The Effect of Cognitive Behavioral Therapy-Based Psychoeducation on Anger Management and Death Anxiety in Individuals Receiving Chemotherapy: A Randomized Controlled Trial

Abstract

This study was conducted to examine the effect of Cognitive Behavioral Therapy (CBT)-based psychoeducation on anger control and death anxiety in individuals receiving chemotherapy. The research was completed as a pretest-posttest experimental design with 80 individuals who received chemotherapy (40 control, 40 experimental). The data were collected using the Personal Information Form, the Controlled Anger Scale (CAR), and the Death Anxiety Scale (DAS). Individuals in the experimental group received eight sessions of CBT-based psychoeducation. We used percent distribution, chi-square test, and t test for dependent and independent groups were used to analyze the data. This study demonstrated that the gap among between the pretest and posttest total scores of the anger scale and death anxiety scale of the individuals in the CBT-based psychoeducation experimental group receiving chemotherapy was statistically significant (p < .05). CBT-based psychoeducation can be recommended as a professional psycho-oncology practice to improve the anger and anxiety in individuals with cancer.

Keywords

anger management cancer cognitive behavioral therapy death anxiety psychiatric nursing psychoeducation

Introduction

Cancer is a chronic illness characterized by uncontrolled proliferation and disintegration of cells in some parts of the body, burdening patients and their relatives in biological, psychological, social, and economic dimensions, and can lead to death (Ozkan & Akın, 2017). Cancer is the second most widespread reason of death after cardiovascular illness, in the worldwide (TUIK, 2019).

Cancer patients experience many physical and psychological symptoms such as nausea, vomiting, fatigue, stress, and anxiety due to the side effects of chemotherapy and symptoms arising from the disease process (Ozdemir & Taşcı, 2017; Ozçelik & Toprak, 2015). Psychiatric disorders develop in approximately 50% of individuals diagnosed with cancer and 90% of these disorders develop in response to the disease and treatment (Güleç & Büyükkınacı, 2011; Münevver et al., 2012). As a result of the long-term and highly detrimental effects of cancer treatment, the individual’s family, work, and social life are affected, resulting in the loss of role and position, depression, hopelessness, helplessness, fear of the future, social isolation, burnout, and anger (Oz, 2001). Crothers has stated that the most vital psychosocial determinant of cancer development is the inability to express emotions, especially anger (Crothers et al., 2004). Anger, being essential in everyone’s daily life, is a natural and universal emotion directed against unfulfilled desires, unwanted results, and unrealized expectations. Uncontrolled anger turns into aggression and self-harm as an unhealthy, internal reaction (Douglas & Dolnak, 2006; Kökdemir, 2004). The fact that cancer remains a disease with high mortality and morbidity has caused it to be accepted as a condition equivalent to death (Cho et al., 2013; Yılmaz et al., 2017). According to Gyllensköld, cancer is thought to be linked to death, while its causes are not fully understood, and the progression is difficult to control and sometimes even uncontrollable. This causes excellent physical, psychological, and social suffering to the individual and the family. All these factors make cancer more frightening and threatening than other chronic diseases (Ulger et al. 2014).

Studies have shown that individuals diagnosed with cancer frequently experience death anxiety (Cesario et al., 2010; Robb et al., 2014). Which is the state of fear that people feel about the fact that their life on earth is coming to an end. There are times when physical illness leads to death anxiety. The first is when the patient learns that they are terminal. When suicide plans and depression may occur. The second is the stage when individuals show fatigue, loss of function, and disability due to organic disease (Aksu & Okçay, 2010; Togluk & Cuhadar, 2021). Problems arising from cancer are mostly fear, anxiety, anger, loss of control, and existential concerns about life and death leading to the recurrence of anger (Oz, 2001). It has been observed that problems such as anxiety, depression, anger, and feelings of helplessness, which are common in cancer, can exacerbate pain, reduce pain tolerance, increase patient distress, limit treatment, and have other side effects (Dedeli & Karadeniz, 2009; Papila, 2008). Anger management training needs to be designed and implemented to protect individual and community mental health (Acker, 2007).

