1. Background
Hope is a vital psychological resource in the context of life-threatening illness, yet it is often significantly diminished when cancer disrupts family life (1). This erosion is particularly pronounced among wives of men with cancer, whose caregiving roles are shaped by ongoing uncertainty, existential distress, and substantial socio-emotional burdens (2). Recent global data confirm cancer as a major public health concern, with over 20 million new cases and nearly 10 million cancer-related deaths reported worldwide in 2022 (3). Within this context, the challenge of sustaining and reconstructing hope among caregivers has emerged as a pressing area of research (4). One of the most critical concerns within this domain is the erosion of hope, given that hope serves as a central psychological resource, supporting coping, fostering resilience, and sustaining engagement in caregiving tasks (5). While numerous studies have examined the psychological consequences of cancer, the majority of this research has focused primarily on patients themselves (6, 7). In contrast, caregiving spouses, particularly wives, encounter distinct psychological dynamics related to hope and despair. Although existing evidence highlights the significant role of interpersonal, social, and cultural factors in shaping hope (8, 9), the intrapersonal processes through which caregivers reinterpret their circumstances and mobilize psychological resources remain insufficiently explored. This gap is especially salient in cultural contexts such as Iran, where wives are often the primary caregivers for men with cancer, and where caregiving occurs under intense emotional and socio-cultural pressures — such as gendered caregiving expectations, emotional suppression, cultural imperatives around family cohesion, and fatalistic or authoritarian discourses around illness (10).
Theoretical frameworks on coping, meaning-making, and empowerment suggest that intrapersonal reframing of crises plays a pivotal role in cultivating resilience. Stress and Coping Theory emphasizes the role of cognitive appraisal in determining whether individuals experience a life crisis as paralyzing or manageable (11). In a similar vein, Rappaport’s empowerment framework (12) and Bandura’s theory of self-efficacy (13) underscore how perceptions of control and personal agency can transform passive suffering into active engagement. Concurrently, research on meaning-making in cancer caregiving has shown that narrative reconstruction of illness contributes to renewed hope and a redefined sense of identity (14, 15). Collectively, these theoretical perspectives suggest that processes such as redefining the meaning of cancer or actively resisting its perceived dominance may serve as key intrapersonal foundations of hope.
This study focuses specifically on two of the intrapersonal foundations of hope formation identified in the broader analysis: Redefining cancer and rising against it. While existing literature has explored interpersonal and cultural factors shaping caregivers’ hope, few studies have addressed how culturally embedded cognitive and behavioral processes mediate this experience. Moreover, current psycho-oncological theories rarely consider the role of cultural narratives and metaphors as drivers of meaning reconstruction and agency in caregiving contexts. This study seeks to address these gaps by exploring the nuanced, culturally grounded intrapersonal mechanisms that enable wives of men with cancer in Iran to reclaim hope in the face of existential threat.
2. Objective
Specifically, it examines how caregiving wives navigate and resist these socio-cultural pressures through intrapersonal processes of redefining cancer and mobilizing resistance, thereby reconstructing hope and reclaiming agency. This focused analytical lens is intended to deepen conceptual understanding, rather than to suggest comprehensiveness or exclusivity.
3. Methods
This study was part of a larger PhD research project conducted in Iran, which explored the formation of hope among wives of men with cancer, developed a cognitive-existential rehabilitation protocol, and evaluated its effectiveness (10). During the qualitative phase of the project, we applied conventional content analysis (16), following Graneheim and Lundman’s framework, which led to the identification of both intrapersonal and extra-personal foundations of hope. The present article focuses specifically on two salient intrapersonal categories: “Redefining Cancer and Its Aspects” (originally situated within the higher-order subcategory Transformation and Meaning Reconstruction) and “Rising Up and Coping” (originally categorized under Manifestation of Confrontation Will). These categories are examined in depth to explore their underlying psychological processes (16).
