Posttraumatic Spiritual Growth: A Phenomenological Investigation of Caner Survivors

1. Posttraumatic Spiritual Growth: A Phenomenological Investigation of Caner Survivors Ryan M. Denney, M.A. The University of Southern Mississippi October 26, 2007

2. Overview • Religion/Spirituality have been shown to be a coping mechanism and to promote resiliency in some trauma survivors. • Many people report increased levels of spirituality following a traumatic experience (911, Hurricane Katrina). • Many people report psychological growth following a trauma (increased coping/resiliency, meaning in life). • Spiritual growth following a traumatic experience has not been thoroughly researched (PTG inventory).

3. The Trauma Continuum • “There is a continuum of stressor severity and there are no crisp boundaries demarcating ordinary stressors from traumatic stressors. Further, perception of an event as stressful depends on subjective appraisal, making it difficult to define stressors objectively, and independent of personal meaning making” (Weathers & Keane, 2007). • Trauma-related disorders have very high comorbidity with major depression, anxiety disorders, substance use disorders, and eating disorders. • Overlapping symptoms of Borderline PD and PTSD: suicidality, dissociation, affect dysregulation, identity disturbance, self-harm, relational difficulties (International Society for the Study of Trauma and Dissociation, 2007).

4. DSM-IV-TR (2000) • Traumatic Stressor:an event that involves actual or threatened death or serious injury, or other threat to one’s personal integrity. • PTSD • Acute Stress Disorder

5. PTG Definition(Calhoun & Tedeschi, 2006) • Traumatic experience: • set of circumstances that significantly challenge the person’s preexisting assumptive world, • disrupts a person’s personal narrative, • a “watershed” experience that divides a life into before and after the event, • an experience or threat of loss, grief, suffering or other negative circumstance that causes a transformation in the view of self, others and philosophy of life.

6. PTG Definition Rationale • Many people have been profoundly affected by their traumatic experience, but may not fit DSM criteria for a trauma-induced disorder. • Due to the subjective, highly variable nature of responses to traumatic experiences, a more broad definition of “trauma” is needed.

7. Cancer as a Trauma • Trauma: injury to the body, or an event that causes long-lasting mental or emotional damage, as that potentially caused by cancer (The National Cancer Institute, 2007). • While not all cancer survivors may have experienced cancer as a “trauma,” having cancer clearly has the potential of being a traumatic experience. • Participants will self-identify their cancer experience as traumatic to them (will be asked on the demographic questionnaire).

8. Posttraumatic Growth “Positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004, p. 1).

9. Purpose • To investigate how having cancer has affected the spiritual growth of cancer survivors. • The goal will be to investigate the phenomenological, or lived experiences of participants with an emphasis on their spiritual growth.

10. Research Question How has having cancer affected the spiritual growth of cancer survivors across 12 domains of spirituality postulated by Tsang and McCullough (2003) and Hill (2005) (see domains list)

11. Why Qualitative? • Most compatible with research question. • Addresses the lack of specificity and depth into PTG and PTSG processes. • Able to address the understudied phenomenon of PTSG. • Gives a “voice” to persons sometimes marginalized.

12. Recruitment of Participants • Key Informants • Contact at the Hattiesburg Chapter of the American Cancer Society will identify participants. • Snowball Sampling

13. Interview Protocol • Non-leading questions (no implied “direction”) • E.g., “How might your cancer experience have affected your motivation or desire to be spiritual?” • Researcher will code for growth • Participants will be given a copy of the interview protocol prior to interview to enhance response quality

14. Potential Implications • Add to our understanding of how spirituality may be used, in a more targeted way, as a coping mechanism in clinical and medical settings. • Inform PTG theory • Add to our understanding of the process of PTGS (Currently no PTSG theory) • Inform instrument construction (what are the most salient domains of PTSG?). • Further refine the domains of spirituality adding to our understanding of the construct of spirituality.

15. Posttraumatic Spiritual Growth: A Phenomenological Investigation of Caner Survivors Ryan M. Denney, Doctoral Candidate The University of Southern Mississippi Dissertation Defense June 11, 2009

16. Overview and Rationale • Spirituality is a multidimensional construct (Hill, 2003; Tsang & McCullough, 2003). • Spirituality has been shown to be a coping mechanism and to promote resiliency in some trauma survivors (Pargament, 2002; Pargament & Ano, 2006). • Many people report psychological growth following a trauma, for example: increased coping/resiliency, meaning in life (Calhoun & Tedeschi, 2006). • Some people report increased levels of spirituality following a traumatic experience (Shaw, Joseph, & Linley, 2005).

