The primary objective of our study was to evaluate the effect of CBTs in enhancing psychological resilience among cancer patients. There is a lack of both quantitative and qualitative evidence from studies that can inform the selection of interventions that are beneficial to the resilience of cancer patients. Most studies are still investigating the relationship between psychological resilience and other psychological variables. Evidence from previous meta-analyses of CBTs commonly employed a broader definition, under which interventions based on deep breathing relaxation with visual imagery, cognitive bias modification (CBM) for attention and interpretation, emotional regulation skill. For instance, Luo et al. (2021) synthesised the evidence on the impact of psychological interventions that target resilience in parents of children with cancer(Luo et al., 2021), that the 5 included RCTs but only 2 of these RCTs have an equal emphasis on both the cognitive and behavioral components. Furthermore, three RCTs were conducted on a theoretical basis among the 12 included studies, including the Stress and Coping Model, PTG theory, and Roy Adaptation Model (RAM). These theories are important for improving the practicality and replicability of RCT. Two RCTs explicitly stated that cognitive behavioral therapy techniques, such as cognitive bias modification for attention and interpretation. Because of the vast differences in intervention content, theoretical foundations, and application techniques of CBT, which makes it difficult to draw specific conclusions about the performance of specific CBT subtypes. In this meta-analytic review, we focus exclusively on resilience-oriented CBTs, which have to teach three types of skills (cognitive, problem-solving, and social). This restricted inclusion resulted in a total of 12 more comparable interventions in our analyses for this specific subtype of CBTs.
The current study showed a wide range in the effect sizes of CBTs. Twelve RCTs were included, revealing a statistically significant effect on psychological resilience of a small magnitude (Z=4.98) immediately after intervention, which was largely maintained at follow-up (Z=3.71), on average over 1-3 months after the intervention. Psychological resilience, as a key personal resource for psychological protection, is critical for improving cancer patients' capacity for psychosocial health, coping with cancer and adverse treatment side effects, and improving their quality of life(Tu et al., 2020). These results reinforce the evidence that CBTs could be indeed effective for the enhance of psychological resilience. However, the wide distribution of effect sizes and overall small effect size highlight the need for future trials to replicate the effects of most successful programs (e.g., those producing the largest effect sizes) and enhance the current versions of those that worked sub-optimally (e.g., those producing the negative effect sizes).
Resilience-oriented CBTs tend to be more effective (although not significantly) when delivered to targeted samples than when delivered universally, such as Stress Management and Resilience Training (SMART) Program. The most common way to improve resilience reported in the literature is to provide individuals with the resources and skills to navigate adversity and thrive in challenging environments(Luo et al., 2021). As a behavioural resiliency factor, problemsolving skills are positively associated with resilience and have been included in resilience training for depressive symptoms in children and adolescents(Ma et al., 2020). For instance, mindfulness-based supportive psychotherapy which focuses on problemsolving skills training includes emotional regulation skill and positive change in life style(Wu et al., 2018). Therefore, future research could look into including problem-solving skills training as part of psychological interventions to boost the resilience of cancer patients.
Relaxation techniques is another type of psychological intervention found to enhance resilience in parents of cancer patients. Participants were taught relaxation techniques such as modifying breathing rate, relaxing muscles throughout the body, stopping negative thinking, and calming emotions to reduce health risk factors such as anxiety. This relaxation technique employs autosuggestion, allowing participants to harness their own inner feelings while relaxed(Wu et al., 2018). Muscle tension relaxation, for example, began with the facial muscles and progressed to the legs. Relaxation training for peripheral muscle systems, when combined with rhythmic breathing and imagination, is intended to promote physical and mental balance. In this way patients can be taught how to relax as a way to reduce psychological distress and improve psychological resilience.
Peer support is an important resource for cancer parents. Different forms of peer support have been provided as a type of psychological intervention included in this review to improve the resilience of the parents. For informational support, peer cancer parents provided community resources and practical advice for caring for cancer patients; for emotional support, peer cancer parents provided an opportunity for cancer parents to express their feelings and discuss their concerns. Peer support from other cancer parents who have had similar experiences may help parents gain confidence in their ability to handle problems, potentially increasing resilience(Jin et al., 2022).
A secondary aim was to explore the possible influence of between-study differences, we compared each studies’ difference from CBT’s sessions, duration, delivery mode, and treatment format. It is worth noting that the follow-up period ranged from one month to three months in those studies, and a meta-analysis revealed that a longer time to follow-up assessment was associated with a statistically smaller effect. The number of sessions ranged from 1 to 12, with an average of 6 sessions. There were some connections found between the number of sessions and ES at post-intervention, with the effect of intervention with more than 6 sessions (Z=14.59) being greater than that of intervention with less than 6 sessions (Z=9.5). The larger effect observed at post-intervention for combined face-to-face delivery mode of CBTs (Z=14.07) compared to online mode of CBTs (Z=10.72), indicating that face-to-face mode is an effective way to improve PR. Despite systematically searching studies, only two studies of online mode were discovered. However, due to the epidemic's impact in recent years, the time and place of psychological intervention have been limited, and the online mode has significant advantages. The first one of online mode is a tripod approach with physical exercise, education, and emotional support, and the second one is the positive psychology intervention (PPI) , which can promote well-being and reduce ill-being, which lack some theoretical framework.
Clinical Impliacation
Robust but relatively small effects shows some potential implications for the furture exploration, including clinical and research. Although a cancer diagnosis can be considered a potentially traumatic event for patients, clinical practice indicates that the majority of patients adapt well and return to a state of mental well-being(Tu et al., 2020). This process, known as “resilience,” is often observed after a major disruptive event(Opsomer et al., 2020b). Consequently, it is effective to enhancing psychological resilience by preventing change in cognitive appraisal, behavioral modification, and/or by providing further practice to enhance psychological resilience. At the same time, behavioural strategies is effective for enhancing the psychological resilience, such as behavior of positive response or safety-seeking. The currently used forms of CBT mainly include problemsolving skills, relaxation techniques, and peer support, which include many CBT skills, such as recognize automatic thinking, cognitive correction, behavior recognition, re-attribution and so on, mainly aim to change patients’ the way of thinking for the disease. These skills are typically performed by clinicians or nurses rather than trained cognitive behavioral therapists. Thus CBTs’ implementation still has some limitations, which need interventionists have a rich experience for CBT.
Study Limitation
Our results also have some limitations. The studies included in this systematic review are heterogeneous in clinical and method, the research sample are in different periods after the end of treatment. The start time of the intervention and the evaluation time of the outcome indicators are not uniform, the method and intensity of the intervention plan vary greatly. In additions, There are many measurement tools for the outcome indicators when the literature is included, and these are the possible reasons for the clinical heterogeneity. At the same time, since only Chinese and English literature are included, it is not excluded that the results of the study are affected by language bias, which may be reduces the credibility of the results. Due to the lack of original data, some RCTs were not included in the meta-analysis, the reduction of research has indirectly affected the generalization of the results. Although we have conducted subgroup analysis based on different identified moderators of PR, there is still moderate to large heterogeneity in each subgroup. This could indicate still have some potentially unidentified variables that lead to systematic variation.
In conclusion, this is currently the first comprehensive systematic review and meta-analysis of the effect of CBT on psychological resilience. Twelve studies were included, revealing a small magnitude significant effect on psychological resilience that was largely maintained at follow-up CBTs, which appear to be effective in enhancing psychological resilience level. Future research should continue to investigate the CBT intervention model for psychological resilience, investigate the effects of different intervention frequency, time, and format on enhancing psychological resilience, and investigate how to further optimize CBTs based on psychological resilience related theories.