3.1. Participants
A purposive sample of 11 women whose husbands were undergoing cancer treatment was recruited from oncology centers in Tehran, including Firouzgar Hospital. Eligibility criteria were as follows: (1) The husband was receiving active cancer treatment and not in the terminal stage; (2) the wife was aged between 20 and 55 years; (3) a minimum of five years of marriage; and (4) adequate verbal communication skills in Persian. To enhance sample diversity, participants were selected to represent variation in educational background, number of children, and socioeconomic status, although these factors were not formal inclusion criteria. Exclusion criteria included having a spouse with a serious non-cancer illness, physical conditions that impeded participation in interviews, or a diagnosis of significant psychiatric disorder or cognitive impairment, based on DSM-5.
Table 1 summarizes the demographic profile of the participants, while Table 2 presents the demographic and clinical characteristics of their husbands diagnosed with cancer.
Table 1.Participant Demographic Characteristics (Summarized; n = 11) a
| Variables/Categories | Values |
|---|---|
| Age (y) | |
| 29 - 55 | 37.2 ± 7.15 |
| Education level | |
| Master’s | 4 |
| Bachelor’s | 3 |
| Associate’s | 2 |
| Elementary | 1 |
| High school | 1 |
| Psychological support history | |
| Yes | 6 |
| No | 5 |
| Parental status | |
| Without children | 6 |
| With children | 5 |
| Duration of marriage (y) | |
| 6 - 17 | 11.4 ± 3.23 |
a Values are expressed as mean ± SD or frequency.
Table 2.Patients' Demographic and Clinical Characteristics (Summarized; n = 11) a
| Variables/Categories | Values |
|---|---|
| Age (y) | |
| 35 - 60 | 42.0 ± 6.90 |
| Cancer type | |
| Prostate | 3 |
| Brain | 2 |
| Leukemia | 2 |
| Colon | 2 |
| Lung | 1 |
| Skin | 1 |
| Years since diagnosis (y) | |
| 1.0 - 3.0 | 1.85 ± 0.79 |
| Outcome | |
| Alive | 11 |
a Values are expressed as mean ± SD or frequency.
3.2. Data collection
Data were collected through in-depth, semi-structured, face-to-face interviews conducted between September 2022 and November 2023. Interviews took place in private, comfortable settings to ensure confidentiality and minimize external distractions. The interviewer, a trained qualitative researcher, maintained an empathic and nonjudgmental stance to encourage openness and trust. Each interview lasted approximately 60 to 90 minutes, and invited participants to reflect in detail on their experiences of hope and hopelessness in the context of their spouse’s illness. The interview guide was structured around broad, open-ended questions, including: “Can you describe your experiences during this period, particularly related to hope or hopelessness?” “What experiences of hope or despair did you encounter during the progression of your husband’s illness?” “How did your sense of hope evolve, and what external factors influenced it?” “What helped you cope with hopelessness?” Probing and follow-up questions were used as needed to clarify ambiguities, deepen narratives, and explore underlying psychological and social dynamics. Interviews continued until data saturation was reached after the 11th participant, in accordance with qualitative research guidelines (17, 18), when no new categories or themes were emerging. All interviews were audio-recorded with participants’ consent, transcribed verbatim, and reviewed repeatedly to ensure analytic immersion.
3.3. Data analysis
Data were analyzed using Graneheim and Lundman’s five-step conventional content analysis (16), involving iterative reading, coding, categorization, and abstraction. Line-by-line coding generated 988 initial codes, which were then clustered through constant comparison and axial coding based on semantic affinity and processual coherence. This process yielded two overarching analytical categories — redefining cancer and rising against and coping — each encompassing several sub-processes aligned with the study’s conceptual framework. This article focuses on 54 of these codes, representing key intrapersonal mechanisms within the broader theme of “Intrapersonal Foundations of Hope Formation”, while additional categories will be addressed in future publications.
