INTRODUCTION
Breast cancer represents a major public health problem for the Western world, with major implications for women's health and psychological well-being (Ries et al., Reference Ries, Melbert and Krapcho2007; Coughlin & Ekwueme, Reference Coughlin and Ekwueme2009; Rowland & Massie, Reference Rowland, Massie and Holland2010). Data from the Israel National Cancer Registry reveals that some 3,269 Jewish women were diagnosed with breast cancer in 2010 (Israel Cancer Registry, 2010). In addition to the substantial global burden caused by breast cancer (Coughlin & Ekwueme, Reference Coughlin and Ekwueme2009; Parkin & Fernández, Reference Parkin and Fernández2006), coping with this illness can result in significant psychological distress for the women and their environment (Wheis & Reiss, Reference Wheis, Reiss and Baider2000).
In the psycho-oncology literature, the interest in such classical psychological outcomes as depression and anxiety (i.e., Reich et al., Reference Reich, Lesur and Perdrizet-Chevallier2008; Montazeri, Reference Montazeri2008) has been broadened to include assessment of such positive outcomes as posttraumatic growth (PTG) and finding benefit, hope, and meaning for both patients and spouses (McClement & Chochinov, Reference McClement and Chochinov2008; Bellizzi & Blank, Reference Bellizzi and Blank2006; Kim et al., Reference Kim, Schultz and Carver2007; Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Sela-Oren2013). The current study focused on PTG and is consistent with this approach, which emphasizes the importance of addressing possible positive outcomes for patients with cancer. In addition, the associations between types of social support (instrumental, emotional, cognitive) provided by different agents and PTG were explored in women with breast cancer.
Being diagnosed with cancer, a life-threatening illness, might be considered a traumatic event (DSM–V; American Psychiatric Association, 2013), resulting in depression, anxiety, and an impaired sense of well-being (Montazeri, Reference Montazeri2008). The perception and formulation of being diagnosed with cancer as a traumatic event, or at least a highly stressful event, leads to the possibility of PTG as a result of coping with the cancer diagnosis. PTG has been described as the subjective experience of positive psychological change reported by an individual as a result of a struggle with major stress or trauma (Tedeschi et al., Reference Tedeschi, Park and Calhoun1998). PTG relates to a variety of positive psychological changes, including increased appreciation of life, setting of new life priorities, a sense of increased personal strength, identification of new possibilities, improved closeness in intimate relationships, and positive spiritual change (Tedeschi et al., Reference Tedeschi, Park and Calhoun1998). PTG is considered to have a five-factor structure that includes these domains as expressed on the PTG scale (Tedeschi & Calhoun, Reference Tedeschi and Calhoun1996). This five-factor structure was also validated in confirmatory factor analysis in women who had survived breast cancer (Brunet et al., Reference Brunet, McDonough and Hadd2010). Notably, PTG has been documented following a variety of traumatic events (Butler et al., Reference Butler, Blasey and Garlan2005), chronic illnesses (Katz et al., Reference Katz, Flasher and Cacciapaglia2001), and life-threatening conditions (Bellizzi & Blank, Reference Bellizzi and Blank2006; Sears et al., Reference Sears, Stanton and Danoff-Burg2003).
A recent meta-analysis and review showed PTG to be moderately related to social support across different settings for possible trauma (Prati & Pietrantoni, Reference Prati and Pietrantoni2009; Barskova & Oesterreich; Reference Barskova and Oesterreich2009). Accordingly, the revised model of PTG (Tedeschi & Calhoun, Reference Tedeschi and Calhoun2004) includes social support as a predictor of positive change after an experience of trauma. Few explanations were provided in order to explain the associations between social support and PTG. For example, it was suggested that social support influences positive adaptation and coping, which enhances personal growth (Schaefer & Moos, Reference Schaefer, Moos and Tedeschi1998), that social resources decrease feelings of isolation (Prati & Pietrantoni, Reference Prati and Pietrantoni2009), and that social support provides opportunities for cognitive processing of an event (Calhoun & Tedeschi, Reference Calhoun and Tedeschi1999).
