Promoting Post-Traumatic Growth among Taiwanese Cancer Survivors: Cultural Issues

Posttraumatic growth (PTG) is a phenomenon notable among cancer survivors who endure aggressive, lifethreatening treatment of severe illnesses. Such growth manifests through improved physical health, strengthened psycho-spiritual resilience, intensified coping skills, and better utilization of resources. Due to the scarce literature, the link between cancer survivorship and PTG remains unclear in Taiwan and further complicated by cultural issues. Presented in this article are summated findings from cross-cultural literature of PTG among cancer survivors, particularly various observations of posttraumatic stress and coping between Eastern and Western cultures. Clinical implications are followed to encourage health care providers to cogitate culture-specific meanings in survivors’ cancer-related posttraumatic experiences. There lies a cultural need to fill in the knowledge gap in order to ultimately promote PTG and improve cancer survivors’ quality of post-cancer life in Taiwan.


Introduction
Posttraumatic growth (PTG) is documented among a certain portion of individuals undergoing traumatic episodes of bereavement, sexual assault, military combat, and terrorist attacks [1]. A collection of positive changes is recently notable amongst individuals after enduring aggressive, life-threatening treatment of severe illness. Only until very lately this prominent phenomenon of posttraumatic changes has been viewed as beneficial, diverging from what previously known as negative health implications of stress, pain and anxiety. A surge of research interest from the last decade has revealed optimistic effects following highly traumatic events, and cancer survivors have potential to grow even after suffering from symptomatic discomfort, progression and recurrence of disease, and possible lose of hope [2]. Such growth may appear even three to five years after cancer treatment is completed; it manifests through improved physical health, strengthened psycho-spiritual resilience, intensified coping skills, and better utilization of resources [3,4]. Enhanced wellbeing and quality of life, coexisting with other destructive psycho-spiritual effects, are often observed as a direct contrast of adverse outcome after cancer [5][6][7][8]. The most common PTG experiences include changes in self-perception, relating to others, new possibilities and spiritual change [3,4]. Accordingly, only approximately half of the survivors have developed PTG [2,7]. Higher levels of PTG have been proved to evidently associate with better social or family well-being [4], lower levels of anxiety [9], lower levels of depression [9,10], and better quality of life. [3,4,9].
With the risen cancer survival rate in Taiwan [11], the link between this unique PTG phenomenon and survivorship, however, remains unclear due to the scarce literature. This article is inspired by a recent review [12] in which two Japanese authors challenged the existing theoretical models of PTG-cancer survivors, "…regardless of their cultural background or personality, will receive benefit from actively interacting with others. " Taiwanese cancer survivors shared the same cultural root in Eastern Asia, have encountered similar cultural issues. Thus far, there is no well-accepted Mandarin assessments designed to adequately assess the onset and maintenance of Taiwanese's PTG, and commonly used inventories [4,6,13,14], mostly originated from Western medical context, might lack cultural relevance. While PTG are complicated by health-seeking styles and preferences of interaction with others, it is worthwhile to discuss whether cancer survivors' PTG in Taiwan might be inappropriately reported [12] as well. In this short communication, a brief introduction of factors, interventions, and implications are introduced, followed by clinical observations from eyes of in-culture Taiwanese oncological nurses. We suggest health care providers cogitate culture-specific meanings in cancer-related posttraumatic experiences when assessing and promoting Taiwanese cancer survivors' PTG.