Cognitive behavioral therapy (CBT) has been used in anger management studies and has been reported to provide satisfactory and lasting benefits (Yalom & Leszcz, 2018). In their systematic review, Görgü and Sütçü reported that CBT group therapy was successful in all studies in reducing anger problems and improving anger control in different samples (Görgü & Sütcü, 2015). In addition, in psychotherapeutic intervention studies on individuals diagnosed with cancer, anxiety, depression, and emotional distress levels were significantly improved (Badger et al., 2007; Classen et al., 2008; Hernando et al., 2020).

The effectiveness of CBT on psychiatric disorders found in individuals with cancer has been examined in many studies, and its benefits have been proven (Mannix et al., 2006; Semple et al., 2006). Upon conducting national and international literature reviews, anger control and CBT in individuals receiving chemotherapy, death anxiety, and CBT were not found. Since our study is unique, it is thought to contribute to the literature on consultation liaison psychiatry nursing and psychooncology. This study planned to investigate the effect of CBT-based psychoeducation on anger management and death anxiety in individuals receiving chemotherapy.

Matherial and Methods

Sample Size

The study population consisted of 159 chemotherapy patients receiving chemotherapy treatment in the Chemotherapy Unit of Batman Training and Research Hospital. The study’s sample size was determined by power analysis: 0.05 error and 0.95 confidence interval, 0.25 effect size, 0.95 representativeness of the, a total of 60 patients, 30 in the experimental group and 30 in the control group. The non-probability sampling method determined patients in the control and experimental groups. A total of 88 chemotherapy patients (experimental group n = 44, control group n = 44) were included in the study, considering that there may be losses from the study. The study was completed with 80 patients (psychoeducation group n = 40, control group n = 40).

Participants

Inclusion Criteria

Individuals between the ages of 18–65 are literate and receiving chemotherapy.

Exclusion Criteria

Patients with any of the following conditions were excluded from the study:

- Having physical (speech, hearing impairment, etc.), neurological, or psychological problems that prevent filling out the research forms

- Additional diagnosis during the education process

- Having received CBT-based training in the last six months

Design and Procedures

Approval was obtained from the Inonu University Scientific Research and Publication Ethics Committee, and legal permit Batman Training and Research Hospital where the study was conducted (approval code: 2023/4565). Individuals were informed that the information they provided would be kept confidential, not used in any other field and that they had the right to withdraw from the at any time during the study. Before starting the study, the patients and their relatives were and their verbal and written consents were obtained.

Intervention

The research was conducted as quasi-experimental with the pretest-posttest control groups. The findings were obtained from individuals who received chemotherapy two days a week in the Chemotherapy Unit of Batman Training and Research Hospital between February 2022 and June 2022 through face-to-face interviews by the researcher. The individuals in the control and experimental groups were administered pretests (Personal Information Form, CAR, and DAS). After eight sessions of psychoeducation applied just to the individuals in the experimental group, posttests (CAR, DAS) were applied to the experimental and control groups. The data collection forms were read to the patients face-to-face by the researcher and marked by the him/her as a result of the responses. Filling out the data collection forms took an average of 30 minutes with each individual. The researcher carried out CBT-based psychoeducation in the experimental group by ınteractive education in a group training style. The researcher who applied CBT-based psychoeducation received “Applied Cognitive Behavioral Therapy Training" and received a certificate of participation as a result of this training. The individuals in the experimental group were divided into five groups of 8 people. The training was applied to each group two days a week, at varying time for a total of 4 weeks with each session lasting an average of 50 minutes. Make-up sessions were organized for individuals who missed the sessions for various reasons or could not attend the sessions (day/date). Training, question-answer, form filling, role play, case formulation, homework, etc., were applied in an interactive style. No intervention was administered to the individuals in the control group. The Consort Flow Chart of the research is shown in Figure 1.

Figure 1.

Consort flow chart of the research study.

Measures

The Personal Information Form consisted of a total of 10 questions (age, gender, disease diagnosis, etc.) containing the socio-demographic information of the individuals determined by the researcher based on the established framework.

Anger trait and Expression Subscales: Questions related to these characteristics consisted of a total of 34 questions. Anger expression style subscale has three different subscales: Controlled Anger, Outward Anger, and Inward Anger (Spielberger et al., 1997). The scale includes a Likert-type rating of 1 to 4 for each item. High scores obtained from the controlled anger subscale indicate the controllability of anger.

