2.a. Did Skill Building mediate Benefit Finding ? (Hyp. 6 & 7) Hypothesis 7: Mediating effect of skill building on benefit finding at T3 and T4Hypothesis 7: Mediating effect of skill building on benefit finding at T3 and T4 Model tested: Model tested: INTRA- PERSONAL SKILLS T2 INTRA- PERSONAL SKILLS T1 BENEFIT FINDING T1 CBSM INTERVENTION CONDITION INTER- PERSONAL SKILLS T2 INTER- PERSONAL SKILLS T1 BENEFIT FINDING T3/T4

34. Dissertation - August 2003 6.2.b. Did Skill Building predict Benefit Finding ? (Results-1 ) No evidence of a long-term effect of changes in coping skills on benefit findingNo evidence of a long-term effect of changes in coping skills on benefit finding  Change scores did not predict BF T2 Interpersonal skills predicted BF at T3 and T4T2 Interpersonal skills predicted BF at T3 and T4 Positive effect of T2 intrapersonal skills* on BF at T3 for those who reported lower BF at T1, and negative effect for those who reported higher BFPositive effect of T2 intrapersonal skills* on BF at T3 for those who reported lower BF at T1, and negative effect for those who reported higher BF  Absolute scores predicted BF * Analyses with SS from friends only & listwise

35. Dissertation - August 2003 6.2.b. Did Skill Building mediate Benefit Finding ? ( Results-2 ) No evidence of a mediation of the long-term treatment effect on BF at T3 via changes in coping skillsNo evidence of a mediation of the long-term treatment effect on BF at T3 via changes in coping skills  Skill building did not mediate the long- term treatment effect on benefit finding No evidence of a mediation of the long-term No evidence of a mediation of the long-term treatment effect on BF at T3 via T2 coping skills treatment effect on BF at T3 via T2 coping skills  Coping skills at T2 did not mediate the long-term treatment effect on benefit finding either

36. Dissertation - August 2003 6.2.c. Did Skill Building predict Benefit Finding ? (Discussion) Patterns of variations in coping skills may explain these initial results:Patterns of variations in coping skills may explain these initial results:  small variations from T1 to T2 (n.s.)  small variations from T1 to T2 (n.s.)  decrease in most skills instead of a build-up  decrease in most skills instead of a build-up T2(or T1) levels of interpersonal skills predicted BF at T3, but the variation (T2-T1) did notT2(or T1) levels of interpersonal skills predicted BF at T3, but the variation (T2-T1) did not  Maybe the predictive part of T2 levels was already present in T1 levels  Maybe the predictive part of T2 levels was already present in T1 levels Other components of the intervention contributed to the long-term effect of the intervention on BFOther components of the intervention contributed to the long-term effect of the intervention on BF

37. Dissertation - August 2003 6.2.d. Did Skill Building mediate Benefit Finding ? (Future Dir.) Revise the operationalization of skill building:Revise the operationalization of skill building: –Changes in skills (not in the use of skills) –Select time points likely to produce larger effect sizes –Concurrent measure of perceived stress Revise the operational design:Revise the operational design: –Address the various changes (frequency, quality) –Select different stages (diagnosis, treatment) –Allow to distinguish intra-individual vs. inter-individual patterns of change across time points What are the other ingredients, which contributed to long-term benefit finding?What are the other ingredients, which contributed to long-term benefit finding?