3.4. Criteria for Trustworthiness of Data
To ensure methodological rigor, we applied Lincoln et al.’s criteria of credibility, dependability, transferability, and confirmability (19): Credibility was enhanced through member checking with participants and peer debriefing with qualitative research specialists. Dependability was ensured by maintaining a detailed audit trail and implementing double-coding by two researchers, followed by supervisory review. Transferability was enhanced through thick description of the participants and the study context. Confirmability was reinforced via reflexive journaling and ongoing discussions within the research team to mitigate potential biases. Reflexivity, defined as critical awareness of how researchers’ perspectives influence interpretation (20), was actively maintained throughout the analytic process. To support this, we applied strategies outlined by Graneheim and Lundman (16), including researcher triangulation, iterative team reflection, and meticulous documentation of analytic procedures. Additionally, illustrative participant quotes were included to illustrate how participants’ narratives informed the analytic interpretations.
3.5. Ethical Approval
This study was approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health (IR.USWR.REC.1398.194). Written informed consent was obtained from all participants, who were assured of confidentiality, voluntary and informed participation, and the right to withdraw from the study at any time.
4. Results
Out of the 988 initial codes extracted, 19 were categorized under “Redefining Cancer and Its Aspects,” and 35 under “Rising Against and Coping”. This paper focuses on these two primary categories and their respective subcomponents, which are summarized in Table 3.
Table 3.The Primary Category and Components of the Research
| Variables | Values |
|---|---|
| Redefining cancer and rising against cancer in hope formation | |
| Redefining cancer and its aspects | (1) Cancer as an authoritarian, destructive force; (2) cancer as a catalyst for self-growth and reconstruction; (3) cancer as a trigger for meaning-making in life; (4) cancer as a challenge that can be managed |
| Rising against and coping | (1) Recognizing the situation as a warlike crisis; (2) defying the paralyzing centrality of cancer; (3) confronting the cancer tradition as oppressive order; (4) mobilizing the agency through proactive action; (5) drawing motivation from goals and future orientation; (6) self-learning and informed coping |
3.1. Redefining Cancer and Its Aspects
Redefining cancer and its aspects refer to the cognitive–interpretive process through which caregivers reframed the illness in ways that transformed its threatening presence into a potential source of hope and resilience. This reframing enabled wives to move beyond paralyzing perceptions of cancer and to engage with the illness as a site of meaning, growth, and agency. Four interrelated dimensions illustrate this process.
4.1.1. Cancer as an Authoritarian, Destructive Force
Participants often portrayed cancer as an authoritarian and coercive force that invaded every aspect of life, demanding complete submission. This framing, while reflecting despair, paradoxically fueled a determination to resist and reclaim agency. As Participant 2 stated: “Cancer is like a dictator; it grabs everything you have and wants to control it all”. Participant 5 explained: “Cancer was like my authoritarian parents, its claws dug into my destiny, denying my will and creating another prison for me”. Participant 3 reflected: “Cancer wants victims, not just the patient. It tries to consume everything: Health, work, future, agency, and family. It seems to hunger for devouring it all”.
4.1.2. Cancer as a Catalyst for Self-growth and Reconstruction
Cancer may be conceptualized as a catalyst for altering the trajectory of one’s life, redirecting it toward personal growth and self-improvement. From this perspective, the illness is regarded as an opportunity to reassess personal values and life priorities. As Participant 5 noted: “Disasters like cancer, which arrive suddenly like a meteor, change the orbit of our self-development and can be a crucial opportunity in life”.
4.1.3. Cancer as a Trigger for Meaning-Making in life
Cancer, as a symbol of life’s limitations and existential pressures, may contribute to a redefinition of one’s experience of life. Interpreting the illness as a factor that fosters spontaneity, individuality, and the emergence of new meaning enables individuals to develop a deeper perspective on existence. As Participant 3 explained: “We realized it’s not only our patients’ health that cancer endangers. We must take back other domains of life from its grip… regaining control and acting gave me a sense of strength”.
4.1.4. Cancer as a Challenge That Can be Managed
A positive perception of cancer as a challenge that can be overcome plays a critical role in reducing stress and fostering hope. This cognitive shift, from viewing the illness as insurmountable to perceiving it as a solvable challenge, helps sustain hope among individuals. For instance, Participant 8 stated: “I began to see cancer not merely as an enemy I had to fight, but as a challenge, something we could confront and find a solution to”.
