Turning the tide: Benefit finding after cancer surgery

ARTICLE IN PRESS

Social Science & Medicine 59 (2004) 653–662

Turning the tide: Benefit finding after cancer surgery Ute Schulz*, Nihal E. Mohamed Freie Universitat, . Berlin, Germany

Abstract Post-traumatic growth and benefit finding after adverse life events are emerging topics in stress and coping research. This study examined personal and social resources of cancer patients and their perception of positive life changes as a consequence of illness. In addition, the mediating role of coping strategies (acceptance and social comparison) was investigated. One month after tumor surgery, 105 cancer patients completed measures of social support and self-efficacy. Coping was assessed half a year after surgery, while benefit finding was examined 12 months post-surgery. Correlational and path analyses showed a link between personal resources (self-efficacy) as well as social resources (received social support) and benefit finding. The effect of self-efficacy disappeared when coping was specified as a mediator between the resources and benefit finding. Social support retained a direct effect on benefit finding. The results emphasize the predictive quality of resources for recovery and adjustment after surgery and the mediating role of coping. Findings are discussed with regard to recent developments in the study of post-traumatic growth. r 2003 Elsevier Ltd. All rights reserved. Keywords: Germany; Self-efficacy; Social support; Benefit; Surgery; Cancer

Introduction Stressful life events, ranging from illness to natural disaster, have been identified as risk factors for the development of anxiety, depression, or diseases. While these negative consequences are well-studied, comparatively little systematic research has been done on the positive outcomes that may occur in the aftermath of crisis (Updegraff & Taylor, 2000). At first thought, it might seem contradictory to expect any good to result from severely stressful episodes. For example, an illness such as cancer has a substantial physical and psychological impact on patients as well as on their social environment. Possibly more than any other illness, the diagnosis and treatment of cancer immediately elicits a wide range of negative emotions, especially several fears: fear of pain and suffering, fear of *Corresponding author. Gesundheitspsychologie, Freie Universit.at Berlin, Habelschwerdter Allee 45, Berlin 14195, Germany. Tel.: +49-30-838-55656; fax: +49-30-838-55634. E-mail addresses: [email protected] (U. Schulz), [email protected] (N.E. Mohamed).

disfigurement by the removal of body parts, fear of costs for care, fear of losing work, family and friends, fear of dependency, and fear of death (e.g., Hobfoll & Walfish, 1984). Even successful surgery, vastly improved pharmacological treatment, and a good prognosis will not necessarily relieve patients and their relatives from thoughts of tumor recurrence at the same or different sites. However, studies on cancer patients indeed report positive changes in various life domains such as richer and closer social relationships with family and friends, new priorities in life, which may translate into changes in daily activities, as well as a greater overall appreciation for life (Antoni et al., 2001; Collins, Taylor, & Skokan, 1990; Klauer & Filipp, 1997). The quality of life experienced by cancer survivors may even exceed that of healthy persons (Danoff, Kramer, Irwin, & Gottlieb, 1983; Tempelaar et al., 1989). Nevertheless, such optimistic findings should not obscure the fact that the consequences of various stressful life events are rather mixed depending on, for example, the type of event, its impact, and individual differences in coping with adverse circumstances.

