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March 2003 Article of the Month
This month's article selection is by George Fitchett,
CPE Supervisor, Rush-Presbyterian-St. Luke's Medical Center, Chicago IL.


Carpenter, J. S., Brockopp, D. Y. and Andrykowski, M. A. [School of Nursing, Vanderbilt University, Nashville TN;]. "Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors." Journal of Advanced Nursing 29, no. 6 (June 1999): 1402-1411.


SUMMARY: Background: It has been observed that people change in a variety of ways after a diagnosis of a life-threatening illness. Further, although such diagnoses are often accompanied by intense physical and emotional distress, some people report growth or transformation resulting from the experience. These authors describe change after a diagnosis of a life-threatening illness as self-transformation. Their study had three specific aims: 1) to describe self-transformation after diagnosis with a life-threatening illness, 2) to describe the demographic and disease-related correlates of self-transformation, and 3) to describe the association, if any, of self-transformation with self-esteem and well-being.

Design: Mixed qualitative and quantitative methods were employed to achieve these aims. The authors conducted semi-structured interviews with 60 women who had been diagnosed with breast cancer. They asked four questions, including, "How have you or your feelings about yourself changed since your breast cancer diagnosis?" These women, and an age-matched group of 60 women who had not had breast cancer, also completed surveys that assessed self-esteem and well-being. Qualitative analysis of the interview data led to the description of three different types of self-transformation. Quantitative methods were used to achieve the other two aims.

Sample: In order to better understand self-transformation, the investigators sought to interview a medically diverse group of women who had been diagnosed with breast cancer. Seventy-eight percent of the women in their sample were diagnosed with Stage IIA or lower disease. The sample was demographically homogeneous, a useful strategy at this stage of research about self-transformation. However, they were not representative of the general population (95% white, 50% with a Bachelors degree or more).

Analysis: The interviews were taped, transcribed, and analyzed. Unlike many qualitative studies that examine key phrases, in this study the unit of analysis was each interview. Comparison of data from the transcripts led to the description of the three groups and the assignment of each interview to one of the groups. A co-investigator independently assigned six of the interviews to one of the three groups with 100% agreement. The investigators discussed their three categories with a focus group of five women who had participated in the interviews. The focus group participants endorsed the results of their analysis.

Qualitative Findings: Analysis of the interview data led to the description of three different types of self-transformation. The types and the proportion of women in each group were: positive transformation 27%, minimal transformation 45%, and feeling stuck 28%. Each of the three types of self-transformation began with the woman's encounter, through her diagnosis with breast cancer, with her mortality. These encounters led to a process of self-evaluation. For women in the minimal transformation group, their self-evaluation led to feelings of self-acceptance. They didn't feel a need to make any big changes in their lives. For women in the positive transformation group, self-evaluation led to significant changes in their lives, in areas like work and relationships. For women who were described as feeling stuck, self-evaluation led to feeling a need to change, but these women also felt unable to change, in part due to fear, lack of time or energy, or lack of support.

Quantitative Findings: The analysis of the survey data revealed that women in the positive transformation group had higher self-esteem and well-being than: 1) cancer survivors who were in the "feeling stuck" group, and also higher self-esteem and well-being than 2) their age-matched counterparts who did not have cancer. They also found that women in the "feeling stuck" group had lower self-esteem and well-being than: 1) women in the other two cancer survivor groups and 2) lower well-being than the women without cancer.

Conclusion: The authors conclude that their study has expanded our understanding of self-transformation, including its demographic correlates and association with self-esteem and well-being. They also describe some of the limitations of the study and other areas for investigation.

COMMENT: The study comes from a team that is investigating self-transformation in cancer patients. The three types of self-transformation that they describe in the paper, and their distribution, make a lot of sense to me. For most people there are no big changes associated with a diagnosis of a life threatening illness, for some there are dramatic positive changes, and some people feel stuck. I liked the detail the investigators offered about the process of self-transformation for women in each of the three groups. I remain in awe, and just a bit skeptical of their ability to find these three clear and coherent groups in the data from 60 interviews. I could easily find 600 types. The women in the study were an unusually well-educated, and perhaps articulate, group. It will be important to see if there are differences in self-transformation in men and women from other social locations.

Diagnosis with Stage I or II breast cancer is a serious matter, but there are also limitations in using this as the paradigm for life-threatening illness. The narratives of patients who encounter other grave diagnoses should also be examined.

I like the clinical implications of the paper. Not everyone with serious illness may need professional spiritual or psychological help. But some people, perhaps about 25%, clearly do.