4.2. Rising Against and Coping with Cancer
Rising against and coping with cancer refers to the dynamic process through which caregivers transition from initial paralysis and despair to intentional action, sustained struggle, and resistance against the multifaceted impacts of cancer. This intrapersonal transformation reflects a fundamental shift in both psychological orientation and behavioral posture: From viewing oneself as a passive victim to adopting the role of an active agent confronting the disease and its oppressive “tradition”. This process can be understood through six interrelated dimensions, which are elaborated below.
4.2.1. Recognizing the Situation as a Warlike Crisis
Recognizing the cancer experience as both a crisis and a war-like situation enables patients’ spouses to approach emerging problems with greater realism and preparedness, often leading to changes in coping strategies. For instance, Participant 3 remarked, “It really feels like war. Things become so bad and so critical that you keep looking for shelter, searching for the strength to stand up to cancer—to stand up to the misfortunes it brings with it, like a black army”.
4.2.2. Defying the Paralyzing Centrality of Cancer
The recognition of the need for resistance and rebellion against the passive centrality imposed by the cancer-dominated world has generated motivation and initiated active engagement. This form of rebellion involves constructing a new, hope-centered reality and actively challenging cancer’s perceived dominance. As Participant 3 explained: “I realized that within this frightening world, full of despair and helplessness, that truly paralyzes and disempowers, one must act. One must take steps that resist paralysis, that somehow rebel against this center of suffering and fear... It becomes necessary to break free from that center, from the terrifying world that cancer creates, to push it back and build a new center grounded in hope”.
4.2.3. Confronting the ‘Cancer Tradition as Oppressive Order’
The perception of the “cancer tradition” as a destructive, totalitarian, and oppressive force can act as a stimulus for resistance across multiple dimensions. This struggle involves confronting not only the physical and psychological consequences of cancer, but also its broader social and existential implications. In this context, Participant 3 remarked: “Seeing cancer as an enemy, and recognizing that my life is in a state of war, makes me want to fight. But it’s not just the cancer itself. Our first battle is with the cancer tradition, that is, how can I put it? With the path of cancer, with this black force and coercion that it imposes on a person, their family, their life... it puts everything under its control and domination”.
4.2.4. Mobilizing the Agency Through Proactive Action
Rather than remaining passive or giving up, individuals in this group exhibit a focus on constructive actions, such as resisting the effects of cancer, protecting their families, and sustaining hope within the home environment. These behaviors reinforce a spirit of resistance. In this context, Participant 3 observed: “In these groups, I realized how important it is to stay active and do something, instead of just sitting around, thinking, and daydreaming. This approach has many benefits. It helps increase our self-confidence”.
4.2.5. Drawing Motivation from Goals and Future Orientation
Future-oriented thinking, focusing on life goals and children’s success, functioned as a key source of motivation to persevere and resist despair. Such goals contributed to sustained motivation and reinforced a sense of hope. As Participant 5 reflected: “To separate myself from despair, I would review and remind myself of my direction, goals, motivations, and aspirations several times a day”.
4.2.6. Self-learning and Informed Coping
A deeper understanding of cancer and the circumstances it creates, achieved through self-education, consultation, and active information-seeking, served as a foundational step in enhancing the ability to cope, resist, and identify promising solutions. As Participant 6 explained: “It was a constant struggle. We needed to fully understand the situation we were in — what exactly we were dealing with, what this cancer-created reality meant for us, and what had actually happened to us. We educated ourselves about the disease, spoke extensively with doctors, and sought out a range of opinions”.
5. Discussion
This study elucidates two intrapersonal processes through which wives of men with cancer reconstruct hope: Redefining cancer and its aspects, and rising against and coping with cancer. Together they delineate a dialectical pathway whereby cognitive–existential reframing (what cancer is and means) is translated into behavioral activation (what to do in the face of it), enabling a transition from paralysis to agency and from threat-saturated experience to renewed meaning and resilience.