0277-9536/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2003.11.019

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Theoretical and empirical groundwork Various theorists have proposed models that help explain the antecedents and outcomes of adaptation processes after crises. For example, according to cognitive adaptation theory (Taylor, 1983), individuals who have been exposed to stressful circumstances actively seek a new balance. In the coping process, people try to establish a psychological equilibrium by restoring their self-esteem and their sense of meaning and mastery (Updegraff & Taylor, 2000). These positive changes result from a selective comparison and evaluation process (Taylor, 1983; Taylor, Wood, & Lichtman, 1983). While Taylor’s theory emphasizes coping strategies such as positive reinterpretation and social comparison as driving agents for a successful adaptation process, Hobfoll’s (1989) conservation of resources theory underlines the importance of a person’s personal and coping resources as predictors of positive long-term effects. In times of need, a sufficient resource reservoir provides effective means to combat stress. Moreover, resource rich individuals are more likely to apply adaptive coping strategies. The role of resources for coping with illness When stressful life events take their toll on physical health and well-being, a number of potentially available resources have been shown to alleviate negative consequences associated with such events. Stress research has focused primarily on two sources of support for the individual, namely, personal and social resources. Personal resources: Among the constructs identified as personal resources, perceived self-efficacy (Bandura 1992, 1997) has received much attention. It defines an individual’s beliefs in his or her own competencies in mastering challenges in life. Low sense of self-efficacy is associated with depression, anxiety, and helplessness. In general, it hampers the person’s motivation to act. In cases of recovery from surgery, self-efficacy has presented its predictive value. Patients with high selfefficacy report fewer symptoms and greater satisfaction with life after bypass surgery as well as lung-cancer. related surgery (e.g., Schwarzer & Schroder, 1997). In another sample of cancer patients, Cunningham and colleagues found strong associations of perceived selfefficacy with quality of life and mood (Cunningham, Lockwood, & Cunningham, 1991). Self-efficacy also positively affects indicators of physical health, such as blood pressure, heart rate, and immunological parameters, in coping with challenging situations. Social resources: The examination of social support effects on health and recovery should begin with a distinction between structural and functional aspects of social networks. Commonly, structural characteristics refer to social integration such as the embeddedness in a

social network, whereas functional characteristics of social support allude to those interactions in which supportive acts occur between people. Social support may take different forms such as emotional, instrumental, or informational, which may exert distinct influence on coping in stressful situations. Further, since perceived and actually received social support may have different effects, both types should be considered separately. Most common in health research, however, is the assessment of perceived support, i.e., potentially available support from the social network, which some authors, for example, Sarason, Sarason, and Pierce (1992), consider a personality trait that influences behavior. Thus, social support is not only understood as social behavior but also as a dispositional person variable. Both accounts of social support are not necessarily closely associated (Dunkel-Schetter & Bennett, 1990) and may diverge considerably in a specific situation. In many studies, the perception of support among breast cancer survivors, for example, has been connected to better social adjustment and higher psychosocial wellbeing (e.g., Bloom & Spiegel, 1984; Dunkel-Schetter, 1984; Holland, Dukes, & Holahan, 2003). One of the rare attempts to examine the influence of received and perceived support simultaneously has been undertaken by De Leeuw and colleagues (De Leeuw et al., 2000). While perceived support alleviated depressive symptoms in a sample of head and neck cancer patients, received support was associated with more depression before treatment. Social support will be provided only when there is an obvious need for support (e.g., expression of pain, immobility) or when the prospective support receiver mobilizes the help. In this respect it is understandable why received social support has been shown to be related to poorer adjustment (e.g., De Leeuw et al., 2000; Komproe, Rijken, Ros, Winnubst, & ’t Hart, 1997). Although self-efficacy and social support can directly enhance well-being by satisfying the human needs for affiliation, affection, and safety, coping strategies have been shown to mediate the relationship between an individual’s resources and health outcomes in stressful situations (Aspinwall & Taylor, 1992; Carver et al., 1993; Holland, Dukes, & Holahan, 2003; Komproe et al., 1997). Coping strategies as mediators Besides various stable personal characteristics, the ways in which individuals deal with a stressful situation are important predictors of adjustment after crisis (e.g., Aldwin & Yancura, in press; Ferring & Filipp, 2000). The literature suggests a number of coping behaviors as well as categories to classify them (e.g., Carver, Scheier, & Weintraub, 1989; Endler & Parker, 1990; Lazarus &

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Folkman, 1984). Not all coping strategies can be regarded as appropriate and useful across all situations. While active coping strategies may reveal their potential to benefit mainly in situations that provide ample scope for actions, unchangeable situations may call for reinterpretation or acceptance. Cancer represents a stressor that cannot be altered by will or actions. Acceptance coping may be most important especially in circumstances calling for more passive accommodation. The recognition that a situation is irreversible can be an adaptive response. In fact, it may be a prerequisite for future attempts to deal with the situation, for example, by engaging in a search for meaning and, eventually, finding benefit in the event. Park, Cohen, and Murch (1996) showed positive reinterpretation and acceptance coping to be amongst the best predictors of stress-related growth. Being diagnosed with cancer shatters commonly held self-beliefs about being a healthy, functioning, and invulnerable person. Social comparison is a coping strategy that helps manage this threat to a person’s self-esteem effectively. It has also been found to be related to post-traumatic growth (Suls, 2003; Taylor, 1983). Taylor and Lobel (1989) report evidence that selfevaluations bolstering self-esteem are made against less fortunate targets. Downward comparisons that enable patients to evaluate themselves more positively have been reported across different disease groups (e.g., Stanton, Danoff-Burg, Cameron, Snider, & Kirk, 1999; Helgeson & Taylor, 1993; Wood, Taylor, & Lichtman, 1985).

