The number of people diagnosed with cancer is increasing every year; yet the mortality rate is not rising (Australian Institute of Health and Welfare, 2004). As more people are living with this illness, it is essential to direct research efforts toward the adaptation and adjustment that occurs post-diagnosis. A wealth of research has investigated the coping strategies used while adjusting to cancer diagnosis. However, most studies have generally documented resultant distress associated with the cancer experience rather than positive outcomes. This focus on the traditional pathogenic paradigm is now being supplemented by a body of research investigating the potential for positive change that may occur post-diagnosis. “Posttraumatic Growth” (PTG; Tedeschi & Calhoun, 1996) describes the potential for an individual to develop beyond their pre-trauma level of psychological functioning and experience substantial beneficial changes in cognitions and emotions as a result of negotiating their traumatic experience. Whilst psycho-oncology research is burgeoning, the current study addresses an area currently overlooked: Are divergent coping strategies associated with different dimensions of PTG?

Coping After a Diagnosis of Cancer
As a single coping strategy cannot be regarded as beneficial across all situations, it is argued that the type of coping strategies utilised will differ depending on the context of the traumatic event (Schulz & Mohamed, 2004). For example, the experience of cancer represents a sequence of events that are difficult to alter; therefore, while active coping may be appropriate in other situations, acceptance or positive interpretation may be more advantageous post-diagnosis (Schulz & Mohamed). To date, coping research within psycho-oncology has documented a number of adaptive and maladaptive coping strategies evident post-diagnosis. These studies have shown that a variety of coping strategies used during this period of time can impact on post-diagnosis psychopathology. For example, coping through acceptance (Stanton, Danoff-Burg, & Huggins, 2002) and emotional expression (Stanton et al., 2000) have been shown to be related to a reduction in distress and an improved quality of life.

In addition to the measurement of negative outcomes that can occur post-diagnosis, the emergence of PTG research within psycho-oncology indicates positive change is an important factor when considering the holistic pattern of coping and recovery. Whilst not denying the multitude of adverse affects that cancer and subsequent treatments have on the individual, the investigation of PTG implies that a positive outcome is not merely an absence of psychopathology. In Calhoun & Tedeschi’s (2006a) comprehensive model of PTG, management of emotional distress is essential in the initial stages post-trauma and the success of managing this emotional distress after a traumatic event is determined by the coping strategies that are implemented. Particular coping strategies that have been identified to promote PTG include positive reappraisal coping (Sears, Stanton, & Danoff-Burg, 2003; Thornton & Perez, 2006; Urcuyo, Boyers, Carver & Antoni, 2005), seeking emotional social support (Thornton & Perez, 2006), and emotional expression (Manne, Ostroff, Winkel, Goldstein, Fox, & Grana, 2004). Utilising a variety of coping strategies when facing traumatic challenges has also been suggested to be more beneficial than the use of a single strategy (e.g., Collins, Taylor, & Skokan, 1990; Franks & Roesch, 2006; Shakespeare-Finch, Smith, & Obst, 2002). The PTG psycho-oncology research investigating coping processes has predominantly been based on studies with breast cancer survivors (e.g., Manne et al., 2004; Sears et al., 2003; Urcuyo et al., 2005). Therefore, further research conducted with a variety of cancer types is needed to broaden this investigation of coping strategies associated with PTG.

Multidimensional Nature of PTG
PTG research to date suggests that positive post-trauma change is not a unitary construct, with quantitative analyses revealing multi-dimensional factor structures across varying cultural contexts (Calhoun & Tedeschi, 2006b). The development of the Posttraumatic Growth Inventory (PTGI) revealed a five-factor structure of Personal Strength, New Possibilities, Relating to Others, Appreciation of Life, and Spiritual Change (Tedeschi & Calhoun, 1996). This factor structure has since been replicated in an Australian sample (Morris, Shakespeare-Finch, Rieck, & Newbery, 2005). Janoff-Bulman (2004) suggests that these different domains of growth are perhaps achieved through disparate processes. The areas of positive change and the different psychological processes that may lead to the different PTG domains are not necessarily exclusive of each other; however, it is also erroneous to discuss them as one entity (Janoff-Bulman).

Despite this assertion that PTG should be considered as a multidimensional construct, very little research has been published that investigates predictor variables such as coping strategies, which are associated with the different growth domains. For example, the majority of studies using the PTGI do not utilise factor scores other than to report descriptive statistics, with analyses being conducted on total PTGI score rather than factor sub-totals. A study which has explored which coping strategies were associated with different areas of growth was conducted with an Australian sample of emergency service workers (Shakespeare-Finch, 2002). In this study, coping was measured with the Coping Resources in Rescue Workers Inventory (McCammon, Durham, Jackson Allison, & Williamson, 1988) with four coping strategies; Positive Reframing, Emotional Support and Expression, Non-work Activities, and Work-related Cognitions. The results revealed that these coping processes were positively correlated with only two of the five PTGI factors: New Possibilities and Relating to Others. Based on such research, further study is warranted in the psycho-oncology field to investigate the potential coping strategies that are associated with the different PTG domains.

