Article Highlights
- Mindfulness is positively associated with posttraumatic growth of Chinese people with cancer.
- Self-compassion mediates the relationship between mindfulness and posttraumatic growth.
- Cognitive reappraisal mediates the relationship between mindfulness and posttraumatic growth.
Individuals often experience different types of traumatic events in their lives. Research findings show that individuals who experience traumatic events may experience negative psychological reactions such as fear, sadness, anxiety, and posttraumatic stress disorder (McLean et al., 2015). Scholars have gradually begun to focus on the positive outcomes of disasters, believing that even though disasters can have negative effects on people, they can also bring new hopes and opportunities (Tian et al., 2016). Human beings have an inherent internal growth mechanism, which can lead them to fight against traumatic events and show positive psychological changes after traumatic experiences (Şengün İnan & Üstün, 2020), a process that is termed posttraumatic growth (PTG). Researchers have found PTG is prevalent in earthquake and tsunami survivors, postwar soldiers, battered women, and other groups of people who have experienced traumatic events (McElheran et al., 2012; Mesidor & Whaley, 2022). Hamama-Raz et al. (2019) observed PTG in people with cancer. In a study conducted with women who had survived ovarian cancer, Oh et al. (2021) found that those with high levels of PTG often had better psychological and emotional treatment outcomes than did those with low levels. As PTG plays an important role in the outcome for people who have cancer, it is necessary to identify the factors that contribute to PTG, which can serve as a theoretical basis for increasing PTG levels in people with cancer.
Researchers have conducted extensive research on cognitive factors, such as cognitive remodeling and rumination, as well as social environmental factors, such as social support and social atmosphere (Wu et al., 2014). Among the factors proposed as potential contributors to PTG, one that scholars have consistently proposed is mindfulness. Described as conscious and nonjudgmental attention to the present, mindfulness highlights the reality of life in the present moment (Kabat-Zinn, 2003). It is considered an important factor in the development of PTG and can be used as an adaptive coping resource (An & Ma, 2020). According to mindfulness-to-meaning theory, mindfulness helps people to understand and accept negative experiences, which may allow them to cope positively with traumatic events and promote adaptive psychological functioning (Garland et al., 2015). In studies on the relationship between mindfulness and PTG, researchers have found that mindfulness contributes to the development of PTG (Huang et al., 2019; Norouzi et al., 2017; Nurfadhilah et al., 2017). However, although scholars have conducted extensive research on PTG, very few studies have been conducted to test the relationship between mindfulness and PTG in the context of treating people with cancer (An & Ma, 2020). Further exploration is needed of the relationship between mindfulness and PTG of people with cancer, as well as the mediating variables in this relationship. Our aim in this study was to examine the relationship between mindfulness and PTG among people in China who had been diagnosed with cancer, as well as the mediating variables in this relationship. We focused on two possible mediating variables—self-compassion and cognitive reappraisal.
Neff (2016) defines self-compassion as individuals’ attitude toward themselves after experiencing negative events. It is the ability to empathize with oneself when experiencing inadequacy, failure, or pain (Neff, 2003), thus comprising a type of positive emotional self-awareness that can protect the individual from the destructive effects of self-judgment, loneliness, and rumination (Yousefi Afrashteh & Hasani, 2022). In their empirical research, Sun et al. (2021) found a moderately positive correlation between mindfulness and self-compassion. Sünbül and Güneri (2019) found that mindfulness had a positive and significant effect on self-compassion. Akase et al. (2020) also showed that participation in mindfulness-based interventions can increase individual self-compassion.
Self-compassion plays a protective role when individuals are exposed to traumatic experiences (Dahm, 2013). Individuals with high levels of self-compassion tend to understand and care for themselves in adverse circumstances (Dahm, 2013). Rather than exaggerating and focusing excessively on their current negative emotions in order to mask their painful feelings, they often display an open and tolerant attitude toward the traumatic events they have experienced, presenting an unbiased understanding of their pain and frustration and viewing their experience as a common experience of all humanity (Neff, 2003). Findings of recent studies have shown that self-compassion is positively associated with PTG (Basharpoor et al., 2021; Khursheed & Shahnawaz, 2020). Wong and Yeung (2017) also observed that self-compassion led to the development of PTG. These findings suggest a mediating effect of mindfulness on PTG through self-compassion.