Method

Objectives

One month after surgery, 255 patients with malignant tumors completed measures of self-efficacy and social support. The patients were on average 62 years old (SD=11.4, range 19–86 years). Women were slightly underrepresented (43%). At the fifth assessment point in time 11 months later, 105 of these patients participated in the study. Both age and gender composition of this longitudinal sample corresponded with the initial sample at wave three (M ¼ 62 years, SD=10.8, range 27–86 years; 39% female patients). Of these 105 patients, 75% were married or lived with a partner. The majority (84%) reported having children. There were no age differences between women and men. The most frequent sites of cancer included: colon (28.6%), stomach (6.7%), rectum (26.7%), esophagus (4.8%), liver and gall bladder (10.5%), and pancreas (12.4%). At the fifth assessment point in time, patients were asked to report their current medical treatment. Few participants (n ¼ 15) did not receive any treatment at that time; the majority, 83 persons, received ambulatory treatment or rehabilitation. Only one participant was in hospital care/rehabilitation. Both ambulant and hospital care was indicated by three persons. For three patients,

In research and clinical practice, there is increasing awareness that the cancer experience is not solely viewed as negative by the patients, but may also have some beneficial sequelae despite disruptive treatment such as surgery. While social support and self-efficacy have been associated with indicators of better adjustment to illness, such as absence of negative affect, reduced anxiety, or higher functional ability, little is known about their role for post-traumatic growth. Consequently, the general aim of the present study was to investigate whether both resources can also predict benefit finding one year after surgery. While testing both resources simultaneously in one model, we can determine the particular contribution of each resource for benefit finding. According to the proposed mediating role of coping factors in the adjustment process, a mediator model with two types of cognitive coping strategies, acceptance coping and social comparison, were specified. We assumed that both coping strategies mediate the relationship between patient resources and benefit finding over time.

Research design and procedure The present study is part of the Berlin Longitudinal Study on Quality of Life after Tumor Surgery. In the surgical wards of four collaborating cancer treatment centers in Berlin, Germany, patients with suspected or confirmed diagnosis of malignant tumors of the gastrointestinal tract were approached by trained interviewers shortly before a scheduled surgery. Structured questionnaires were administered five times. For the first two waves, one to three days before and five to seven days after surgery, questionnaires were provided and collected at the surgical wards. For waves 3–5, questionnaires were mailed to the participants 1, 6, and 12 months, respectively, after surgery. A stamped, addressed envelope was provided with each questionnaire. At the time of data collection for the third wave, only those patients who had actually undergone surgery, whose cancer diagnosis had been either confirmed by histological analysis or had not yet been falsified, and who had returned a complete questionnaire on least one of the first two waves were approached. Several measures, e.g., self-efficacy, were introduced at that time because patients’ medical conditions shortly before and after surgery did not allow lengthy questionnaires. Therefore, unless noted otherwise, all subsequent dropout analyses refer to the initial sample at wave 3. Participants

