Psychosocial determinants of post-traumatic stress among cancer survivors
Cancer survivors can experience a number of consequences of their disease, both physical and psychological. In this thesis, I aimed to clarify the psychosocial processes that reduce or increase post-traumatic stress after cancer. “Social support,” for instance, has often been linked to post-traumatic stress, but I describe several problems with this concept. Alternatively, inspired by the Social Identity Approach (SIA) to health, I proposed that group identification, or a sense of belonging and commonality with social groups, might predict levels of post-traumatic stress after cancer. In line with Social Cognitive Processing Theory (SCPT), I also proposed that cancer survivors’ perceptions that members of their social groups are closed, judgmental, and unreceptive in conversations about cancer (“group constraints”) might predict post-traumatic stress. I proposed that these constructs might act in tandem to predict levels of post-traumatic stress. To begin my programme of research, I conducted a meta-analysis that established factors contributing to post-traumatic stress disorder (PTSD). I also found an increased prevalence of PTSD among cancer survivors compared to controls without cancer. This meta-analysis demonstrated that cancer survivors can experience PTSD related to their illness. Subsequently, I undertook a series of quantitative questionnaire studies to establish psychosocial determinants of post-traumatic stress. My questionnaire included scales measuring post-traumatic stress, social support, group identification, and group constraints. In a pilot study, I used convenience sampling to test out the acceptability of the questionnaire and to provide a foundation for further hypothesising. Then, I distributed this piloted questionnaire to colorectal cancer survivors in Tayside. In initial “wave 1” cross-sectional analyses of this data, I found that social support was not an independent predictor of post-traumatic stress in multivariate analyses. However, group constraints consistently and independently predicted post-traumatic stress. Group identification exerted an effect on post-traumatic stress by reducing group constraints. I then distributed the same questionnaire a second time to the same respondents from wave 1 in order to collect longitudinal data. The results of the data from respondents at both waves 1 and 2 revealed that social support was, in fact, a likely causal predictor of post-traumatic stress. Constraints within the family also causally reduced post-traumatic stress. Family identification was a weak causal factor in reducing post-traumatic stress, but reciprocally, post-traumatic stress reduced group identifications. The longitudinal data also provided further, albeit not strong, support for the hypothesis that family identification reduces post-traumatic stress by reducing constraints on conversations within the family. Finally, in light of the consistent evidence from the quantitative studies above that conversational constraints are associated with increased post-traumatic stress, I conducted a qualitative interview study with a small number of cancer survivors aiming to characterise their experiences of conversations about cancer. The participants reported a broad range of experiences, beyond just constraints versus openness. These findings have broad implications for both theory and practice. For instance, in the final chapter, I discuss ways in which these results motivate further research on intersections between the Social Identity Approach and cancer-related post-traumatic stress. I also discuss implications for interventions going beyond traditional trauma exposure techniques.
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