Suggestions for the Use of the Article for Discussion in CPE: 

The article raises a number of interesting clinical and research questions for students to consider. What assumptions do you have about the impact of a life-threatening diagnosis on people? What do you think about the three groups identified by these investigators? Can you think of any patients who would be examples of one or more of these groups? Can you share details about a case and why you think the case is an example of one of the groups? Do you think there are additional groups or sub-groups that were not identified by these investigators? What would you say are the implications of the three groups for spiritual care? Can you think of ways that you can predict or identify which patients might end up in the different groups? How can we identify and help those patients who may get stuck as they try to cope with serious illness? The investigators outline a transformation process that begins as women come face to face with their mortality. It continues with self-evaluation, and then decisions about whether or not the women feel a need to make any changes in their lives. Have you seen other steps in the transformation process that were not identified by these investigators? Can you think of any cases that illustrate one or more stages of the transformation process?

With their description of women who desire to makes changes in their lives, but feel stuck, the investigators describe a process that may be related to spiritual struggle or spiritual risk. Research about spiritual struggle and spiritual risk suggests they have a negative impact on mortality, recovery, and adjustment to illness. The bibliography (below) provides additional resources for students who wish to explore this theme.

Supervisors can also use the article to illustrate the kinds of interesting information that can be gathered from qualitative research. Chaplains frequently possess two important qualities necessary for qualitative research: they are attentive listeners and observers and they have disciplined self-awareness. What role do you think religion or spirituality play in the encounter with mortality or other stages of the transformation process described here? If you were to conduct a qualitative study to examine the role of religion/spirituality in the transformation process, what questions would you ask in the interviews?


Related Items of Interest: 


Exline, J. J., Yali, A. M. and Lobel, M. "When God disappoints: difficulty forgiving God and its role in negative emotion." Journal of Health Psychology 4, no. 3 (July 1999): 365-279. 

Fitchett, G. "Screening for spiritual risk." Chaplaincy Today 15, no. 1 (1999): 2-12. 

Fitchett, G. "Selected resources for screening for spiritual risk." Chaplaincy Today 15, no. 1 (1999): 13-26. 

Fitchett, G., Rybarczyk, B. D., DeMarco, G. A. and Nicholas, J. J. "The role of religion in medical rehabilitation outcomes: a longitudinal study." Rehabilitation Psychology 44, no. 4 (November 1999): 333-353. 

Fitchett, G., Meyer, P. M. and Burton, L. A. "Spiritual care in the hospital: Who requests it? Who needs it?" Journal of Pastoral Care 54, no. 2 (Summer 2000): 173-186. 

Fitchett, G., Murphy, P. E., Gibbons, J. L. and Cameron, J. "Spiritual risk: prevalence and correlates in three patient groups." Unpublished paper, presented at the Society for the Scientific Study of Religion, Columbus OH (2001). 

Koenig, H. G., Pargament, K. I. and Nielsen, J. "Religious coping and health status in medically ill hospitalized older adults." Journal of Nervous and Mental Disease 186, no. 9 (September 1998): 513-521. 

Oxman, T. E., Freeman, D. H., Jr. and Manheimer, E. D. "Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly." Psychosomatic Medicine 57, no. 1 (January-February 1995): 5-15. 

Pargament, K. I., Smith, B. W., Koenig, H. G. and Perez, L. "Patterns of positive and negative religious coping with major life stressors." Journal for the Scientific Study of Religion 37, no. 4 (December 1998): 710-724. 

Pargament, K. I., Koenig, H. G., Tarakeshwar, N. and Hahn, J. "Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study." Archives of Internal Medicine 161, no. 15 (August 13-17, 2001): 1881-1885. 



Maxwell, J. A. Qualitative Research Design: An Interactive Approach. Thousand Oaks, CA: Sage Publications, Inc., 1996. 

Mayan, M. J. An Introduction to Qualitative Methods: A Training Module for Students and Professionals. Edmonton, Canada: Qual Institute Press, 2001. [NOTE: (Added 8/15/09): This version of the text is now out of print, but author Maria Mayan has notified the Network that the material has been re-published in a new book, The Essentials of Qualitative Inquiry (2009), from Left Coast Press.]  

O'Connor, T. St. J. "Dante, qualitative research, and wonderings." Journal of Pastoral Care and Counseling 56, no. 4 (Winter 2002): 313-315. 

O'Connor, T. St. J., Koning, F., Meakes, E., McLarnon-Sinclair, K., Davis, K. and Loy, V. "Quantity and rigor of qualitative research in four pastoral counseling journals." Journal of Pastoral Care 55, no. 3 (Fall 2001): 272-280. 

Rice, P. L. and Ezzy, D. Qualitative Research Methods: A Health Focus. New York: Oxford University Press, 1999. 

Weiss, R. S. Learning from Strangers: The Art and Method of Qualitative Interview Studies. New York: The Free Press, 1994. 


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