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information on their treatment could not be obtained. Asked for the type of treatment they had received in the last month, nine patients indicated chemotherapy, a single patient received radiotherapy. Two patients were treated with chemotherapy and an additional therapy, whereas one patient received chemo- and radiotherapy. In the last four weeks prior to the assessment, 58 patients did not receive any medical treatment. Twentynine patients indicated a different treatment not listed in the questionnaire. Those treatments included regular check-ups, aftercare, ultrasound, or treatment for noncancer-related health problems. Information on the treatment type was missing for five patients. Measures Self-efficacy: Participants completed the General SelfEfficacy scale by Schwarzer and Jerusalem (1995). The responses for the 10 items range from strongly disagree (1) to strongly agree (4), e.g., ‘‘I can always manage to solve difficult problems if I try hard enough’’. The high validity and reliability of the scale has been demonstrated in many studies across various research contexts and ethnically diverse populations (e.g., Scholz, Gutie! rrez-Don˜a, Sud, & Schwarzer, 2002). In this sample, the internal consistency was Cronbach’s a=0.91. Social support: The Berlin Social Support Scales (BSSS; Schulz & Schwarzer, 2003; Schwarzer & Schulz, 2000) were used to assess various facets of social support and were developed for the study of cancer patients. Due to test constraints, only received social support was measured at all waves and used in the present analysis. Patients were asked to think about a person who is closest to them and to evaluate how this person reacted to them. The instruction is geared toward a retrospective assessment of support receipt, but one that is chronologically close to the current situation. The nine items distinguish emotional (e.g., ‘‘This person comforted me when I was feeling bad’’; Cronbach’s a=0.91) and instrumental (e.g., ‘‘This person took care of many things for me’’; Cronbach’s a=0.68) support. The answering format ranges from strongly disagree (1) to strongly agree(4). Coping: Coping was assessed six months after surgery by two scales: Acceptance and social comparison. For both scales, the item responses ranged from strongly disagree (1) to strongly agree (4). (1) Acceptance: Two items were generated to assess patient efforts in accepting the illness with a positive outlook rather than a sense of defeat (‘‘I have learned to live with my illness’’ and ‘‘I have adjusted to the limitations caused by the disease’’). Cronbach’s a of acceptance coping was=0.61. (2) Social comparison: The patient’s optimistic outlook on his or her coping efficacy in comparison with others was measured with three items that were

developed on the basis of the Coping with Surgical Stress Scale (COSS; Krohne, de Bruin, El-Giamal, & Schmukle, 2000). The items’ rather general wording suggests a broader frame of reference for making a statement on expected coping success. The questions implicitly refer to both physical and psychological aspects of coping with the illness (e.g., ‘‘I thought that I, compared to others, could deal with the situation much better’’; Cronbach’s a=0.71). The cross-sectional intercorrelation at wave 4 among the two coping constructs was significant but moderate (r ¼ 0:37; po0:01). The item examples above are translations from German. Benefit finding: The American version of the Benefit Finding Scale (Antoni et al., 2001) was translated into German. The instrument consists of 17 items and uses the same answering format as the American original, a five-point scale ranging from not at all (1) to very much (5). However, the instruction differs slightly from the original. In order to ensure that the answers to the statements refer to the surgery, patients were primed to think about the surgery they underwent one year ago. Also, the term cancer, a popular generic term for malignant neoplasms, was replaced by the broader term tumor, which refers to any abnormal cell growth whether malignant or benign. We decided in favor of this procedure for three reasons: (1) In terms of diagnoses, the sample composition turned out to be rather heterogeneous. In some instances, results of the histological analysis of tumor tissue after surgery did not confirm the initial diagnosis. Such information was obtained from the final medical reports that were accessible weeks and sometimes even months after a patient’s discharge from hospital. Thus, some participants who were approached at the fifth wave did not have cancer but benign tumors. (2) Even some patients with a diagnosed malignant tumor refused to regard themselves as cancer patients. Whether this refusal was due to a physician’s failure to inform the patients correctly, patient denial, or a misunderstanding of the definition of cancer is subject to speculation. (3) The time lag of 12 months between surgery and wave 5 implies a greater variance in recovery of the patients than, for example, shortly after surgery. While some patients might be symptom free and consider themselves as cured of cancer, others might still struggle with chemotherapy or other treatment. Therefore, the instruction primes the participants. ‘‘You underwent surgery one year ago because you have or had a tumor. Patients sometimes feel that the illness makes contributions to their lives as well as causing problems. Indicate how much you agree with each of the following, using these response options’’. Benefit finding was assessed in different domains, for example, acceptance of life imperfections (‘‘My illness has led me to be more accepting of things’’). The internal

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consistency of the item set was very high (Cronbach’s a=0.93). For descriptive purposes, we report the relationship of benefit finding with other indicators of adjustment to cancer and surgery. Measures included three new items on worry (Cronbach’s a=0.85) as well as an eight item scale on depression comprising two new items and six items from the German version of the Center for Epidemiological Studies Depression Scale (CES-D; Hautzinger, 1988; Radloff, 1977, Cronbach’s a=0.83). Further, global quality of life was measured by the EORTC-Quality of Life Questionnaire (EORTC-QLQC30, Aaronson et al., 1993; Cronbach’s a=0.92). Additionally, patients were asked about the type of medical treatment and the subjective impairment the treatment had caused. Information on health problems unrelated to cancer (e.g., cardiac and renal disease) was obtained from medical files. Based on this information, a morbidity index was computed. Two single items assessed the patient’s satisfaction with his or her own coping efforts and the support provided by a loved one.

