Coping processes relevant to posttraumatic growth: an evidence-based review

PTG has been widely researched in other oncological fields, especially in the field of breast cancer. OCC patients are an important subgroup of oncological patients as the biological nature of the disease and treatment modalities related to oral cancer results in concomitant loss of function, psychosocial problems as well as loss of quality of life. Such negative effects have been detected to lead to increased PTG in other fields of cancer research. Therefore, it was hypothesized that oral cancer patients might develop PTG, too. Performing an evidence-based review, the authors’ aim was to provide a more structured pathway model for future research especially in the field of OCC. It was found that PTG knowledge especially within the OCC research is lacking. In this review, only studies using the standardized questionnaires for PTG assessment have been included to allow a more standardized comparison. There are many different types of coping processes that have shown some positive outcome regarding PTG but it is the authors’ intention to only focus on “the processes” that have shown significant positive relationship with PTG (Table 1) .

There are a number of factors that ought to be considered in determining the quality of evidence to inform a conceptual framework of interventions for OCC proposed (Fig. 2). Firstly, the evidence compiled is from heterogeneous patient samples and thus coping styles of one particular cancer may not readily be adaptable or useful for OC cancer per se. Secondly, assessment of the “coping processes” varied considerably and in many cases relied on non-standardized measurement instruments (questionnaires), thus differences in measurement approaches may have influenced outcomes observed. Considering such limitations, a hypothetical model for PTG in the OCC discipline is proposed (Fig. 2).

This review identified a few positive coping processes that significantly promoted PTG as well as overriding factors and certain personality traits that lead a person to be more inclined to use this identified coping processes. The overriding factors were identified as benefit finding and meaning making [1, 24] and marital support [23] which will be discussed below. Hope and optimism were the identified personality traits rendered the patient more inclined to practicing positive coping processes [7, 8]. There were a few positive coping processes that have consistently showed significance where positive reframing, religious coping, positive affectivity, active and adaptive coping, rumination, positive attention bias, and problem solving coping. Most of the studies were cross-sectional, thus preventing identification of causal relationship; however, it is our intention here to present these few proven significant processes to allow researchers to develop prospective studies as well as interventional studies that can promote these processes. Our understanding from the literature is that each coping process interrelates with each other. They also developed at specific times along the long process of cancer recovery [32]. It lies in the intention of the authors that the identification of these processes might influence future research to focus toward the points of time when particular processes would develop. This on his part might have an impact on the development and implementation of more timely specific interventional psychological programs. Further on, a theoretical framework for specific interventions to influence the development of PTG in patients at different stages of the disease (Fig. 2) has been forwarded. Thus, psychological programs promoting coping strategies, aiming at specific attributes in particular stages in the cancer tale of woe should be considered in OCC management. In the initial stages, interventions related to social support, couple / family, personality traits, and promoting cancer rumination should be enacted as the here presented results have shown, all of the factors representing patients’ predispositions to positive coping processes mentioned before.

It has long been recognized that “social support” plays an important role in coping with cancer, including OCC patients [20, 22]. In particular, the involvement of spouses/partner and family appears to be important in developing appropriate coping strategies [22, 23]. Evidence in the OCC field has already identified that patients from strong supportive marriages/partnerships are more able to develop benefit finding and meaning making [33]. Therefore, couples or family therapy probably should be implemented to yield the necessary support for both the patients and their spouses at the earliest time possible. Another important facet of social support may come from contact with persons who have experienced a similar adversity. Improved coping response was found in patients being in contact with persons who have experienced a similar adversity [34].

Overriding constructs are “benefit finding” (BF) and “meaning making” (MM). BF is a process in which the patient creates a new positivity to the adverse event based on the benefit the patient identifies. This process makes the individual look at the adverse event as an opportunity to self-improve and at the same time develop PTG to uphold the damaged self-esteem [1, 24]. MM on the other hand is a process which develops after the adverse events in which the individual starts reviewing their current beliefs and world assumptions. This will then allow the individual to derive positive explanations regarding the adverse event and start making sense of the cancer experience thus allowing change in their basic beliefs. MM generates new vision of the self, others and world beliefs which all directly relates to coping [1]. Interestingly, BF and MM have a positive effect on increasing the use of positive coping processes in patients [11]. Thus, any psychological intervention that can increase benefit finding and meaning making earlier on in the cancer process may be able to enhance coping and ultimately bring about PTG in OCC patients.

The next area of focus relates to “positive active coping” which includes religious and spiritual development, problem solving coping initiatives, active cancer rumination, and acceptance coping which all show significant association with PTG [12, 18, 19, 26, 27, 29, 30]. All these positive coping processes are significant contributors to PTG as they require effort to process rebuild the patient’s beliefs and outlook in life [19]. Acceptance, coping strategies, humor, and rumination appear particularly important in the early stages of cancer leading patients to develop a more positive outlook later on in the cancer experience [18, 21, 23, 27, 35]. This implies that interventional therapies might play a role in the development of positive coping strategies in OCC patients with particular relevance in the early stage of cancer.

The proposed hypothetical framework for PTG (Fig. 2) in OCC management is based on this evidence-based review of literature, thus providing a sound theoretical framework. This theoretical framework might also provide a guide for future research in other cancer research fields. It certainly offers various practical strategies and pathways to potentially enhance PTG throughout the trajectory of OCC. Even though some outlined interventions/strategies have already been proven effective in other cancer research fields, there still is a dearth of specific evidence in OCC research.

There is a great need for future studies of psychological interventions to complement cancer management holistically as well as to validate the here proposed theoretical framework with respect to future interventions throughout the trajectory of OCC.