5.1. Redefining Cancer and its Aspects: Discursive Reconstitution
The data from the present study suggest that some caregivers redefine cancer as a coercive and negative authority that operates through a destructive, domineering, and all-consuming tradition; one that seeks to engulf not only the patient but also everything associated with them, including their family and caregivers. Although Sontag warned that military metaphors can be fear-inducing and demeaning (21), our findings suggest otherwise in certain contexts. Consistent with the study by Semino et al., which highlights the motivational and agentic functions of war metaphors for caregivers (22), our data show that redefining cancer as an authoritarian and coercive force — embedded within a totalitarian and destructive “tradition” that invades the life domains of both patients and caregivers — can contribute to psychological empowerment. This reframing fosters agency and supports the regeneration of hope. These findings align with Empowerment Theory, which posits that meaning-making in times of crisis, particularly through the concept of “struggle”, can enhance individuals’ sense of control, foster conscious decision-making, and reduce psychological passivity, thereby promoting self-empowerment (12). In the present study, we observe an interpretive shift in which cancer is positioned within a narrative of struggle, one that, as Sulik also emphasizes (23), reconfigures the individual's emotional stance from passivity to active confrontation. This narrative defines coping as a conscious act of resistance. It also enables caregivers to adopt a distinct and active role, thereby reclaiming a sense of control. Participants externalized cancer as a coercive and authoritarian force, representing it as a negative authority operating within a totalitarian and destructive “tradition” that permeates various domains of life. By employing this metaphorical framing, they moved beyond helplessness and fatalistic resignation, engaging instead in a process of “empowering externalization”. This allowed them to embody diffuse and ambiguous fears in the form of a concrete enemy, thereby adopting a more active stance and gaining a greater sense of psychological agency. This strategy is conceptually aligned with the narrative therapy practice of “externalizing the problem,” a technique that reduces passivity and fosters agentic engagement (24). Furthermore, the transformation of diffuse and formless fear into a tangible threat echoes Yalom’s ideas in existential psychotherapy, which suggest that when individuals are unable to tolerate pervasive existential anxiety, they unconsciously convert it into specific fears (25), a transformation that, in our findings, leads to its management. In this sense, the military metaphors employed by participants not only dramatized their experience but also facilitated the articulation of fear and anxiety in a coherent psycho-narrative framework. The construction of such a framework, motivational, oppositional, and oriented toward meaning-making, can play a critical role in restoring hope and reconstructing identity among both patients and caregivers (26, 27). More recent studies, such as that of Ren and Ahn (28), indicate that in the context of life-threatening illness, the way couples cope with crisis significantly influences their psychological transformation and meaningful personal growth. Consistent with these findings, the present study also revealed that, for some caregivers, the experience of a spouse’s serious illness served as a turning point for psychological development, value reappraisal, and personality transformation. In this regard, the theory of post-traumatic growth (29) and the concept of the “search narrative”, which emphasizes transformation through illness (30), converge on the idea that confronting a crisis can pave the way for redefining life goals, enhancing self-awareness, and shifting personal attitudes. According to the present study, and in line with the model of meaning-making in crisis (31), the onset of cancer has been interpreted as a catalyst for redefining life’s meaning and experience among the wives of men diagnosed with cancer. Those who were able to engage in this meaning-making process, by reframing illness and suffering as opportunities to strengthen relationships or reassess life priorities, were also able to extract hope from their lived experience of the crisis. However, at this stage, reframing one’s attitude toward cancer as a manageable challenge becomes critically important. According to our findings, when the spouse or caregiver perceives cancer not as an uncontrollable catastrophe but as a challenge that can be managed, they are more likely to shift away from helplessness and psychological stagnation and move toward a state of hope and agency. The concept of controllability appraisal, as articulated in stress coping theory (32) and self-efficacy theory (13), suggests that perceiving a crisis as manageable can increase the likelihood of adopting active, problem-focused, and constructive coping strategies. According to our findings, such strategies are associated with a more hopeful outlook on the future and a greater sense of agency in the caregiving process.