Cognitive reappraisal is another concept related to mindfulness and PTG. There are two main emotion regulation strategies, expressive suppression and cognitive appraisal. The goal of regulating one’s emotions by actively reassessing the meaning of events is termed cognitive reappraisal (Gross, 2015). It acts as a healthy and adaptive emotion management technique, increasing positive emotions or decreasing negative emotions by changing how a traumatic event is perceived. Mindfulness enhances cognitive flexibility, allowing for the selection of adaptive reappraisals. The open, receptive, nonjudgmental, and nonresponsive attitude of individuals with high levels of mindfulness toward emotional experiences helps to improve their ability to regulate emotions (Liu et al., 2015). According to the mindful reappraisal model, participating in mindfulness-based interventions can help individuals to gain more diverse awareness and pay more attention to environmental information, thus improving their cognitive reappraisal (Troy et al., 2013). In several studies, researchers have found a positive relationship between mindfulness and cognitive reappraisal (Garland et al., 2009, 2011). Hanley et al. (2017) also found that mindfulness plays a central role in improving cognitive reappraisal.
Research has shown that cognitive reappraisal helps people cope with traumatic situations by regulating their emotions (Butler et al., 2019). After experiencing a traumatic event, individuals with high levels of cognitive reappraisal can re-establish their understanding of the impact of the emotional event, re-evaluate their emotional state, make efforts to repair negative emotions, and establish a better psychological state (Tian et al., 2016). Therefore, cognitive reappraisal helps individuals to improve their negative emotions after trauma, regulates the negative effects of posttraumatic stress disorder on individuals, and also helps individuals to achieve PTG. According to the functional model of PTG, positive change after trauma requires a process of cognitive restructuring, and cognitive reappraisal helps people to rethink the whole event more actively, form a new life narrative, and ultimately facilitates the generation of PTG (Tedeschi & Calhoun, 2004). Cognitive reappraisal helps people to see their traumatic experiences as an opportunity to grow, learn about themselves, and find a new purpose in their life, thereby allowing them to improve their difficult situation by changing their negative emotions (Zhou et al., 2015). Zhou et al. (2018) also showed that cognitive reappraisal was positively related to PTG. These findings suggest a mediating effect of mindfulness on PTG through cognitive reappraisal.
Although the concept of PTG has been studied in the context of some adverse life events, the growth process resulting from the impact of cancer has practical and theoretical significance. Our aim in this study was to explore the mediating roles of self-compassion and cognitive reappraisal in the association between mindfulness and PTG of people in China who had been diagnosed with cancer, in order to gain a better understanding of these people and promote their PTG. Based on the current literature, three main hypotheses were developed:
Hypothesis 1: Mindfulness will have a positive association with posttraumatic growth of people with cancer.
Hypothesis 2: The association between mindfulness and posttraumatic growth of people with cancer will be mediated by self-compassion.
Hypothesis 3: The association between mindfulness and posttraumatic growth of people with cancer will be mediated by cognitive reappraisal.
The hypothetical model is shown in Figure 1.
Figure 1. Hypothetical Model
Method
Participants
For this study, we randomly selected 315 men and women who had been or were being treated for cancer (176 men and 139 women) living in different regions of China. The study was conducted from May to August 2022 (see Table 1 for details).
Inclusion criteria were a) voluntary participation in the survey and the ability to answer all survey items; b) a certain level of language comprehension and expression ability; and c) a cut-off point of two months since diagnosis for participation because Chinese scholars have previously found that cooperation of people newly diagnosed with cancer in answering questionnaires is not high. Exclusion criteria were a) receiving treatment for other types of serious or chronic diseases and b) mental or cognitive problems.
This study was approved by the Medical Ethics Committee of Mudanjiang Medical University, and all participants and their families were informed and gave consent.