The buffering role of social support as a factor decreasing psychological distress has been consistently demonstrated in persons with different stages of cancer (Baider et al., Reference Baider, Ever-Hadani and Goldzweig2003; Hodgkinson et al., Reference Hodgkinson, Butow and Hunt2007; Lethborg et al., Reference Lethborg, Aranda and Cox2007; Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Braun2010; Rodin et al., Reference Rodin, Walsh and Zimmermann2007). Social support has also been found to be related to PTG in cancer patients (Scrignaro et al., Reference Scrignaro, Barni and Magrin2011). The major types of support discussed in the psycho-oncology literature are spousal, familial, social, and belief-based (Goldzweig et al., Reference Goldzweig, Hasson-Ohayon and Meirovitz2010; Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Braun2010; Goldzweig et al., Reference Goldzweig, Andritsch and Hubert2008; Shelby et al., Reference Shelby, Crespin and Wells-Di Gregorio2008), with special theoretical and empirical attention given to the spouse as an important source of support for patients (Petrie et al., Reference Petrie, Logan and DeGrasse2001; Baider et al., Reference Baider, Ever-Hadani and Goldzweig2003).
Although it is recognized that various types and agents of support exist, studies rarely refer to the diversity of types and agents of support while exploring the relationship between social support and PTG. The importance of considering different agents and types of support while exploring the relationship between social support and PTG stems from the psycho-oncology literature which shows that different agents have diverse contributions to psychological outcomes (Goldzweig et al., Reference Goldzweig, Hasson-Ohayon and Meirovitz2010; Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Braun2010). In addition, Prati and Pietrantoni (Reference Prati and Pietrantoni2009) suggested that the effects of social support on PTG are likely to change when comparing different types of support. Thus, social support from a spouse or from friends might contribute differently to PTG. In addition, emotional support might provide a different contribution to PTG than instrumental or cognitive support.
Based on the above, the aim of our current study was to employ an exploratory approach to investigate whether there are differences between the relationships of various agents and types of support and posttraumatic growth. The agents of support that were examined, with their relationship to PTG, are spousal, familial, social, and belief-based. The types of support that were examined, with their relationships to PTG, were emotional, instrumental, and cognitive.
METHOD
Participants
Eighty women with breast cancer who were undergoing medical treatment and follow-up in a major public hospital located in central Israel participated in our study. The inclusion criteria were coping with breast cancer and being able to complete self-reports in Hebrew. The mean age was 53.24 years (SD = 9.24) and the mean number of years since diagnoses was 5.79 (SD = 5.04). Sixty-one percent of participants had an academic education. Patients were coping with different stages of illness: stage I, 29 (38.7%); stage II, 12 (16.0%); stage III, 4 (5.3%); and stage IV, 30 (40%). No significant differences were found in the study variables for women with different stages of illness. The Eastern Cooperative Oncology Group (ECOG) Performance Scale score (Conill et al., Reference Conill, Verger and Salamero1990) of patients was 0 for the majority of women (60, 80.0%), representing a high functional status. ECOG and stage data were missing for five women. All women were married or living with a partner.
Procedures
The study was approved by the ethics committee of the participating hospital and by the treating physicians. Potential participants were identified by the staff at the breast cancer unit and invited by researchers to take part in our study. The women who agreed to participate were offered an informed consent form and self-report questionnaires.
Instruments
The Post-Traumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, Reference Tedeschi and Calhoun1996) is a 21-item self-report inventory that examines the degree of positive change that occurs following trauma. The inventory includes five subscales reflecting different aspects of PTG: relating to others (seven items), new possibilities (five items), personal strength (four items), spiritual change (two items), and appreciation of life (three items). Scores were calculated in a 6-point Likert-type response format. The internal reliability (Cronbach's α) of the total score and subscales in the current study ranged from 0.54 to 0.89.
