Cancer is a disease that affects all aspects of the human being and creates stressful situations for sufferers. It represents a significant change in patients’ lives, as they must readjust emotionally and physically to this new situation (e.g., O’Brien & Moorey, Reference O’Brien and Moorey2010). Lazarus and Folkman’s (Reference Lazarus and Folkman1984) stress and coping paradigm has been one of the most useful conceptual frameworks for understanding the process of psychological adaptation to cancer. According to these authors, coping can be defined as constantly changing cognitive and behavioral efforts carried out in an attempt to manage (reduce or tolerate) the different situations that are appraised as stressful or that test the person’s resources. Adaptive types of coping are those that successfully reduce stress and encourage positive emotions, promoting long-term patient health (Campos, Iraurgui, Páez, & Velasco, Reference Campos, Iraurgui, Páez and Velasco2004).
However, new approaches must be explored to increase the understanding of the adjustment process involved in cancer. The construct known as “belief in a just world” (BJW) suggests that people need to believe that the world is just, that people get what they deserve, and that they deserve what they get (Lerner, Reference Lerner1980; Stroebe, Postmes, Täuber, Stegeman, & John, Reference Stroebe, Postmes, Täuber, Stegeman and John2015). This belief enables people to deal with their social environment and to maintain order and stability. When these beliefs are threatened, people are motivated to maintain them, and it is here that their functionality might emerge. In the 1970s, general BJW, which refers to a general belief in a just society in which everyone is treated fairly, started to be differentiated from personal BJW, which is related to the justice of events in peoples’ personal lives and to more adaptive processes (Rubin & Peplau, Reference Rubin and Peplau1973). Individual BJW serves as a cognitive diagram for interpreting reality. It is a positive illusion that can contribute to the maintenance of subjective well-being and an increase in self-esteem (Dalbert, Reference Dalbert1999), helping people to trust in being treated fairly by others (Dalbert, Reference Dalbert1997). Some studies support the hypothesis that believing in a just world encourages investment in medium- and long-term goals (Hafer, Begue, Choma, & Dempsey, Reference Hafer, Bègue, Choma and Dempsey2005; Sutton, Stoeber, & Kamble, Reference Sutton, Stoeber and Kamble2017). This argument could also be related to the coping process, because it entails an active and participative strategy over the course of the disease (Hafer & Rubel, Reference Hafer and Rubel2015). Moreover, BJW, particularly personal BJW, has been related to coping strategies in some health-illness processes (Otto, Boos, Dalbert, Schöps, & Hoyer, Reference Otto, Boos, Dalbert, Schöps and Hoyer2006), playing an important mediating role in well-being in processes such as chronic pain (McParland & Knussen, Reference McParland and Knussen2010). Yet, as far as we know, no prior studies have explored the role of BJW in the health processes of cancer patients and its possible relationship with coping strategies.
On the other hand, over the past decades, the concept of emotional intelligence (EI) has proved useful in research on emotional adaptation mechanisms in stressful situations in general. EI (Salovey, Bedell, Detweiler, & Mayer, Reference Salovey, Bedell, Detweiler, Mayer, Lewis and Haviland-Jones2000), understood as the capacity of people to perceive, assimilate, understand, and regulate both their own emotions and the emotions of others, plays a fundamental role in individual emotional well-being and psychological adjustment (Extremera & Fernández-Berrocal, Reference Extremera and Fernández-Berrocal2006; Salovey et al., Reference Salovey, Bedell, Detweiler, Mayer, Lewis and Haviland-Jones2000). In the case of cancer patients, different studies have shown that patients with high EI levels tend to experience lower levels of anxiety, fewer worries, less distress, and a better quality of life (Rey, Extremera, & Trillo, Reference Rey, Extremera and Trillo2013; Smith et al., 2012; Teques, Carrera, Ribeiro, Teques, & Llorca Ramón, Reference Teques, Carrera, Ribeiro, Teques and Llorca Ramón2016).
The main objective of this research was to study the relations between BJW and emotional intelligence, with the subjective well-being (anxiety/depression) and quality of life of patients with cancer. We hypothesize that personal (not general) BJW and EI, especially emotional reparation abilities, will be positively related to patients’ emotional well-being and quality of life.
Method
Participants
Participants were Spanish-speaking cancer patients who were being treated at a large public hospital in the south of Spain. The hospital serves a population that is mostly white and middle- to lower-class and whose main source of income comes from jobs belonging to the services sector. Criteria for inclusion in this study were age > = 18 years, ability to communicate effectively with healthcare professionals, and written informed consent. Exclusion criteria included having received the diagnosis in the last month or being in a terminal stage of their disease; that is to say, in such an advanced phase that it limited the patient’s cognitive and physical ability to participate in the study. In total, 88 patients were approached: 68 agreed and provided written informed consent, and 20 declined. The final sample was then composed of 35 men and 33 women, with a mean age of 53.5 years (range: 20 to 86). They were outpatients (n =56) and patients (n =12).