17. Importance • Spirituality has not been traditionally researched as a multidimensional construct (Hill, 2005). • PTSG has not been an area of investigation in its own right—to date spirituality has been folded into broader PTG categories (PTG inventory; Tedeschi & Calhoun, 1996) • Spirituality is a diversity variable

18. Purpose and Research Question • Purpose: To investigate the phenomenological experience of posttraumatic spiritual growth of cancer survivors • Research Question: How does surviving cancer impact the multidimensional spiritual growth of survivors? I.E., What is survivors’ lived experience of multidimensional spiritual growth following cancer?

19. Sampling Procedure • Upon IRB approval, an informant at the local chapter of the American Cancer Society gave the researcher’s contact info to potential participants. • Snowball sampling

20. Participants • 3 Focus Groups (medical professionals, survivors, clergy) • 13 cancer survivors • 10 women, 3 men • 12 Caucasian, 1 African American • Age Range: 44-73, mean age 61 • 7 married, 3 divorced, 2 single, 1 widowed • 5 Baptist, 5 Methodist, 2 Catholic, 1 LDS • 8 breast cancer, 2 Leukemia, 1 colon cancer, 1 lung cancer, 1 ovarian cancer • Length of time they had cancer: 6 months to 22 years, mean 5 years

21. Interview Protocol • Asked questions tapping multiple dimensions of spirituality • Modified questions based on focus group feedback (e.g., deleted the phrase “cancer free” • Participants were given a copy of the interview protocol prior to interview • Questions were neutrally worded so as not to bias responses toward growth

22. Data Analysis • Phenomenological data analysis (Colaizzi, 1978) • Interviews were transcribed verbatim and read in their entirety • Significant statements identified (meaning units) • Codes: summary statement of the identified meaning units • Domains: cross-case clustered analysis of codes

24. Rigor Enhancing Techniques: Credibility Credibility: results accurately represent participants’ reality. • Referential adequacy—direct link to participant words • Audio recording • Verbatim transcriptions • Triangulation—several sources of information • Several participants • Outside auditor • Integrating findings into existing theory • Disconfirming Evidence • Reporting of “No Growth” domains • Member Checking • Participants confirmed interview accuracy

25. Rigor Enhancing Techniques: Transferability Transferability: transferring (generalizing) findings to similar people, settings, and times of original study • Thick Descriptions • Presenting details about participant demographics and context • Using participant words to augment and support findings

26. Rigor Enhancing Techniques: Dependability Dependability: accurate, impartial report of findings • Dependability Audit • Outside Auditor—a dispassionate peer reviewed methods and analyzed transcripts • Committee members’ scrutiny • Reflexivity

27. Rigor Enhancing Techniques: Confirmability Confirmability: results objectively corroborated by the obtained data • Confirmability Audit • Concurrent with dependability audit • Field Notes • Confirmability enhanced by triangulation, member checking, and referential adequacy techniques

28. Participants’ Definition of Spirituality • “Spirituality is my relationship with God.” • “His [God’s] presence in your life…at all times being aware of his love and that he knows every little thing that is going on.” • “The inner peace that comes from knowing that God is present in your life.”

29. Reports of Spiritual Growth • “I think it [having cancer] made me stronger, my religious values, my faith.” • “I feel like my spirituality has grown tremendously because of this.” • “I am more spiritual.” • “From that time on, it was much easier to stay in touch with my spirituality.” • “The level of my commitment was raised and deepened and I don’t know how to express it.”

30. Domain 1Increased God Locus of Control (11) • Increased acceptance of God being in control “Ultimately I have no control over this. I can turn it over to God and let him carry it.” • Increased surrendering of fate to God/Acceptance “Acceptance is the key to cancer. It is the key to religion, to spirituality.” “Putting him [God] in charge of what I did instead of myself was probably how I grew the most.”

31. Domain 1Increased God Locus of Control “I walked out in my front yard, looked up, my hands and arms to the sky and I said, ‘Lord this is too big for me to handle by myself, so here I am. If you’ll get me through it I’ll do what you tell me to do.’ I put my faith in the divine healing power. Prayer and faith is the strongest part of coping with cancer.”

32. Domain 2Increase in Divine Peace (8) • Fear of death/the future followed by peacefulness “If God’s plan for my life is that I’m gonna die from breast cancer, then I accept that. It’s like a calmness and a strength that I can’t explain.” • Peace attributed to Spirituality “I had such a peace that came from my faith and my belief.” “Where is this peace and this evenness in my life coming from? Well, it is coming from God.”

33. Domain 2Increase in Divine Peace “I have made the choice not to live in fear of it [cancer] coming back. I believe in my heart that it may eventually be what I die of, but we are all going to die of something. People that know me will just say that it seems there is such a calmness now. I don’t have the fear. I leave it in God’s hands and I do not have any of that fear and anxiety when I do.”