Factors and Strategies to Promote PTG
Posttraumatic stress after cancer, a negative traumatic event [7], may arise from any time point between the discovery of a disease, treatment, and remission [15]. Even though only less than 5% of the cancer survivors meet the criteria of posttraumatic stress disorder (PTSD) [16,17], occurrences of intrusive thoughts, avoidance behaviors and hyper-vigilance are often observed, counting for 15-25% among them [18]. Thoughts, images, or memories related to cancer, and possible fears of recurrence [16] might constantly challenge patients' self-concept and worldview, resulting in affective and cognitive discordance and causing stress symptoms. Because of the small portion of cancer survivors diagnosed with PTSD, little evidence exists to link PTSD and PTG. However, intrusive thoughts are found as one of the major predictors of PTG [19], and greater levels of posttraumatic stress symptoms seem to correlate with better PTG [20]. It would be a common myth to believe that terminal cancer patients have little room to grow; in fact, even when dying patients had no chance of receiving treatment or continue living, PTG often occur during terminal care [12,16,[21][22][23].
Currently the well-accepted PTG theory is a multifactorial model [7]: cancer survivors' growth is affected by personal, event related-and environmental factors. Older patients with comorbidity problems had lower levels of PTG compared with their younger counterpart [10,21]. Young, female patients [9,20] of better socio-economic and educational status also report higher levels of PTG [10,20,21], as well as those with better physical function [10,19] and in retirement [21]. The results of relationships between time since diagnosis and PTG [9], the type of cancer [22] and the type of treatment [19,22], nonetheless, have not been consistent, despite one study specifically found significantly lower PTG among bone tumors survivors than that of other cancers [19].
Literature showed successful strategies have been developed to help individuals cope with stressful traumatic events and thus promote PTG. Through a cognitive and emotional re-forward conversion process [23,24] cancer survivors may learn to manage emotions, solve problems, engage in alternatives, search meanings, reach goals, and experience growth. Other approaches suggest to improve both quality of life and PTG by pursuing spirituality, increasing religious activities, using humor and positive reframing [9,10,20], as well as practicing optimism [9]. Studies showed that even recurring negative thoughts about traumatic events have therapeutic meanings, and positive reappraisals could be used to facilitate PTG [20]. Since cancer survivors with better social support had achieved higher PTG [9,10,24], the benefits of acquiring psychological support from survivors' family and friends are indisputable. Healthcare professionals are also regarded as the most important caregivers to provide support; in fact, utilization of nurse counseling was one of the major predictors to enhance PTG [20].

Cultural Issues of PTG Assessment
The existing PTG literature has been based mostly on a Western medical model. While positive psychology is a presumption of presentday cancer care [25,26], coping by positive reappraisal a strong predictor of PTG [27]. However, Matsui and Taku concerned that such positive reappraisals related to PTG and health-seeking behaviors may not be universally valued and there exists cultural differences. For example, Barr suggested gender could be a cultural issue: guilt and fear of death have contributed to PTF in males but shame is related to PTG in females. Guilt and shame were mentioned [12] as cultural factors. Based on our ethical consulting experiences in the States, individuals in a Christianity-based culture, familiar with the idea of "a new creature" in biblical teaching, are likely to reflect, repent, and remorse, and they " in this guilt culture may take action…to improve themselves [12]. " There has been no literature examining Taiwanese cancer survivors' guilt and shame in PTG development. Our experience was that many Taiwanese are not familiar with the guilt but could identify the shame culture of saving face. To actively grow after cancer through self-improvement is not commonly seen. Taiwanese have long been influenced by traditional beliefs of Taoism [28]. Pursuing for growth after traumatic experiences is against their motto of keeping life "neutral, " and the philosophical Taoist teaching says in many ways a person should never act too negatively or positively. They would not want to propose any extremes; many believe in destinies and follow the flow in order to get ultimate peace in mind. This explains why Asian cancer survivors might endue and accept pain, resulting in a lower level of PTG [12]. In the review article, "…people in Eastern cultures may be neither over-positive nor over-negative…in turn may discourage reporting PTG. Cancer survivors in Japan, for example, may not feel a strong need to be positive…which in turn may lead them to report a lower level of PTG [12]. Similarly, we have interviewed many Taiwanese patients to whom reporting or pursuing PTG is not of their concerns, and their reasons behind are to stay neutral in every way, including medical decision-making.
Mishel's Uncertainty of Illness theory [29] could be used to explicate Taiwanese' "no fighting" philosophy that reappraising uncertainty as part of life leads to psychological growth. A secondary study described that Taiwanese family caregivers of cancer patients accept the uncertainty of life by resigning themselves to the fate, because "…it may be easier for (these) Taiwanese to deal with illness-related uncertainty [30]. " Our clinical experience also observed that many Taiwanese people's stress coping mechanism is fatalism but not positive reappraisal. Fatalism could explain why some Taiwanese cancer survivors express no interests in PTG interventions, since they simply are not enthusiastic about correcting wrongs, strengthening weakness, or confronting conflicts in order to acquire positive changes.
Another cultural issue is the perceived pressure to exhibit positive changes after traumatic events. This deliberate cognitive processing [31] of displaying positivity may play an important role in the intention to report growth after cancer. Among Japanese students in the states, social pressure was found to positively correlate with PTG [32], indicating that the higher level of PTG might come from perceived pressure. Although no similar studies have been conducted in Taiwan, perceived pressure from significant others is a common among Taiwanese cancer survivors. Many patients have been observed to "pretend" and "act" positive after receiving cancer treatment, in particular in front of families and friends. One Taiwanese patient who survived lymphoma has recalled, "After I removed my spleen, I have to show other people I am fine. I was grateful and joyful…I cannot burden my family. It is the only right thing to do and it is what I am supposed to do…after all, I am the deacon of the church. " Clearly in this case, his reported PTG might be overly estimated because of a possible shame culture and the cultural effect of "saving face. " Determinants of posttraumatic growth among Chinese cancer survivors were found different from Western culture [33], and the PTG dimensions were highly interpersonal and intrapersonal in the Chinese sample. Whilst the Taiwanese social norm is to preserve "family face, " grow physically and psychologically strong in order to overcome cancer may become stressful for survivors.
It also holds true that most interdependent Taiwanese take "family harmony" as their top priority in making medical decisions [28]; personal growth, if any, is then considered within the whole family unit. Survivors might also consider the total influence on the extended families and thus unable to report any specific positive difference after cancer. PTG concerned solely based on an individual's positive changes would be culturally incomprehensive. For example, a simple question "Please share with me how you've become after your surgery/ chemotherapy?" may be difficult for Taiwanese survivors in the early grieving stage, since they are not ready to reach out to others after a traumatic event and the "saving face" effect has prevented them to seek for assistance or report growth. There is an imperative need to examine commonly used open-ended interviews or standardized questionnaires [1,[33][34][35][36]. In summary, Taiwanese cancer survivors, similar to their Japanese counterparts [12], may not be aware of the PTG concept, feel no need to actively pursue or report any growth after cancer, and perceive certain peer pressure to display fabricated positivity.