Results Dropout analysis: Of the 255 eligible patients at wave 3, 105 (41%) completed questionnaires also at 6 and 12 months after surgery, respectively. Given this considerable decrease in sample size, we tested whether any systematic differences between the two samples existed. First, demographic variables were analyzed for a possible influence. Patients in both samples did not differ regarding age, gender, marital status, or having children. Second, neither the type of treatment nor the experienced impairment by the treatment could be related to dropout. Measures of depression, worry and the number of diagnoses, an indicator of morbidity, did not reveal any differences between those patient groups. Only global quality of life was significantly lower in those 150 cancer patients who left the study (F(1.239)=4.08, po0:05). Death records were not accessible. However, in 20 cases (13%), relatives of deceased patients informed the project group about the death. Preliminary analysis: Before testing the proposed models, the relationship between benefit finding and a number of demographic, health, and medical variables was examined. Analyses of age and gender effects on benefit finding did not yield any differences. Moreover, neither marital status nor having children made a difference for finding benefit in the illness. Table 1 shows the correlations between benefit finding and other indicators of adjustment, i.e., worry, depression, quality of life. None of these were significantly related to benefit finding in this analysis. This result

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Table 1 Cross-sectional Pearson correlations of benefit finding with other indicators of psychosocial adjustment at 12 months postsurgery (N ¼ 105) Benefit finding Global quality of life Worry Depression Satisfaction with own coping Satisfaction with provided support Number of additional diagnoses

0.15 0.02 0.13 0.45 0.26 0.03

po0.05, po0.01.

Table 2 Means and standard deviation (SD) of self-efficacy and received social support at 1 month (t3), coping at 6 months (t4), and benefit finding 12 months (t5) post-surgery (N ¼ 105)

Self-efficacy t3 Emotional support t3 Instrumental support t3 Acceptance t4 Social comparison t4 Benefit finding t5

Mean

SD

3.06 3.69 3.77 3.30 2.83 3.56

0.53 0.52 0.44 0.71 0.78 0.90

points to the discriminant validity of benefit finding as an independent construct. Furthermore, no relationship was found between number of additional health impairments and benefit finding. A positive relationship with the outcome existed between patients’ ratings of their own coping efforts and the support provision by their significant other. A significant negative relationship between benefit finding and subjective impairment by the illness occurred only for those 39 patients who still received medical treatment (chemo- or radiotherapy) almost one year after surgery, (for physical impairment r ¼ 0:34; po0:05; for psychological impairment r ¼ 0:36; po0:05). Correlations between predictor and outcome variables: Table 2 displays the mean and standard deviation for the predictor variables and benefit finding at the prescribed points in time. A mean of 3.56 (SD=0.90, maximum 5) for benefit finding signifies a moderate level of benefit experience. In comparison, the mean score of depression (M ¼ 14:16; SD=4.42, maximum 32) represents a rather low to moderate level of depressive symptoms. However, this low level is not due to a possible selection bias, but corresponds with the trend in the entire sample. Subsequently, the correlations between the predictor variables and benefit finding are presented in Table 3. Age and gender differences were found neither for the resources nor the coping modes under study.

