國立臺北護理健康大學 生死教育與輔導研究所
碩士論文
Posttraumatic growth and demoralization after cancer: the effects of patients’
meaning-making
研究生：葉北辰 指導教授：李玉嬋 博士
中華民國 102 年 2 月
致謝 Acknowledgement
雖然這篇論文不盡完美，但哪有完美的論文呢？而且要發生許多許多好事才 能完成這一篇論文，雖然陳之藩在「謝天」一文中說道「…無論什麼事，得之於 人者太多，出之於己者太少。因為需要感謝的人太多了，就感謝天罷…」，那個 謝天對基督徒來說就是感謝神吧？但我還是想要一一對很多人表達感謝。
感謝指導教授李玉嬋老師，您經典語錄”真心的相信”或”至少還活著”背後的 生命態度對我有重要深遠的影響，也讓這篇論文能用它自己的速度長成它自己的 樣子，或說讓我在北護這幾年來能用我自己的速度長成我自己的樣子。還要感謝 論文口委：佩怡老師用柔軟的心來看生硬的量性研究，向我揭開研究主題的其他 重要層面；寬佳老師不只在方法學上給予需多重要的指導，您對研究的熱忱也激 勵我很多；方俊凱醫師是研究計畫的主持人和啟動者，不只在計畫進行上提供我 們最有力的後援，也在論文的概念架構和撰寫上給予我很多提醒和指正。
謝謝研究計畫的合作夥伴玉菁，研究計畫的合作上妳總是能夠督促我和鼓勵 我，一起去北京的EAPON對著多數為華人的聽眾用英文報告也是相當難忘的體 驗。還有北護生死所的同學們，謝謝阿麵，妳是我在生死所前兩年最重要的夥伴！
謝謝美麗，聽完妳final的時候有給我很多激勵作用！謝謝Lisa和Lei，不管是 所有實質的幫忙、討論，還是那些在line小框框裡的對話！
感謝我前任老闆雷庚玲老師，如果沒有台大發展Lab的訓練和磨練，這篇論 文是寫不出來的，雖然當時很辛苦，但現在很喜歡和雷老師開玩笑地回憶「當年 北辰給我一個震撼教育XD」，這個笑點大概只有我們Lab的人才懂。謝謝立容 和季珊，雖然我們師出同門但是好像不太討論研究，我們談的是生活和生命吧！
謝謝逸人，雖然戲稱你為光明燈，但現在亦師亦友的內在客體是從許許多多 的存在處境相遇而來的，或許這也見證了我的成長與進步。謝謝純慧，我兩個的 碩士論文都有妳在旁邊一起打拼耶！謝謝建業，統計部分有你的熱心相助真是太 感恩了！謝謝勝翔，我們可以一起打籃球到幾歲呢？敬那些在球場和你家客廳的 會心時刻！謝謝小哥的烏鎮行，也慢慢開始懂你跟我說的那些生活哲學！謝謝天 豪，兩家一起出遊的景象可不是當年在北A最後一排苦讀普心時可以想像的！
最後要感謝我的爸媽，正因為有你們的支持，我才能在這個階段依然徜徉在 心理學研究的領域中摸索、探求和等待成長；也要感謝我弟，雖然小我五歲，但 是越來越像同儕，常常在聊天當中給我很多啟發和激勵！謝謝親愛的姿吟，不但 可以幫我看論文或討論研究，更給我無條件的愛與支持，促發我變成一個更好的
人！
最後的最後，要感謝200位參與研究的癌症病人，你們用生命經驗留下重要 的資料，我無法一一言謝，但那許多訪談時的生命交會時刻給我很多力量，也期 待自己可以把你們的良善的力量分享下去，幫助更多其他癌症病友和家庭！
Thanks Paul and Darcy, I’ll never forget all the happy moment in 2010 summer I’ve been with you. That trip was a big breakthrough in my comfort zone, and let me know nothing is impossible. And lots of encounter
conversations beside your garden, in the kitchen or living room, even on the way we drove to Wisconsin or we walked by the disc golf court, did influence me positively when they come to my mind. Thank you for your kindness and valuing me so much, make me believe in myself to accomplish this thesis.
摘要
「罹患癌症」本身是一重大壓力源與創傷事件，當癌症病人在面對於疾病的 威脅時可能感到失志（demoralization），亦可能在罹癌經驗的奮力因應中產生 創傷後成長（posttraumatic growth，PTG）。這兩種心理歷程的發展可能跟病人 如何從自己的癌症中發現意義有關。因此，本研究目的主要瞭解癌症病人失志、
創傷後成長和發現意義的關聯性。
研究參與者為200位的門診與住院的肺癌、白血病和淋巴癌的病人，在知情 同意後完成問卷內容，包括：基本資料表、中文版失志量表(DS‐MV)、創傷後成 長量表（PTGI）、發現意義問題（對癌症的理解程度SM和生病後的正向改變BF）
等問卷。
結果發現，DS‐MV與PTGI、SM(sense‐making)、BF(benefit‐finding)、罹病時 間 (TSD，time since diagnosis)皆呈現顯著負相關。亦即若癌症病人在生病後的主 觀感到創傷後成長較高，較能夠理解自己何以得癌症、從罹癌經驗中找到較多正 向改變，甚至光是隨著時間越來越長，癌症病人的失志感受都會下降。然而對 DS‐MV的複回歸分析中也發現，SM × TSD和SM × BF的交互作用顯著。進一步 分析的結果顯示，罹病時間較長的癌症病人失志較低，但是罹病時間較短的癌症 病人若對自己生病的理解程度高，則其失志感受和罹病時間長的病人一樣低。第 二個交互作用也呈現相似的模式，若癌症病人能從生病經驗中找到較多的正向改 變，其失志程度較低；但是就算自覺的正向改變沒有那麼多，若病人對生病的理 解程度高，其失志感受和前者一樣低。
從研究結果可知促發病人試著對自己的生病產生個人意義的理解，並試著從 生病經驗中發現個人的正向改變，有助於增進創傷後成長和降低失志。而交互作 用的結果也發現，我們雖然無法加速時間或是太快地邀請病人去探索生病經驗中 的正向改變，但依然可以藉由促發病人對於生病的理解，從中發現意義，而降低 癌症病人的失志。
關鍵詞：癌症、失志、創傷後成長、發現意義
Abstract
Background/Objectives: It’s common for cancer patients to experience positive and
negative mental processes after diagnosis, such as post traumatic growth (PTG) or demoralization. Although demoralization and PTG are both related to meaning making, little attention has been paid to the correlation among these concepts. The current study attempted to investigate the relationship between demoralization, PTG, and meaning making (focusing on sense-making of cancer and benefit-finding in the experience) on cancer patients.
Methods: A lung-cancer/lymphoma/leukemia sample of 200 patients in Mackay
Memorial Hospital completed Demoralization Scale (DS-MV), Posttraumatic Growth Inventory (PTGI), and questions that assessed sense-making (SM) and benefit-finding (BF).
Results: DS-MV was negatively correlated with PTGI, SM, BF, TSD (time since
diagnosis). Multiple regression analysis showed that meaning-making has different effects on DS and PTG. The interactions SM × BF and SM × TSD was significant on DS, the higher SM the lower DS when BF or TSD are low.
Conclusions: The suffering of cancer may turn on the mental process of
demoralization, PTG, and meaning-making in patients. Ways to promote
meaning-making of cancer patients to increase PTGI and buffer demoralization will be discussed.