34. Domain 3Enhanced Prayer Experience (9) • Increased quality (but not frequency or duration) of prayers “It increased the concentration and intensity and energy that I put into them [prayers].” • Deeper emotional connection or psychological bond with God “It brought me closer [to God]. It seemed like having that cancer put me sure enough in his arms. It’s just like it’s a closer bond now.” • Increased spontaneity “They [prayers] are just more conversational now. Instead of having a separate prayer time, it is just more a part of everything I do throughout the day. Just that awareness of God in every situation.”

35. Domain 3Enhanced Prayer Experience “I probably became more teachable during that time. And because I was so needy I was more willing to listen. I would just picture myself literally sitting in his [God’s] lap with my head against him, and it wasn’t like that before. It just made me seek Him in a different way because of how he literally met every one of those needs. It has really made me look at him like a daddy.”

36. Domain 4Increased Spiritual Support (6) • Spiritual support from family/friends “When I was diagnosed with cancer, I was just overwhelmed with the support I got. I had people writing me and telling me that I was in their prayers and I received letters and phone calls from people I didn’t really know.” • Novel spiritual experiences with others “People would just come up behind me [at church] and touch me and pray for me.”

37. Domain 4Increased Spiritual Support “I feel like they [family/friends] really did rally and were very supportive. I had people that were just lifting me up in every possible way. I had a steady stream of people coming through my [hospital] room and I had all kinds of people pray with me in my room. It was just an experience that I wouldn’t take anything for.”

38. Domain 5Heightened Sense of Divine Purpose (8) • Divine purpose for the cancer experience. Ranged from vague to specific “I know he [God] has a plan for my life and that I have work to do.” “Maybe it [the reason for having cancer] was to be able to be there for other people, to listen to them, to tell them that I am a cancer survivor, to make them feel a little more at ease about what they are going through.”

39. Domain 5Heightened Sense of Divine Purpose “There’s no doubt that everything I’ve been through, God has brought it to this incredible plan for me. And I will gladly have gone through this and whatever else I need to go through to bring about his purpose for me.”

40. Domain 6 (novel)Increased Evangelism (4) • More motivation to talk about spiritual beliefs “Before I had cancer, I didn’t share God with others like I should. I give my testimony a lot more often than I used to.” • Increased boldness, less fear “I was always afraid to talk to anybody about my faith. But I’ve found most people don’t mind hearing it. I was supposed to have died but I didn’t and I feel God had a part in that. Most people take that kind of seriously.”

41. Domain 6 (novel)Increased Evangelism “I never would have been one that would have gone up front and prayed on the alter or talked to anybody about my feelings. That Sunday whenever I got to go home [from the hospital], I went to church and stood in front of the church and told everybody what had happened and about the miracle and their prayers and what it had done for me. I would have never done that before. I have completely changed. I just feel like anybody that will listen I’ll tell about my story and I’ve probably told it a million times.”

42. Domain 7 (novel)Enhanced Spirituality of Family and Friends (7) • Positive impact on family’s spirituality “I think there has been a renewed sense of the importance of faith in my family.” “To some extent every member of my family experienced a deepened spirituality and a heightened commitment to the Lord.” “Not only did cancer re-affirm my faith, it helped my children have faith.”

43. Domain 7 (novel)Enhanced Spirituality of Family and Friends • Increased public prayers of significant others “One of my sons went to youth and they had a prayer vigil for me the night they found out.” • Increased spiritual activity in faith community “When she found out I had cancer, immediately she put that ministry in place.”

44. No Growth Domains • Spiritual history • No effect on spiritual beliefs • No effect on conflict resolution “I just didn’t have any difficulties [in relationships] that I remember.”

45. Miscellaneous Quotes • “Being cured would be nice, but I don’t think I would say I would’ve not liked to have ever had this experience because it has really improved my life.” • “Cancer is not a death sentence. It takes courage and determination.” • “All prayers are not answered. That is another thing it [cancer] taught me.” • “There are worse things than dying. Living and not being able to love or just being after money or whatever, that is worse than dying.”

46. Implications and Contribution • Inform PTG Theory • Increased understanding of the construct of spirituality and its difference from religion • Increased understanding of the process of PTSG • Spiritual growth was reported across several domains of spirituality setting the stage for future domain-specific research • Beginning point for understanding how spiritual growth may aid coping—corollaries and predictors • Introduced the idea of vicarious posttraumatic spiritual growth • Beginning point for a measure of posttraumatic spiritual growth—further illuminated salient domains

47. Limitations • Inability to generalize results, transferability only • Results are only explanatory, not predictive • Participants were demographically homogeneous: all Christian, mostly female, breast cancer survivors, Caucasian • Self-selection/Informant’s potential bias when selecting participants • All participants reported being quite spiritual prior to cancer experience—more likely to engage their spirituality to cope

48. Clinical Implications • Spirituality can be a facet of resilience. • Spirituality can be a source of coping. • Important to understand how spirituality can be used to aid coping. • Difficult life experiences can have a positive impact on lived experience (spirituality included).

49. Questions, Comments, and Discussion