The Cancer Perceived Agents of Social Support (CPASS) (Goldzweig et al., Reference Goldzweig, Hasson-Ohayon and Meirovitz2010) is a 12-item questionnaire that combines two theoretical content facets of social support (agent of support: spouse, family, friends, spiritual community; type of support: emotional, cognitive, instrumental). Each question assesses both facets. For example, the item “To what extent do you feel you are supported emotionally by your spouse?” represents a combination of emotional support (type of support) and spouse (agent of support). The answers are registered on a 5-point Likert-type scale (from 1 = not at all to 5 = a lot), and scores are calculated as means. Studies have shown that this scale has high validity and reliability (Goldzweig et al., Reference Goldzweig, Hasson-Ohayon and Meirovitz2010; Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Braun2010). In the current study, we employed the agent of support facet and calculated means for each, as well as the type of support facet with means for each. Each agent domain score included three items, and each type of support domain score included four items. The internal reliability values (Cronbach's α) for the current study were found to be satisfactory and ranged from 0.74 to 0.94 for the various agents and types of support.
Statistical Analysis
Pearson correlations and hierarchical regression analyses were conducted in order to examine the relationships between types of support as provided from different agents and PTG.
RESULTS
The distributions of the total PTG and total support variables were found to be within the limits of a normal distribution (Shapiro–Wilk test for normality: p = 0.072 and 0.092, respectively). Simple correlation analyses were conducted in order to examine the relationship between the types and agents of social support and PTG. Table 1 presents these correlations across all dimensions of PTG. As can be seen from the table, total PTG score had a positive significant correlation with total social support score and all its subscales (types and agents), excluding spousal support. In addition, specific dimensions of PTG were found to have significant positive correlations with total support score and all types and agents of support, excluding spousal support. Interestingly, while examining the relationships between types of support and PTG dimensions, only cognitive type was found to be related to all aspects of PTG. Thus, social support provided by family, friends, and belief systems was found to be related to PTG, while support provided from spouses was not. In addition, all PTG dimensions and total score were found to be related to the cognitive type of social support, while only a few were found to be related to emotional and instrumental types of social support.
Intercorrelations between social support from different agents and PTG dimensions
*p < 0.05, **p < 0.01, ***p < 0.001.
Two regression analyses were conducted in order to determine the specific contribution of different agents and types of support to PTG. The regression for agents of support is presented in Table 2, and the regression for types of support in Table 3. In these analyses, total PTG score was the predicted variable and the four agents of support or three types of support were the predictors, all entered in one step. As can be seen in Table 2, all four agents of support explained 32% of the PTG variance, with only friends and belief-based support acting as significant contributors beyond the other agents. Thus, in the regression analysis, neither spousal nor family support offered a significant contribution to prediction of PTG. Interestingly, a post-hoc analysis revealed that women reported receiving similar levels of support from their spouses (mean = 3.99, SD = 1.20) and friends (mean = 3.88, SD = 0.89), but that the support provided from their spouse was not related to their PTG. With regard to types of support, as can be seen from Table 3, while all types of support explained 60% of the variance, only cognitive-type support acted as a significant contributor beyond other types.
Regression analysis of the contribution of social support provided from different agents to PTG
*p < 0.05, **p < 0.01, ***p < 0.001.
Regression analysis of the contribution of types of social support to PTG
*p < 0.05, **p < 0.01, ***p < 0.001.
DISCUSSION
While previous studies have shown social support to be related to PTG in cancer patients (Scrignaro et al., 2010) and that this relationship might differ with various types of support (i.e., emotional vs. instrumental) (Prati & Pietrantoni, Reference Prati and Pietrantoni2009), examination of specific agents and types of support as related to PTG has not received much attention. Our current study presents an examination of the relationship between PTG and the types and agents of social support in women with breast cancer. Our results show that the three agents of support (family, friends, and beliefs) are related to PTG, while spousal support is not related to any of the PTG dimensions or total score. In addition, when all agents of support were entered into a regression model, only friends and belief-based support contributed significantly to prediction of PTG. Our findings also point out that, though all types of support are related to total PTG score, cognitive-type support is the only one related to all PTG dimensions and the only one to predict PTG in the regression analysis. Thus, with regard to agents of support, our results point out the importance of friends and belief-based support, emphasizing the lack of association between spousal support and all PTG dimensions. With regard to types of support, the results highlight the importance of cognitive support as a contributor to PTG.