Procedure and design
The Ethical Committee of the Hospital approved this study. Due to patients in this hospital having very different levels of reading ability, all the data, including those from self-report questionnaires, were collected by means of a structured interview. Second and fourth authors, both psychologists appropriately trained in this type of methodology, carried out the interviews. In addition, certain patient information referring to the type of cancer and the stage of the disease was required from the Oncology Service. Prior to the interview, patients were personally informed about the objectives of the study by the last author (psycho-oncologist in this Service) and were told that written consent to participate voluntarily in the research would be required. Furthermore, the confidentiality and anonymity of their responses was guaranteed. They were also advised that they could terminate the interview at any time if they so wished. At all times, it was guaranteed that their medical or psychological treatment would not be affected. The interviews lasted approximately 40 minutes. Data were collected between 2011 and 2013. This research can be classified as a retrospective expostfacto study with only one group and multiple measures (León & Montero, Reference León and Montero2008).
Measures
The following instruments composed the structured interview: Sociodemographic data. First, the interviewer collected data referring to demographic aspects (age, gender, geographical location, marital status, and educational level).
Hospital Anxiety and Depression Scale (HADS) ( Zigmond & Snaith, Reference Zigmond and Snaith1983 ; Spanish version by Tejero, Guimera, Farré, & Peri, Reference Tejero, Guimera, Farré and Peri1986 ). This scale was used as a measure of adjustment and emotional well-being. The HADS is used to assess anxiety disorders and depression within a hospital context. It is comprised of two subscales that respectively measure these parameters. Each scale consists of seven items, and each item is scored according to a four-point Likert-type scale (range 0–3), in which the answer that best identifies the patient’s condition is marked. In general, it shows adequate reliability data in terms of internal consistency and test-retest reliability. In our study, the Cronbach’s alpha was .74 for the depression subscale and .88 for the anxiety subscale.
Trait Meta-Mood Scale–24 (TMMS–24) ( Fernández-Berrocal, Extremera, & Ramos, Reference Fernández-Berrocal, Extremera and Ramos2004 ). This scale assesses the metacognition of emotional states. The items are scored on a five-point Likert-type scale, being 1 strongly disagree and 5 strongly agree. It contains three key emotional intelligence dimensions: Attention to Feelings (frequency with which an individual directs attention to his or her affective states; Items 1 to 8); Clarity of Feelings (ability to identify and label one’s affective state; Items 9 to 16); and Mood Repair (ability to regulate moods; Items 17 to 24). The Cronbach’s alpha for each component was: Attention to Feelings = .90; Clarity of Feelings = .85; and Mood Repair = .83.
European Organisation for Research and Treatment of Cancer (EORTC): QLQ–C30 (version 3.0) ( Aaronson et al., Reference Aaronson, Ahmedzai, Bergman, Bullinger, Cull, Duez and de Haes1993 ; Spanish version by Arraras Urdaniz et al., Reference Arraras Urdaniz, Villafranca Iturre, Arias de la Vega, Domínguez Domínguez, Lainez Milagro, Manterola Burgaleta and Martinez Aguillo2008 ). This questionnaire was used to measure the functional aspects of health as related to quality of life. It contains five functional subscales: “Physical functioning,” “role functioning,” “emotional functioning,” “cognitive functioning,” and “social functioning” and a global health and quality-of-life subscale. In our case, only scores on this subscale will be reported; this subscale is the one that better capture the patients’ global estimations of their quality of life and also correlates with the other ones (Aaronson et al., Reference Aaronson, Ahmedzai, Bergman, Bullinger, Cull, Duez and de Haes1993). It is composed of two items: “How would you rate your overall health during the past week?” and “How would you rate your overall quality of life during the past week?”. Each item is rated on a scale from 1 (very poor) to 7 (excellent).
General Belief in a Just World (GBJW) and Personal Belief in a Just World (PBJW) ( Dalbert, Reference Dalbert1999 , Reference Dalbert2001 ). These two scales were used to assess BJW, with a total of 13 items. The first scale (GBJW) has six items that assess the extent to which a person believes in a just world (“I think basically the world is a just place”; Dalbert, Reference Dalbert2001), and the second (PBJW) includes seven items designed to detect the conviction that events in people’s personal lives are just (“I am usually treated fairly”; Dalbert, Reference Dalbert1999). Patients responded to the items on a Likert-type scale, ranging from totally disagree (1) to totally agree (6), where high scores indicate strong BJW. Three items were eliminated for reasons of internal consistency. With the final pool of items, the Cronbach’s alphas were .68 for GBJW and .79 for PBJW.