The Death Anxiety Scale was a 15-item, true-false scale measured individual’s anxiety and their fear and risk of death of death (Templer, 1970). The total score obtained from the scale reflected the severity of death anxiety.

Process Steps

The researcher prepared CBT-based psychoeducation sessions in light of the literature and expert opinions (Oflaz & Demiralp, 2007; Türkçapar, 2018). The CBT-based psychoeducation program sessions were administered as follows:

Session 1: An empathic and safe environment was provided by introducing the practitioner to the patients in the groups. By using therapeutic communication methods between the group members and the trainer, individuals receiving chemotherapy could participate in the training process. The importance and rules of the therapy process were explained to the group and were informed about the research and psychoeducation. The days and hours of the training were determined by the individuals who wanted to participate in the study. Written consent and pretest were applied to the individuals.

Session 2: The session started with the individual’s mood control. The primary purpose of the session was to give a briefing about anger, death anxiety, and CBT. The session’s agenda was determined and explained. The causes, symptoms, and management of anger and death anxiety were explained based on the framework of CBT. Individuals were allowed to express themselves about their approach to anger and death anxiety. A homework assignment was given to each of the patients so they could write down the events that would make them angry and arouse death anxiety in them. They were asked to hand in the statements at the next therapy session.

Session 3: The session started with mood control of the individuals. After the homework was checked, the previous session was summarized. The A-B-C model, which forms the backbone of CBT, was explained on the board with examples, role plays, and forms. With the ABC model, changes in thoughts, emotions, and behaviors caused by anger and death anxiety were explained. Examples of coping with anger and death anxiety with the ABC model were also discussed.

Session 4: This session started with individuals’ mood control. The primary purpose of this session was to record cognitive distortion and negative automatic thoughts. The concepts of core and intermediate beliefs, negative automatic thoughts, and cognitive distortion were defined with examples. Cognitive distortion and negative automatic thoughts related to anger and death anxiety experienced by individuals were addressed with the ABC method. A homework was given as "filling in the automatic thought and cognitive error recording form until the next session."

Session 5: The primary purpose of this session was to gain awareness of providing cognitive alternatives. By ensuring the active participation of the group members in the therapy, alternative thoughts were discussed by providing cognitive awareness of the sense of anger and death anxiety. A homework was given to the subjects to record their thoughts on their anger and causes of anxiety. Also, they were asked to alternative thoughts that corrected their fear and anxiety.

Session 6: The session started by discussing the previous session and checking the homework. The primary purpose of this session was to teach breathing and relaxation exercises and to realize the relaxation effect on the individual. In the session, diagraphmatic breating and relaxation exercises were taught with practice. After discussing the content of the agenda, individuals were given breathing and relaxation exercises as the next homework.

Session 7: This session started with individuals’ mood control and the situation that occupied the individuals' consciousness were discussed. The previous sessions were discussed to discover what the individuals had learned so far and the situations in which they had problems. The primary purpose of this session was to practice exposure in the session as if they were experiencing anger and death anxiety in real life. İmaginary experiment. We discussed how to cope with the situations by imagining adverse events that might trigger the disease. The agenda and individuals were told to use breathing and relaxation exercises during the imaginary exposure and were given a homework assignment.

Session 8: The session was continued with the mood control of the individuals. Group members were asked to share their achievements and the skills they acquired. An evaluation was made about the stage at which individuals reached in coping with their problems. Feedback on suggestions and criticisms about the program was received, and post-tests were applied to the individuals.

Statistical Analyses

The statistical software, version 25 was used to evaluate the data, and a significance level of p < .05 was accepted. Demographic and descriptive characteristics of the individuals were expressed as the means and percentage values. The data normal distribution was analyzed by Kolmogorov-Smirnov and Shapiro-Wilk tests. In the analysis of personal information form the data, Percentage distribution, Arithmetic mean, Chi-square test, and Standard deviation were used. Mean scores of CAR and DAS scales and pre-post test, we used ındependent groups’ t-tests and dependent groups’ t-tests.

Results

Sample Characteristics

The data in Table 1 demonstrated that the participants in the experimental and control groups were homogeneous in terms of descriptive characteristics.

Table 1.

Dispersion of Introductory Characteristics of Individuals in the Experimental and Control Groups.