Key words: posttraumatic growth; demoralization; meaning-making; cancer
目次
Introduction 1
Methods 7
Results 10
Discussion 18
References 25 附錄
附錄一 基本資料表 30
附錄二 心理痛苦壓力量表 31
附錄三 失志量表 32
附錄四 個人健康問卷 33
附錄五 貝克自殺意念量表 34
附錄六 創傷後成長量表 35
表目次
Table 1 Goodness-of-fit indices for three models of the structure of
PTGI……… 10 Table 2 Dependent variables between cancer sites……….. 11 Table 3 M, SD, and correlations between variables……… 11 Table 4 Interactive and main effects of sense-making, benefit-finding, and
time since diagnosis on PTG……….. 13 Table 5 Interactive and main effects of sense-making, benefit-finding, and
time since diagnosis on DS-MV………. 14
圖目次
Figure 1 The simple slopes of sense-making on demoralization at high and
low levels of time since diagnosis………. 15
Figure 2 The simple slopes of sense-making on demoralization at high and
low levels of benefit-finding………. 16
Figure 3 The simple slopes of benefit-finding on demoralization at high and
low levels of sense-making………... 17
Introduction
Mental state in cancer patients has received much attention in recent years due to the development of psycho-oncology. Numerous studies pay attention to general psychiatry symptoms in cancer patients such as depression, distress, or the cancer impact on patients’ quality of life, etc. (Mermelstein & Lesko, 1992; Mitchell, Vahabzadeh, & Magruder, 2011; Montgomery, Pocock, Titley, & Lloyd, 2002).
Previous researches have also found that meaning-making process or meaning in life correlates with cancer patients’ emotional well-being, coping strategies, and
adjustment following cancer (Chan, Ho, & Chan, 2007; Jim, Richardson,
Golden-Kreutz, & Andersen, 2006; C. L. Park, Edmondson, Fenster, & Blank, 2008).
One specific term “demoralization” which is experienced as a persistent inability to cope, together with associated feelings of helplessness, hopelessness,
meaninglessness, subjective incompetence and diminished self-esteem, has been used as a main kind of maladjustment indicator in psycho-oncology studies (Clarke &
Kissane, 2002; Cockram, Doros, & de Figueiredo, 2009; Kissane, Clarke, & Street, 2001; Mehnert, Vehling, Hocker, Lehmann, & Koch, 2011). On the other hand, contrary to normal expectations, both positive and negative mental processes are seen after impact of cancer. Posttraumatic growth, a phenomenon of positive psychological growth beyond baseline values, is also observed in cancer patients (Cordova,
Cunningham, Carlson, & Andrykowski, 2001; Ho, Chan, & Ho, 2004; Crystal L. Park, Chmielewski, & Blank, 2010; Schroevers & Teo, 2008; Tedeschi & Calhoun, 2004).
However, although demoralization and posttraumatic growth are important
experiences of cancer patients, little attention has been paid to the correlation between the two mental processes. More importantly, previous studies have overlooked the
predictors of these two mental processes, which had been hypothesized in present study is meaning-making. Because of meaningless is the core factor of demoralization (Clarke & Kissane, 2002; Kissane, et al., 2004), and cancer patients’ sense of global meaning has protective function on their demoralization and depression (Vehling, et al., 2012). On the other side, cancer survivors’ efforts at meaning-making may
influence the extent to which they successfully experience posttraumatic growth (C. L.
Park, et al., 2008).We propose patients’ meaning-making of cancer would lead to the two different mental process: demoralization and posttraumatic growth.
The assessment of meaning-making in present research focused on two major construals of meaning: sense-making and benefit-finding, the paradigm used in loss and grief researches (C. G. Davis, Nolen-Hoeksema, & Larson, 1998; Holland, Currier,
& Neimeyer, 2006). This is because loss (at least in an expended definition) could subsume a welter of human experiences, including bereavement, natural disaster, job loss, aging, and physical illness, et cetera (Harvey, 2002). The experience of cancer could have been interpreted to a kind of loss in health, original life, personal identity or hope. The grief theoretical model is a suitable framework to study demoralization and posttraumatic growth.
Therefore, the current study will assess posttraumatic, demoralization, and meaning-making in cancer patients at the same time to explore how cancer patients process them, and evaluate the independent and joint effects on demoralization and posttraumatic growth of finding meaning in cancer.
Posttraumatic growth in cancer patients
Posttraumatic growth is the experience of positive change that occurs as a result of struggling with highly challenging life crises, especially those that impact people’s fundamental beliefs or life narratives. Tedeschi and Calhoun (1996) proposed at least
three board categories of posttraumatic growth have been identified: changes in self-perception, changes in interpersonal relationships, and a changed philosophy of life. With the development of the Posttraumatic Growth Inventory (PTGI; Tedeschi and Calhoun, 1996) and following research outcomes, posttraumatic growth could be manifested in more ways, including appreciations of life, increased meaningful interpersonal relationships, more sense of personal strength, new
possibilities/priorities, and higher existential or spiritual life (Tedeschi & Calhoun, 2004). These five dimensions are the factor structure of PTGI, and established well psychometric properties (Taku, Cann, Calhoun, & Tedeschi, 2008; Tedeschi &
Calhoun, 1996).
Research in posttraumatic growth among cancer patients has been triggered primarily by several reasons, including: diagnosis of cancer can lead to posttraumatic stress disorder; increasing survival rates among cancer patients; and positive
psychology encourages focusing on cancer patients’ fighting spirit and hope (Bush, 2009; Rajandram, Jenewein, McGrath, & Zwahlen, 2010; Sumalla, Ochoa, & Blanco, 2009). Posttraumatic growth has been discovered in the field of oncology, and PTGI is one of the most popular instruments for measuring posttraumatic growth in research (Brunet, McDonough, Hadd, Crocker, & Sabiston, 2010; Ho, et al., 2004; Jaarsma, Pool, Sanderman, & Ranchor, 2006; Schroevers & Teo, 2008). Ho and colleagues (2004) proposed there are cultural differences in posttraumatic growth between East and West cancer patients. Confirmatory factor analysis in their study showed a different factor structure from the original English-language version of the PTGI (21 items). The dimensions of posttraumatic growth in Chinese sample could be four factors first order model (self, spiritual, life orientation, and interpersonal), and could also be broadly dichotomized into an interpersonal and an intrapersonal (a
second-order factor with self, spiritual, and life orientation loaded onto) dimension . A
Chinese Posttraumatic Growth Inventory (CPTGI; 15 items) was developed by Chinese sample in Hong Kong (Ho, et al., 2004). One of present study aims is to examine which model fit the data in current study in Taiwan better by confirmatory factor analysis, thereby deciding to use PTGI or CPTGI scores as the indicator of posttraumatic growth.
Demoralization in cancer patients
On the other hand, demoralization also has been commonly observed in the medically and psychiatrically ill. Patients need to maintain meaning-based coping during serious illness which challenging their assumptive world or personal meaning, in order to keep hope and bear stress (Folkman & Greer, 2000; Crystal L. Park &
Folkman, 1997). When the maladjustment of cancer patients in particular situations turn to general situations, they would experience demoralization, including existential despair, hopelessness, helplessness, and loss of meaning and purpose in life (Clarke &
Kissane, 2002). Although sharing symptoms of distress, demoralization is differentiated from depression by subjective incompetence in the former and
anhedonia in the latter. Demoralization can occur in cancer patients who are depressed or not, as a better predictor of their suicide ideation or a useful screening criteria for clinical intervention (Cockram, et al., 2009; Kissane, 2004; Kissane, et al., 2001).
Kissane and colleagues (2004) developed the demoralization scale (DS) which is one of the most popular instruments for measuring demoralization in research. Hung, et al.