Statistical analysis
All the analyses were conducted with program SPSS v.20. First, we run bivariate correlations between the variables of interest; second, multiple regression analyses to test the predictive relations hypothesized.
Results
Descriptive Analysis
The profile of the 68 cancer patients interviewed (35 men and 33 women) corresponds to a majority of married patients (79.4%) and retired patients (53.7%). The most frequent diagnoses were colorectal cancer and breast cancer, 16.4% each. Of the interviewees, 31.7% were in Stage I of the disease, 17.5% were in Stage II, 11.1% in Stage III and 39.7% were in Stage IV. Furthermore, 64.7% were in active treatment (chemotherapy in 90% of them, hormonal therapy 5% and radiological therapy 5%), 27.8% were in remission, and only 5.9% were in a palliative stage. The mean time since diagnosis was 3.13 years (SD = 3.82)
Correlations between variables
As can be seen in Table 1, general BJW did not show a significant relation with any of the other variables, except with personal BJW. However, personal BJW was positively related to the Mood Repair component of the TMMS and quality of life, and negatively related to depression and anxiety. The relations of emotional intelligence components with subjective well-being (anxiety/depression) and quality of life of patients can also be seen in Table 1.
Table 1. Pearson r Correlations between Variables of Interest
Note: GBJW= general belief in a just world; PBJW = personal belief in a just world. QL = quality of life.
** The correlation is significant at a .01 level (bilateral). * The correlation is significant at a .05 level (bilateral).
Predictors of patients’ well-being
In order to study the relations of BJW (General and Personal) and EI with patients’ well-being, three multiple regression analyses were performed. These variables were taken as predictors, and patient scores for Anxiety, Depression and Quality of Life were taken as predicted variables (see Table 2).
Table 2. Multiple Regression Analyses
Note: General BJW = general belief in a just world; Personal BJW = personal belief in a just world.
** p < .01. * p < .05. +p < .10.
In the regression analysis performed for the “Anxiety” variable, personal BJW was negatively related to Anxiety, β = –.27, t = –2.11 p < .05. In other words, patients with a firmer personal BJW showed lower levels of Anxiety. With regard to the EI dimensions, Attention to Feelings was positively related to Anxiety, β = .39, t = 3.58, p < .01.
In the regression analysis performed for the “Depression” variable, it was found that Attention to Feelings was marginally related to Depression, β = .22, t = 1.87 p = .06: as in the case of Anxiety, patients that attended more to their emotions showed higher scores in Depression. No relationship was found between any of the other predicting variables and Depression scores.
Finally, in the case of “Quality of Life,” it may be observed that the ability to Regulate emotions related positively to Quality of Life, β = .34, t = 2.52, p < .05. Personal BJW also predicted (although marginally) this variable, β = .24, t =1.70, p = .06. Cancer patients who showed a better ability to regulate emotions and those with a firmer personal BJW reported having a better Quality of Life.
Discussion
The main objective of this research was to study some of the factors involved in the subjective well-being and quality of life of cancer patients, in particular BJW and EI. On the one hand, the results have indicated that participants with higher scores in personal BJW showed lower levels of anxiety and a marginally significant tendency to exhibit more quality of life. These are without doubt the most novel results, as no previous studies have analyzed the relevance of this belief in people undergoing oncological processes. Nevertheless, it is in line with other studies conducted in the health field, which support the importance of BJW for the improvement of mental health. For example, Otto et al. (Reference Otto, Boos, Dalbert, Schöps and Hoyer2006) found that personal, but not general, BJW was associated with less depression, anxiety, and other psychological symptoms such as social insecurity, hostility, and paranoid ideation in posttraumatic stress populations. Furthermore, in patients with chronic pain, it has been found that personal BJW related negatively to pain intensity, disability, and psychological disorders (McParland & Knussen, Reference McParland and Knussen2010). In another recent study, personal and general BJW was measured in patients with chronic pain, and both related negatively to anxiety, although gender acted as a moderating variable (McParland, Knussen, Lawrie, & Brodie, Reference McParland, Knussen, Lawrie and Brodie2013).