Introductory characteristics	Control group		Experimental group
Introductory characteristics	N	%	N	%
Age
18–33	2	5.0	1	2.5
34–49	13	32.5	23	57.5
50–65	25	62.5	16	40.0
Gender
Female	28	70.0	27	67.5
Male	12	30.0	13	32.5
Marital status
Married	5	12.5	6	15.0
Single	35	87.5	34	85.0
Education level
Literate	24	60.0	19	47.5
Primary education	4	10.0	16	40.0
Secondary education and above	12	30.0	5	12.5
Working status
Yes	7	17.5	3	7.5
No	33	82.5	37	92.5
Living place
Province	26	65.0	30	75.0
District	10	25.0	6	15.0
Village	4	10.0	4	10.0
Income status
Bad	18	45.0	21	52.5
Normal	18	45.0	19	47.5
Good	4	10.0	0	0
Medical diagnosis
Lung CA	5	12.5	7	17.5
Breast CA	13	32.5	16	40.0
Colorectal CA	9	22.5	6	15.0
Prostate CA	2	5.0	2	5.0
Other CA	11	27.5	9	22.5
Disease duration
0–3 years	25	62.5	25	62.5
4–7 years	15	37.5	15	37.5
Disease phase
First	0	0	0	0
Second	10	25.0	6	15.0
Third	19	47.5	24	60.0
Terminal stage	11	27.5	10	25.0

The data in Table 2 demonstrated that the pretest anger scale and death anxiety scale mean scores of the individuals in both groups were similar, and the gap between them was statistically insignificant (p > .05).

Table 2.

Comparison of Pretest Controlled Anger Scale and Death Anxiety Scale Total Score Averages of Individuals in Experimental and Control Groups.

	Pretest
	Experimental group (n = 40)	Control group (n = 40)	*Testing and significance
	(X ± S.S)	(X ± S.S)	*Testing and significance
Controlled anger scale total score	18.32 ± 7.05	17.20 ± 4.66	t = −0.841
Controlled anger scale total score	18.32 ± 7.05	17.20 ± 4.66	p = .403
Death anxiety scale total score	7.80 ± 1.36	8.22 ± 1.40	t = 0.971
Death anxiety scale total score	7.80 ± 1.36	8.22 ± 1.40	p = .335

Independent samples t test.

The data in Table 3 demonstrated in the post-CBT evaluation, the mean total score of the controlled anger scale was higher in the experimental group than in the control group. The mean total score of the death anxiety scale was lower in the experimental group than in the control group, and the gap was statistically significant (p = .001).

Table 3.

Comparison of Posttest Controlled Anger Scale and Death Anxiety Scale Total Point Means of Individuals in Experimental and Control Groups.

	Posttest
	Experimental group (n = 40)	Control group (n = 40)	*Testing and significance
	(X ± S.S)	(X ± S.S)	*Testing and significance
Controlled anger scale total score	24.67 ± 2.74	17.20 ± 4.52	t = -0.893
Controlled anger scale total score	24.67 ± 2.74	17.20 ± 4.52	p = .001
Death anxiety scale total score	6.72 ± 0.98	8.00 ± 1.45	t = 3.598
Death anxiety scale total score	6.72 ± 0.98	8.00 ± 1.45	p = .001

Independent samples t test.

The data in Table 4 demonstrated that in the mean total score of the controlled anger scale of the individuals in the experimental group after CBT shows a statistically significant difference compared to before CBT (p = .001). The mean total score of the death anxiety scale of the individuals in the experimental group after CBT shows a statistically significant difference compared to before CBT (p = .011). In the experimental group, there was an increase in the mean total score of the controlled anger scale in the posttest compared to the pretest. In the experimental group, there was a decrease in the mean total score of the death anxiety scale in the posttest compared to the pretest.

Table 4.

Collation of Pretest and Posttest Controlled Anger Scale and Death Anxiety Scale Total Point Means of Individuals in Experimental and Control Groups.