Table 1. Sociodemographic and Medical Data of Participants
Procedure
An online survey was conducted. The survey was created using the Questionnaire Star network platform and shared with participants via WeChat and other mobile communication applications, along with instructions. Participants could answer the questions on a mobile phone or computer. Before distributing the survey, the participants were informed that the data collected in this survey was for scientific research only and would not be shared with others. They were asked to answer according to their own situation. The whole process took approximately 15 minutes.
Measures
Participants completed measures to assess their mindfulness, self-compassion, cognitive reappraisal, and PTG levels. Sociodemographic and clinical data (such as age and gender) were also collected.
The Mindful Attention Awareness Scale
The Mindful Attention Awareness Scale, developed by Brown and Ryan (2003) and translated into Chinese by S. Chen et al. (2012), was used to measure level of mindfulness. This scale consists of 15 items in one dimension (e.g., “It’s difficult for me to continuously focus on what's happening”). Each item is scored on a 6-point scale (1 = never; 6 = always). Greater mindfulness is indicated by a higher total score. Results in previous studies indicate that the scale is valid and reliable and can be used to assess mindfulness of Chinese people (S. Chen et al., 2012). In our study Cronbach’s alpha value was .88.
Self-Compassion Scale
The Self-Compassion Scale developed by Neff (2003) and translated into Chinese by J. Chen et al. (2011), was used to assess the participants’ level of self-compassion. This scale contains 26 items and a 5-point scoring technique is used (1 = extremely inconsistent behavior, 5 = highly consistent behavior). It consists of six dimensions: self-kindness (e.g., “I try to be loving toward myself when I’m feeling emotional pain”), acceptance of the present situation (e.g., “When something upsets me I try to keep my emotions in balance”), universal humanity (e.g., “When things are going badly for me, I see the difficulties as part of life that everyone goes through”), isolation (e.g., “When I fail in something important to me, I feel lonely in the midst of failure”), self-judgment (e.g., “I’m disapproving and judgmental about my own flaws and inadequacies”) and overidentification (e.g., “When I’m feeling down, I tend to obsess and fixate on everything that’s wrong”). The first three dimensions are examples of positive self-compassion, whereas the last three dimensions are forms of negative self-compassion. The scores of the three negative dimensions are reversed when calculating the total score. The level of self-compassion is directly correlated with the total score. Results in previous studies indicate that the scale is valid and can be reliably applied to the Chinese population (J. Chen et al., 2011). In this study Cronbach’s alpha value was .86.
Emotion Regulation Questionnaire
The Emotion Regulation Questionnaire, developed by Gross and John (2003) and translated into Chinese by Wang et al. (2007). It was used to measure participants’ level of cognitive reappraisal. This scale consists of 10 items in two dimensions. A sample item for cognitive reappraisal (six items) is “When faced with stressful situations, I think about them in a way that calms me down,” and for expressive suppression (four items) a sample item is “I won't express my emotions.” A 7-point scale is used, with 1 = strongly disagree and 7 = strongly agree. Results in previous studies have shown that the scale is valid and can be used reliably with the Chinese population (Wang et al., 2007). In this study we used only the cognitive reappraisal dimension and Cronbach’s alpha value was .88.
Posttraumatic Growth Inventory
The Posttraumatic Growth Inventory was developed by Tedeschi and Calhoun (1996) and translated into Chinese by Zhou et al. (2015). It was used to measure the level of posttraumatic growth among participants. This scale contains 22 items in five dimensions, new possibilities (three items, e.g., “I have established a new direction for my life path”), spiritual change (three items, e.g., “I have a better understanding of spiritual things”), personal strength (five items, e.g., “I know I have the ability to handle difficulties”), relationship with others (six items, e.g., “I am closer to others”) and appreciation of life (five items, e.g., “I can make my life better”). A 6-point scale is used, with 0 indicating strongly disagree and 5 indicating strongly agree. The level of posttraumatic growth is directly correlated with the total score. Cronbach’s alpha value in our study was .83.
