In 2007 in the United States alone, nearly 1.5 million individuals

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1 Benefit Finding in the Cancer Caregiving Experience YOUNGMEE KIM, PHD, RICHARD SCHULZ, PHD, AND CHARLES S. CARVER, PHD Objective: To characterize the domains of benefit finding in caregiving among close family members of cancer survivors and to relate the domains of benefit finding in cancer caregiving to other psychosocial variables. Although cancer is a problem that involves the entire family, little is known about which caregivers of cancer survivors are likely to find meaning in their caregiving experience or about the relationship of benefit finding to caregivers psychological adjustment. Methods: A total of 896 family caregivers participated in the American Cancer Society Quality of Life Survey for Caregivers. Participating caregivers were primarily middle-aged (mean age 54 years), educated (76% received high school degree), and affluent (69% earned $40,000 annual household income). Results: Six domains of benefit finding in caregiving were identified by principal axis factor analysis: acceptance, empathy, appreciation, family, positive self-view, and reprioritization. The comparison between six- and one-domain models of benefit finding demonstrated the superiority of the six-domain model. A series of hierarchical regression analyses showed that the domains of benefit finding were uniquely associated with life satisfaction and depression and that not all aspects of benefit finding in caregiving related to better adjustment. Specifically, coming to accept what happened and appreciating new relationships with others related to greater adaptation. Becoming more empathetic toward others and reprioritizing values related to greater symptoms of depression. Conclusions: These findings suggest that caregivers may benefit from interventions that enhance their ability to accept their situation and find meaning in their caregiving experience, which may improve their satisfaction with life and reduce their depressive symptoms. Key words: benefit finding, caregiving, cancer care. CES-D Center for Epidemiologic Studies Depression Index. INTRODUCTION In 2007 in the United States alone, nearly 1.5 million individuals will be newly diagnosed with a cancer, and 550,000 will die from this disease (1). Although the 5-year survival rate for all cancers has improved from 50% ( ) to 65% ( ) (1), people still perceive cancer as a life-threatening disease. Consequently, a cancer diagnosis is likely to immediately evoke existential apprehensions and concerns for the individuals with the disease as well as their families and close friends. Many studies have documented the negative secondary impact of cancer on the family, such as heightened levels of psychological distress equal to or even greater than those of survivors (2 4). Recent studies, however, have also shown that both patients and their families can find benefit in the challenges associated with cancer. Different terminologies (e.g., benefit finding, posttraumatic growth, stress-related growth) and measurement tools have been used to describe the phenomenon of personal growth or positive changes after an encounter with a challenging or traumatic life experience. In this study, we use the term benefit finding to refer to this phenomenon. Most studies on benefit finding with regard to cancer have focused on the individuals who have been diagnosed with cancer (5 10). Those studies found that women who had been diagnosed with breast cancer came to appreciate life, became From the Behavioral Research Center (Y.K.), American Cancer Society, Atlanta, Georgia; Department of Psychiatry (R.S.), University of Pittsburgh, Pittsburgh, Pennsylvania; and Department of Psychology (C.S.C.), University of Miami, Miami, Florida. Address correspondence and reprint requests to Youngmee Kim, Behavioral Research Center, American Cancer Society, 250 Williams Street NW, Atlanta, GA youngmee.kim@cancer.org Received for publication May 5, 2006; revision received December 1, This study was funded by the American Cancer Society National Home Office, intramural research. DOI: /PSY.0b013e cf /07/ Copyright 2007 by the American Psychosomatic Society closer to family, and became more spiritual, when compared with healthy women matched on age and educational levels (11). Three out of four families in the United States have at least one member who is a cancer survivor (12); yet, little is known about the family members growth experiences from the challenge of dealing with cancer in a close relative. Cancer caregiving differs in important ways from other groups of caregivers with regard to the levels of caregiving involvement and caregiving outcomes (13,14). This makes comparisons with other groups of caregivers somewhat tenuous. A small number of studies have examined benefit finding among family members of cancer survivors, primarily spouses of breast cancer survivors. For example, Weiss (15) found that husbands reported an experience of benefit finding 1 to 5 years after their wives breast cancer diagnosis, although at lower levels than their wives did. Manne, Ostroff, and colleagues (4) replicated these findings with partners of breast cancer survivors who were 18 months post diagnosis. Manne, Babb, and colleagues (16) also examined benefit finding among wives of men with prostate cancer. They found that participants in a psychoeducational intervention group reported gains in the use of positive reappraisal coping and reductions in denial coping. Although these variables are not the same as benefit finding, they are similar in some respects. Studies on benefit finding in caregiving experiences with other illnesses, such as human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) (17) and multiple sclerosis (18), have also emerged in recent years in qualitative (19) and quantitative studies (17,18). These studies suggested that the benefit finding phenomenon may occur among family caregivers of persons with medical illnesses as well as the patients themselves. The study reported here extends this literature by pursuing two broad goals: to characterize the domains of benefit finding among diverse family members (i.e., spouse versus nonspouse) providing care to a relative with cancer and to relate the domains of benefit finding in cancer caregiving to psychosocial correlates and outcome variables. 283