Groups		Pre test	Post test	*Test and significance
Groups		(X ± S.S)	(X ± S.S)	*Test and significance
Experimental group (n = 40)	Controlled anger scale total score	18.32 ± 7.05	24.67 ± 2.74	t = -3.491
	Controlled anger scale total score	18.32 ± 7.05	24.67 ± 2.74	p = .001
	Death anxiety scale total score	7.80 ± 1.36	6.72 ± 0.98	t = 2.666
	Death anxiety scale total score	7.80 ± 1.36	6.72 ± 0.98	p = .011
Control group (n = 40)	Controlled anger scale total score	17.20 ± 4.66	17.20 ± 4.52	t = -1.306
	Controlled anger scale total score	17.20 ± 4.66	17.20 ± 4.52	p = .703
	Death anxiety scale total score	8.22 ± 1.40	8.00 ± 1.45	t = 1.778
	Death anxiety scale total score	8.22 ± 1.40	8.00 ± 1.45	p = .083

Dependent groups t test.

Discussion

This study was conducted to investigate the effect of cognitive behavioral therapy-based psychoeducation on anger control and death anxiety in individuals receiving chemotherapy, in line with the literature. It was determined that the difference between the posttest anger control total mean scores of the individuals in the experimental and control groups was statistically significant after CBT-based psychoeducation. The mean CAR total score of the individuals in the experimental group after CBT showed a statistically significant difference compared to that before CBT. Based on this finding, the anger control level in the experimental group patients increased. The findings of the study are consistent with the literature. Akgün Şahin (2012) reported in his study “The effect of symptom control training given to patients receiving chemotherapy treatment on anger and stress coping levels” that the anger control level of the experimental group given psychoeducation increased significantly (Akgün Şahin, 2012). In their meta-analysis study, Lipsey et al. (2007) examined 58 studies to determine whether the CBT program was effective on offenders. CBT-based programs have been shown to be useful in anger management, relationship regulation, and problem-solving (Lipsey et al., 2007). Görgü and Sütcü (2015) stated in their systematic review that CBT group therapy was successful in reducing anger problems and increasing anger control in different samples (Görgü & Sütcü, 2015). Considering that the anger control total scores of the individuals who participated in the CBT-based psychoeducation program increased after the intervention, while there was no change in the anger control total score averages of the individuals in the control group without intervention. It can be said that the intervention had a positive impact on the anger control total scores. According to the results of our study, it can be stated that CBT-based psychoeducation is an effective psychosocial practice to increase the anger control of individuals receiving chemotherapy. The following techniques were applied in the intellectual intervention of CBT-based psychoeducation: Awareness of the definition, symptoms, and management of anger, explanation of the relationship between event-emotion-thought-behavior, identification of negative automatic thoughts during anger, and examination of thought errors. In addition, techniques such as breathing-relaxation exercises and imaginary exposure in behavioral intervention are thought to be effective. For these reasons, it is thought that the anger control level of individuals receiving chemotherapy might have increased. When the interventions applied to reduce and control anger were examined, it was found that cognitive-behavioral interventions were mostly used, and these interventions yielded successful results (Acker, 2007; Bilge & Ünal, 2005; Mannix et al., 2006; Yalom & Leszcz, 2018).

After CBT-based psychoeducation, it was determined that the gap among the post-test death anxiety total mean scores of the participants in the experimental and control groups was statistically significant. The mean DAS total score of the individuals in the experimental group after CBT showed a statistically significant difference compared to that before CBT. Based on this finding, it can be said that the death anxiety level of the experimental group patients decreased. Çam and Gördeles Beşer (2011) reported in their study “Examining the effectiveness of psychiatric nurse interventions for death anxiety of patients with lung cancer" that there was a significant decrease in the death anxiety levels among the individuals in the experimental group as a result of the interventions (Çam & Gördeles Beşer, 2011). Therefore, the findings of the study are in line with the literature. In the control group of patients, it was determined that the difference between the mean DAS total scores in the posttest compared to the pretest was not statistically significant (p > .05). Based on the results of the study, it can be stated that CBT-based psychoeducation can be used as a successful psychosocial practice to reduce the death anxiety of individuals receiving chemotherapy. The following techniques are considered to be effective in CBT-based psychoeducation: Ensuring cognitive awareness of death anxiety, explaining the relationship between event-emotion-thought-behavior, examining the meaning given to the cancer event and cognitive distortions, breathing-relaxation exercises are thought to be effective. For these reasons, it is thought that the death anxiety of individuals receiving chemotherapy may have decreased. In psychotherapeutic intervention studies conducted with individuals diagnosed with cancer, it was observed that anxiety, depression, and emotional distress levels improved significantly. The effectiveness of CBT in psychiatric disorders seen in individuals diagnosed with cancer has also been evaluated in many studies, and its benefits have been reported (Badger et al., 2007; Classen et al., 2008; Hernando et al., 2020).