5.2. Rising Against and Coping with Cancer: Counter-Discursive Agency
The data from the present study indicate that “standing up and coping with cancer” reflects a psycho-behavioral trajectory through which caregivers transition from an initial state of passivity and powerlessness toward active engagement, crisis management, and psychological reconstruction.
The first component in this process involved perceiving the situation as a state of war or crisis. As emphasized in the coping readiness on preventive psychiatry theory (33) and the problem-oriented coping model (32), recognizing a situation as a crisis serves as a prerequisite for the mobilization of coping resources. In our findings, framing the illness through concepts such as “invasion” or “emergency conditions” facilitated a form of psychological readiness that enabled individuals to shift from the role of passive victim to a state of active involvement.
The second component involved an uprising against the passivating centrality of cancer. In line with Bandura’s concept of agency (34), caregivers reclaimed their focus from the illness’s psychological dominance. They then reoriented this focus toward a “center of hope”, thereby enabling a shift in their emotional structure from passivity to active coping. This cognitive restructuring, defined not as denial of the illness but as a reordering of priorities, facilitated sustained effort and psychological resistance amid uncertain prospects. If, for Heidegger, existential anxiety (Angst) is a force that confronts individuals with the authentic possibilities of their existence — that is, anxiety can shake a person out of passive immersion in what “everyone says”, pull a person out of “going along with others”, reveal one’s finitude, prompt a sense of responsibility, and lead to a resolute, self-directed stance in reclaiming and acting on one’s possibilities (35) — then the caregivers in this study, who were confronted with their spouse’s illness as a source of existential anxiety, were able to reclaim the possibility of authentic living by distancing themselves from the narrative dominance and paralyzing centrality of cancer as a Negative Other and coercive “dictator”, by “taking back” threatened life domains through regaining control and acting, and by constructing a new “center of hope” through confronting cancer and its oppressive “tradition”. In this sense, authentic living was expressed as a state of self-authorship and freedom, characterized by renewed “direction, goals, motivations, and aspirations”.
In a related philosophical vein, Albert Camus, in The Myth of Sisyphus, emphasizes resistance and rebellion against existential emptiness, as well as the creation of meaning in the midst of meaninglessness (36). The rewriting of narratives and resistance to the imposed tradition of cancer — a tradition that is passive-inducing, despairing, and suggestive of existential absurdity — align with and affirm Camus’s notion of a passionate commitment to life and his conception of rebellion as fidelity to existence in the face of absurdity. In the present study, rather than yielding to cancer tradition, participants demonstrated a lived commitment to life by emphasizing the need to find the “strength to stand up to cancer”, to “take steps that resist paralysis”, and to frame meaning as an active struggle — such as viewing the “first battle” as a battle with the cancer tradition itself and understanding “cancer as a destructive yet transformative force that can alter the trajectory of self-formation and open vital possibilities for life”.
Third, confronting the “tradition and consequences of cancer” as a culturally oppressive discourse represented another dimension of this process. As Bonanno (37) and White (24) have demonstrated, rewriting stereotyped narratives and constructing narratives of resistance facilitates psychological resilience and the reconstruction of identity. In the present study, consistent with the findings of Basnyat et al. (38), caregivers generated new narratives of hope and resistance by rejecting fatalistic accounts and redefining cancer as an imposed and authoritarian force — a narrative aligned with the concept of “narrative resilience” (39).
Fourth, these cognitive shifts were manifested in pragmatic behaviors. Caregivers adhered to a problem-focused coping model (32) by consistently engaging in treatment, participating in decision-making, maintaining a supportive family atmosphere, and assuming an active caregiving role. Such purposeful actions not only enhanced behavioral efficacy but also fostered emotional stability, a stronger sense of control, and the restoration of hope. A qualitative study (40) similarly showed that caregivers restored their sense of agency through protective caregiving roles and purposeful efforts to maintain hope — an outcome closely aligned with the process of agency re-centering described in the present study.