Health Care Providers' Role
In light of research evidence, supportive and behavioral interventions, originated mostly from Western culture, have been developed as useful means to promote cancer survivors' PTG. However, while the existing PTG models highly encourage survivors engaging in group activities by problem-solving strategies [24], sharing emotions, and seeking social support [23], our experience in Taiwan noticed that not all survivors prefer to interact with others to gain growth. This finding is consistent with the review article [12]. For many Taiwanese, families and friends are believed sufficient resources to satisfy almost all needs; taking a proactive approach or using support services is not unnecessary and complicated by issues of negative connotations and stigmatization related to cancer. Selfrevelation of the diagnosis, emotion expression about cancer-related experience, and renegotiation of self-identity are considered fairly shameful or redundant to strangers. Quite a number of Taiwanese patients, withholding little personal control and deferring decisions to families, do not feel any needs to be in charge. Our experience showed that many Taiwanese survivors usually are not aware of available counselling [20] and active coping strategies [37] to promote PTG. Acceptance and commitment therapy [13] or effective psychotherapeutic interventions [14,38] are not well-received as well.
Despite the Easter and Western cultural dissimilarities and the fact that not all Taiwanese prefer group therapies or in-depth psychological counselling, it is still beneficial for healthcare providers to utilize successful group therapy to enhance coping. Consideration for each group member's individuality, trust, self-efficacy, effective communication and reinforcement are universally appropriate, regardless of the cultural background. Therapeutic activities may not necessarily be facilitative approaches of recognition or reassessment in order to increase personal positive changes after cancer at the individual level. "Comfort group" will allow room for either anonymous members or a circle of families and friends to deliberate, integrate, and find personal meanings about the cancer disease. A home grown model that integrates prevailing Western strategies of active coping and reflective activities must be tailored for survivors in a "saving face" culture, so they will feel respected and accepted by strangers and further equipped before revealing themselves to discuss their cancer trauma. Cultural sensitive programs may be pilot-tested in small groups, especially for those older survivors of lower socioeconomic levels who strongly value traditional Chinese-ethnic beliefs. Further research is required beyond current understanding of Taiwanese cancer survivors' PTG for clinical implications to enhance their quality of post-cancer life in Taiwan.