Data Analysis
Firstly, we used descriptive analyses and Pearson correlations to calculate the mean, standard deviation, and correlation between variables using SPSS (Version 22.0). Secondly, we constructed a multiple mediation structural equation model to test the effect of mindfulness, self-compassion, and cognitive reappraisal on PTG of the participants using Mplus (Version 7.4). Third, the bias-correlated bootstrapping procedure in Mplus (Version 7.4) was used to analyze the direct and indirect effects between variables based on a 1,000 resample. The effects were tested at a significance level of .05 and a bias-corrected 95% confidence interval (CI).
Results
Descriptive Statistics
Means, standard deviations, and correlations between variables were calculated based on total scores for each of the measures. There were significant positive correlations (all p < .01) between mindfulness, self-compassion, cognitive reappraisal and PTG (see Table 2).
Table 2. Means, Standard Deviations, and Correlations for Study Variables
Multiple Mediation Analysis
We examined each path in the model and found that the paths between mindfulness and PTG, mindfulness and self-compassion, mindfulness and cognitive reappraisal, self-compassion and PTG, and cognitive reappraisal and PTG were all significant (see Figure 2). The results showed that the structural equation model had a satisfactory fit (see Table 3).
Figure 2. Multiple Mediation Structural Equation Model for Mindfulness, Self-Compassion, Cognitive Reappraisal, and Posttraumatic Growth of Chinese People With Cancer
Note. N = 315. x = mindfulness; m1 = self-compassion; m2 = cognitive reappraisal; y = posttraumatic growth.
*** p < .001.
Table 3. The Fit Indices of the Model
Note. CFI = comparative fit index; TLI = Tucker–Lewis index; RMSEA = root mean square error of approximation; SRMR = standardized root mean square residual.
To test the indirect effect of mindfulness on PTG through self-compassion and cognitive reappraisal, bias-corrected bootstrapping estimates were computed using Mplus (Version 7.4). If the CI excludes zero, there is a mediating effect. We included two indirect pathways. The results showed that both self-compassion and cognitive reappraisal played mediatory roles between mindfulness and PTG with the 95% CI not including zero (see Table 4).
According to the path coefficients of the structural model, the total value of the mediation effect of self-compassion and cognitive reappraisal on PTG is .328. The indirect effect of mindfulness on PTG accounts for 62.48% of the total effect.
Table 4. Direct and Indirect Paths and Standardized Estimates for Mediation Effects of Self-Compassion, Mindfulness, and Cognitive Reappraisal on Posttraumatic Growth
Note. x = mindfulness; m1 = self-compassion; m2 = cognitive reappraisal; y = PTG. CI = confidence interval; LL = lower limit; UL = upper limit.
Thus, a significant and positive relationship was observed between mindfulness and PTG, confirming Hypothesis 1. We also found that mindfulness may increase PTG by indirectly increasing self-compassion, confirming Hypothesis 2. The results also showed that cognitive reappraisal could mediate the relationship between mindfulness and PTG, which confirmed Hypothesis 3.
Discussion
We constructed a multiple mediation model to examine the associations between mindfulness and PTG and the mediating role of self-compassion and cognitive reappraisal among Chinese people with cancer. The results indicate that, among our participants, mindfulness was significantly and positively related to PTG, and self-compassion and cognitive reappraisal played mediating roles between the two.
Consistent with previous studies (An & Ma, 2020; Huang et al., 2019), a significant and positive relationship was observed between mindfulness and PTG. According to the mindfulness-to-meaning theory, mindful individuals are more likely than their peers to evaluate their trauma and see it as a step toward personal change and growth (Garland et al., 2015). As an adaptive process and an important protective factor in coping with traumatic events, mindfulness can improve emotional regulation by enhancing external and internal awareness of biological and cognitive processes, thereby reducing the risk of psychological disorders (LeBlanc et al., 2021). Mindfulness allows individuals to focus on the present moment with a nonjudgmental and nonreactive mindset, thereby reducing the distress associated with negative life events. As a result, people with cancer who are mindful can manage the negative feelings and emotions associated with the disease more effectively and adaptively than those who are not mindful. This can lead them to accept their circumstances, acknowledge their progress, improve their relationships with others, find new possibilities, perceive themselves as stronger than they are, and experience spiritual growth (Aliche, 2023).