Fifth, focusing on future goals as sources of motivation played a pivotal role. As Snyder’s hope theory (41) posits, hope rests on the interconnection of goals, pathways, and agency. Caregivers in this study identified objectives such as maintaining family health and sustaining their shared life as motivational drivers, thereby broadening the mental horizon of hope in the midst of crisis.
Finally, learning and self-education constituted another pathway for reconstructing agency. In line with Bandura’s self-efficacy theory (13), enhancing knowledge and skills fosters a stronger sense of control. Our findings showed that by seeking medical information, consulting with experts, and participating in educational sessions, caregivers not only improved their caregiving competence but also reinforced the psychological foundations of hope and motivation.
This study offers a culturally situated reconfiguration of cancer caregiving in Iran by introducing the concept of "Cancer Tradition" — an oppressive socio-existential narrative that directs life, body, family, and time. Challenging dominant psycho-oncological models centered on emotional adaptation, it reframes hope as a culturally embedded act of resistance. Within this framework, caregivers are not passive supporters but active agents navigating two novel intrapersonal mechanisms: Reframe-Enact and Redefinition-Action. These cycles dynamically connect metaphorical reframing, existential meaning-making, and behavioral agency. This triadic pathway — linking metaphor, meaning, and agency — offers a novel theoretical contribution that reframes hope not as an emotion, but as a culturally embedded form of existential defiance. The metaphor of cancer as a totalitarian force catalyzes this transformation, offering an empowering narrative alternative. Rather than coping with suffering, caregivers reposition themselves by resisting symbolic domination and reclaiming life domains.
These findings expand psycho-oncological theory through integration of narrative therapy, cultural existentialism, and agentic models of hope. A summary of these contributions is presented in Table 4, situating this study within and against global frameworks of illness experience.
Table 4.Conceptual Contributions and Novelty of the Study Compared to Global Psycho-oncology Literature
| Core Dimension of Novelty | Conventional Psycho-oncology Literature | This Study’s Distinct Contribution |
|---|---|---|
| (1) Concept: Cancer tradition | Cancer often viewed as medical or personal hardship; No structured socio-existential conceptualization. | Introduces “Cancer Tradition” as a culturally rooted oppressive order regulating body, time, family, and future — a novel cultural-existential construct. |
| (2) Process models (new mechanisms) | Focus on linear coping stages or meaning-making; Often reductionist. | Proposes two new intrapersonal cycles: (1) Reframe-enact, (2) Redefinitionction — showing dynamic transformation of hope via cognition and action. |
| (3) Metaphor-meaning-agency triad | Metaphors (e.g. battle) treated as problematic or irrelevant; Agency not usually linked to metaphoric cognition. | Unveils a novel triadic pathway — metaphorical reframing → motivational meaning-making → agency — through which hope is culturally constructed and enacted. |
| (4) Cultural-gendered context (Iran) | Generic caregiver roles; minimal cultural or gender specificity; Based on Western individualism. | Grounded in Iranian caregiving wives’ experiences, where hope, agency, and responsibility are intertwined with moral, familial, and cultural expectations. |
| (5) Theoretical synthesis and depth | Typically relies on 1 - 2 mainstream theories (e.g., Lazarus, Snyder, Sontag); Limited conceptual integration. | Integrates 20+ theoretical frameworks (Heidegger, Camus, Yalom, Sontag, Frankl, Bandura, Lazarus, Ricoeur, Semino, etc.) into a coherent interpretive narrative. |
5.3. Strengths and Limitations
This study offers in-depth, culturally grounded insights into the intrapersonal foundations of hope formation among wives of men with cancer — an area rarely addressed in global psycho-oncology research. The use of qualitative content analysis, together with rigorous trustworthiness criteria, enhanced the credibility of the findings.
Nevertheless, several limitations must be acknowledged: The study included 11 participants from a single cultural context, which constrains the transferability of findings to other settings. Only wives of male patients were included, limiting the diversity of perspectives represented. As with all qualitative research, the findings are derived from participants’ subjective narratives and may not be generalizable to all caregiver populations.