It was hypothesized that the relationship between social support and PTG might be due to facilitation of disclosure and cognitive processing of a stressful event. This is because social support provides “discussion of perspective, offering of beliefs, and the use of metaphor to explain experience” (Calhoun & Tedeschi, Reference Calhoun and Tedeschi1999, p. 68). Integrating this idea with the current study's results suggest that this does not take place between the women coping with breast cancer and their spouses. Rather, it may be that these women turn to their friends for this kind of discussion. This might be because the spouse is experiencing stress and is either not available as a source of support or that the patient does not perceive him as a possible partner in the kind of discussion that might promote PTG. Interestingly, as mentioned in the results section, a post-hoc analysis revealed that women reported receiving similar levels of support from their spouses and from their friends. This finding indicates that the women did perceive their spouses as equally supportive as their friends but that the spousal support did not contribute to their PTG. Similarly, it has been found that in women with breast cancer, spousal support, in contrast to familial support, is not related to psychological distress (Hasson-Ohayon et al., Reference Hasson-Ohayon, Goldzweig and Braun2010). While correlated with PTG, familial support was not found to be a significant contributor to PTG in the regression model. It can be assumed that the women did not differentiate between support from family and support from friends in terms of contribution to their own PTG, so that family support did not provide a significant contribution to PTG greater than that offered by the support of friends.
The relationship found in the current study between PTG and belief-based support suggests an additional explanation to account for the process by which PTG occurs. While social support provided by friends and family fosters an opportunity for disclosure and discussion, belief-based support might suggest a means for inducing and fostering hope and personal growth via a more intrapsychic process. This idea is consistent with a previous study that showed hope to mediate between religiosity and coping in women with breast cancer (Hasson-Ohayon et al., Reference Hasson-Ohayon, Braun and Galinsky2009). It is also in accord with the review published by Shaw et al. (Reference Shaw, Joseph and Linley2005), which suggested that religion and spirituality are important and beneficial when coping with the aftermath of trauma.
The cognitive type of social support was found to be the most significant type of support with regard to PTG. The fact that the posttraumatic growth of the women in our current study was associated with cognitive support (i.e., information provided as a means of support) suggests that information may foster the growth process. This process might be induced by enhancing reconsideration of values and implications of an event triggered by new information that is provided. Indeed, it has been suggested that traumatic events challenge cognitive schemas (Janoff-Bulman, Reference Janoff-Bulman1992), so that a cognitive reappraisal is required to enhance positive adaptation to trauma, resulting in self-growth (Sears et al., Reference Sears, Stanton and Danoff-Burg2003; Park & Helgeson, Reference Park and Helgeson2006). According to our current study, this cognitive appraisal might stem from the knowledge provided by different agents of support.
The current study stresses the importance of friends and belief systems as sources of growth for women coping with breast cancer. It also points out the importance of cognitive support when coping with breast cancer. This may lead to tailoring interventions that aim to increase the efficient use of these sources of support.
While considering the findings of our study, a few limitations should be taken into consideration. First, though no relationships were found between stage of illness and study variables, it should be noted that the sample in our study comprised women with breast cancer in different stages of illness. Second, the study was cross-sectional, and casual conclusions cannot be inferred. This point is important due to a recent longitudinal study that found PTG to be a predictor of posttraumatic stress in soldiers, and thus questioned the value of growth enhancement after a traumatic event (Engelhard et al., Reference Engelhard, Lommen and Sijbrandij2014). In addition, our study did not include a qualitative assessment, which might add to our understanding of the unique experience of PTG when coping with physical illness (Hefferon et al., Reference Hefferon, Grealy and Mutrie2009), and our sample size was relatively small. Future longitudinal studies that include qualitative assessment and a larger and more homogenous sample are needed in order to further validate the results of this work.