In addition, the mediation effect analysis indicated that mindfulness may increase PTG by indirectly increasing self-compassion. Specifically, we found that mindfulness was associated with greater self-compassion, which was further associated with greater PTG. Mindfulness can evoke positive psychological qualities, such as self-compassion, which is particularly important for people with cancer (Aliche, 2023). Mindfulness guides individuals to focus on their current feelings through a peaceful and kind attitude, and helps them to cultivate self-compassion (Tian & He, 2021). It can also help people resist the destructive effects of negative self-judgment and use emotion regulation strategies more effectively by developing a more benevolent and compassionate attitude toward themself during trauma (Yousefi Afrashteh & Hasani, 2022).
As a positive attitude, self-compassion can help people with cancer restructure their perception of themself and their environment through self-care and understanding, and promote positive thinking about the impact and significance of traumatic events (Zhu et al., 2019). People who have cancer and who have high levels of self-compassion live with a positive attitude and evaluate traumatic events from a positive cognitive perspective (van der Donk et al., 2020). They also maintain a sense of balance between their thoughts and feelings, view their illness as a common human experience, and express goodwill and understanding toward themselves, which helps them in developing PTG effectively (Basharpoor et al., 2021). Compared with individuals high in self-compassion, those low in self-compassion are unable to treat traumatic events and themselves with a positive attitude, suffer more emotional distress, and immerse themselves in negative rumination and emotions related to the traumatic events. This will lead to a greater number of, and more severe, negative symptoms of psychological disorder (Winders et al., 2020) and will hinder the development of PTG.
Finally, the results also showed that cognitive reappraisal could mediate the relationship between mindfulness and PTG. Specifically, our results showed that mindfulness was associated with a more extensive cognitive reappraisal, which was further associated with greater PTG. Scholars believe that mindfulness can move individuals to use the emotional regulation mode of cognitive reappraisal (Garland et al., 2017). The emphasis in mindfulness is on awareness of the present and present experiences, changing the thought process from the doing mode to the being mode and paying less attention to future expectations, which leads to the positive effect of cognition and promotes the use of reappraisal strategies (Liu et al., 2015).
In addition, cognitive reappraisal promotes PTG. This also supports the view put forward by scholars in previous studies that cognitive reappraisal is conducive to achieving positive psychological outcomes and is a healthy emotion regulation strategy. According to the emotional regulation process model, cognitive reappraisal can help people who have cancer construct a new perception of the disease and realize the importance of the world, reduce their negative emotional experiences and behavioral expressions, alleviate their negative feelings, and enable them to face difficulties from a more positive perspective, which can result in PTG (Gross, 1999). Cognitive reappraisal can also help people with cancer to re-evaluate the meaning of negative events, trust their abilities, reflect on their life, and find new possibilities after the disease has affected them, thereby helping them to achieve PTG.
The results of this study have theoretical and practical implications. We found that self-compassion and cognitive reappraisal independently mediated the association between mindfulness and PTG. This not only supports the mindfulness-to-meaning theory, but also expands the scope of this model and confirms that the theory is applicable to the Chinese context. The findings can also guide people with cancer who need psychological support. They can be provided with training to improve their mindfulness level, which can enhance their self-compassion and cognitive reappraisal, thus promoting the development of PTG.
The study has several limitations. First, the study is correlational. We used a cross-sectional design, and the results cannot indicate causality. In the future, a longitudinal study should be conducted to establish the causal relationship among the different factors. Secondly, in this study we examined mediation effect only. We identified the mediators between mindfulness and PTG, but future studies are needed to examine the moderators of the factors we examined. Thirdly, in this study we used a single data collection technique. Data were collected using a survey, which raised the possibility of common method bias. The survey used in this study contained a large number of items, which may have caused fatigue in responding to all of them. Future research should use additional psychometric tools, such as interviews and shorter surveys.
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