(2010) translated DS in Mandarin, cooperated with Kissane through back translation, accomplished demoralization scale-Mandarin version (DS-MV). DS-MV has good reliability and validity in researches of cancer patients in Taiwan (Hung, et al., 2010;
Lee, et al., 2012).
Meaning-making of cancer: two conceptualizations
Demoralization and posttraumatic growth are both important mental processes in cancer patients. As mention previously, the two different processes seem to diverge from cancer patients make meaning of their cancer or not. Although varying in details, most models hypothesize that the experience of a highly stressful or traumatic event challenges people’s basic beliefs or meaning structures about their self and the world.
At the same time, some type of meaning making or cognitive processing to reconstruct those beliefs or meaning occurs, resulting in perceptions that one has grown or better adjustment through this process (Janoff-Bulman, 2004; Taylor, 1983;
Tedeschi & Calhoun, 2004). Davis, et al. (1998) differentiated two major construals of meaning: making sense of the event and finding benefit in the experience.
Sense-making denotes the comprehensibility of the loss or the bereaved person’s capacity to find some sort of benign explanation for the suffering experience, usually constructed in spiritual or philosophical terms. Conversely, benefit-finding refers to the loss entailed the bereaved person’s paradoxical ability to uncover a “silver lining”
in the personal or social consequences of the loss, such as more meaningful interpersonal relationships, an increased sense of personal strength, or changed priorities.
Davis and colleagues (1998) demonstrated that each of these two construals of meaning predicted emotional adjustment to the loss both concurrently and
prospectively. There was no interaction between sense-making and benefit-finding when predicting emotional adjustment. In addition, making sense of loss is associated with less distress in the first year since loss, whereas benefit finding from loss is strongly associated with adjustment at 13 and 18 months after loss. That means there should be a significant interaction effect would be expected between sense-making and time since loss, as well as benefit-finding and time since loss, in their prediction
of emotional adjustment (C. G. Davis, et al., 1998).
Holland and colleagues (2006) expanded above study (C. G. Davis, et al., 1998) by utilizing a larger group of participants and more diverse forms of bereavement, and examined the role of sense-making, benefit-finding, and time since loss in predicting complicated grief (CG, elevated and persistent separation distress, seriously impaired functioning, and difficulties “moving on” with life following the loss of a loved one).
Holland, et al. (2006) found that that making sense and finding benefit from one’s experience of loss are both associated with decreased complications in grieving.
Contrary to the findings of Davis and colleagues (1998), sense-making is a stronger predictor of grief outcomes compared to benefit-finding. In addition, the relation of sense-making and benefit-finding to CG does not vary as a function of time since loss, suggesting that neither meaning-making nor attenuation of CG should be expected by the passage of time alone. From the model of loss and grief model, the purpose of current study is to examine the role of sense-making, benefit-finding, and time since diagnosis in predicting better mental adjustment among cancer patients, especially lower demoralization and higher posttraumatic growth.
Methods
Participants
After the approval of the Institutional Review Board, participants were recruited from Mackay Memorial Hospital in Taipei city, Taiwan. Participants met the
following three criteria for eligibility: 1. each was at least 20 years old and informed diagnosis of cancer; 2. MMSE (Mini-mental state examination) was over 24 points; 3.
patients whose diagnosis was lung-cancer, lymphoma, or leukemia. Potential participants were approached by study assistants (well trained intern counseling psychologists) to invite participation in current study. Those who agreed to participate completed the assessment package after informed consent.
The current sample consisted of 200 Chinese cancer patients in Taiwan, 95 males (48%) and 105 females (52%), ranged in age from 20 to 72 years with a mean of 50.7 years (S.D. = 11.33). Cancer sites were: lung-cancer (n = 93, 46.5%), lymphoma (n = 67, 33.5%), and leukemia (n = 40, 20%). Time since diagnosis of participants ranged from less than one month to survived 27 years (Mean = 35 months, S.D. = 44.43 months). Marital status included 22.5% single, 65.5% married, 9% divorced, and 3%
widowed. Educational status distributed from elementary school (15.5%), junior high school (16.5%), senior high school (29.5%), and 38.5 % had gained a university degree or higher education.
Measures
Demoralization scale-Mandarin version (DS-MV)
The original Demoralization Scale (Kissane, et al., 2004) was designed to assess existential distress in patients with advanced disease and has been proved to be useful
in psycho-oncology study and practice (Mehnert, et al., 2011; Vehling, et al., 2012).
The Mandarin Version of Demoralization Scale was developed by Hung et al. (2010) and has demonstrated good reliability and validity. DS-MV includes 24 items
categorized in five subscales: Loss of Meaning (five items, α = .84), Dysphoria (five items, α = .69), Disheartenment (six items, α = .88), Helplessness (four items, α = .72), and Sense of Failure (four items, α = .63). Participants respond in 5-point scale from 0 to 4 which best fits to their situation. DS-MV has been found to show high internal reliability (full scale α = .92) and divergent /convergent validity with the McGill Quality of Life Scale-Taiwan Version (r = -.68, p<0.001), and Beck Hopelessness Scale (r = .70, p<0.001), indicating that the DS-MV has acceptable psychometric properties when used in Taiwanese cancer patients (Hung, et al., 2010).
Posttraumatic growth inventory (PTGI)
Permission was obtained from the original authors of the PTGI (Tedeschi &
Calhoun, 1996) and authors of the Chinese version of the PTGI (Ho, et al., 2004).
PTGI is composed of 21 declarative statements which responses are made from 0-5 describing the degree of change (e.g., 0 = I did not experience this change as a result of my crisis; 3 = I experienced this change to a moderate degree as a result of my crisis; 5 = I experienced this change to a very great degree as a result of my crisis, in current study the crisis is cancer). PTGI includes five factors that accounted for about 60% of the variance, including Relating to others (7 items, e.g., Putting effort into my relationships); New possibilities (5 items, e.g., I established a new path for my life);
Personal strengths (4 items, e.g., Knowing I can handle difficulties); Spiritual change (2 items, e.g., A better understanding of spiritual matters); and Appreciation of life (3 items, e.g., An appreciation of the value of my own life). Both the full scale (α = .90) and the separate subscales (α = .67 ~ .85) of the PTGI have good internal reliability.
And the test-retest reliability (a small group over two months) for the PTGI was acceptable at r = .71.
The Chinese version of the PTGI was developed from PTGI by translation and back-translation in Hong Kong, and was used on Chinese cancer survivors in Hong Kong. The internal reliability coefficients (α) of subscales ranged from .63 to .79, except for Spiritual change (α = .37). The Chinese version of the PTGI, which was used in present study, is based on the Chinese version of the PTGI translated by Ho, et al. (2004), but considering the cultural differences between Hong Kong and Taiwan, made parts of modify by a senior clinical psychologist with PHD degree in clinical psychology.
Sense-making and benefit-finding
Sense-making and benefit-finding were assessed by single-item questions on a 5-point scale and open-ended questions. Sense-making was assessed first by having participants respond to the question, “How much sense would you say you have made of your cancer?”, from 1 (not at all) to 5 (a great deal of sense). Later, benefit-finding was measured in the same way, “Have you found any positive change from the experience of your cancer?”, from 1 (not at all) to 5 (very much change). These single-item questions correspond well to the single-item questions that other
researchers have used to measure the two construals of meaning (C. G. Davis, et al., 1998; Holland, et al., 2006).
