BREAST CANCER PATIENT’S EXPERIENCE OF POST-TRAUMATIC GROWTH: RELATIONSHIP WITH COPING STRATEGIES AND SOCIAL SUPPORT

Shams Un Nisa 1 and Touseef Rizvi 2 . 1. Contractual Lecturer, Department of Psychology, University of Kashmir, Hazratbal, Srinagar, 190006. 2. Sr. Asst. Professor, Department of Psychology, University of Kashmir, Hazratbal, Srinagar, 190006. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (10), 1826-1832 1827 distress. Women who have been surgically treated for breast cancer often experience important life changes such as insomnia, loss of appetite and difficulty in returning to usual household and employment responsibilities. The diagnosis also holds further implications for social relations and psychological well-being. All these changes can cause psychological and emotional distress, most commonly depression, anxiety and hopelessness. On the other hand, breast cancer can also form a turning point which can unfold to contribute to positive changes in the survivors' life. Many survivors of breast cancer express perceptions of benefit or stress-related growth related to their experiences (Cordova, Cunnigham, Carlson, & Andrykowski, 2001;Weiss, 2004).  found that 83% of women with early-stage breast cancer report positive consequences from their cancer experience. Some of the frequently reported positive changes include altered priorities, better relationships with others, a greater sense of purpose, and a greater appreciation of one-self and one's life (Dow, Ferrell , Haberman , & Eaton, 1999;Schroevers, Ranchor, & Sanderman 2006). A number of factors have been found to influence the process of posttraumatic growth. It is acknowledged that using adequate and adaptive coping strategies produces growth (Armeli, Gunthert & Cohen, 2001). It was found that there is a relationship between posttraumatic growth and different coping strategies such as positive reinterpretation (reframing/reappraisal) ( (Dirik & Karanci, 2008;Sheikh, 2008). Problem-focused coping strategies involve attending to problem directly and attending to actual person situation relationship and has been found to be related to post-traumatic growth (Dirik & Karanci, 2008). This coping strategy is asserted to promote growth, because active involvement in problem may lead the person to have enhanced self-efficacy and self-confidence that may promote growth. Literature supports the relationship between post-traumatic growth and problem focussed coping strategies. A positive relation was found between post traumatic growth and problem focussed coping (Kesimci, Goral & Gencoz, 2005). Similarly, Armeli, Gunthert and Cohen (2001) stated that individuals using problem focused coping experience more growth.
Research suggests that social support also increases the probability of developing positive changes after trauma. This refers to both the availability of support and perceived or obtained support. Emotional support represents a particularly important type of help, especially if obtained immediately after an experienced traumatic event. The possibility of sharing thoughts and feelings and expressing emotions supports the processing of trauma and raises the chances for posttraumatic growth (Tedeschi & Calhoun, 1996). Harvey, Barnett and Overstreet (2004) emphasized that the possibility of sharing emotions with other people is a key factor in the process of coping with trauma. Therefore, the availability of a support network, including formal groups offering help to individuals in need, is of vital importance. This type of support promotes positive changes even in those traumatized persons who do not seek help actively. Tedeschi & Calhoun (2004) suggested that the important role of support is associated with the fact that offered support mobilizes persons experiencing trauma to active, problem-oriented rumination (deliberate rumination). In contrast to intrusive rumination, this type of rumination has defined objectives and leads to adaptive reinterpretation of cognitive schemas regarding the world and the self and establishing a new, more realistic vision of reality, which in turn promotes the development of positive changes. Support from persons who have experienced or still experience similar trauma is vitally important, albeit difficult. Self-comparison with persons who are in even more difficult situations and still cope with trauma can constitute a very important and supportive source of power. This was emphasized by Taylor (1983) in her concept of cognitive adaptation.
The central focus of this paper was the relationship of coping strategies and social support with post-traumatic growth in cancer patients. We expected positive changes to be significantly related to coping strategies and social support. Second we also examined the influence of coping strategies and social support on post-traumatic growth.

