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COPYRIGHT 2005 American Association of Neuroscience Nurses
Abstract: The purpose of this quasi-experimental study was to evaluate the effectiveness of a cognitive-behavioral intervention for women with multiple sclerosis (MS). Thirty-seven adult women with MS participated in a group-based intervention program titled "Beyond MS," which was led by master's-prepared psychiatric nurses. For participants, the program involved reading a manual and meeting for five weekly group sessions. Perceived health competence, coping behaviors, psychological well-being, quality of life, and fatigue were measured at four time periods: 5 weeks before the beginning of the intervention, immediately before the intervention, at the end of the 5-week intervention, and at a 6-month follow-up. There were significant improvements in the participants' perceived health competence (p < .01), indices of adaptive and maladaptive coping (p < .04), and most measures of psychological well-being (p < .05) from pre- to postintervention. The positive changes brought about by this relatively brief intervention program were maintained during the 6-month follow-up period. This cognitive-behavioral intervention has also been used effectively in the rheumatoid arthritis population and may be adaptable to benefit individuals with other chronic conditions.
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Multiple sclerosis (MS) is a chronic, progressive, demyelinating disease of the central nervous system. The current prevalence in the United States is approximately 350,000 (Holland, 2004), with an annual incidence of about 12,000 and initial onset typically occurring between the ages of 18 and 45 years (Frohman, 2003). Given the progressive nature of MS, individuals living with this condition must cope with substantial disease-related stress and the uncertainty of their future disease course.
Although the role of stress in triggering MS exacerbations has been debated for years, recent studies have established finks between stressful life events and exacerbations (Ackerman et al., 2002; Buljevac et al., 2003; Mohr, Goodkin, Nelson, Cox, & Weiner, 2002; Mohr, Hart, Julian, Cox, & Pelletier, 2004). On a daily basis, persons with MS deal with significant stressors related to uncertainty about the future, functional and cognitive impairments, and general loss of control in their lives (Minden, 1992). After diagnosis, their greatest stressors include fatigue, uncertainty about the future, and difficulties in maintaining a job (Buelow, 1991). Researchers have also documented the experience of chronic sorrow, encompassing sadness, anger, frustration, fear, and helplessness, that surfaces when persons with MS feel out of control (Hainsworth, 1994; Minden, 1992). High levels of uncertainty about the future course of the illness and perceived stress have been correlated with mood disturbances in persons with MS (Kroencke, Denney, & Lynch, 2001; Wineman, Schwetz, Goodkin, & Rudick, 1996). Many individuals with MS become depressed, with point prevalence rates reported in the literature between 25% and 54% (Beatty, 1993; Chwastiak et al.; Murray, 1995; Schiffer, 1990). The depression may be partially caused by MS-specific processes, but a variety of psychosocial factors also can contribute to depression in this population (Mohr & Cox, 2001). The emotional component of this disease experience, therefore, presents complex and difficult challenges. There is a need for effective psychosocial interventions to help individuals with MS cope with the emotional challenges associated with living with the condition.
This article presents findings of a cognitive-behavioral intervention program for women with MS. The program was designed to enhance perceived control and thereby affect coping skills as well as psychological and physical outcomes.
Review of the Literature
The manner in which individuals handle their emotional challenges may affect the course of their disease. Perceptions of disease-related stressors, particularly uncertainty, affect coping behaviors that can, in turn, affect psychological outcomes (Brassington & Marsh, 1998; Wineman, Durand, & Steiner, 1994). Learned helplessness, the antithesis of perceived control, has been significantly correlated with both social and functional disability in persons with MS (McGuinness, 1996). Perceptions of helplessness have been associated with both neurological impairment and emotional instability and mediated the relationship between impairment and fatigue severity (Van der Werf, Evers, Jongen, & Bleijenberg, 2003). literature as a construct affecting psychological and physical outcomes. For persons with MS, an effective internal locus of control has been linked with positive psychosocial adjustment, less depression, an active personal life (Murray, 1995), and a more benign course of MS (Wassem, 1991). Self-efficacy represents a form of perceived control applied to specific challenges and has been a significant predictor of adjustment to MS (Wassem, 1992). After adjusting for sociodemographic and medical factors in their regression analyses, Schwartz, Coulthard-Morris, and Zeng (1996) reported that a low sense of mastery was the best psychosocial predictor of both global fatigue and fatigue-related distress. More severe fatigue was correlated with higher levels of depression in their sample. Self-efficacy has emerged as a significant predictor of health-promoting behaviors in individuals with MS (Stuifbergen & Becker, 1994), with subsequent impacts on quality of life, as demonstrated in a structural equation model of health promotion and quality of life derived from a sample of 786 individuals with MS (Stuifbergen, Seraphine, & Roberts, 2000). Gulick (2001) found that certain personal attributes (i.e., positive attitude, a sense of humor, perceived control over stress) mediated the effects of emotional distress on functionality in a large sample of 686 persons with MS. The psychosocial literature on MS therefore implies that psychosocial interventions for this population should focus on improving perceptions of control or self-efficacy.
Various approaches to psychosocial intervention have been attempted in this population. Support groups (Spiegelberg, 1980), medical discussion groups (Pavlou, Hartings, & Davis, 1978), extensive group psychotherapy (Crawford & McIvor, 1985; Hartings, Pavlou, & Davis, 1976), cognitive-behavioral therapy (CBT) groups (Foley & Bedell, 1987; Larcombe & Wilson, 1984), CBT delivered via reading a manual or conducting a telephone interview (Mohr et al., 2000), and coping-skills interventions (Schwartz, 1999; Schwartz & Rogers, 1994). Among these researchers, those who used some form of cognitive-behavioral intervention found them to be effective at significantly reducing depression levels (Crawford & McIvor; Foley & Bedell; Larcombe & Wilson; Mohr et al.), symptoms of depression (Mohr et al.), and anxiety and distress levels (Crawford & McIvor). Most of the samples were small (i.e., fewer than 30 participants per treatment group).
More recent interventions partially based on the behavioral principles of social cognitive theory (Bandura, 1986, 1998) have reported positive psychological and physical changes. Mathiowetz, Matuska, and Murphy (2001) used a 6-week energy conservation course in a quasi-experimental study in which 54 subjects served as their own controls. The researchers' intervention resulted in significant improvements in fatigue impact, self-efficacy, and several aspects of quality of life (i.e., vitality, social functioning, mental health). Stuifbergen, Becker, Blozis, Timmerman, and Kullberg (2003) used a randomized controlled trial to assess the effectiveness of a wellness intervention program for women with MS. This program used an eight-session format to deliver health-promotion information and practice techniques, incorporate individualized goal setting and monitoring, and attempt to enhance self-efficacy for health behaviors. The intervention resulted in significant improvements in self-efficacy, health behaviors, and...
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