Results
Confirmatory factor analysis of the factor structure of PTGI and CPTGI
We used confirmatory factor analysis (CFA) to examine the goodness-of-fit of the five factors structure manifested by Tedeschi and Calhoun (1996), four factors model, and second-order model proposed by Ho et al. (2004) in the Chinese version of PTGI. CFA was conducted by Analysis of Moment Structures (AMOS 16.0.1). The goodness-of- fit indices (which have been reported in Ho, et al., 2004) of the three CFA models are summarized in Table 1. CFA results showed that there are no differences between the three models. For ease of comparison with the majority of researches on posttraumatic growth, the following analyses were conducted with the PTGI (21 items, Tedeschi and Calhoun, 1996) scores as the indicator of PTG.
Table 1. Goodness-of-fit indices for three models of the structure of PTGI (N=200)
Factor model χ2 df p GFI AGFI CFI TLI RMESA
5 factors CFA model 494.811 179 .000 .812 .758 .887 .867 .094 4 factors CFA model 212.655 84 .000 .877 .824 .924 .905 .088 Second-order CFA model 215.442 86 .000 .874 .824 .924 .907 .087
Relations of PTG, Demoralization, Sense-making and Benefit-finding
There is no significant differences between scores of PTGI, DS-MV, and meaning-making questions among patients with different cancer cites, besides lung cancer patients’ demoralization is higher than lymphoma patients’ (F = 3.66, p < .05).
Table 2. Dependent variables between cancer sites
Tumor diagnosis N PTGI DS-MV SM BF
Lung cancer 93 50.59 30.81a 2.67 3.00
Leukemia 40 60.58 27.48 2.83 3.15
Lymphoma 67 53.54 25.18b 2.63 3.08
Total 200 53.58 28.26 2.69 3.05
a > b sig., p < .05
Table 3 shows the means, standard deviations, and bivariate correlations for PTG scores, DS-MV scores, time since diagnosis (TSD), sense-making, and benefit-finding.
Demoralization was negatively associated with PTG, TSD, sense-making and
benefit-finding. That is, with time demoralization decreases. In addition, participants who reported making more sense of their cancer, finding greater benefit, or having higher PTG after diagnosis experienced less demoralization. Posttraumatic growth was related to more benefit-finding but not sense-making. Similar to Holland, et al.
(2006), a significant positive correlation was found between benefit-finding and sense-making. Notably, TSD was not significantly correlated PTG, benefit-finding, or sense-making.
Table 3. M, SD, and correlations between variables (N=200)
Variables M SD DS TSD SM BF
Post-Traumatic Growth(PTG) 53.58 26.00 -.22** -.02 .11 .63**
Demoralization(DS) 28.26 13.32 -.15* -.15* -.19**
Time Since Diagnosis(TSD) 35.01 44.43 .07 .05
Sense-Making(SM) 2.69 1.30 .18*
Benefit-Finding(BF) 3.05 1.28
*p<.05; **p<.01
In order to test the model put forth by Holland, et al. (2006), we performed a multiple regression analysis. The independent variables, including sense-making, benefit-finding, and TSD, were centered before conducting this multiple regression analysis. Centered scores were used to form the interaction terms in order to minimize problems with multicollinearity and to aid interpretation of the first order terms in the test (Aiken & West, 1991). Three interaction terms were created: 1.sense-making × TSD, 2. benefit-finding × TSD, and 3. sense-making × benefit-finding. PTGI and DS-MV were separately regressed onto sense-making, benefit-finding, SD, and the three interactions. These equations with first order terms were constructed in the first model and the interaction terms in the second model. Table 4 and 5 displays
regression coefficients for these analyses.
When regression was conducted onto PTGI scores, model 1 (with only the first order terms in the regression, including sense-making, benefit-finding, and TSD) predicted 40.4% of the variance in PTGI scores, R2 = .404, F (3, 196) = 44.21, p<.001.
In model 2, the interaction terms were added, and overall these second order terms didn’t increase the predictive ability, R2change = .003, F change(3, 193) = .336, p = .799. It is worth noting that only benefit-finding emerged as a unique predictor of
posttraumatic growth in the first model, B = 12.863, t = 11.316, p < .001.
Table 4. Interactive and main effects of sense-making, benefit-finding, and time since diagnosis on PTG (n=200)
Predictors B SE B β t R2
Model 1 .404***
Sense-Making .125 1.125 .006 .111
Benefit-Finding 12.863 1.137 .635 11.316***
Time since Diagnosis -.035 .032 -.06 -1.079
Model 2 .407
Sense-Making .202 1.148 .010 .176
Benefit-Finding 13.032 1.156 .643 11.275***
Time since Diagnosis -.039 .034 -.067 -1.151
Sense-Making × Time since Diagnosis -.021 .03 -.047 -.688 Benefit-Finding × Time since Diagnosis -.004 .027 -.009 -.135 Sense-Making × Benefit-Finding -.263 .841 -.018 -.313
***p<.001
On the other hand, the regression equation conducted onto DS-MV scores was fitted in different model. The first order model predicted 6.8% of the variance in DS-MV scores, R2 = .068, F (3, 196) = 4.78, p<.01. In model 2, overall these second order terms significantly increased the predictive ability of the regression, R2change
= .054, F change(3, 193) = 3.982, p<.01. It revealed that benefit-finding, TSD, sense-making × TSD, and sense-making × benefit-finding were significant predictors of demoralization.
Table 5. Interactive and main effects of sense-making, benefit-finding, and time since diagnosis on Demoralization (n=200)
Predictors B SE B β t R2
Model 1 .068**
Sense-Making -1.171 .72 -.114 -1.626
Benefit-Finding -1.669 .728 -.161 -2.292*
Time since Diagnosis -.041 .021 -.135 -1.955
Model 2 .122**
Sense-Making -1.293 .715 -.126 -1.807
Benefit-Finding -1.972 .720 -.190 -2.738**
Time since Diagnosis -.043 .021 -.144 -2.028*
Sense-Making × Time since Diagnosis .041 .019 .180 2.164*
Benefit-Finding × Time since Diagnosis -.011 .017 -.053 -.626
Sense-Making × Benefit-Finding 1.264 .524 .166 2.414*
*p<.05, **p<.01
However, similar to the model proposed by Davis, et al. (1998), an examination of the beta coefficients in model 2 revealed that sense-making × TSD interaction term was a significant predictor of demoralization, B = .041, t = 2.164, p < .05.
Contrary to Davis, et al. (1998) but like the model suggested by Holland, et al. (2006), the interaction between sense-making and benefit-finding was significant in this model, B = 1.264, t = 2.414, p < .05. In addition, these two interactions were interference type of interaction effects.
To investigate these significant findings further, a second set of analyses was performed with these two interaction terms: sense-making × TSD, and sense-making
× benefit-finding. The interaction between sense-making and TSD was decomposed
by testing the simple slopes of sense-making on demoralization at low and high levels of TSD (categorized by below and above time since diagnosis median = 19.5 month).
It showed that sense-making and demoralization negatively correlated with each other
when time since diagnosis is low, B = -2.211, t = -2.354, p = .021; but they were not associated significantly when time since diagnosis is high, B = -.993, t = -.905, p
= .368. The results suggest that participants who survived longer experienced less demoralization no matter make sense of their cancer or not. In contrast, when
participants were diagnosed of cancer in a relative brief period, making more sense of cancer was linked with lower demoralization. See in Figure 1.
Figure1. The simple slopes of sense-making on demoralization at high and low levels of time since diagnosis.