38. Dissertation - August 2003 6.3.a. Did Social Relations mediate Benefit Finding ? (Hyp. 8) Hypothesis 8:Mediating effect of changes in social relations on Benefit finding (T3/T4)Hypothesis 8:Mediating effect of changes in social relations on Benefit finding (T3/T4) Model tested: Model tested: BENEFIT FINDING T1 BENEFIT FINDING T4 SOCIAL RELATIONS T3/T4 SOCIAL RELATIONS T1 INTER- PERSONAL SKILLS T2 INTER- PERSONAL SKILLS T1 INTRA- PERSONAL SKILLS T2 INTRA- PERSONAL SKILLS T1

39. Dissertation - August 2003 6.3.b. Did Social Relations mediate Benefit Finding ? (Results-1) Changes in social relations from T1 to T3 predicted benefit finding at T3Changes in social relations from T1 to T3 predicted benefit finding at T3 Changes in social relations could not mediate the effect of skill building on benefit finding ( absence of such an effect )*Changes in social relations could not mediate the effect of skill building on benefit finding ( absence of such an effect )* Changes in social relations from T1 to T3 did not mediate the treatment effect on benefit finding at T3Changes in social relations from T1 to T3 did not mediate the treatment effect on benefit finding at T3 * Yet, mediation evidenced with an analysis listwise

40. Dissertation - August 2003 6.3.b. Did Social Relations mediate Benefit Finding ? (Results-2) Interpersonal Skills T2 Benefit Finding T3  =.20 (p =.011)  =.20 (p =.036)  =.14 (p =.064) Social Relations T3  = -.18 (p =.044) Interpersonal Skills T2 X Social Relations T1 A tentative illustration of a mediation of the relationship between interpersonal skills at T2 and benefit finding at T3 via social relations at T3 (analysis listwise)

41. Dissertation - August 2003 6.3.c. Did Social Relations mediate Benefit Finding ? (Discussion) Improvement in social interactions from T1 to T3 contributed to explain enhanced benefit finding at T3Improvement in social interactions from T1 to T3 contributed to explain enhanced benefit finding at T3 The absence of a mediating effect of social relations again suggests that other products of the intervention contributed to the long-term effect of the intervention on benefit findingThe absence of a mediating effect of social relations again suggests that other products of the intervention contributed to the long-term effect of the intervention on benefit finding

42. Dissertation - August 2003 6.3.d. Did Social Relations mediate Benefit Finding ? (Future Dir.) Could the results obtained with a complete-case approach be reproduced with a larger and more complete sample?Could the results obtained with a complete-case approach be reproduced with a larger and more complete sample? Replicate the study, with a new methodology : –Revise the operationalization of variables –Incorporate a measure of perceived stress –Multiple imputations to handle missing data –Hierarchical modeling statistical procedure –Eventually, collect data prior to surgery

43. Dissertation - August 2003 Outline 1. Introduction in brief 2. Method in brief 3. Preliminary Analyses 4. Results 5. Discussion 6. Methodological Limitations 7. Conclusion

44. Dissertation - August 2003 7.1. Conclusion 3 Factors predicted Benefit Finding at T3: Emotional processing and other coping skills at T2 for those who reported lower levels of benefit finding at baselineEmotional processing and other coping skills at T2 for those who reported lower levels of benefit finding at baseline Support-seeking behaviors at T2Support-seeking behaviors at T2 Changes in social relations from T1 to T3Changes in social relations from T1 to T3 But did not mediate the treatment effect observed at T3

45. Dissertation - August 2003 7.2. Conclusion (Cont’d) Diversity of beneficial outcomes for a limited range of coping toolsDiversity of beneficial outcomes for a limited range of coping tools  some facets of BF may not be influenced by the CBSM intervention What is measured in the BF scale may be largely independent from what is targeted in the CBSM modules (e.g., life readjustment, shift in life priorities and relationships, enhanced sense of purpose)What is measured in the BF scale may be largely independent from what is targeted in the CBSM modules (e.g., life readjustment, shift in life priorities and relationships, enhanced sense of purpose)  Existential/Experiential dimension of BF

46. Dissertation - August 2003 Early detection of perceived benefitsEarly detection of perceived benefits  Existential content in the intervention as early as at the treatment stage  Need for indicators of those facets of benefit finding to measure the impact of the intervention and variations across time and situations  Need for indicators of those facets of benefit finding to measure the impact of the intervention and variations across time and situations 7.3. Conclusion (Cont’d)