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Table 3 Intercorrelations between self-efficacy, received social support, coping and benefit finding at 1 month (t3), 6 months (t4) and at 12 months (t5) post-surgery

Emotional support t3 (ES) Instrumental support t3 (IS) Self-efficacy t3 (SE) Acceptance t4 (AC) Social comparison t4 (SC) Benefit finding t5 (BF)

ES t3

IS t3

SE t3

AC t4

SC t4

0.76 0.06 0.21 0.30 0.41

0.17 0.27 0.25 0.38

0.32 0.27 0.26

0.37 0.31

0.47

BF t5

Note: N ¼ 101;  po0:05;  po0:01; N ¼ 95:

Direct effect model Initially, social support and self-efficacy were specified to predict benefit finding as a positive outcome of having cancer. The two scales of received support (emotional and instrumental support at wave 3) served as indicators of an exogenous construct labeled Received Social Support that was linked to the endogenous variable of benefit finding measured 11 months later. In addition, the two variables indicating the exogenous construct Self-efficacy were obtained by randomly splitting the scale into two halves, and scoring each half separately . (Rock, Werts, Linn, & Joreskog, 1977). The two resources were specified as being correlated. The model was analyzed with AMOS 4 (Arbuckle & Wothke, 1999), based on complete data from 98 patients, using the maximum likelihood estimation procedure. This resulted in a satisfactory fit between model and data, w2 ð6; n ¼ 98Þ ¼ 6:14; p ¼ 0:41; GFI ¼ 0:98; RMSEA ¼ 0:02). Fig. 1 displays the model. For finding benefit, patients’ resources, especially received social support, accounted for a substantial proportion of the variation (20% variance of benefit finding). While social support was most important, self-efficacy also mattered (X ¼ 0:20; po0:05). Both resources accounted jointly for 26% of the variance in benefit finding. There was no significant association between received social support and self-efficacy beliefs reported one month after surgery. Mediator model In a second step, acceptance and social comparison were used as mediators. The analysis again returned a satisfactory fit between model and data, w2 ð33; n ¼ 95Þ ¼ 33:33; p ¼ 0:45; GFI ¼ 94; RMSEA ¼ 0:01), but shed a slightly different light on the role of resources for positive adjustment to illness. Concerning their predictive quality for benefit finding, only social support continued to have a significant direct effect. Although partially mediated by

Received Social Support 1 month post OP

0.45** 0.26

0.10

Benefit Finding 12 months post OP

0.20* Self-Efficacy 1 month post OP

Fig. 1. Structural equation model testing direct effects of personal (self-efficacy) and social (social support) resources on benefit finding (standardized regression coefficients; po0:05; po0:01).

social comparison, support was still able to account for a substantial proportion of the variation in patient benefit finding (11.6% variance of benefit finding). On the contrary, self-efficacy’s previously significant contribution to benefit finding was mediated by social comparison and retained only a marginal direct effect on experiencing benefits after tumor surgery. Furthermore, both resources were significantly associated with acceptance coping and social comparison. As expected, self-efficacy was associated with favorable comparisons with others (X ¼ 0:34; po0:05) and with acceptance (X ¼ 0:42; po0:01). Social support had a somewhat smaller influence on acceptance (X ¼ 0:26; po0:10) and social comparison (X ¼ 0:29; po0:05). However, only optimistic social comparison exercised substantial influence on benefit finding (X ¼ 0:47; po0:01), see Fig. 2). Patients who believed strongly in

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Received Social Support 1 month post OP

0.34**

0.29*

0.26

†

0.43

Social Comparison 6 months post OP 0.47**

Benefit Finding 12 months post OP

0.29* 0.08

-0.10 Acceptance 6 months post OP 0.34**

0.42*

0.10

Self-Efficacy 1 month post OP

Fig. 2. Structural equation model testing direct and indirect effects of personal (self-efficacy) and social (social support) resources on benefit finding. Social comparison mediates between resources and benefit finding (standardized regression coefficients; wpo0:10; po0:05; po0:01).

their own capacity to cope with the specific situation of having cancer were able to find benefit in the disease a year after they had been in hospital. The influence of acceptance on benefit finding was negligible. Altogether, resources and coping accounted jointly for 43% of the variance in benefit finding. Comparison of the indirect, direct, and total effects of both resources underline social support’s importance for finding benefit in the cancer experience [total effects: self-efficacy 0.38 (0.21), social support 0.82 (0.45)].