5.4. Clinical Implications
The model suggests that culturally sensitive cognitive-existential interventions can be deliberately sequenced into the following modules: Externalization and naming of the oppressive order for example, when caregivers described feeling overwhelmed and powerless, the therapist may help externalize the problem by saying: “As you talk about cancer, it sounds less like a personal weakness and more like a force imposing its own rules on your life and family. Let’s call this force the ‘Cancer Tradition’ and look together at how it tries to limit your freedom, hope, and sense of agency.” Growth-oriented reappraisal (values clarification, identity work) For example, when caregivers struggled with feelings of passivity and fate, the therapist may invite a growth-oriented reappraisal by asking: “When you notice the part of you that feels forced or helpless, what does your wiser, more responsible self say about who you want to be in this situation?” The therapist may further explore values and identity by highlighting the caregiver’s role as an active author of her life, capable of choosing, creating meaning, and taking responsibility for hope and future direction. Meaning Reconstruction (narrative re-authoring, dignity-conserving dialogue) For example, in sessions focused on meaning reconstruction, the therapist may invite the caregiver to integrate newly clarified beliefs and values into a coherent life narrative by asking: “If this phase of life were guided by freedom, responsibility, and commitment rather than fear and resignation, how would you describe the meaning of what you are living through now?” Manageability planning (problem-solving aligned with perceived control) For example, when caregivers felt overwhelmed by uncertainty, the therapist may help translate hope into manageable action by asking: “What aspects of this situation are within your control this week, and what are not?” The therapist may then support problem-solving by collaboratively identifying one or two realistic steps — along with possible obstacles and alternative plans — that strengthen the caregiver’s sense of control and reduce helplessness.
5.5. Contributions and Future Directions
Future research should investigate the temporal sequencing and mediating mechanisms of the reframe-enact loop through longitudinal designs, quantify key mediators such as perceived control and narrative coherence, and test modular intervention packages derived from the proposed model. Future studies may examine whether metaphorical reframing contributes to the formation of meaning systems and dialectical narratives oriented toward confrontation with cancer and its oppressive tradition as a negative authority, and whether these processes play a role in mobilizing agency and enhancing hope among caregiving spouses.
5.6. Conclusions
This study makes three interrelated conceptual contributions to psycho-oncology. First, it presents the culturally grounded construct of “Cancer Tradition”: an oppressive, all-encompassing order perceived as regulating bodies, time, family, and future. By naming this aggressive structure and locating it outside the self, caregivers enacted what can be called existential defiance and uprising, transforming private suffering into a form of existential resistance. This reframes existing empowerment narratives by locating agency not only within the self but also within narrative acts of resistance, as theorized by Ramya and Sheelam in their study of narrative resilience among caregivers of advanced cancer patients (42) — counter-discourses that challenge hegemonic illness narratives (24). This process facilitates the separation of personal narratives from dominant societal scripts such as “cancer equals death,” “incurability,” or “inescapable decline,” thereby allowing caregivers to move beyond a position of victimhood and reclaim a meaningful, agentic role.
Second, the study delineates two novel dual-loop intrapersonal mechanisms — Reframe-Enact and Redefinition-Action — capturing how cognitive reframing and narrative resistance evolve into existential agency. These sequential pathways trace transformations from metaphor to motivational meaning-making, then to action. Third, the findings reveal a culturally embedded triadic process — linking metaphor, meaning, and agency — through which hope is reconstructed not as emotional optimism, but as existential resistance. This model, rooted in the unique social roles of Iranian caregiving wives, reframes caregiving as an agentic, culturally mediated struggle for narrative sovereignty and psychological renewal.
It should be noted that while this article focused on two intrapersonal processes, it does not claim exclusivity. Rather, these processes and their components operate alongside other intra- and extra-personal foundations identified in our broader program of research (10), jointly shaping the complex ecology of hope within Iranian caregiving contexts.
