The Effect of Cognitive Behavior Stress Management Program on the Distress, Coping Skills, and the Social Support of Omani Women with Breast Cancer: A Pilot Study

  • Nishat Shams Ministry of Health,P.Box 390,Muscat Shatti Qurum, Oman
  • Mohammed Al-Azri Sultan Qaboos University Hospital, P. Box:3 Muscat -Al Khoudh--Oman
Keywords: Omani women, cognitive-behavior therapy, effectiveness, breast cancer, cognitive behavior stress management.


Cognitive behavior stress management (CBSM) is an effective intervention that is suitable for use with women who have been diagnosed with breast cancer;  however, the effectiveness of CBSM in an applied clinical setting has not been examined in an Omani cultural context. Therefore, we examined the effectiveness of an 8-week CBSM group program using a sample of 6 Omani women who had been diagnosed with early-stage breast cancer. The purpose of this case study was to examine clinically significant changes in distress, social support, and the psychological ability to cope with breast cancer from pretest to posttest and follow-up (i.e., 1 month later). Overall, the group yielded strong positive effect sizes indicating clinical improvement over time in distress symptoms and social support, but strong unfavorable effect sizes in cognitive avoidance.  All women met the measurement criteria for anxiety and depression at baseline. The 2 participants who had the highest levels of baseline distress demonstrated the most pronounced improvements in depression and anxiety at posttest; however, their scores had returned to baseline levels at follow-up. On the other hand, the qualitative feedback of all 6 women underscored the effectiveness of the program in facilitating cognitive restructuring, relaxation, and social support. The present findings offer preliminary support to the effectiveness of CBSM in reducing psychological distress, improving coping skills, and fostering social support skills among Omani women with breast cancer. However, the program also had a few unfavorable results with regard to one coping strategy, namely, cognitive avoidance. Nevertheless, the findings suggest that social support can alleviate distress and improve coping skills among Omani women who struggle with breast cancer and its treatment. Further, strategies that can address cognitive avoidance and temporally sustain the positive effects of CBSM must be examined in future studies. This sentence sounds rather incomplete because it is missing a dependent variable (e.g., effective in reducing/improving  . . . ). Therefore, please consider including this information for better clarity. As with the previous sentence, this one sounds slightly incomplete because the dependent variables have not been listed. Therefore, please consider doing so to enhance clarity. I have removed this word because you used both quantitative and qualitative techniques. The meaning of this sentence is unclear. However, I have edited it as follows (see below) based on contextual information. Please use it if it is consistent with your intended meaning. “Overall, the program alleviated distress symptoms, and the corresponding effect sizes were large. However, the program also lead to an undesirable increase in cognitive avoidance; the effect size for this trend was also large.” The use of the term “rebounded” is inappropriate in this instance. Therefore, I have made the necessary change here and in all instances in this document.


. Z. Al-Sharbati, C. Hallas, H. Al-Zadjali, and M. Al-Sharbati. “Sociodemographic and clinical characteristics of patients attending psychotherapy in a tertiary care hospital in Oman.” Sultan Qaboos University Medical Journal, vol. 12(1), pp. 25-32, Month. 2012. doi: 10.12816/0003084

. Al-Moundhri M, Al-Bahrani B, Pervez I, Ganguly SS, Nirmala V, Al-Madhani A, et al. . The outcome of treatment of breast cancer in a developing country–Oman. Breast 2004. Apr;13(2):139-145. 10.1016/j.breast.2003.10.001 [PubMed] [Cross Ref]

. Ministry of Health. (2014). Oman establishment for press, publication and advertising. Muscat.