However, it should be asked why, in processes of oncological diseases, the possession of a firmer personal BJW helps improve how anxiety and quality of life are experienced. The BJW construct tries to explain how people manage to maintain their mental balance and their lives with confidence and tranquility despite their well-being being threatened (Correia, Reference Correia2000). In other words, personal BJW could be a personal resource or a defense mechanism or coping strategy that buffers the stress related to traumatic events, and, at the same time, it could be associated with greater acceptance, well-being, and mental health. Therefore, people who believe that this world is just might conclude that there must be a good reason for their illness and its causes (Nudelman& Shiloh, Reference Nudelman and Shiloh2011), reducing the anxiety entailed by non-acceptance or attributing it to factors of an unjust nature.
From a clinical point of view, this result emphasizes the importance of potentiating cancer patients’ explanations of their disease that allow them to give meaning to their illness experience. As Hafer and Rubel (Reference Hafer and Rubel2015) pointed out, BJW may be defended by people in part because it contributes to the establishment and pursuit of long-term goals but also because it can give meaning or purpose to life. Along the same lines, different investigations have shown a positive relationship between cancer patients’ well-being and the construct known as Meaning in Life (Teques et al., Reference Teques, Carrera, Ribeiro, Teques and Llorca Ramón2016, Tomás-Sábado et al., Reference Tomás-Sábado, Villavicencio-Chávez, Monforte-Royo, Guerrero-Torrelles, Fegg and Balaguer2015), which also emphasizes the beneficial effects of giving meaning to one’s existence.
Our results also point to another factor that influences patient subjective well-being and quality of life: emotional intelligence. The dimension Attention to Feelings was positively related to anxiety and depression, whereas patients who showed a greater ability to regulate emotions presented a better quality of life. The results regarding the dimension Attention to Feelings are in line with previous studies: people with high levels of Attention to Feelings report a higher number of depressive and anxiety symptoms, possibly because excessive attention to emotions hampers the ability to understand causes, motives, and consequences (Thayer, Rossy, Ruiz-Padial, & Johnsen, Reference Thayer, Rossy, Ruiz-Padial and Johnsen2003). In the case of Mood Repair, the results of our investigation do coincide with those of previous studies. Greater regulation and emotional reparation abilities are positively associated with better overall achievements in life, better adjustment to stressful experiences, active coping, and distraction. They are negatively associated with rumination, which entails a greater ability to interrupt negative emotions and extend positive ones (Williams, Fernández-Berrocal, Extremera, Ramos-Díaz, & Joiner, Reference Williams, Fernández-Berrocal, Extremera, Ramos-Díaz and Joiner2004). Taken as a whole, our data on EI are in line with those presented recently by Stanton and Low (Reference Stanton and Low2012), who found that, within the oncological population, a high ability to perceive, assimilate, understand, and regulate one’s own emotions and those of others is related to a better quality of life, less anxiety, less worry, and better perceived social support. But they also are in line with the results obtained by Teques et al. (Reference Teques, Carrera, Ribeiro, Teques and Llorca Ramón2016), which show that the positive relationship between EI and quality of life is even higher in cancer patients than in the general population. From a clinical point of view, all these results emphasize the need to incorporate EI training activities into the psychological care programs of cancer patients. However, the absent of relations in our study between the dimension Clarity of Feelings and the different measures of well-being does not coincide with previous studies that have found it to be associated with a better psychological and physical adjustment and life satisfaction (Extremera & Fernández-Berrocal, Reference Extremera and Fernández-Berrocal2005). People that easily identify emotions during stressful events need less time to attend to their emotional reactions. They use less cognitive resources, which, at the same time, allows them to assess alternative actions, keep their thoughts on other tasks, or use more adaptive coping strategies (Extremera & Fernández-Berrocal, Reference Extremera and Fernández-Berrocal2005; Palmer, Donaldson, & Stough, Reference Palmer, Donaldson and Stough2002).
Finally, the relationship that was found between our three dependent variables, anxiety, depression, and quality of life, must also be highlighted. In the present study, patients that showed lower levels of anxiety and depression revealed a better quality of life. Although these are only correlations and therefore prevent the extraction of causal directionality conclusions, they are in line with the trend shown by a large number of previous studies on the importance of the prevention of anxious-depressive symptomatology in oncological processes as a protective factor for a better quality of life (i.e., Font & Cardoso, Reference Font and Cardoso2009; Smith et al., 2012).
Although this study has produced interesting findings, it also presents certain limitations that must be acknowledged, particularly the small number of cancer patients interviewed (n = 68). This situation was due, without doubt, to the complexity and difficulty of accessing the sample. Despite the difficulty in accessing these patients, it is a future challenge to increase the sample in order to study in depth the strategies that are adaptive to the oncological process and the stage of the disease during which they can be used.
Despite this, our study underlines the need to take into consideration personal BJW and EI in psychological treatments for cancer patients, given their influence on anxiety and depression levels and on patient quality of life and well-being.