The same pattern was found within the interaction between sense-making and benefit-finding, which was separated by testing the simple slopes of sense-making on demoralization at low and high levels of benefit-finding (categorized by below and above benefit-finding median = 3). Results revealed that sense-making and
demoralization didn’t correlated significantly when benefit-finding is high, B = .513, t
= .496, p =.621; but there was a significant negative association between
*p<.05
sense-making and demoralization when benefit-finding is low, B = -3.268, t = -3.257, p = .002. In order to test the model put forth by Holland, et al. (2006), we
decomposed the interaction between sense-making and benefit-finding in another way, testing the simple slopes of benefit-finding on demoralization at low and high levels of sense-making (categorized by below and above sense-making median = 3).
Contrary to the patterns found in Holland and colleagues’ (2006) findings,
benefit-finding and demoralization was negatively associated when sense-making is low, B = -2.744, t = -2.551, p =.012. However, when sense-making is high, no significant association was found between benefit-finding and demoralization, B = -.801, t = -.816, p = .417. Put more simply, these analyses suggest that cancer patients with low sense-making and low benefit-finding tended to adjust worst; and who with high sense-making and high benefit-finding experienced lowest demoralization. These findings are depicted graphically in Figure 2 and Figure 3.
Figure 2. The simple slopes of sense-making on demoralization at high and low levels of benefit-finding.
Figure 3. The simple slopes of benefit-finding on demoralization at high and low levels of sense-making.
Discussion
Over all, this study indicates that posttraumatic growth and time since diagnosis are negatively correlated with demoralization. Furthermore, the present findings shows that benefit-finding from one’s experience of cancer is associated with increased posttraumatic growth, but sense-making, benefit-finding, and time since diagnosis are associated with decreased demoralization. Although benefit-finding and time since diagnosis are stronger predictors of demoralization compared to
sense-making, sense-making from one’s experience of cancer significantly buffer demoralization at low level of these two predictors.
Correlation between demoralization and posttraumatic growth
The present results show that cancer patients with higher posttraumatic growth experienced lower demoralization. However, our findings also reveal that the amount of time has elapsed after diagnosis of cancer is a relatively weak predictor of patients’
degree of posttraumatic but a stronger predictor of demoralization. A potential
explanation for these patterns could be the dual process model (DPM) of coping with bereavement which identified two oscillating coping processes (M. Stroebe & Schut, 1999).
The DPM specifies two types of stressors: loss orientation and restoration orientation. Past research found that bereaved people not only have to cope with the loss of the loved one by them self, but also have to make most adjustments in their lives that come about as secondary consequences of the death. Both of these aspects are potential sources of stress and anxiety (M. S. Stroebe & Schut, 2001). The loss-oriented coping includes dealing with, concentrating on, and working through some aspect which focus directly on the loss experience itself, all the grief work such as denial or avoidance of life changes, crying about the death, yearning for the person;
the restoration-oriented coping refers to the processes one uses to cope with the secondary stressors that accompany one’s new status after the death, including mastering the tasks that the bereaved person had undertaken, dealing with
arrangements for reorganizing life, and developing new identities. Stroebe and Schut (2001) proposed the dual process model enables research to define meaning according to loss or restoration orientation. For example, a bereaved person did nothing but stay at home all day long, for loss-orientation would involve meanings like “I cannot do anything but missing her presence every moment of the day”, whereas the same outcome of restoration-oriented meaning would be “I’m afraid of taking responsibility all by myself without her”. Stroebe and Schut (2001) also emphasized that although the two types of stressor are interrelated, bereaved people cannot attend to both at the same time: coping at one point in time is either loss or restoration oriented. In fact, bereaved people can, to some degree, choose to ignore or concentrate on one aspect or others of loss and changes in their lives. So “oscillation” is a necessary regulatory process in DPM, which is a dynamic process (fundamental to adaptive coping) of alternation between loss and restoration orientation.
In order to cope effectively, Stroebe and Schut (1999, 2001) proposed that bereaved people must oscillate between loss-oriented coping and restoration-oriented coping. Oscillation is essential for optimal psychological adjustment; bereaved people must attend to practical as well as emotional matters, and they may turn to
restoration-oriented activities as respite from negative emotions associated with the lost attachment. They stay at one side until too stressful to take and swing to the other side, vice versa. As time goes by, the oscillation of bereaved persons will slow down and stay at restoration-orientation more often (Richardson, 2010; M. Stroebe & Schut, 1999; Margaret Stroebe & Schut, 2010).
If we consider cancer patients’ demoralization and posttraumatic growth in DPM,
it’s obviously to categorize demoralization in loss orientation and posttraumatic growth in restoration orientation. Consistent with researches about other negative mental health indicators (such as depression, distress, anxiety), demoralization after cancer was related to increased negative mental health (Grassi, Sabato, Rossi, Biancosino, & Marmai, 2005; Hung, et al., 2010; Kissane, et al., 2004; Marchesi &
Maggini, 2007); while posttraumatic growth after cancer was related to reduced negative mental health (Barskova & Oesterreich, 2009; Ho, et al., 2004; Sawyer, Ayers, & Field, 2010; B. Tallman, Shaw, Schultz, & Altmaier, 2010). It’s the same patterns in DPM, loss-orientation was predictive of negative psychological adjustment, while restoration-orientation was related to better adjustment (Wijngaards-de Meij, et al., 2008). In our findings, the negative correlation between demoralization and posttraumatic growth hint these two psycho-oncology processes could be alternative orientation. And demoralization decrease with time since diagnosis also fit the pattern of DPM that the swing between the two orientations will slow down and bereaved people stay at restoration-orientation more with longer time since loss. Although the present study design is not strong empirical evidence of DPM, our findings still call attention to consider demoralization and posttraumatic growth as two types of stressors of cancer patients when coping with diagnosis of cancer. We supposed that demoralization represents cancer patients focus on the loss dimension of their cancer (e.g. loss of one’s health or identity); while posttraumatic growth displays cancer patients are trying to reconstruct their personal meaning in the experience of cancer.
So it’s normal, even maybe necessary, for cancer patients to experience
demoralization and posttraumatic growth as a dual process coping with their cancer.
Predictors of posttraumatic growth and demoralization
However, what leads to the two different mental processes? The results of multiple regressions in current study indicate that 1) benefit-finding was significantly
associated with posttraumatic growth, neither sense-making nor time since diagnosis;
2) attenuation of demoralization could be expected by passage of time and finding more benefit, and their interactions with sense-making account for a substantial amount of the variability in demoralization.
As posttraumatic growth, finding benefit or positive changes from cancer is also common in cancer patients (Schroevers, Kraaij, & Garnefski, 2011; B. A. Tallman, Altmaier, & Garcia, 2007; Thornton, et al., 2012). In addition, benefit finding and posttraumatic growth are suggested conceptually related, but distinct, constructs (Christopher G. Davis & Nolen-Hoeksema, 2009; Sears, Stanton, & Danoff-Burg, 2003). We proposed that benefit-finding is a potential factor to increase posttraumatic growth, there was similar findings in the longitudinal study of breast cancer patients (Mols, Vingerhoets, Coebergh, & Van de Poll-Franse, 2009); and from theoretical, empirical, and practical points of view, Davis (2008) also suggested benefit-finding reflects one of three different processes that have distinct implications for
posttraumatic growth. However, neither main effect nor simple main effect of time since diagnosis on posttraumatic growth was found in our findings, which had been found in other researches (Barskova & Oesterreich, 2009; Helgeson, Reynolds, &
Tomich, 2006). One potential explanation of the controversial findings is that posttraumatic growth is a dynamic process which needed one’s effort to cope with stressful event (Calhoun & Tedeschi, 2001; Christopher G. Davis, 2008; Tedeschi &
Calhoun, 2004). No matter taking posttraumatic growth as an outcome or a coping strategy (Zoellner & Maercker, 2006), meaning making efforts of cancer patients are related to better adjustment through the successful creation of adaptive meanings made from the cancer experience (C. L. Park, et al., 2008). To find benefit from cancer is one main kind of adaptive meaning making efforts, we suggest that it wouldn’t just happen with time but one’s efforts on it.