. Kumar S, Burney IA, Al-Ajmi A, Al-Moundhri MS. Changing trends of breast cancer survival in sultanate of oman. J Oncol. 2011;2011: 316243. [PMC free article] [PubMed]

. Banning M, Hafeez H, Faisal S, Hassan M, Zafar A.. The impact of culture and sociological and psychological issues on Muslim patients with breast cancer in Pakistan. Cancer Nurs 2009. Jul-Aug;32(4):317-324. 10.1097/NCC.0b013e31819b240f [PubMed] [Cross Ref]

. M. Al-Moundhri, B. Al-Bahrani, I. Pervez, S.S. Ganguly, V. Nirmala, Al-Madhani, et al. “The outcome of treatment of breast cancer in a developing country.” Oman. Breast, vol. 13(2), pp. 139-45, Month, 2004. doi: 10.1016/j.breast.2003.10.001

. M. Al-Azri, H. Al-Awis, S. Al-Rasbi, and M. Al-Moundhri. “Coping with a diagnosis of breast cancer among Omani.” Women Journal of Health Psychology, vol. 19(7), pp. , Month. 2014. doi:10.1177/1359105313479813

. Shapiro SL, Lopez AM, Schwartz GE, Bootzin R, Figueredo AJ, Braden CJ, et al. . Quality of life and breast cancer: relationship to psychosocial variables. J Clin Psychol 2001. Apr;57(4):501-519. 10.1002/jclp.1026 [PubMed] [Cross Ref]

. Cooper CL, Faragher EB.. Psychosocial stress and breast cancer: the inter-relationship between stress events, coping strategies and personality. Psychol Med 1993. Aug;23(3):653-662. 10.1017/S0033291700025435 [PubMed] [Cross Ref]

. O. Farouk, E. El-Sheshtawy, W. Abo-Elez, H. Ashour, and M. El-Zaafran. “Coping strategies in Egyptian ladies with breast cancer.” BCBCR, vol. 97, pp. , Month, 2014. doi: 10.4137/bcbcr. s14755

. Compas, B. E., & Luecken, L. (2002). Psychological adjustment to breast cancer. Current Directions in Psychological Science, 11, 111–114.

. Hack, T. F., & Degner, L. F. (2004). Coping responses following breast cancer diagnosis predict psychological adjustment three years later. [Peer Reviewed]. Psycho-Oncol- ogy, 13, 235–247.

. Wade, T. D., & Lee, C. (2005). The impact of breast cancer on the lives of middle-aged women: results from the Australian Longitudinal Study of Women’s Health. Health Psychology, 24(3), 246–251.

. Antoni, M. H., Wimberly, S. R., Lechner, S. C., Kazi, A., Sifre, T., Urcuyo, K. R., et al. (2006). Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress manage- ment intervention among women undergoing treatment for breast cancer. American Journal of Psychiatry, 163, 1791–1797.

. Beatty, L., Oxlad, M., Koczwara, B., & Wade, T. (2008). The psychosocial concerns and needs of women recently diagnosed with breast cancer: a qualitative study of patient, nurse and volunteer perspectives. Health Expectations, 11, 331–342.

. C.E. DeSantis, F. Bray, J. Ferlay, B.O. Anderson, and O. Jemal. “International variation in female breast cancer incidence and mortality rates.” Cancer Epidemiology Biomarkers Prevention, vol. 24(10), 1495-506, Month. 2015. doi:10.1158/1055-9965

. R. Renganathan, S. Ramasubramaniam, V. Seshan, A. Al-Balushi, W. Al-Amri, and Y. Al-Rawahi. “What do Omani women know about breast cancer symptoms?” Oman Medical Journal, vol. 29(6), pp. 408-13, Month. 2011. doi: 10.5001/omj.2014.110

. R.A. Khaduri. “Oman women past, present, and future.” Internet: Files/English/highLights/6.aspx, Sep. 6, 2007 [May 4, 2014].

. Bultz, B. D., & Carlson, L. E. (2006). Emotional distress: The sixth vital sign – future directions in cancer care. Psycho Oncology, 15, 93–95.

. S.L. Shapiro, A.M. Lopez, G.E. Schwartz, R. Bootzin, A.J. Figueredo, C.J. Braden, et al. “Quality of life and breast cancer: Relationship to psychosocial variables.” Journal of Clinical Psychology, vol. 57(4), pp. 501-19, Month. 2001. doi: 10.1002/jclp.1026

. R. Glaser, B. Rabin, M. Chesney, S. Cohen, and B. Natelson. “Stress-induced immunomodulation: Implications for infectious disease?” JAMA, vol. 281, pp. 2268-70, Month. 1999. doi: 10.1001/jama.281.24.2268 22.

