Future Research And Theoretical Directions

While many of the individual paths in both the normative and restorative models have been examined in prior research, there is much room for additional inquiry testing the models' predictions. A few particular research needs will be highlighted here.

First, although the models were designed to be consistent with existing research findings, there have been relatively few tests of the full normative model, and no tests of the complete restorative model. Therefore, it would be valuable to test the full set of relations posited by each model or at least major subsets of each model, such as the role of coping efficacy as a mediator of the effects of coping methods and support systems on posttrauma SWB recovery. Second, existing tests of the normative model have mostly involved college students and cross-sectional research designs.32 What would be particularly valuable at this stage—and, indeed, essential to support extensions of the theoretical framework to practice—would be research involving clinical populations (particularly cancer survivors) and designs capable of testing the tenability of cause-effect relations among the theoretical variables (e.g., longitudinal research). Such research might especially focus on the posited pathways through which traits affect domain and life satisfaction, and the unique contribution that cognitive, behavioral, and social variables are assumed to make, above and beyond the effects of traits.

Third, there is need to design interventions derived from the theory, testing their efficacy against relevant comparison conditions (e.g., no-treatment control, patient education, standard cognitive-behavioral therapy). Intervention research could provide convincing tests of causality (e.g., does goal-directed activity enhance, rather than merely predict, improved domain-satisfaction?). It would be valuable for such research to focus on cancer survivors and those coping with other stressful life conditions, and to examine the potential impact of psychosocial interventions on physical outcomes.48 Theory-derived interventions could take various forms, ranging from remedial verbal therapy to more proactive efforts at secondary prevention (e.g., community workshops, structured groups). The latter may be particularly worth pursuing, given their potential to forestall more serious emotional difficulties and to potentiate patients' naturally occurring strengths and support systems.

Finally, it is worth emphasizing that emotional well-being, no matter how important in and of itself, represents only one aspect of psychosocial adjustment. Other important dimensions would include, for example, the absence (or tolerable levels) of psychological symptoms and the adequacy of role functioning in one's major life spheres.4 Comprehensive study of the posttrauma recovery process, including tests of the restorative well-being model, would therefore do well to include multiple indicators of psychosocial adjustment that are assessed from multiple perspectives (e.g., self, significant others, work associates).

7.0. CLINICAL IMPLICATIONS OF THE RESTORATIVE WELL-BEING MODEL

Although the restorative (and normative) models may hold useful implications for assisting cancer survivors to recover their emotional equilibrium, it should be noted that the suggestions offered in this section are largely speculative. They are a sampling of intervention possibilities that can be derived from the theory and relevant research in the well-being literature. Research is needed to assess the extent to which the theory can be generalized specifically to the experiences of cancer survivors. The theory was included in this Handbook in an effort to promote a more comprehensive framework for understanding the process of emotional recovery in cancer survivors. It is hoped that this conceptualization will assist researchers and clinicians to integrate findings and generate new approaches to aid survivors in their efforts to regain and maintain a sense of well-being.

7.1. Cognitive, Behavioral, and Social Routes

Pending further research, I believe that the model points to several potentially valuable cognitive, behavioral, and social targets and resources for assisting cancer survivors to contribute to their own affective regulation. None of these should be seen as a "silver bullet." Rather they compose a sort of "ordinary magic" that allows people to display emotional resilience in ways that may seem mundane but, nevertheless, can make a large difference to those facing adverse conditions. They also resemble personal and environmental resources and strategies that have been identified in the developmental resilience literature.52

One potential target lies in the goal-setting process. The cancer experience may, among other things, have disrupted some patients' (a) access to, or enjoyment of, their central life domains (e.g., work may have been temporarily halted or a valued job may have been lost) and/or (b) progress toward valued life goals. Thus, a useful clinical focus may be to identify current life goals as well as those that have been blocked or impeded by the cancer experience. Steps can be taken to explore the possibility of reviving or transforming former goals, avenues for setting new goals, resources needed for goal pursuit, methods to mark progress at goal pursuit, and ways to celebrate success and respond to disappointment. By making explicit a process that is often implicit in most people's lives, cancer survivors may see new opportunities for influencing their own domain and life satisfaction.