In the other hand, the pattern of results in demoralization provides only partial replication of the research of Davis, et al. (1998) and Holland, et al. (2006). The predictors of demoralization in cancer patients display similar models as the complicated grief or distress in bereavement.
After losing a loved one through death, studies found that with increasing meaning-making, people experienced lower distress (C. G. Davis, et al., 1998) and complicated grief (Holland, et al., 2006). In current study, we also found cancer patients who make more meaning from cancer experience less demoralization.
However, the 2-way interactions between predictors (sense-making, benefit-finding, and time since event) aided diverge predictions of negative mental health indicators.
Davis, et al. (1998) suggested that making sense of the loss is important in the early period of adjustment to a loss, while finding benefit may be a more long-term process that reveals over time. Conversely, Holland, et al. (2006) proposed sense-making and benefit-finding interact with each other (but not with time since loss) when predicting complicated grief. In our findings, time since diagnosis interacted with sense-making but not benefit-finding, moreover, sense-making and benefit-finding interact with each other when predicting demoralization. These trends suggested that sense-making maybe an important moderator in cancer patients’ level of demoralization.
These several findings should be considered not only different research designs but also different kind of losses. Losing a loved one through death could be mainly categorized in interpersonal loss; while diagnosis with cancer (loss of health) could be seen as intrapersonal loss. Their impacts on persons are different in variety domains, such as self identity, attachment, reappraisal of loss or reconstruction of meaning (Christopher G. Davis, 2001; Harvey, 2002). Moreover, cancer may be different than other traumas or losses and the adjustment process from cancer may interact with this ecology of circumstances in different ways, including difficulty in identifying a single
stressor, the internal source of the event, cancer as a future, ongoing and chronic integration threat, and greater perceived control differences between cancer and others traumas (Sumalla, et al., 2009). Diagnosis of cancer and lose a loved one through death are different kind of loss experience. Holland, et al. (2006) proposed the most favorable adaptation to bereavement is associated with high sense-making but low benefit-finding, perhaps because bereaved persons framed the loss in one’s
sense-making terms would view any implication of finding personal benefit as being selfish. However, in our findings, high sense-making and high benefit-finding were associated the most favorable mental adjustment among cancer patients. It suggests patients who make sense of cancer in their own meaning framework and find benefit in their experience of cancer, would not blame themselves selfish as bereaved persons.
These findings taken together provide preliminary evidence for the important role of meaning-making after personal loss, and suggest there are individual differences between different kinds of loss.
Implications
Consistent with other work in loss and grief fields (Calhoun & Tedeschi, 2001;
Christopher G. Davis, 2001; Holland, et al., 2006; Robert A. Neimeyer, 2001; R. A.
Neimeyer, 2004; M. S. Stroebe & Schut, 2001), the present results suggest cancer patients who find a appraisal of meaning in the experience of cancer seem to fare better in the adaptive process of cancer. Therefore, counselors working with patients struggling in their cancer could utilize strategies which focus on sense-making and benefit-finding. To help cancer patients in accommodating their global meaning or developing meaningful life narrative (Clarke & Kissane, 2002; R. A. Neimeyer, 2004;
Tedeschi & Calhoun, 2004). The most important is, all the meaning-making efforts compensate with each other, cancer patients who got higher posttraumatic growth
experienced less demoralization, and trying to uncover positive changes in the experience of cancer may be the most powerful factor to increase posttraumatic growth. Cancer patients with less benefit-finding experience higher demoralization, but sense-making buffer this effect.
Another set of implications stems from how the simple passage of time was shown to ameliorate demoralization. Just as the old saying: Time cures all things. As time goes by, patients experienced less demoralization. There is no strategy to force time, but counselors could facilitate patients to make more sense from cancer to get similar effectiveness.
Limitations and future directions
A non-experimental, cross-sectional design precluded causal statements based on current study alone; we still need longitudinal studies to validate our findings. The individual differences of cancer cites’ effect on patients were not considered in present study; with more amount of participants in future study, it could be taking a closer look of these individual differences in different cancer. Nonetheless, the current findings support a model of grief in meaning-making plays an important role in psycho-oncology. These patterns deserve replication and further exploration at variety level of analyses or through a blend of qualitative and quantitative methods in future studies.
References
Aiken, L. S., & West, S. G. (1991). Multiple regression : testing and interpreting interactions. Newbury Park, Calif.: Sage Publications.
Barskova, T., & Oesterreich, R. (2009). Post-traumatic growth in people living with a serious medical condition and its relations to physical and mental health: A systematic review. Disability and Rehabilitation: An International,
Multidisciplinary Journal, 31(21), 1709-1733.
Brunet, J., McDonough, M. H., Hadd, V., Crocker, P. R., & Sabiston, C. M. (2010).
The Posttraumatic Growth Inventory: An examination of the factor structure and invariance among breast cancer survivors. Psycho Oncology, 19(8), 830-838.
Bush, N. J. (2009). Post-traumatic stress disorder related to the cancer experience.
Oncology Nursing Forum, 36(4), 395-400.
Calhoun, L. G., & Tedeschi, R. G. (2001). Posttraumatic growth: The positive lessons of loss. Neimeyer, Robert A [Ed], 157-172.
Chan, T. H. Y., Ho, R. T. H., & Chan, C. L. W. (2007). Developing an outcome measurement for meaning-making intervention with Chinese cancer patients.
Psycho-Oncology, 16(9), 843-850.
Clarke, D. M., & Kissane, D. W. (2002). Demoralization: its phenomenology and importance. Australian & New Zealand Journal of Psychiatry, 36(6), 733-742.
Cockram, C. A., Doros, G., & de Figueiredo, J. M. (2009). Diagnosis and measurement of subjective incompetence: The clinical hallmark of demoralization. Psychotherapy and Psychosomatics, 78(6), 342-345.
Cordova, M. J., Cunningham, L. L., Carlson, C. R., & Andrykowski, M. A. (2001).
Posttraumatic growth following breast cancer: A controlled comparison study.
Health Psychology, 20(3), 176-185.
Davis, C. G. (2001). The tormented and the transformed: Understanding responses to loss and trauma. Neimeyer, Robert A [Ed], 137-155.
Davis, C. G. (2008). Redefining goals and redefining self: A closer look at posttraumatic growth following loss. Stroebe, Margaret S [Ed], 309-325.
Davis, C. G., & Nolen-Hoeksema, S. (2009). Making sense of loss, perceiving benefits, and posttraumatic growth. Lopez, Shane J [Ed], 641-649.
Davis, C. G., Nolen-Hoeksema, S., & Larson, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75(2), 561-574.
Folkman, S., & Greer, S. (2000). Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other.
Psycho-Oncology, 9(1), 11-19.
Grassi, L., Sabato, S., Rossi, E., Biancosino, B., & Marmai, L. (2005). Use of the Diagnostic Criteria for Psychosomatic Research in Oncology. Psychotherapy and Psychosomatics, 74(2), 100-107.
Harvey, J. H. (2002). Perspectives on loss and trauma : assaults on the self. Thousand Oaks, Calif.: Sage Publications.
Helgeson, V. S., Reynolds, K. A., & Tomich, P. L. (2006). A meta-analytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 74(5), 797-816.
Ho, S. M., Chan, C. L., & Ho, R. T. (2004). Posttraumatic growth in Chinese cancer survivors. Psychooncology, 13(6), 377-389.