2 Y. KIM et al. Domains of Benefit Finding in Cancer Caregiving Benefit finding has been conceptualized as a phenomenon with multiple manifestations (8,9,20,21). Both open-ended and structured scales have been used to assess this construct, with some inconsistencies from one study to another. For example, Tedeschi and Calhoun (21) categorized posttraumatic growth into five domains: new possibilities, relating to others, personal strength, appreciation of life, and spiritual change. Tomich and Helgeson (9) also suggested five domains of benefit finding for breast cancer survivors: personal priorities, daily activities, family, world views, and relationships. Bower and Segerstrom (20) postulated four types of benefit finding: an accepting attitude toward life, positive change in self-view, change in interpersonal relationships, and a deeper sense of purpose in life with a greater focus on important goals and priorities. Overall across studies, changes in self-view, interpersonal relationships, attitude toward life, and spirituality have been identified consistently as subdomains of benefit finding. Because benefit finding with regard to cancer has been mostly studied in individuals who were themselves diagnosed with cancer, the first goal of this study was to explore the domains of benefit finding among family caregivers of cancer survivors. We used the 17-item Benefit Finding Scale described by Antoni and colleagues (5). The goal was to provide empirical evidence about the types of benefits reported by family members who have been caregivers of cancer survivors. Psychosocial Correlates of Benefit Finding in Cancer Caregiving The stress and coping paradigm is the most widely used framework for elucidating how individuals stress appraisals influence their mental and physical health outcomes (22). The primary appraisal of the stressor, such as the severity of the threat, has been associated with levels of benefit finding, supporting the view of Tedeschi and Calhoun (21) that personal growth likely develops from painful and difficult events. For instance, cancer survivors who were diagnosed with an advanced stage of the disease reported greater benefit finding (9,11). For caregivers, their perceptions about their new role as caregivers and the health status of the care recipients may also function as significant stressors (23). Therefore, we hypothesized that greater caregiving stress (i.e., higher levels of perceived stress from providing care, poorer mental and physical of the care recipient) would be associated with greater benefit finding in cancer caregiving. A second important appraisal follows from resources available to the individual (secondary appraisal). The more the perceived resources, the lower the stress (22,24). Three personal or social resource variables were considered in this study: sociodemographic, spiritual/religious coping, and social support variables. These variables were used to test the second goal of the study, which was to identify personal and social characteristics that would relate to a higher or a lower level of benefit finding from providing care to a family member with cancer. With regard to sociodemographic resource variables, the associations with benefit finding have not been consistent across studies. For example, greater benefit finding has been linked to younger age (4,6,25,26) and lower education-income status (9), but another study found more benefit finding among those with more education (8). Thus, we explored the relationships between sociodemographic variables and benefit finding in cancer caregiving. With regard to coping strategies, certain strategies are more likely to emerge along with benefit finding (27,28). For example, cancer survivors who use coping strategies such as positive reappraisal (4,8), emotional expression (11,29), or emotional processing (4,30) have been found to report greater benefit finding. Coping strategies pertaining to religion or spirituality are also common. A recent national survey for caregivers documented that approximately four fifth of cancer caregivers use prayer to cope with caregiving demands (31). Studies with college students, although not directly pertaining to cancer, also related religious coping to greater benefit finding (32,33). Whereas some coping strategies (e.g., positive reappraisal) have been studied frequently and have related consistently to benefit finding, religious coping has been studied less frequently. Religious coping appears to share a similar adjustment mechanism with benefit finding by searching for meaning and focusing on existential concerns. For this reason, we elected to examine religious coping as a coping resource. We hypothesized that greater use of religious coping would relate to greater benefit finding among cancer caregivers. The perceived availability of social support as a social resource variable has also been related to greater benefit finding in cross-sectional studies of husbands of breast cancer survivors (34), persons with multiple sclerosis (35), caregivers of persons with HIV/AIDS (18), and college students who experienced a variety of stressful life events (33). We thus hypothesized that greater perceived availability of social support would be associated with greater benefit finding in cancer caregiving. In addition to identifying resource correlates of benefit finding, we also sought to explore the relationship between benefit finding and adjustment outcomes among cancer caregivers. Experiencing personal growth or positive changes after a challenging life event does not negate the adverse impact of the event (33). In other words, benefit finding may relate to positive and negative aspects of adjustment differently. Studies examining both positive and negative aspects of psychological adjustment have related benefit finding more to positive than to negative reactions (9). However, the number of studies to do this among caregivers is still limited (18). Furthermore, studies with breast cancer patients have failed to yield a consensus about how benefit finding relates to psychological adjustment (9,36). Thus, we also sought to relate finding benefit in a caregiving role to both positive (life satisfaction) and negative (depression) aspects of psychological adjustment. As we controlled for stressor and psychosocial characteristics of the individual, we examined the associations between benefit finding and these two indicators of psychological adjustment. 284