A second target, and one quite consistent with goal-setting, may entail a focus on getting survivors reengaged with valued life activities that may have been foreclosed or limited by the cancer experience. As noted earlier, such activities lend a sense of structure and purpose to life, provide a context for goal pursuit and value fulfillment, and can help ward off rumination and social isolation. Choice of activities is an individual matter but, in general, activities that have an outward focus and involve social interaction may be particularly useful.39,53 Among other things, social activities (e.g., interactions with friends, community service) contain opportunities for both receiving and giving social support. Activities that have the potential to promote "flow," whether they are social or not, may also be intensely enjoyable. (Flow is a state of complete absorption that is associated with involvement in skill-stretching

activities ).

The importance of reentry, or increasing involvement, in valued life activities can probably not be overemphasized. At least some of the emotional impact of the cancer experience—apart from its existential threats, pain, and discomfort—may be due to its potential to obstruct access to the pleasurable activities in which patients would normally immerse themselves.54 To the extent that patients develop depressive symptoms, they may further avoid social and other formerly pleasure-inducing situations, perpetuating a negative emotional spiral. Viable routes to curtail that spiral might include aiding patients to (a) identify and reengage in activities that formerly brought them enjoyment, (b) explore new options for such involvement, and (c) remain as actively engaged as possible in their usual valued life tasks during the course of cancer treatment. The latter option has the obvious advantage of minimizing disruptions in valued life domains from the beginning, thereby lessening any negative effects on SWB. Of course, such activity-promoting efforts need to take into account such considerations as the patient's physical stamina and the possible side effects of his/her treatment regimen. Cognitive techniques may be useful to help the patient accept his/her current limitations, set reasonable performance standards, and focus on incremental steps toward desired levels of activity involvement or skill proficiency.

Many other potential coping strategies can be gleaned from the literatures on well-being, psychological resilience, and posttraumatic growth. For instance, emotional and other benefits may be obtained through physical exercise,53 relaxation,55 social support seeking,48 and therapeutic writing.56 The latter activity may offer the opportunity to gain insight and perspective on the cancer experience, including identifying potential positive aspects of the experience (e.g., valuable lessons learned about oneself, reprioritization of one's values and goals, strengthening of relational bonds). Many survivors spontaneously discover such benefits; indeed, 47% of the respondents in Wolff's (this volume) survey indicated that dealing with cancer had positive effects on their lives. Although therapeutic writing can provide a helpful structure for persons to find their own meaning in stressful life events, deliberate efforts to promote "benefit-finding" need to be approached with caution because some may experience them as insensitive to the burdens they have had to endure.57

7.2. Secondary Prevention and Remedial Efforts

Many of the cognitive and behavioral strategies mentioned above may develop naturally as a consequence of survivors' interactions with their support systems. However, not all persons are fortunate enough to have adequate support systems, and even some that do may not be ideally positioned to plumb their support systems for the things they need to foster their own emotional recovery. In such situations, secondary prevention efforts may provide an excellent opportunity to empower survivors' own natural tendencies toward emotional recovery, while monitoring their progress at containing psychological symptoms such as anxiety and depression.

When structured as group interventions or workshops, secondary prevention may have the added benefits of efficiency and can capitalize on curative conditions that are unique to group settings (e.g., sense of universality). Moreover, composing groups that contain members or facilitators who have been living with cancer for differing lengths of time can allow more experienced cancer survivors to serve as potent coping models, promoting the coping efficacy and strategies of those newer to the cancer experience. It is noteworthy that 70% of the participants in Wolff's survey (this volume) indicated that they would assist in survivorship activities. The involvement of more experienced cancer survivors may well benefit themselves27 as well as others, for example, by contributing to one's sense of life purpose and "mattering."