Discussion Patients in the present sample reported on the experience of benefit finding in the one-year period after tumor surgery. The structural equation model showed that patient resources were positively related to benefit finding. Social support appeared to be the strongest predictor of positive changes in the aftermath of stressful surgery, both directly and indirectly through social comparisons. While social comparison, in line with Taylor’s theory, had a mediating role in the benefitfinding process, acceptance did not. In terms of selfefficacy and social support, the model showed different effects for the two resources studied. After social comparison and acceptance coping were added to the model, self-efficacy did not retain a direct influence on

benefit finding. Social support, on the other hand, maintained its predictive value for recovery. The conceptualization of self-efficacy implies a positive and optimistic outlook on the future that is based on previous experience mastering difficult circumstances. Its significant relationship with social comparison is to be expected because both are associated with deriving a positive and optimistic view of oneself. So the effect of self-efficacy on benefit finding was largely mediated by social comparison. The pronounced effect of social comparison on benefit finding, however, may be partly ascribed to the operationalization of the construct in this study. The wording of social comparison was geared towards the specific situation the patients find themselves in. Thus, by relating to the same context, social comparison may exercise greater influence on benefit finding than the rather general construct self-efficacy. Acceptance, the second coping strategy studied, was also predicted by self-efficacy as measured five months before. Confidence in one’s coping potential appeared to lead to acceptance of the illness. However, acceptance did not significantly predict benefit finding. In the present study, the experience of benefit is conceptualized as a desirable outcome of an adjustment process stretching over an extended period of time. Indeed, the findings support the idea that resources and coping are precursors of positive changes and, as such, need time before demonstrating their beneficial potential.

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However, for a better understanding of stress-related growth, frequent measurements of benefits could have value. Assuming that benefit finding may have occurred much earlier in the patients’ adjustment process, it could have exerted influence on coping through fostering those strategies leading to positive evaluation of the situation. Moreover, if benefit finding is related to coping strategies and these strategies supposedly change over time, a subject of further investigation is determining which coping strategies help find the greatest benefit at various stages of the adjustment process. Additional predictors of benefit finding were revealed in correlation analyses. One year after tumor-related surgery, patients did not differ in benefit finding depending on whether or not medical treatment for the illness was still necessary. For those who received treatment, however, a negative relationship between subjective impairments by the treatment and benefit finding was reported (see also Fromm, Andrykowski, & Hunt, 1996; Park et al., 1996; Ryff, 1989). In line with Mohr and colleagues (Mohr et al., 1999), commonly used indicators of coping effectiveness such as worry or anxiety, depression, and quality of life were unrelated with benefit finding in our study. Other researchers (Katz, Flasher, Cacciapaglia, & Nelson, 2001) demonstrated such a link between benefit finding and positive health-related consequences (e.g., reduced emotional distress, less fatigue) in a sample of cancer and lupus patients. It remains unclear whether lower levels of distress are due to benefit finding or vice versa. Contrary to other studies in which enacted support was related to higher distress (e.g., Hobfoll & Lerman, 1989), patients in this study profited from the support they had received. The appreciation of close personal relationships has been defined as one facet of benefit finding. Against this background, it does not come as a surprise that received social support and patient satisfaction with this support was linked to benefit finding. Cutrona and Russell (1990) have described social support as coping assistance. Here, both tangible (instrumental support) and intangible (emotional support) forms of social support were equally strongly correlated with benefit finding. This finding notwithstanding, it should be noted that benefits could have been experienced earlier after the stressful event and, as a consequence, helped to elicit supportive behavior from the social network: Patients who accept their situation and value positive changes are more likely to respond positively to offers of support and so receive more subsequently. In terms of research, further theoretical and empirical work should aim at identifying the unique nature of various conceptualizations of positive change after crisis. Benefit finding and personal growth, for example, are terms often used interchangeably (Antoni et al., 2001; Thornton, 2002). Moreover, multiple

indicators of benefit finding could help to determine more precisely in which life domains positive changes occur. The present study has employed the German version of the benefit finding scale for the first time. Additional studies are needed to determine its validity and reliability in various research contexts. In summary, addressing the various issues in the study of posttraumatic growth is an important and challenging task of future research that will have multiple practical implications for clinical work.

Acknowledgements The authors would like to thank Ralf Schwarzer and Aleksandra Luszczynska for their valuable comments on an earlier draft of this paper. Further, the authors are thankful to Eric Jandciu for editing the manuscript. We would also like to thank the other members of the tumor . . project group Sonja Bohmer, Charis Forster, and Steffen Taubert as well as the physicians of the four participating hospitals.

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