3 BENEFIT FINDING IN CAREGIVING METHODS Participants The American Cancer Society s Quality of Life Survey for Caregivers was designed to assess the impact of cancer on the quality of life of family members and close friends who care for cancer survivors. The data reported here are from the second wave of baseline data collection (August 2003 to February 2006). Participants were nominated by cancer survivors who completed the Study of Cancer Survivors. The survivors were asked to nominate individuals in a family-like relationship who constantly provided help to them. Eligibility criteria for participating in the caregiver study were as follows: a) age 18 years, b) ability to speak/read English or Spanish, and c) residence in the United States. A total of 896 close family members completed the survey (67.9% response rate), of whom 779 provided complete data for all study variables. Participants with incomplete data did not differ in most respects from those who provided complete information (p.11), except that family members who had missing data were older (t 3.29, p.001) or were less likely to provide care to a breast cancer survivor ( , p.05). Missing values ranged from 1.8% (n 16) to 5.8% (n 52) of a total of 896. Although the degree of missing data is not substantial, we used SAS PROC MIANALYZE for multiple imputation of missing values in the main study analyses. The self-reported levels of mental and physical of the care recipients (i.e., cancer survivors) were assessed with the Medical Outcomes Study Index (MOS SF-36) (37). The level of mental of the care recipients was comparable to the mean of the general population in the United States, whereas their physical was comparable to the 25th percentile of the population (37). Participating caregivers were primarily Caucasians (94.6%), middle-aged, educated, and affluent (Table 1). Approximately two thirds were female and spouses of the cancer survivors. Cancer types of care recipients were breast (28%), prostate (20%), colorectal (13%), lung (10%), non-hodgkin s lymphoma (8%), ovarian (6%), skin (5%), and TABLE 1. Descriptives of Study Variables Mean SD Possible Range Stressors Perceived caregiving stress Care-recipient s mental Care-recipient s physical Sociodemographics Age (actual) Gender (female), % 64.8 Education ( high school), % 76.3 Household income ( $40,000), % 68.5 Spouse, % 66.0 a Religious coping Social support Benefit finding in cancer caregiving Overall Acceptance domain Empathy domain Appreciation domain Family domain Positive self-view domain Reprioritization domain Psychological adjustment Life satisfaction Depression (CES-D) N 779. SD standard deviation; CES-D Center for Epidemiologic Studies Depress Index. a 4.2% parents; 7.3% sibling; 16.6% offspring; 3.8% friends. other ( 5% each of bladder, kidney, and uterine). The cancer had been diagnosed an average of 2.2 years (SD 0.6 year, range 1.3 to 4.7 years) before the caregivers completed the survey. The average duration of providing care was 19 months (SD 16 months). Procedure A packet containing an introductory letter, survey, self-addressed stamped envelope, frequently-asked-questions brochure, and a 60-minute phone card as an incentive was mailed to the nominated caregiver. Returning the completed survey served as informed consent to participate. If the caregivers had not returned the survey by 3 weeks after the initial mailing, follow-up phone calls were made. A second packet, which included the same materials except the phone card, was mailed 5 weeks after the initial mailing. A second follow-up phone call was made 8 weeks after the initial mailing if the caregivers had not returned the survey. This study was conducted in compliance with the regulation of Emory University Institutional Review Board. Measures Stressors Three measures served as indicators of the levels of stress associated with caregiving: perceived caregiving stress, care recipient s mental, and care recipient s physical. The extent to which caregivers felt overwhelmed by tasks and responsibilities was the index of perceived caregiving stress, assessed by the 4-item stress overload subscale of the Pearlin Stress Scale (38). The mean of the four items rated on a 4-point Likert-style format (1 not at all, 4 completely) represented the level of perceived caregiving stress, with higher scores reflecting greater stress from providing care to the cancer survivor. This scale had acceptable internal consistency (39) in the present study ( 0.70). Two additional stress indicators were the levels of care recipient s mental and physical (23). The mental score was a composite of weighted vitality, social, role-emotional, and mental health subscale scores. The physical score was a composite of weighted physical, role-physical, bodily pain, and general health subscale scores. Higher composite scores reflected better mental and physical, thus less likely to be stressful to caregivers. Psychosocial characteristics of caregivers Three psychosocial characteristics of caregivers included sociodemographic characteristics, religious coping, and social support. The sociodemographic characteristics examined included self-reported age, gender, education, household income, and spousal status (i.e., spouse versus nonspouse). The second psychosocial characteristic assessed was the extent to which family caregivers used religious coping strategies. This was measured using the religious coping subscale of the Brief COPE (40). The two items were rated on a 4-point scale (1 not at all, 4 a lot), and the mean score had high internal consistency ( 0.91). The third psychosocial characteristic assessed was the perceived availability of social support, that is, the extent to which the family caregivers perceived that emotional, informational, and instrumental support were available to them. This was measured using the 6-item version of the Interpersonal Support Evaluation List (41). The mean of the 6 items, rated on a 4-point scale (1 definitely false, 4 definitely true), had acceptable internal consistency ( 0.56). Benefit finding The degree to which family caregivers find meaning and experience personal growth was measured using the 17-item Benefit Finding Scale (5,28). The items were the same as used in previous studies. Instructions were modified so that participating caregivers rated each item in response to providing care for their relatives through their cancer experience, using a 5-point Likert-style format (1 not at all, 5 extremely). The composite score had good internal consistency in the present study ( 0.95). Psychological adjustment Two variables were included, a positive and a negative indicator of psychological adjustment. As a positive indicator of psychological adjustment, the 285