Method:-
Sample and Procedure:-Participants were selected with the assistance from Department of Radiation Oncology, Government Medical College, Karan Nagar, Srinagar and Department of Oncology, Noora Hospital, Zainakote, Srinagar. A total of 176 patients were selected for the study. The inclusion and exclusion criteria for sample group were as follows: (1) Patients having definite diagnosis of breast cancer. (2) At least six months' time duration since the diagnosis of the disease. (3) Patients providing informed consent. (4) Patients with other physical or psychological problems were excluded from the study. (5) Patients with history of metastases and critically ill patients were excluded from this study (6) Patients who had no knowledge of their diagnosis were also excluded from this study (7) Lack of patient's consent to participate in the study was another exclusion criterion. Researcher explained the aims and the procedure of the study to the authorities and their consent for conducting the study was obtained. Subsequently patients who met the inclusion criteria set by the researcher were chosen. Some of the patients were under treatment whereas others were on follow-up appointment at the hospital. The data was collected individually from the participants. The researcher introduced herself to the patients and explained the aim and purpose of the study. Confidentiality was ensured to the participants and they were told that they could stop and discontinue at any time of the study. Verbal consent was taken from each of the participants. The scales were applied by the researcher in face to face format. For all the scales necessary instructions were given and researcher helped the participants in marking their answers if they experienced difficulties. For illiterate patients the scales were administered by the researcher providing all help in understanding the questions and marking the answers. Data was collected from both out-patient department (OPD) as well as in-patient department (IPD). Coping Strategies:-Coping was assessed using Brief COPE (Carver, 1997). This scale has been designed to assess broad range of coping responses among adults for all diseases. It consists of 28 items rated on a 4-point Likert scale from "I haven't been doing this at all" to "I have been doing this a lot". These items are divided into fourteen sub-scales. Each of the 14 sub-scales is comprised of 2 items, total scores on each sub-scale range from 2 (minimum) to 8 (maximum). Higher scores indicate increased utilization of that specific coping strategy. Empirical evidence exists indicating the sound psychometric properties of the scale. Internal reliabilities for the 14 subscales range from = 0.57-0.90 (Carver, 1997). The criterion-related validity has been established by correlating the Brief Cope with Brief Psychiatric Rating Scale (BPRS) measuring dissimilar construct (r= -0.44) and positively associated with positive social functioning (SAS) (r= 0.33) (Meyer, 2001). Though COPE sub-scales are intended to be used independently research has suggested that sub-scales of denial, substance abuse, self-blame, behavioural disengagement, self-distraction capture avoidant coping and the sub-scales of active-coping, use of emotional support, use of instrumental support, positive reframing, planning, humour, acceptance and religion best capture approach or adaptive coping ( To have a more practical measure one original sub-scale of substance abuse was discarded due to cultural issues. The score of active-adaptive coping was computed by adding the subscales of Active Coping, Use of Emotional Support, Use of Instrumental Support, Positive Reframing, Planning, Humour, Acceptance, Religion, Venting and Self-distraction. The score of avoidance coping was computed by adding the sub-scales of Denial, Self-blame and Behavioural Disengagement (Carver, Scheier & Weintraub, 1989;Danheur et al., 2013). The authors found the Cronbach's α-coefficient of 0.74 for active-adaptive coping and 0.69 for avoidance coping in this study.

Social Support:-
For the assessment of social support Multi-Dimensional Scale of Perceived Social Support (Zimet, Dahlem, Zimet & Farley, 1988) was used. It consists of 12 items which are rated on a 7-point Likert scale. These 12 items assess support from three sources "Friends", "Family" and "Significant Other". There is enough empirical evidence indicating the sound psychometric properties of MSPSS. Coefficient alpha ranged from.81 to.90 for Family subscale, from .90 to .94 for the Friends sub-scale, from .83 to .98 for Significant other sub-scale and .84 to .92 for the 1829 scale as a whole (Zimet, Powell, Farley, Werkman & Berkoff, 1990). In this study Cronbach's α-coefficient was 0.71 for friends sub-scale, 0.89 for family sub-scale, and 0.91 for significant other sub-scale.
Statistical Analysis:-Descriptive analyses were performed and means and standard deviations will be presented. Concerning the relationship between coping strategies, social support and post-traumatic growth we used Pearson's correlation (p≤0.05). Next we used the multiple regression analysis to examine the influence of coping strategies and social support on post-traumatic growth. Table 1 presents the means, standard deviations and ranges of the study variables. In table 2 and table 3 the relationships among study variables are shown. Regarding the relationship between study variables we found a significant and positive relationship of active-adaptive coping (r= .38, p<0.01), social support from friends (r= .29, p<0.01), family (r= .15, p<0.05), significant other (r= .31, p<0.01) with post-traumatic growth.