Surprisingly, relatively few of Wolff's respondents reported that they had participated in either counseling or support groups—even though sizeable percentages of them had experienced considerable problems in coping and many were dissatisfied with aspects of their natural support systems. The reasons for this disparity between need and help-seeking are unclear and probably complex. However, to the extent that part of the problem involves lack of (or difficulty accessing) services, innovative technological options might be considered. For example, the Internet has been used recently as the medium for delivering a well-being intervention to large numbers of participants,26 and online cancer support resources have been available for some time.58 There is much room for the design and testing of additional innovative, theory-based virtual support groups, workshops, or well-being exercises for cancer survivors.

In certain cases, more remedial, psychotherapeutic interventions may be helpful for survivors who are having an especially difficult time regaining a sense of emotional well-being. Some of these may include persons with a preexisting tendency toward high negative affect. For them, the cancer experience may have exacerbated a natural susceptibility to negative emotions and a penchant for interpreting life experiences in pessimistic terms. Brown et al.22 offer useful suggestions for working with clients prone to experience high negative affect. Their perspective suggests that it may be more fruitful to deal with the cognitive and behavioral concomitants of this predisposition (e.g., helping clients to recognize, accept, and learn to work with their negative moods) than to try to change their personalities.

Where more intensive intervention seems indicated, it may be useful to employ cognitive behavioral therapy (CBT) techniques. CBT has been shown to produce substantial short-term effects on depression, anxiety, and QOL indicators—and continuing, if more modest, effects on QOL in cancer survivors at follow-up assessments (8 months or more postintervention).3 (It will be recalled that QOL indicators often include measures of life satisfaction.) These effects were more marked in individual than in group interventions. By contrast, patient education interventions had little effect on symptoms or QOL.

CBT is entirely consistent with the sort of treatment elements that might be derived from the restorative model. In addition to the typical treatment elements in CBT interventions, the restorative model would imply a particular focus, as suggested above, on expansion of coping and problem-solving strategies, bolstering of coping efficacy, assistance in building and/or accessing natural social supports, identification of options for valued life participation and goal pursuit, and special attention to negotiating issues that might impede task involvement and goal progress (e.g., environmental barriers, downward cognitive comparisons between one's former and current capabilities, unreasonable performance standards that focus only on ultimate goal attainment rather than incremental progress toward one's goals). In fact, given the well-documented ability of goal progress to promote well-being in nonclinical settings,7 a good portion of therapy might fruitfully revolve around the goal setting and pursuit process, thereby empowering clients to exert a greater measure of affective self-control.

Augmenting this admittedly problem-focused coping orientation, interventions might well include an emotion-focused agenda (e.g., achieving insight, refram-ing negative events as challenges and opportunities for growth). Indeed, various emotion-focused coping strategies (e.g., emotional expression59; acceptance, use of humor42) have been found to be helpful in breast cancer patients. Emotion-focused counseling might profitably deal as well with the continuing worries about death and the recurrence of cancer that many survivors experience (Wolff, this volume). This balance of problem-focused and emotion-focused strategies recalls the "serenity prayer" in its implicit acknowledgment of those things over which one has some control (e.g., involvement in valued activities, choice of goals) as well as those that cannot be controlled (e.g., whether the cancer will ultimately return, how long one will live).

In sum, the overarching goal of secondary prevention or remedial intervention derived from the restorative model is to promote enhanced domain and life enjoyment, ideally through agentic and nonchemical means. Such an approach may call for a day-at-a-time philosophy (e.g., "what can I do today that would give me pleasure or help me progress toward my goals?") since goal-directed activity is an ongoing process rather than an ultimate destination. While psychosocial interventions may not optimally affect physical functioning or survival rates in the aftermath of cancer,3,60 they may nevertheless hold great potential to promote recovery of emotional well-being and other aspects of adjustment, thereby enabling cancer survivors to derive as much pleasure and productivity from life as their temperaments and the vagaries of human mortality will allow.

ACKNOWLEDGMENTS

I thank Edna M. Szymanski and Terence J.G. Tracey for their valuable comments on an earlier draft of this chapter.

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