Study Limitations

The ongoing COVID-19 pandemic and the meaning given to cancer and death anxiety by the society during the research process made it difficult to conduct psychoeducation sessions and collect data. The fact that this research was conducted in a single center, over a limited time constitutes a weakness of this research.

Recommendations

To increase the anger control and death anxiety skills of individuals receiving chemotherapy, it is recommended to provide psychoeducation based on CBT-based techniques in addition to medical treatment.

Clinical Implications

Individuals with cancer experience anxiety, fear, anger, helplessness, tension, and depression due to the uncertainty in their lives (Crothers et al., 2004). It has been observed that these problems worsen the cancer pain, reduce pain tolerance, increase the individual’s suffering, and negatively affect the treatment (Dedeli & Karadeniz, 2009; Papila, 2008). According to the World Cancer Report published by WHO, psychosocial elements of oncologic care provided to patients are an indispensable part of the national cancer care plan. It is essential to provide psycho-oncologic services in all cancer treatment units (Boyle & Levin, 2008). In psychotherapeutic intervention studies conducted with individuals diagnosed with cancer, it has been observed that anxiety, depression, and emotional distress levels improved significantly. The effectiveness of CBT in psychiatric disorders seen in individuals with cancer has been examined in many studies, and its benefits have been proven (Badger et al., 2007; Classen et al., 2008; Hernando et al., 2020; Mannix et al., 2006; Semple et al., 2006).

Finally, based on our study results, CBT-based psychoeducation was found to be effective in improving anger control levels and decreasing death anxiety levels of individuals receiving chemotherapy.

Conclusion

Before CBT-based psychoeducation, participants in the experimental and control groups had poor anger control levels and moderate death anxiety levels,

The anger control scores of individuals receiving chemotherapy in the experimental group increased significantly compared to the individuals in the control group,

The death anxiety scores of individuals receiving chemotherapy in the experimental group decreased compared to the individuals in the control group.

Footnotes

Authors’ Note

This research was written as a doctoral thesis.

Acknowledgments

We want to thank all individuals receiving chemotherapy who voluntarily participated in our study and the healthcare personnel who facilitated our research.

Ethical Statement

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed Consent

Informed consent was obtained from all individuals who participated in this study.

ORCID iD

Sabri TOGLUK

Data Availability Statement

Data supporting this study’s findings are available from the corresponding author upon reasonable request.

Author Biographies

Dr Sabri TOGLUK, PhD, Psychıatrıc Nursıng, Lecturer Siirt University/Vocatıonal School Of Health Servıces/Medıcıne, Servıces And Technıques Department/Dıalysıs Pr.) 01.03.2019 - Continues. Inonu Unıversıty/Instıtute of Health Scıences/Psychıatrıc Nursıng (Dr), The effect of cognitive behavioral therapy-based psychoeducation on anger control and death anxiety in individuals receiving chemotherapy (2023) Thesis Advisor: (Funda Kavak Budak). GazııAntep Unıversıty / Instıtute of Health Scıences / Psychıatrıc Nursıng (MD), The effect of death anxiety on psychosocial adjustment in individuals with chronic obstructive pulmonary disease (2017) Thesis Advisor: (DÖNDÜ ÇUHADAR).

Dr Funda KAVAK BUDAK, PhD, Psychıatrıc Nursıng, Inonu University Faculty of Nursing 2012 – Continues. Ataturk Unıversıty Instıtute Of Health Scıences/Psychıatrıc Nursıng (Dr), The effect of yoga on the level of functional recovery in patients with schizophrenia (2016) Thesis Advisor:(MINE EKINCI). Ataturk Unıversıty Instıtute of Health Scıences/Psychıatrıc Nursıng (MD), The life of patients with schizophrenia living in their own homes and those living in sheltered housing Comparison of qualities and functional recovery levels (2011) Thesis Supervisor: (MINE EKINCI).

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