4 Y. KIM et al. degree to which family caregivers were in general satisfied with their lives during the past 4 weeks was measured by the Satisfaction With Life Scale (42), using a 7-point scale (1 strongly disagree, 7 strongly agree). This 5-item scale had good internal consistency in the present study ( 0.88). The negative measure of psychological adjustment was the overall level of depressive symptoms experienced in the past 4 weeks. This was measured using the 20-item Center for Epidemiologic Studies Depression Index (CES-D) (43). Approximately one fourth of family members (26.2%) in this sample had CES-D scores of 16, the usual criterion for moderate depression. Data Analyses Stressors and psychosocial characteristics of caregivers served as statistical predictors of the domains of benefit finding. These variables also served as covariates when testing associations of benefit finding with psychological adjustment. Descriptive information concerning the study variables is reported in Table 1. To accomplish the first aim of the study, which was to characterize the domains of benefit finding in cancer caregiving, factor analyses of the 17-item Benefit Finding Scale (Table 2) were conducted. Both descriptive and factor analyses were performed with participants who had complete data (n 779). The second aim of the study, to test study hypotheses and exploratory research questions, was examined with all participants (n 896). For those analyses, SAS PROC MI was used to generate multiple imputations for missing values (range 1.8% 5.8%), producing five data sets with imputed values. Results of hierarchical regression analyses for each of the data sets with imputed values were then subjected to SAS PROC MIANALYZE procedure to combine the results (44). These findings are reported in Tables 3 and 4. RESULTS Domains of Benefit Finding in Cancer Caregiving The first goal of the study was to examine factor structure in the 17-item Benefit Finding Scale (5,28) as applied to a sample of caregivers of cancer survivors. We first performed an exploratory factor analysis. The number of factors was determined by a parallel analysis, which performs better than the scree test used to determine the number of factors (45). Parallel analysis is a variant on the scree test, comparing eigen values derived from factoring a completely random set of data involving the same number of items and participants with eigen values for the actual data. Plots of these two sets of eigen values in descending order guide the point where the eigen values from actual data drop below the line defined by the average eigen values from the random data (46). The eigen values from the current data drop below the eigen values from the random data after 7 factors. These results suggest that six factors should be extracted for the Benefit Finding Scale applied to family caregivers of cancer survivors. Next, principal axis factoring analysis with promax rotation (46) extracted six factors. Factor loadings in the pattern matrix demonstrated that the six factors had clear patterns: each primary factor loading was 0.40 than the loadings on other factors for the same item with three exceptions (differences for these three ranged from 0.03 to 0.17). Only one of these three items loaded 0.40 on two factors (factors 5 and 6): Helped me become a stronger person, more able to cope effectively with future life challenges. (It should be noted, however, that all items had the highest loading on the first factor in the unrotated matrix.) As shown in Table 2, the first factor includes three items indicating changes in effort to accept things, which we labeled Acceptance. The second factor includes four items indicating increases in empathy for all human beings, which we labeled Empathy. The third factor includes three items indicating changes in appreciation in life, which we labeled Appreciation. The fourth factor includes two TABLE 2. Factor Loadings After the Promax Rotation From the Principal Axis Factoring Analysis Having provided care for the survivor through his/her cancer experience has... Factor Loading on Highest Loading Domain N 779. Factor 1: Acceptance ( 0.90) Taught me how to adjust to things I cannot change Helped me take things as they come Led me to be more accepting of things Factor 2: Empathy ( 0.89) Shown me that all people need to be loved Made me more aware and concerned for the future of all human beings Taught me that everyone has a purpose in life Made me realize the importance of planning for my family s future Factor 3: Appreciation ( 0.78) Contributed to my overall emotional and spiritual growth Led me to meet people who have become some of my best friends Helped me become more aware of the love and support available from other people Factor 4: Family ( 0.79) Brought my family closer together Made me more sensitive to family issues Factor 5: Positive Self-view ( 0.87) Led me to deal better with stress and problems Taught me to be patient Helped me become a stronger person, more able to cope effectively with future life challenges Factor 6: Reprioritization ( 0.78) Helped me realize who my real friends are Helped me become more focused on priorities, with a deeper sense of purpose of life

5 BENEFIT FINDING IN CAREGIVING TABLE 3. Standardized Coefficients From Hierarchical Regression Analyses for Predicting Overall or Subdomains of Benefit Finding in Cancer Caregiving Subdomains of Benefit Finding in Cancer Caregiving Overall Acceptance Empathy Appreciation Family Positive Self- View Reprioritization Step 1: Stressors Perceived caregiving stress ** ** Care recipient s mental Care recipient s physical * ** R 2 for stressor variables 0.01* 0.01*** * 0.02*** Step 2: Psychosocial characteristic variables Age * Gender (female) * Education ( college) 0.09** 0.08* 0.15*** * Income ( $40,000) Spouse Religious coping 0.35*** 0.21*** 0.30*** 0.44*** 0.28*** 0.28*** 0.25*** Social support 0.20*** 0.17*** 0.11*** 0.22*** 0.20*** 0.14*** 0.16*** R 2 for psychosocial variables 0.21*** 0.12*** 0.15*** 0.29*** 0.14*** 0.14*** 0.13*** N 896. Gender: female 1, male 0; education: college 1, high school 0; income: $40,000 1, $40,000 0; spouse: spouse 1, nonspouse 0. *p.05, **p.01, ***p.001. TABLE 4. Standardized Coefficients From Hierarchical Regression Analyses