Holland, J. M., Currier, J. M., & Neimeyer, R. A. (2006). Meaning reconstruction in the first two years of bereavement: The role of sense-making and
benefit-finding. Omega: Journal of Death and Dying, 53(3), 175-191.
Hung, H. C., Chen, H. W., Chang, Y. F., Yang, Y. C., Liu, C. L., Hsieh, R. K., et al.
(2010). Evaluation of the reliability and validity of the Mandarin Version of Demoralization Scale for cancer patients. Journal of Internal Medicine of Taiwan（Chinese）, 21, 427-435.
Jaarsma, T. A., Pool, G., Sanderman, R., & Ranchor, A. V. (2006). Psychometric properties of the Dutch version of the Posttraumatic Growth Inventory among cancer patients. Psycho Oncology, 15(10), 911-920.
Janoff-Bulman, R. (2004). Posttraumatic Growth: Three Explanatory Models.
Psychological Inquiry, 15(1), 30-34.
Jim, H. S., Richardson, S. A., Golden-Kreutz, D. M., & Andersen, B. L. (2006).
Strategies used in coping with a cancer diagnosis predict meaning in life for survivors. Health Psychology, 25(6), 753-761.
Kissane, D. W. (2004). The contribution of demoralization to end of life decisionmaking. Hastings Cent Rep, 34(4), 21-31.
Kissane, D. W., Clarke, D. M., & Street, A. F. (2001). Demoralization syndrome - a relevant psychiatric diagnosis for palliative care. Journal of Palliative Care, 17(1), 12-21.
Kissane, D. W., Wein, S., Love, A., Lee, X. Q., Kee, P. L., & Clarke, D. M. (2004).
The Demoralization Scale: a report of its development and preliminary validation. J Palliat Care, 20(4), 269-276.
Lee, C. Y., Fang, C. K., Yang, Y. C., Liu, C. L., Leu, Y. S., Wang, T. E., et al. (2012).
Demoralization syndrome among cancer outpatients in Taiwan. Supportive
Care in Cancer, 20(10), 2259-2267.
Marchesi, C., & Maggini, C. (2007). Socio-demographic and clinical features associated with demoralization in medically ill in-patients. Social Psychiatry and Psychiatric Epidemiology, 42(10), 824-829.
Mehnert, A., Vehling, S., Hocker, A., Lehmann, C., & Koch, U. (2011).
Demoralization and Depression in Patients with Advanced Cancer: Validation of the German Version of the Demoralization Scale. J Pain Symptom Manage.
Mermelstein, H. T., & Lesko, L. (1992). DEPRESSION IN PATIENTS WITH CANCER. [Article]. Psycho-Oncology, 1(4), 199-215.
Mitchell, A. J., Vahabzadeh, A., & Magruder, K. (2011). Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research. Psycho-Oncology, 20(6), 572-584.
Mols, F., Vingerhoets, A. J. J. M., Coebergh, J. W. W., & Van de Poll-Franse, L. V.
(2009). Well-being, posttraumatic growth and benefit finding in long-term breast cancer survivors. [Article]. Psychology & Health, 24(5), 583-595.
Montgomery, C., Pocock, M., Titley, K., & Lloyd, K. (2002). Individual quality of life in patients with leukaemia and lymphoma. Psycho-Oncology, 11(3), 239-243.
Neimeyer, R. A. (2001). The language of loss: Grief therapy as a process of meaning reconstruction. Neimeyer, Robert A [Ed], 261-292.
Neimeyer, R. A. (2004). Fostering posttraumatic growth: A narrative elaboration.
Psychological Inquiry, 15(1), 53-59.
Park, C. L., Chmielewski, J., & Blank, T. O. (2010). Post-traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults. [Article]. Psycho-Oncology, 19(11), 1139-1147.
Park, C. L., Edmondson, D., Fenster, J. R., & Blank, T. O. (2008). Meaning Making and Psychological Adjustment Following Cancer: The Mediating Roles of Growth, Life Meaning, and Restored Just-World Beliefs. Journal of Consulting and Clinical Psychology, 76(5), 863-875.
Park, C. L., & Folkman, S. (1997). Meaning in the context of stress and coping.
Review of General Psychology, 1(2), 115-144.
Rajandram, R. K., Jenewein, J., McGrath, C. P. J., & Zwahlen, R. A. (2010).
Posttraumatic growth: A novel concept in oral cavity cancer care? [doi: DOI:
10.1016/j.oraloncology.2010.08.010]. Oral Oncology, 46(11), 791-794.
Richardson, V. E. (2010). The Dual Process Model of Coping with Bereavement: A Decade Later. [Article]. Omega: Journal of Death & Dying, 61(4), 269-271.
Sawyer, A., Ayers, S., & Field, A. P. (2010). Posttraumatic growth and adjustment among individuals with cancer or HIV/AIDS: A meta-analysis. [doi: DOI:
10.1016/j.cpr.2010.02.004]. Clinical Psychology Review, 30(4), 436-447.
Schroevers, M. J., Kraaij, V., & Garnefski, N. (2011). Cancer patients' experience of positive and negative changes due to the illness: relationships with
psychological well-being, coping, and goal reengagement. [Article].
Psycho-Oncology, 20(2), 165-172.
Schroevers, M. J., & Teo, I. (2008). The report of posttraumatic growth in Malaysian cancer patients: relationships with psychological distress and coping strategies.
[Article]. Psycho-Oncology, 17(12), 1239-1246.
Sears, S. R., Stanton, A. L., & Danoff-Burg, S. (2003). The yellow brick road and the emerald city: Benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer. Health Psychology, 22(5), 487-497.
Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement:
rationale and description. Death Studies, 23(3), 197-224.
Stroebe, M., & Schut, H. (2010). The Dual Process Model of Coping with
Bereavement: A Decade On. [Article]. Omega: Journal of Death & Dying, 61(4), 273-289.
Stroebe, M. S., & Schut, H. (2001). Meaning making in the dual process model of coping with bereavement. Neimeyer, Robert A [Ed], 55-73.
Sumalla, E. C., Ochoa, C., & Blanco, I. (2009). Posttraumatic growth in cancer:
Reality or illusion? Clinical Psychology Review, 29(1), 24-33.
Taku, K., Cann, A., Calhoun, L. G., & Tedeschi, R. G. (2008). The factor structure of the posttraumatic growth inventory: a comparison of five models using confirmatory factor analysis. J Trauma Stress, 21(2), 158-164.
Tallman, B., Shaw, K., Schultz, J., & Altmaier, E. (2010). Well-being and posttraumatic growth in unrelated donor marrow transplant survivors: A nine-year longitudinal study. Rehabilitation Psychology, 55(2), 204-210.
Tallman, B. A., Altmaier, E., & Garcia, C. (2007). Finding benefit from cancer.
Journal of Counseling Psychology, 54(4), 481-487.
Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American Psychologist, 38(11), 1161-1173.
Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory:
measuring the positive legacy of trauma. J Trauma Stress, 9(3), 455-471.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic Growth: Conceptual
Foundations and Empirical Evidence. [Article]. Psychological Inquiry, 15(1), 1-18.
Thornton, A. A., Owen, J. E., Kernstine, K., Koczywas, M., Grannis, F., Cristea, M., et al. (2012). Predictors of finding benefit after lung cancer diagnosis. Psycho
Oncology, 21(4), 365-373.
Vehling, S., Lehmann, C., Oechsle, K., Bokemeyer, C., Krüll, A., Koch, U., et al.
(2012). Is advanced cancer associated with demoralization and lower global meaning? The role of tumor stage and physical problems in explaining existential distress in cancer patients. [Article]. Psycho-Oncology, 21(1), 54-63.