. Arathuzik D. 1994. Effects of cognitive–behavioral strategies on pain in cancer patients. Cancer Nurs 17(3):207–214.

. B.D. Bultz and L.E. Carlson. “Emotional distress: The sixth vital sign – future directions in cancer care.” Psycho Oncology, vol. 15, pp. 93-5, Month. 2006. doi: 10.1002/pon.1022

. C. Burgess, V. Cornelius, S. Love, J. Graham, M. Richards, and A. Ramirez. “Depression and anxiety in women with early breast cancer: Five-year observational cohort study.” British Medical Journal, vol. 330(7493), pp. 1-4, Month. 2005. doi: 10.1136/bmj.38343.670868.d3

. National Comprehensive Cancer Network Distress Management Panel, 2005

. L. Beatty and B. Koczwara. “An effectiveness study of a CBT group program for women with breast cancer.” Clinical Psychologist, vol. 14(2), pp. 45-53, Month. 2010. doi: 10.1080/13284207.2010.500307

. National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown, NSW: National Breast Cancer Centre, 2003, pp.

. National Health and Medical Research Council. Psychosocial clinical practice guidelines: Information, support and counselling for women with breast cancer. Canberra: Commonwealth of Australia, 2000, pp.

. T.J. Meyer and M.M. Mark. “Effects of psychosocial interventions with adult cancer patients: A meta-analysis of randomized experiments.” Health Psychology, vol. 14(2), pp. 101-8, Month. 1995. doi: 10.1037//0278-6133.14.2.101

. M.H. Antoni. Stress management intervention for women with breast cancer. Washington, DC: American Psychological Association, 2003, pp.

. B.A. McGregor, M.H. Antoni, A.E. Boyers, S.M. Alferi, B.B. Blomberg, and C.S. Carver. “Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer.” Journal of Psychosomatic Research, vol. 56, pp. 1-8, Month. 2004. doi: 10.1016/s0022-3999(03)00036-9

. Browall, M., Ahlberg, K., Karlsson, P., Danielson, E., Persson, L. O., & Gaston-Johansson, F. (2008). Health-related quality of life during adjuvant treatment for breast cancer among postmenopausal women. European Journal of Oncology Nursing, 12, 180–189.

. M.H. Antoni, S.C. Lechner, A. Kazi, S.R. Wimberly, T. Sifre, K.R. Urcuyo, et al. “How stress management improves quality of life after treatment for breast cancer.” Journal of Consulting & Clinical Psychology, vol. 74(6), pp. 1143-52, Month. 2006. doi: 10.1037/0022-006x.74.6.1152

. J.S. Beck. Cognitive behavior therapy: Basics and beyond. New York, NY: Guilford Press, 2011, pp.

. Matthey, S. (1998). p 5 .05 – But is it clinically significant? Practical examples for clinicians. Behaviour Change, 15, 140–146.

. S.H. Lovibond and P.H. Lovibond. Manual for the Depression Anxiety Stress Scales (DASS). Sydney, Australia: University of New South Wales, 1995, pp.

. M. Watson, M. Law, M. dos Santos, S. Greer, J. Baruch, and J. Bliss. “The Mini-MAC: Further development of the Mental Adjustment to Cancer Scale.” Journal of Psychosocial Oncology, vol. 12(3), pp. 33-46, Month. 1994. Retrieved from

. C.D. Sherburne and A.L. Stewart. “The MOS Social Support Survey.” Social Science and Medicine, vol. 32(6), pp. 705-14, Month. 1991. doi: 10.1016/0277-9536(91)90150-b

. R.S. Lazarus and S. Folkman. Stress, appraisal and coping. New York, NY: Springer, 1984, pp..

. S. Matthey. “p 5 .05 – But is it clinically significant? Practical examples for clinicians.” Behavior Change, vol. 15, pp. 140-6, Month. 1998. doi: 10.1017/s0813483900003247

. M.H. Antoni and C.S. Carver. (2001). “Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer.” Health Psychology, vol. 20(1), pp. 20-32, Month. 2001. doi: 10.1037//0278-6133.20.6.458a