Predicting Life Satisfaction and Depression Life Satisfaction Depression Step 1: Covariates: stressors and sociodemographic variables Perceived caregiving stress 0.21*** 0.34*** Care recipient s mental 0.14*** 0.11** Care recipient s physical 0.10** 0.06 Age Gender (female) Education ( college) *** Income ( $40,000) * Spouse Religious coping 0.11*** 0.08** Social support 0.25*** 0.26*** R 2 for Covariates 0.18*** 0.28*** Step 2: Benefit finding in cancer caregiving Overall 0.10** 0.05 R 2 for benefit finding: overall 0.01** 0.00 Acceptance domain 0.14** 0.14** Empathy domain ** Appreciation domain 0.11* 0.01 Family domain Positive self-view domain * Reprioritization domain 0.16** 0.17*** R 2 for benefit finding: domains (average) 0.04*** 0.03*** N 896. Gender: female 1, male 0; education: college 1, high school 0; income: $40,000 1, $40,000 0; spouse: spouse 1, nonspouse 0. *p.05, **p.01, ***p.001. items about getting closer to family members, which we labeled Family. The fifth factor includes three items indicating positive changes in self perception, such as becoming stronger and better able to manage stress and problems, which we labeled Positive Self-View. The last factor includes two items indicating changes in evaluating importance of certain values, which we labeled Reprioritization. Composite scores for each domain of benefit finding, created by averaging relevant items, were used in the subsequent analyses. The six benefit finding composites had good internal consistency (Table 2). An overall score was highly related to each domain score (0.75 r 0.89, p.001) and the six domain scores were also highly related to each other (0.55 r 0.74, p.001). We further tested the factor structure of benefit finding in cancer caregiving by conducting confirmatory factory analyses, comparing six- and one-factor approaches. The six domains model, which emerged from our exploratory analysis, fit the data satisfactorily, , df 104, p.001, Normed Fit Index (NFI) 0.95, Comparative Fit Index (CFI) 0.96, Root Mean Square Error of Approximation (RMSEA) The six domains model then was compared with a single domain model. The analysis revealed that the six domain model fit the data significantly better than a unidimensional model ( 2 1,798.49, df 119, p.001, NFI 0.83, CFI 0.84, RMSEA 0.13; 2 diff with df 15 1,269.62, p.001). Benefit Finding Correlates in Cancer Caregiving The next goal was to examine the correlates of benefit finding in cancer caregiving with stressors and psychosocial characteristics of caregivers. First, a regression analysis on the single composite score (averaging the 17 items) was conducted to compare our findings among caregivers with earlier findings among can- 287

6 Y. KIM et al. cer survivors. As shown in the overall column in Table 3, family members who reported greater caregiving stress were less educated, used religion or spirituality to cope with the stress associated with their relative s cancer, and those family members who had greater social support were more likely to report overall greater benefit finding in caregiving. The associations of the resource variables were much more substantial than those of stress variables. Next, a series of hierarchical regression analyses were conducted, predicting each of the six benefit finding domain scores by stressors in Step 1 and psychosocial characteristics of caregivers in Step 2. As shown in Table 3, higher levels of stress related to greater benefit finding in some domains, but the effects were generally small and inconsistent. Among sociodemographic variables, older age and male gender were associated only with appreciation of life; less education related to three out of six domains of benefit finding in caregiving; income and spousal status did not relate to any domain of benefit finding. On the other hand, other psychosocial variables were consistent correlates of all domains of benefit finding. Specifically, religious coping and social support variables were significant correlates of benefit finding domains, as hypothesized. We then examined associations between benefit finding and two psychological adjustment variables, using two sets of hierarchical regression analyses. In the first step, all stressor and psychosocial characteristics of caregiver variables were entered into the equation as covariates. Either the overall benefit finding score or all the six domain scores were added in the second step to examine the unique association of benefit finding, beyond the effects of covariates, with life satisfaction or depression. As shown in Table 4, in Step 1 greater life satisfaction was reported by family caregivers with lower levels of stress from providing care, those who cared for cancer survivors with better mental and physical, caregivers who utilized more religious coping strategy, and caregivers who had greater social support. The composite score of overall benefit finding entered in Step 2 related to greater satisfaction with life. In another analysis, when the overall benefit finding score was replaced with the six domain scores, three subdomains of benefit finding (Acceptance, Appreciation, and Reprioritization) related to life satisfaction significantly, above and beyond effects of covariates on life satisfaction, but other subdomains did not. Of particular interest was the fact that not all of these associations were in the same direction. Family caregivers who came to accept things and appreciate life were more likely to be satisfied with their life, whereas those who came to reprioritize their values were less likely to be satisfied with their life. With regard to depression, caregiving stress, care recipient s mental, education, income, religious coping, and social support were all significantly related to depressive symptoms. Above and beyond the effects of these variables, the overall benefit finding score did not relate to depressive symptoms. Among the separate domains of benefit finding, however, four related significantly to the family caregiver s levels of depressive symptoms. Again, not all associations were in the same direction. Caregivers who reported having more of a tendency to accept things and a more positive self-view were lower in depression symptoms. Those who reported being more empathetic about the existential value of all human beings and those who reported reprioritizing their values in life reported greater depressive symptoms. All these associations were independent of care-related