Influence of Coping Strategies on Post-Traumatic Growth:-
Multiple regression analysis was applied to find out whether active-adaptive and avoidance coping strategies significantly influence post-traumatic growth. As can be seen in the Table 4 Active-adaptive coping (β = .39, p < .01), could predict 14% of the variance (R 2 = .14; F (2, 173) = 15.159, p < .01) in the model of post-traumatic growth in breast cancer patients. However, Avoidance Coping (β = .03, p = .67) was not found to be a significantly influencing post-traumatic growth in the model. Avoidance coping .06 .14 .03 0.42 .03 Note: R 2 = .14 (p ≤ .01); ** p ≤ .01.

Influence of Social Support on Post-Traumatic Growth:-
To examine the influence of social support on post-traumatic growth multiple regression analysis was applied. As can be seen from the Table 5 Support from family (β = .18, p < .05) and Support from significant other (β = .24, p < .01) could predict 13% of the variance (R 2 = .13; F (3, 172) = 19.04, p < .01) in the model of post-traumatic growth 1830 in breast cancer patients. However, Support from friends (β = .83, p = .40) was not found to be a significantly influencing post-traumatic growth. Note: R 2 = .13 (p ≤ .01); ** p ≤ .01.

Discussion:-
This study focussed on the experience of post-traumatic growth in breast cancer patients due to illness. The finding that active-adaptive coping is significantly related to post-traumatic growth is in line with previous studies (Sears, Stanton & Danoff-Burg, 2004). Health care professionals can utilize cognitive and mindfulness-based techniques so that patients can be assisted to recognize and acknowledge both positive and negative changes in their lives since the traditional cognitive behavioural therapies such as coping skills training, cognitive restructuring etc. have already proved useful and highly effective for managing the pain and distress associated with cancer (Tatrow & Montgomery, 2006 (Markus & Kitayama, 1991). Post-traumatic growth has also been found to be positively related with social support (Baglama & Atak, 2015). The finding of this study that support from family and significant other influences post-traumatic growth can have implications for organising and facilitating activities involving family that provide support for the development of autonomy, skills and sense of belonging to the community in women with breast cancer. Patients may also be assisted in their adaptation to breast cancer by combining the strategies to decrease patient's avoidant tendencies with the strategies that stimulate active approach of difficult situations.
When interpreting these results several limitations need to be taken into account. First of all, this study is crosssectional in nature; therefore, the results do not imply causality. This study used only relational design and because the purposive sampling was used there was no random assignment of participants and there was not any experimental manipulation, so it is difficult to infer causality. Cross sectional studies do not fully clarify the relationship between predictors and outcomes. For example, although it is possible that certain coping strategies may lead to post-traumatic growth (as hypothesized in this study), it is also possible that individuals who have experienced growth may employ more adaptive coping strategies. Therefore, predictors and outcomes may be confounded in cross-sectional research. Future studies should be longitudinal instead of cross-sectional and there should be random assignment of participants so that the causal roles of personality traits, coping and social support in post-traumatic growth can be clarified.
Second, many participants answered the questions orally and they might have given socially desirable answers. Third, the results of the current study are applicable only on breast cancer patients. The factors and determinants of PTG may vary in other samples in the context of different nature of traumatic events. Fourth this study is based on a small sample, taken from only one major Oncology Center and two private hospitals, so caution should be exercised in generalizing the results to a larger population due to representativeness issues. The large sample of patients from different hospitals may provide greater generazibility and controlling for other baseline characteristics and situational factors will further validate the findings.