Wijngaards-de Meij, L., Stroebe, M., Schut, H., Stroebe, W., van den Bout, J., van der Heijden, P. G. M., et al. (2008). Parents grieving the loss of their child:
Interdependence in coping. [Article]. British Journal of Clinical Psychology, 47(1), 31-42.
Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology -- A critical review and introduction of a two component model. [doi: DOI:
10.1016/j.cpr.2006.01.008]. Clinical Psychology Review, 26(5), 626-653.
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基本資料表
1. 您的性別：□0女性 □1男性；出生年：民國______年
2. 教育程度：□1國小 □2國中 □3高中職 □4大學(或專科) □5研究所以上 3. 婚姻狀況： □1未婚 □2已婚 □3分居 □4離婚 □5寡居
4. 您生病前的職業狀況：□1就業中 □2就學中 □3家庭主婦（夫） □4 待業中 □5退休 5. 您現在的職業狀況：□1與生病前相同 □2無法負荷之前的工作需先暫停
6. 您目前正在住院中：□0否 □1是
7. 疾病類別：□1肺癌 □2血液腫瘤（初次診斷時間民國_____年____月）
8. 疾病期別：□1第一期 □2第二期 □3第三期 □4第四期 □0不清楚 9. 您目前正在接受癌症治療︰□1是 □0否
（若目前已無進行治療，則最後一次治療結束時間是民國_____年____月）
10. 治療方式（可複選）： □1化療（包含標靶治療）□2放射線治療 □3手術 □4其他
附件 2: 心理痛苦壓力量表
請您依據過去一週以來(包括今天)的感覺，回答下列的問題並圈選量尺上的數字:
(範例) 您覺得您感覺到的心理痛苦(壓力)程度?
請您勾選下面所陳列的各項問題，
是可能造成您有上述所感覺到心理壓力或心理痛苦的可能原因。
是 否 實際問題
□ □ 小孩 □ □ 家事 □ □ 保險/財政 □ □ 交通往返 □ □ 治療的決定
家人問題
□ □ 處理小孩的事 □ □ 處理伴侶的事 □ □ 懷孕
□ □ 家人健康議題 □ □ 關於宗教/靈性
是 否 身體問題 □ □ 外表
□ □ 洗澡/穿衣 □ □ 呼吸 □ □ 便秘
□ □ 腹瀉 □ □ 進食 □ □ 疲憊 □ □ 感到腫脹 □ □ 發燒 □ □ 行走 □ □ 消化
□ □ 記憶/專注 □ □ 口乾 □ □ 噁心感
是 否 (續)身體問題 □ □ 鼻子乾燥/阻塞 □ □ 疼痛
□ □ 性 □ □ 皮膚乾/癢 □ □ 睡眠 □ □ 手/腳顫抖
是 否 情緒問題 □ □ 憂鬱 □ □ 害怕 □ □ 緊張 □ □ 難過 □ □ 擔心
□ □ 對於平常的活動
失去興趣
無痛苦(壓力)
非常大痛苦(壓力)
附件 3:失志量表
請仔細閱讀每一個句子，圈選代表您的同意程度
非 常 不 同 意
不 同 意
不 確 定
同
意
非 常
同 意 1.我可以為別人做許多有價值的事。 1 2 3 4 5 2.我的人生似乎是無意義。 1 2 3 4 5 3.我的日常生活沒有目標。 1 2 3 4 5 4.我已經喪失生活中的角色。 1 2 3 4 5 5.我不再覺得能控制情緒。 1 2 3 4 5
6.我的心靈平安。 1 2 3 4 5
7.沒有人幫的了我。 1 2 3 4 5 8.我覺得我幫不了我自己。 1 2 3 4 5
9.我覺得很無望。 1 2 3 4 5
10.我有罪惡感。 1 2 3 4 5
11.我覺得很煩燥。 1 2 3 4 5 12.我能妥善處理我的生活。 1 2 3 4 5 13 我的人生有許多遺憾。 1 2 3 4 5 14.生命不再值得繼續活下去。 1 2 3 4 5 15.我容易覺得受到傷害。 1 2 3 4 5
16.我對許多事情感到生氣 1 2 3 4 5 17.我對自己的成就感到驕傲 1 2 3 4 5 18.我對發生在我身上的事感到痛苦 1 2 3 4 5 19.我是有價值的人 1 2 3 4 5 20.我寧願不要活著 1 2 3 4 5
21.我覺得既難過又悲慘 1 2 3 4 5 22.我對生活感到洩氣 1 2 3 4 5 23.我感到相當孤立或孤獨。 1 2 3 4 5 24.我被發生在我身上的事困住了。 1 2 3 4 5
附件 4:個人健康問卷
過去兩週中，你會覺得… 一
點 也 不
有 幾 天
超 過 一 半
幾 乎 天 天
1.做事沒有興趣或樂趣? 0 1 2 3
2.憂鬱
(你會覺得心情低落或是鬱悶、感到絕望?)
0 1 2 3
3.睡眠問題(睡不著、易醒、睡太多) 0 1 2 3
4.覺得疲倦或沒有體力? 0 1 2 3
5.吃不下或吃太多? 0 1 2 3
6.覺得自己不好
(覺得自己失敗或讓自己或家人難過、丟臉)
0 1 2 3
7.注意力不集中(讀報、看報紙) 0 1 2 3 8.行動或說話慢，或比平常更明顯坐立不安 0 1 2 3 9.有死亡的念頭或想傷害自己 0 1 2 3
附件 5: 貝克自殺意念量表
請細心閱讀下列各組的句子。圈選各組中一句最能描述你過去一週，包括今 天在內的感受。在做決定之前，要確實讀完所有題意。
第一部分:
1. 0 我頗有強烈的求生意願 1 我有薄弱的求生意願 2 我沒有求生意願 2. 0 我沒有求死意願
1 我有薄弱的求死意願 2 我頗有強烈的求死意願 3. 0 我求生的理由勝過求死
1 我求生或求死的理由約略相等 2 我求死的理由強過求生
4. 0 我沒有自殺的欲望 1 我有點想要自殺
2 我頗有強烈的自殺欲望
5. 0 假如我發現自己生命受威脅，我會 試圖求生
1 假如我發現自己生命受威脅，我會 讓生死聽天由命
2 假如我發現自己生命受威脅，我不 會採取避免死亡的必要步驟。
假如你在上面第 4 組和第 5 組都圈 0 就請跳過第二部分(第 6 組至 19 組的句 子)直接圈選第 20 組。假如你在第 4 組 或第 5 組圈選的是 1 或 2，就請繼續選 答第 6 組
第一部分小計 _
第二部分
6. 0 我有短暫自殺念頭，不過很快就過去了。
1 我有一段相當持續的時間想要殺。
2 我有長時間想要自殺。
7. 0 我很少或祇偶爾想要想到自殺。
1 我時常想要自殺。
2 我持續地想要自殺。
8. 0 我不接受自殺的觀念。
1 我既不接受亦不拒絕自殺的觀念。
2 我接受自殺的觀念。
9. 0 我不會自殺
1 我不確定自己不會自殺 2 我無法不自殺
10. 0 因為我的家人、朋友、宗教，及自 殺不成功可能帶來的傷害等等理 由，我不會自殺。
1 因為我的家人、朋友、宗教，以及 自殺不成功可能帶來的傷害等等 理由，自殺時我有顧慮。
2 即使為了我的家人朋友宗教，以及 自殺不成功可能帶來的傷害等等 理由，我仍不在乎自殺。