stress, sociodemographic characteristics, religious coping, and perceived availability of social support. In sum, more religious coping, greater social support, and lower education were significant correlates of more benefit finding in cancer caregiving. In contrast, sociodemographic variables other than education and almost all stressor variables failed to be significant or consistent predictors of benefit finding in caregiving. Although very similar stressors and psychosocial characteristics of caregivers related to the six domains of benefit finding, domains of benefit finding were distinctively associated with positive and negative indicators of the caregiver s psychological adjustment. DISCUSSION The two goals of this study were to characterize the domains of benefit finding among family caregivers of cancer survivors and to examine how benefit finding related to other psychosocial variables and measures of psychological adjustment. Our findings indicate that it may be useful to distinguish among multiple domains of benefit finding in cancer caregiving. Our findings also point to the significant involvement of religious coping and social support in benefit finding. Finally, they demonstrate that specific domains of benefit finding relate differently to indicators of psychological adjustment. Domains of Benefit Finding in Caregiving The phenomenon of experiencing personal growth from challenging life events, such as providing care to a family member with cancer, appears to be multifaceted. We found six components of this phenomenon. We also found evidence that caregivers are more likely to report benefit finding if they engage in religious coping and perceive the availability of social support. The associations for religious coping and social support variables (and, to a lesser extent, educational background) were consistent across the six domains of benefit finding. On the other hand, the domains of benefit finding did not relate uniformly to indicators of psychological adjustment. If we had looked only at the overall benefit finding score, we would not have known that two domains of benefit finding related to less depression and two other domains related to more depression. This was true despite the substantial relationships among the domains themselves. The six domains of benefit finding identified in this study of caregivers of cancer survivors are similar to those identified in other studies of cancer survivors (8,10,20) and in studies of spouses of cancer survivors (4). The findings provide evidence 288

7 BENEFIT FINDING IN CAREGIVING that family members who confront the challenge of caring for a person with cancer also gain a sense of personal strength and new possibilities through the experience. Correlates of Benefit Finding in Caregiving: Stressors and Psychosocial Characteristics of Caregivers We examined a diverse range of stressor, demographic, and psychosocial factors as correlates of benefit finding. The level of perceived caregiving stress was a significant (although weak) predictor of the acceptance and reprioritization domains of benefit finding. This finding supports position maintained by Tedeschi and Calhoun (47) that stress must be severe to prompt benefit finding; this finding is consistent with other empirical studies (8,9,11,48), although for only two domains out of six. Our findings are consistent with the possibility that stress from providing care may activate processes leading to reevaluation of circumstances and acceptance of the changes after cancer disrupted the family. In contrast, the other stress factors (care recipient s functional status) showed inconsistent or no significant association with benefit finding. These findings are consistent with literature documenting that the individual s appraisal of caregiving stress, rather than the functional status of the care recipient, is the key factor in the caregiver s well-being (23). Among the sociodemographic variables, the caregiver s level of education was a significant inverse predictor of three out of six domains of benefit finding. Our finding that lower education related to greater benefit finding is consistent with the finding of Tomich and Helgeson (9). However, that pattern was not displayed with income level, which is often treated as similar to education as indicators of socioeconomic status. In a supplementary analysis (data not shown), we excluded education from the equation to rule out the possibility of multicollinearity between education and income and found that the relationships of income remained nonsignificant (p.10). All domains of benefit finding were substantially correlated with two variables: religious coping and social support. Religious coping assesses the degree to which family caregivers cognitively restructure the event to search for the spiritual meaning of cancer (49), and social support measures the extent to which caregivers perceived that emotional, instrumental and tangible support were available to them when needed (41). As suggested by the cognitive processing perspective (50), these characteristics related to more benefit finding in this study, implying that acknowledging one s spiritual needs and the significance of social support are critical components of growth after traumatic or major life experiences (4,33,51). These results also highlight the multiple pathways through which psychosocial factors may help caregivers find meaning in their caregiving role. Benefit Finding in Cancer Caregiving and Psychological Adjustment This study provides the first demonstration that the ability to find meaning in providing care to a cancer patient in one s family relates to both positive and negative psychological adjustment indicators. Furthermore, our findings provide a more nuanced picture of how psychological adjustment relates to positive experiences from providing care. Significant predictors of positive adjustment (i.e., more satisfaction with life) include being more accepting of things and appreciating life more, and less reprioritization of values in life. On the other hand, negative adjustment (i.e., higher levels of depressive symptoms) was predicted by less acceptance, more empathy, less positive changes in self-view, and more reprioritization. These associations were significant above and beyond the variances in adjustment that were explained by stressor, demographic, religious coping, or social support variables. These findings suggest that accepting new possibilities of