Rationale and Aims of Current Study
Whilst there is considerable coping research based within the pathogenic paradigm, studies investigating the relationship between coping and positive change post-diagnosis are just taking form. As the majority of this research has been conducted with breast cancer survivors, studies are needed on a variety of cancer types to investigate coping within a broader context. Also, as PTG has been shown to be a multidimensional construct, a gap exists in the current literature investigating the varying coping strategies that are associated with different areas of positive change that may occur after being diagnosed with cancer. Therefore this study:

Overall, the coping processes found to be associated with PTG after a diagnosis of cancer indicate that positive interpretation, social support, active coping and venting emotions are important in adjusting to this experience. These coping strategies are comparable to suggestions from previous research that emotion-focussed coping would be evident post-diagnosis (Manne et al., 2004; Sears et al., 2003; Thornton & Perez, 2006). Contradictory to previous theoretical suggestions, the results from this study reveal that the COPE subscale of active coping was associated with PTG, whilst acceptance coping did not appear to be evident. The phrasing of the acceptance coping questions in the COPE Inventory included “I get (got) used to the idea this happened and that it can’t be changed” and “I learn(ed) to deal with it”. For an individual dedicated to doing everything they can to fight this disease, perhaps acceptance coping as phrased in the COPE Inventory is not beneficial to this situation, nor associated with PTG.

The COPE subscale of Positive Interpretation was found to be associated with all five areas of growth. While there is some conceptual overlap between positively interpreting the event and an outcome of positive change, the correlations in the current study did not exceed .50. These results, in addition with previous studies that have revealed unique predictors for positive interpretation coping and PTG (Sears et al., 2003; Thornton & Perez, 2006), suggest that these two constructs are related but distinct from each other. Further study is needed to explore these predictors and provide evidence for the conceptual distinction between positive growth as an outcome and positive interpretation as a coping strategy. For cancer survivors, seeking social support (both emotionally and instrumentally) was associated with the perception of new possibilities in life and improved relationships with others. Social support provides the opportunity to express feelings and receive practical assistance and advice after the diagnosis of cancer. Consequently, this type of support can aid in the promotion of cognitively processing the event and strengthening relationships with others. This benefit of expressing emotions is reiterated in the current study with the COPE subscale of Focussing on and Venting Emotions being positively associated with New Possibilities. Active coping is also found to be associated with PTG, suggesting that taking an active role in one’s own treatment or life direction after being diagnosed with cancer is important in terms of being able to perceive positive change in new possibilities. Interestingly, the COPE subscales in the current study that had low reliability and were removed from analyses were all maladaptive strategies (behavioural disengagement, mental disengagement, and denial).

Whilst theoretical implications indicated that the coping strategies used would be unique to the circumstance, the results from this study reveal that the coping processes associated with PTG for the cancer survivors were similar to that of emergency service workers (Shakespeare-Finch, 2002). The four coping processes identified as integral to emergency service workers (positive reframing, emotional support and expression, non-work activities, and work-related cognitions) are comparable to those COPE subscales (positive interpretation, emotional support, focus on/venting emotions, and active coping) that were significantly correlated with New Possibilities and Relating to Others with the cancer survivors. The similarity of results from these diverse Australian populations increases confidence in identifying salient coping variables that are of benefit in general post-trauma situations. This also indicates that the cancer experience does not produce a unique situation in terms of how the individual will cope post-trauma and how this will be related to PTG.

Strengths and Limitations of Current Study Leading to Future Directions
Coping processes were investigated in terms of PTGI factors, with these results lending support toward the theoretical assumption that divergent psychological processes lead to different areas of positive change (Janoff-Bulman, 2004). The current study addressed a unique question and provides new information in emergent coping and PTG literature; however, the cross-sectional design prevents identification of causality between coping strategies and perception of benefits post-diagnosis. It may be that people who have higher PTG are better able to utilise adaptive coping strategies, such as mobilizing their coping resources. The current study assessed coping in relation to how the individual has dealt with the cancer in general. The heterogeneity in the type of experiences faced post-diagnosis may have reduced sensitivity for detecting associations between specific coping strategies and PTGI. According to coping self-regulation theory (Carver & Scheier 1982, 1988, 1990), the efficacy of coping strategies that improve adjustment to stressful situations is specific to the challenge faced. Effective coping self-regulation requires that the person be adept in implementing a variety of coping methods, and be able to select coping strategies according to the demands of the challenges faced (Scott, Halford, & Ward, 2004). Therefore, future research that involves both a longitudinal design and measures of participants’ psychological adjustment to specific stressors within the disease experience will help to address these issues.

The current study also relied upon participants’ self-report of their current disease status and prognosis. This information may have been biased by the individual’s primary coping appraisals of the threat the cancer posed to their life and coping resources. Patients also have poor understanding of medical information and the implications that information has for their well-being. There is often low agreement between patients and treating cancer specialists about disease and treatment information. Future studies should include a subjective measure of threat or challenge the participant associates with the event and also include objective measures of prognostic and treatment information from medical records.