emotional and spiritual growth, appreciation for new relationships with others, and maintaining core priorities in life are key elements in thriving when caregivers are faced with the challenges of cancer in their family. On the other hand, our findings that empathy and reprioritizing are linked to greater depressive symptoms suggest that some caregivers may develop a heightened sense of vulnerability as a result of their experience with a relative with cancer. Becoming aware of the vulnerability of the self and others or having fewer positive illusions appears to relate to greater depressive symptoms (52). In addition, changing one s longstanding core priorities in life, although possibly resulting in improvement in one s quality of life, appears to come with the cost of some degree of life disruption and psychological distress. These findings suggest that different domains of benefit finding function differently through an evolving process of adaptation. Fine-grained longitudinal studies would be needed to elucidate the circumstances and phases in benefit finding trajectories and their adaptive value. Our findings provide suggestions for clinicians to be able to identify cancer caregivers who may have difficulty in finding meaning in their caregiving role, based on caregivers education, use of religious coping, and perceptions of social support. Furthermore, our findings hint that certain kinds of services might be more effective in mitigating the dissatisfaction with life and psychological distress associated with cancer care. Cancer caregivers may benefit from interventions designed to assist them in acknowledging the changes in their life due to their relative s cancer and the value of their caregiving role. Caregivers who express increased empathy toward others or changes in major values in life may also benefit from programs and services to reduce depressive symptoms. Limitations and Directions for Future Studies Several limitations of the present study should be also noted. First, the cross-sectional nature of the data precludes causal interpretations. Whether finding benefit from providing care to a family member with cancer has true consequences can be examined only in longitudinal studies. We plan to address these concerns with follow-up data on this sample. Second, all variables included in this study were selfreported and therefore may not reflect genuine positive changes but may be affected by social desirability, response shift (53), or defensive reactions (48). In addition, the internal 289

8 Y. KIM et al. consistency of the measure for social support was at the lower end of the conventionally acceptable range. Thus, the findings related to social support should be interpreted with caution. Although our findings hint that not all kinds of benefit finding are adaptive, more refined information is needed on this issue. Third, we included only one family member per cancer survivor in the study. Each family member or close friend experiences different levels and kinds of stress from the cancer of their loved one and has different coping resources available. The impact of cancer on a particular family cannot be comprehensively evaluated by studying one family member. Current findings should be replicated in future studies that include the multiple family members as well as the cancer survivor. Fourth, we examined only psychological correlates of benefit finding and the effect sizes observed in hierarchical regression analyses were small to modest. It may also be fruitful to investigate behavioral (e.g., cancer screening, healthy diet, and physical activity) and physical (e.g., immune, illness development, and mortality) correlates and consequences of benefit finding in caregiving. Finally, generalizability of the current findings is limited to family members who are Caucasian, relatively more educated, and affluent. It will also be important to replicate these findings with ethnic minorities and individuals of lower socioeconomic status. CONCLUSION Notwithstanding these limitations, the findings add significant information to a growing body of research on family caregivers of individuals with cancer. Many family members, but not all, report experiencing personal growth from providing care to their relative with cancer. Such growth experiences emerged in multiple domains. Although stressor and psychosocial variables (namely, education level, use of religious coping strategies, and availability of social support) related in similar ways to the majority of six domains of benefit finding in caregiving, the same was not true of psychological adjustment variables. Findings suggest that not all aspects of benefit finding in caregiving relate to better adjustment. Specifically, coming to accept what happened and appreciating new relationships with others related to greater adaptation. Becoming more empathetic toward others and reprioritizing values related to greater symptoms of depression. These findings suggest that caregivers may benefit from interventions that enhance their ability to accept their situation and find meaning in their caregiving experience, which may improve their satisfaction with life and reduce depressive symptoms. Portions of this article were presented at the Positive Life Changes, Benefit-Finding and Growth Following Illness, May, 2005, Storrs, Connecticut. The authors extend their appreciation to Dr. Fred Grouzet, Rachel Spillers, Chiewkwei Kaw, and Luhua Zhao for their data collection and management; Dr. Corinne Crammer for her editorial assistance; and all the families who participated in this investigation. The first author dedicates this research to the memory of Heekyoung Kim. REFERENCES 1. American Cancer Society. Cancer facts and figures, Atlanta, GA: American Cancer Society; Gallagher J, Parle M, Cairns D. Appraisal and psychological distress six months after diagnosis of breast cancer. Br J Health Psychol 2002;7: Kim Y, Duberstein PR, Sörensen S, Larson MR. Levels of depressive symptoms in spouses of people with lung cancer: effects of personality, social support, and caregiving burden. Psychosomatics 2005;46: Manne S, Ostroff J, Winkel G, Goldstein L, Fox K, Grana G. Posttraumatic growth after breast cancer: patient, partner, and couple perspectives. Psychosom Med 2004;66: Antoni MH, Lehman JM, Kilbourn KM, Boyers AE, Culver JL, Alferi SM, Yount SE, McGregor BA, Arena PL, Harris SD, Price AA, Carver CS. Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 2001;20: Lechner SC, Zakowski SG, Antoni MH, Greenhawt M, Block K, Block P. Do sociodemographic and disease-related variables influence benefitfinding in cancer patients? Psychooncology 2003;12: McGregor BA, Antoni MH, Boyers A, Alferi SM, Blomberg BB, Carver CS. Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer. J Psychosom Res 2004;56: Sears SR, Stanton AL, Danoff-Burg S. The yellow brick road and the emerald city: benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer. Health Psychol 2003;22: Tomich PL, Helgeson VS. Is finding something good in the bad always good? Benefit finding among women with breast cancer. Health Psychol 2004;23: Thornton AA. Perceiving benefits in the cancer experience. J Clin Psychol Med Settings 2002;9: Cordova MJ, Cunningham LL, Carlson CR, Andrykowski MA. Posttraumatic growth following breast cancer: a controlled comparison study. Health Psychol 2001;20: American Cancer Society. Cancer facts and figures, Atlanta, GA: American Cancer Society; Clipp E, George LK. Dementia and cancer: a comparison of spouse caregivers. Gerontologist 1993;33: Stetz KM, Brown MA. Physical and psychosocial health in family caregiving: a comparison of AIDS and cancer caregivers. Public Health Nurs 2004;21: Weiss T. Posttraumatic growth in women with breast cancer and their husbands: an intersubjective validation study. J Psychosoc Oncol 2002; 20: Manne S, Babb J, Pinover W, Horwitz E, Ebbert J. Psychoeducational group intervention for wives of men with prostate cancer. Psychooncology 2004;13: McCausland J, Pakenham KI. Investigation of the benefits of HIV/AIDS caregiving and relations among caregiving adjustment, benefit finding, and stress and coping variables. AIDS Care 2003;15: Pakenham KI. Benefit finding in multiple sclerosis and associations with positive and negative outcomes. Health Psychol 2005;24: Carlisle C. The search for meaning in HIV and AIDS: the carers experience. Qual Health Res 2000;10: Bower JE, Segerstrom SC. Stress management, finding benefit, and immune function: positive mechanisms for intervention effects on physiology. J Psychosom Res 2004;56: Tedeschi RG, Calhoun LG. The posttraumatic growth inventory: measuring the positive legacy of trauma. J Trauma Stress 1996;9: Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; Pinquart M, Sörensen S. Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: a meta-analysis. J Gerontol B Psychol Sci Soc Sci 2003;58:P Park CL, Folkman S. Meaning in the context of stress and coping. Review of General Psychology 1997;1: Andrykowski M, Brady MJ, Hunt JW. Positive psychosocial adjustment in potential bone marrow transplant recipients: cancer as a psychosocial transition. Psychooncology 1993;2: Schroevers MJ, Ranchor AV, Sanderman R. The role of age at the onset 290

9 BENEFIT FINDING IN CAREGIVING of cancer in relation to survivors long-term adjustment: a controlled comparison over an eight-year period. Psychooncology 2004;13: Pakenham KI. Relations between coping and positive and negative outcomes in carers of persons with multiple sclerosis (MS). J Clin Psychol Med Settings 2005;12: Urcuyo KR, Boyers AE, Carver CS, Antoni MH. Finding benefit in breast cancer: relations with personality, coping, and concurrent well-being. Psychology & Health 2005;20: Pennebaker JW, Colder M, Sharp LK. Accelerating the coping process. J Pers Soc Psychol 1990;58: Cordova MJ, Giese-Davis J, Golant M, Kronnenwetter C, Chang V, McFarlin S, Spiegel D. Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit. J Psychosom Res 2003;55: National Alliance for Caregiving, AARP. Caregiving in the U.S. Washington, DC: Hensel M, Egerer G, Schneeweiss A, Goldschmidt H, Ho AD. Quality of life and rehabilitation in social and professional life after autologous stem cell transplantation. Ann Oncol 2002;13: Park CL, Fenster JR. Stress-related growth: predictors of occurrence and correlates with psychological adjustment. J Soc Clin Psychol 2004;23: Weiss T. Correlates of posttraumatic growth in husbands of breast cancer survivors. Psychooncology 2004;13: Mohr DC, Dick LP, Russo D, Pinn J, Boudewyn AC, Likosky W, Goodkin DE. The psychosocial impact of multiple sclerosis: exploring the patient s perspective. Health Psychol 1999;18: Carver CS, Antoni MH. Finding benefit in breast cancer during the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis. Health Psychol 2004;23: Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 health survey manual and interpretation guide. Boston, MA: The Health Institute Medical Center; Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: an overview of concepts and their measures. Gerontologist 1990;30: Nunnally JC. Psychometric theory. 2nd ed. New York: McGraw-Hill; Carver CS. You want to measure coping but your protocol s too long: consider the brief COPE. Int J Behav Med 1997;4: Cohen S, Mermelstein R, Kamarck T, Hoberman HM. Measuring the functional components of social support. In: Sarason IG, Sarason BR, editors. Social support: theory, research, and applications. Lancaster, England: Nihjoff published in Cooperation with NATO Scientific Affairs Division; Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with the life scale. J Pers Assess 1985;49: Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Measurement 1977;1: Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods 2002;7: Reise SP, Waller NG, Comrey AL. Factor analysis and scale revision. Psychol Assess 2000;12: Russell DW. In search of underlying dimensions: The use (and abuse) of factor analysis in Personality and Social Psychology Bulletin. Pers Soc Psychol Bull 2002;28: Tedeschi RG, Calhoun LG. Trauma and transformation: growing in the aftermath of suffering. Thousand Oaks, CA: Sage; McFarland C, Alvaro C. The impact of motivation on temporal comparisons: coping with traumatic events by perceiving personal growth. J Pers Soc Psychol 2000;79: Harrison MO, Koenig HG, Hays JC, Eme-Akwari AG, Pargament KI. The epidemiology of religious coping: a review of recent literature. Int Rev Psychiatry 2001;13: Creamer M, Burgess P, Pattison P. Reaction to trauma: a cognitive processing model. J Abnorm Psychol 1992;101: Wiser S, Arnow B. Emotional experiencing: to facilitate or regulate? J Clin Psychol 2001;57: Taylor SE, Brown JD. Illusion and well-being: a social psychological perspective on mental health. Psychol Bull 1988;103: Sprangers MAG, Schwartz CE. The challenge of response shift for quality-of-life-based clinical oncology research. Ann Oncol 1999;10: