Psycho-Oncology

Psycho-Oncology 17: 112–121 (2008)

Published online 25 April 2007 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1207

Assessing spiritual growth and spiritual decline following

a diagnosis of cancer: reliability and validity of the
spiritual transformation scale
Brenda S. Cole1, Clare M. Hopkins2*, John Tisak3, Jennifer L. Steel4 and Brian I. Carr4
1
Department of Behavioral Medicine, University of Pittsburgh Cancer Institute, Pittsburgh, PA 15232, USA
2
School of Nursing, Carlow University, Pittsburgh, PA, 15213, USA
3
Department of Psychology, Bowling Green State University, Bowling Green, OH, USA
4
School of Medicine, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

* Correspondence to: School of Abstract

Nursing, Carlow University,
Pittsburgh, PA, 15213, USA.
E-mail: hopkinscm@carlow.edu
Received: 19 September 2006
Revised: 23 February 2007
Accepted: 28 February 2007
This study assessed the factor structure, reliability, and validity of an instrument designed to
assess spiritual transformations following a diagnosis of cancer}the Spiritual Transformation
Scale (STS). The instrument was administering to 253 people diagnosed with cancer within the
previous 2 years. Two underlying factors emerged (spiritual growth (SG) and spiritual decline
(SD)) with adequate internal reliability (alpha ¼ 0.98 and 0.86, respectively) and test–retest
reliability (r ¼ 0:85 and 0.73, respectively). Validity was supported by correlations between SG
and the Positive and Negative Affect Scale (PANAS) Positive Affect Subscale (r ¼ 0:23;
p50.001), the Daily Spiritual Experiences Scale (r ¼ 0:57; p50.001), and the Post-traumatic
Growth Inventory (r ¼ 0:68; p50.001). SD was associated with higher scores on the Center for
Epidemiological Studies Depression scale (r ¼ 0:38; p50.001) and PANAS-Negative Affect
Subscale (r ¼ 0:40; p50.001), and lower scores on the PANAS-Positive Affect Subscale
(r ¼
0:23; p50.001), and the Daily Spiritual Experiences Scale (r ¼
0:30; p50.001).
Hierarchical regression analyses indicated that the subscales uniquely predicted adjustment
beyond related constructs (intrinsic religiousness, spiritual coping, and general post-traumatic
growth). The results indicate that the STS is psychometrically sound, with SG predicting better,
and SD predicting poorer, mental and spiritual well-being following a diagnosis of cancer.
Copyright # 2007 John Wiley & Sons, Ltd.
Keywords: spiritual transformation; spiritual change; spiritual growth and spiritual decline;
religion; spirituality and cancer

Introduction more advanced disease [13]. The post-traumatic

Mental health professionals have historically been
concerned with the negative effects of traumatic
experiences [1] and with efforts to minimize
psychological distress and physical health sequelae.
More recently, both theoretical [2] and empirical [3]
attention has been given to the potential for
positive post-traumatic changes. While concepts
have included such things as perceived benefits [4]
or adversarial growth [5], they tend to refer to
changes across four domains: world view, relation-
ships with others, goals, and sense of self [6].
Determining the clinical implications of these
changes, generally referred to as post-traumatic
growth [3,7], is a relatively new line of research, but
studies suggest that post-traumatic growth tends to
be associated with better psychosocial adjustment
to a traumatic event [8,9].
Analogously, people diagnosed with cancer also
report cancer-related growth [10–12] that may be
greater for some subgroups such as people with
changes mirror those reported by people con-
fronted by non-cancer events and similarly include
changes in world view, relations to self and others,
and life priorities [7,13,14]. As with other traumatic
events, growth after a diagnosis of cancer tends to
be associated with better adjustment to cancer [15].
For many people, post-trauma transformations
have spiritual dimensions}both in terms of the
meaning given to the transformation and the
changes in life values that ensue [6,16]. Yet, the
spiritual aspects of post-trauma growth have only
been minimally studied and researchers have
argued for more rigorous investigations [17,18] of
this construct within the broader research agenda
of understanding links between religious/spiritual
processes and health [8,19]. Clearly, this is espe-
cially important for people coping with cancer,
given the substantial body of evidence linking
spiritually oriented processes with better adjust-
ment to the illness [20–22]. Spiritual transformations
may play a role in this link, and the identification of

Copyright # 2007 John Wiley & Sons, Ltd.

The spiritual transformation scale
such a relationship could guide the development of
support services for this population.
A more in-depth study of the effects of spiritual
growth (SG) or transformation following a cancer
diagnosis has been limited by the lack of a
psychometrically sound instrument that specifically
assesses this construct. Several instruments have
been used to assess various aspects of spiritual life
within the process of coping with cancer. The
Spiritual Well-Being Scale (SWBS) has been used
to assess religious and existential well-being;
however, several methodological issues have been
raised including the detection of ceiling effects [23].
The Functional Assessment of Chronic Illness
Therapy}Spiritual Well-Being Scale (FACIT-SP)
has been used to assess life meaning/peace, and the
use of faith as a coping resource [18]. The Systems
of Belief Inventory has been used to measure
beliefs/practices and social support tied to a faith
community and the Spiritual Involvement and
Beliefs Scale has been used to assess external
rituals, internalized beliefs and SG, existential
beliefs and meditation, and personal application
of spiritual principles [23].
While various items on these scales might
correspond to SG, limitations remain. None of
these tools directly measure the construct of SG or
transformation following trauma in a way that
differentiates spiritual change from other, perhaps
related, spiritual variables such as a stable tendency
to find spiritual meaning in traumatic events. None
of the scales include items that correspond to all of
the various domains of change (e.g. change in self
or change in world view) that have been included in
measures of post-traumatic growth scales that are
not specifically spiritually based. And finally, while
Pargament [24] has pointed to the importance of
assessing both positive and negative aspects of
spiritual coping in the face of trauma, no scales of
post-trauma growth have assessed the counter to
SG (i.e. spiritual decline (SD)).
Given these limitations, this study designed and
assessed the factor structure and reliability of a
newly developed scale, the Spiritual Transforma-
tion Scale (STS), which measures both SG and SD
across four domains (world view, goals/priorities,
sense of self, and relationships). It was expected
that STS items reflective of SG and SD would load
on two separate factors. However, it was also
possible that the four domains of change (i.e. world
view, etc.) would factor out separately as well; thus,
each domain was represented by several items to
allow for this possibility.
Construct validity was tested by the subscales’
associations with commonly used religious/spiri-
tual variables that would be expected to correlate
with spiritual transformations (i.e. intrinsic reli-
giousness and spiritual coping) and post-traumatic
growth that is not exclusively religious/spiritual in
nature. Associations between SG, SD, and adjust-
Copyright # 2007 John Wiley & Sons, Ltd.
113
ment were also assessed. It was hypothesized that
SG would be associated with positive spiritual
coping, intrinsic religiousness, and general post-
traumatic growth, along with better psychological
and spiritual adjustment; that SD would be
negatively associated with intrinsic religiousness
and post-traumatic growth, positively associated
with negative spiritual coping, and negatively
associated with psychological and spiritual well-
being; and that the STS would uniquely predict
adjustment above and beyond that predicted by the
similar constructs of religious coping, intrinsic
religiousness, or general post-traumatic growth.
As exploratory analyses, associations between SG,
SD, and mysticism were also investigated to further
elucidate the experiences of transformation.
Methods
Participants
Cancer patients at medical clinics in Pittsburgh,
Pennsylvania, who met the inclusion criteria (i.e.
over age 18 and diagnosed with cancer in the
previous 2 years) were asked to take part in a study
about ‘life changes following a diagnosis of cancer.’
Spirituality was not identified as a specific interest
of the study to avoid obtaining a pro-spiritual
sample. Questionnaires were distributed to 415
people and 265 people returned them, with 253
providing usable data. Among this sample, only
those people who did not skip items on the STS
were included in the factor analyses (N ¼ 244).
Procedures
After obtaining written informed consent, partici-
pants were given the questionnaire battery to
complete on site or return by mail with follow-up
calls made as needed. The battery assessed: (1)
background variables (demographic, religious, and
medical variables); (2) post-traumatic growth; (3)
intrinsic religiousness; (4) spiritual coping; (5)
mysticism; (6) depression; (7) positive and negative
affect; (8) spiritual well-being; and (9) spiritual
transformations. Participants were also asked to
identify someone who knew them well to rate them
on the STS, providing an observer’s rating as a
validity check. Observer ratings for 225 partici-
pants were obtained. Ninety participants were
administered the STS a second time by mail,
approximately two weeks after the first adminis-
tration for test–retest analysis, with 58 question-
naires returned.
Measures
The STS was developed through two processes.
First, based on an extensive literature review and
the clinical experience of the authors, an initial
Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
114
60-item STS was formulated that reflected spiritual
changes across four domains: world view, life
goals, relationships, and sense of self. Items
reflected both SG and SD, and utilized non-theistic
language to apply to religiously diverse partici-
pants. Second, qualitative interviews were con-
ducted with 15 individuals who had been diagnosed
with cancer in the previous 2 years and reported a
post-diagnosis spiritual change. These participants
were also shown the initial STS and they provided
critical feedback about items. Qualitative themes
identified through the interview and participants’
critiques were used to refine the STS items to better
reflect participants’ language and experience, re-
sulting in a 42-item questionnaire rating the extent
to which participants had experienced spiritual
changes since their cancer diagnosis. This article is
a report of the study to further refine and estab-
lish the psychometric properties of this scale.
Several background variables were assessed.
Demographic variables included: age, gender,
ethnicity, education, income, marital status, and
employment status. Religious background vari-
ables [25] included: religious affiliation, attendance
at religious services, frequency of prayer/medita-
tion, self-reported religiousness, and self-reported
spirituality. Medical variables included: time since
diagnosis, type and stage of cancer, and diagnosis
status (new vs recurrent).
Construct validity was assessed using several
scales. The Post-traumatic Growth Inventory
(PTGI) [26] is a 21-item scale assessing post-
traumatic growth. Internal consistency has ranged
from 0.67 to 0.85. Construct validity has been
evident in moderate correlations with optimism
and openness to experience. Intrinsic religiousness
[27] is a 10-item tool assessing the extent to which
religion is central to a person’s life. Reported
reliability is 0.90. Validity is supported through
correlates with five widely used scales (e.g. the
Feagin Intrinsic–Extrinsic Scale). The Brief
RCOPE [28] contains two subscales assessing
positive and negative religious coping. Internal
consistency ranges from 0.81 to 0.90 and the
subscales have differentially predicted adjustment.
The directions were modified to refer specifically to
coping with the cancer diagnosis. And finally, The
Mysticism Scale [29] is a 32-item commonly used
scale with two subscales assessing Mystical Experi-
ence and Religious Interpretation. The subscales
have been associated with similar constructs such
as intrinsic religious motivation (0.58–0.68) and
religious experiences (0.34–0.56). The directions
were modified to refer to mystical experiences since
the diagnosis of cancer.
Three adjustment variables were included to
assess both mental and spiritual well-being. The
Center for Epidemiological Studies-Depression [30]
scale is a widely used self-report measure of
depressive symptoms. A brief 10-item version was
Copyright # 2007 John Wiley & Sons, Ltd.
B. S. Cole et al.
utilized (see [31]). The Positive and Negative Affect
Scale (PANAS) [32] is a widely used 20-item scale
that assesses positive and negative affective states.
And finally, The Daily Spiritual Experience Scale
(DSES) [33] assesses the relational and affective
aspects of spiritual life. Higher scores indicate a
higher degree of spiritual experiences. This tool has
high internal consistency (alpha of 0.94 and 0.95)
and test–retest reliability (alpha of 0.92). The scale
has differentiated religious from non-religious
persons. To be consistent with the other measures,
the instructions were modified to refer to the past 7
days.
The DSES is not typically conceptualized as a
measure of spiritual well-being. However, there are
few measures of this domain and the most widely
used scale, the SWBS may have problems with
ceiling effects, as pointed out by the scale authors
[34] and based on previous unpublished research by
the first author on this paper. Moreover, the SWBS
was problematic for this study in that it combines
both beliefs and experiences. These may not always
be congruent. One might have a global belief that
God is benevolent, but not be currently experien-
cing that benevolence affectively in the midst of
coping with cancer. For this study it was important
to assess the participants’ current experiences of
spiritual wellness. The items in the DSES have face
validity for assessing this construct (e.g. ‘I find
strength in my religion or spirituality’) and overlap
considerably with items on the SWBS: both scales
assess positive qualities of one’s relationship with
God}believing that God loves me (SWBS) and
feeling God’s love (DSES). In addition, the DSES
was preferable because it assesses broader aspects
of spiritual wellness by also including spiritual
aspects of relationships with other people and
nature (e.g. ‘I am spiritually touched by the beauty
of creation’) which are consistent with the domains
of change explored in this study.
Results
Sample characteristics
Participants were primarily Caucasian (n ¼ 241;
95%) and female (n ¼ 198; 78%). Average age was
58 (SD ¼ 11:00; range ¼ 28–86 years). Most parti-
cipants were married or in a long-term relationship
(196; 78%); working full time (73; 29%) or retired
(72; 29%); and had at least a high school degree/
GED (119; 47%) or a college degree (126; 50%).
Household incomes were less than $20 000 for 25
(10%) participants, between $20 000 and $34 999
for 38 (15%) participants, between $35 000 and
$49 000 for 45 (18%) participants, between $50 000
and $74 000 for 58 (23%) participants, over $75 000
for 75 (29%) participants, and unreported by 6
(2%) participants. This was the first cancer
Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
The spiritual transformation scale
diagnosis for most participants (198; 75%). Cancer
type included 113 (45%) breast, 31 (12%) melano-
ma, 26 (10%) ovarian, 18 (7%) liver, 11 (4%)
lymphoma, and 54 (22%) other. Stage of illness
included: 6 (2%) Stage 0, 57 (23%) Stage I, 38
(15%) Stage II, 47 (19%) Stage III, 26 (10%) Stage
IV, and 78 (31%) unknown. Time since diagnosis
ranged from 0.19 to 23.96 months, with a mean of
6.65 months (SD ¼ 5:41).
Religious affiliations included 127 (50%) Protes-
tant, 99 (39%) Roman Catholic, 13 (5%) other, 8
(3%) Jewish, and 5 (2%) none. Religious atten-
dance ranged from several times a year or less for
98 (39%) participants, one to three times per
month for 54 (21%) participants, to once a week or
more for 101 (40%) participants. Frequencies of
prayer/meditation tended to be high and were once
a day or more for 171(68%) participants, one to a
few times per week for 46 (18%) participants, and a
few times per month or less for 35 (14%)
participants. Participants on average rated them-
selves above the mid-point on the four-point scale
% ¼ 2:90;
assessing level of religiousness (X
% ¼ 3:14;
SD ¼ 0:81) and level of spirituality (X
SD ¼ 0:78).
Scale structure and descriptive statistics
The factor structure of the 42-item STS was tested
using Principal Axis factor analyses with iterations
and oblique rotation. Two items were dropped.
‘I more often let go of things in a way that is
spiritual to me’ was dropped because it was often
skipped. ‘I am more often aware that there is
something standing between me and the sacred
(e.g. God, Allah, Buddha, Nature, etc.)’ was
dropped because it loaded on a factor inconsistent
with its face validity. Two factors emerged (see
Table 1). Each item loaded on only one of the two
factors above the standard cutoff of 0.40 and was
weakly correlated with the second factor (below
0.20). Two subscales were formed based on these
analyses: SG (i.e. a stronger spiritual orientation
related to world view, goals, relationships with
% ¼ 3:76; SD ¼ 1:70) and SD
others, sense of self) (X
(i.e. a loss or weakening of spiritual associations
with these domains) (X % ¼ 1:46; SD ¼ 0:74). SG
accounted for 48% of the variance and SD
accounted for 12%. The bivariate correlation
between the two subscales was not significant
(r ¼
0:03; p40.05).
Reliability
Internal consistency was excellent for both the SG
(Cronbach alpha ¼ 0:98) and SD (Cronbach
alpha ¼ 0:86) subscales. Test–retest reliability was
acceptable based on Pearson correlations: r ¼ 0:85
(p50.001) for SG and r ¼ 0:73 (p50.001) for SD.
Copyright # 2007 John Wiley & Sons, Ltd.
115
Predictors of STS subscale scores
Background variables (demographic variables,
religious variables, and medical factors) were
assessed as predictors of STS scores. Based on
Spearman bivariate correlations for ranked data
and Pearson R correlations for interval data, SG
was significantly associated with age (r ¼
0:16;
p50.05), religious service attendance (r ¼ 0:23;
p50.001), frequency of prayer/meditation (r ¼
0.37, p50.005), level of religiousness (r ¼ 0:34;
p50.001), level of spirituality (r ¼ 0:46; p50.001),
and time since diagnosis (r ¼ 0:22; p50.001). SD
was associated with age (r ¼
0:13; p50.05),
religious service attendance (r ¼
0:23; p50.001),
level of religiousness (r ¼
0:20; p50.01), and
level of spirituality (r ¼
0:18; p50.01).
Categorical data were assessed using either a
t-test or ANOVA with post hoc pairwise compar-
isons using Bonferroni adjustments to control Type
I error. Participants reported higher SG scores if
% ¼ 3:89; SD ¼ 1:67; n ¼ 198)
they: were female (X
% ¼ 3:29; SD ¼ 1:66; n ¼ 55)
compared to male (X
(tð251Þ ¼
2:31; p50.05); had a recurrence of a
% ¼ 4:39; SD ¼ 1:74; n ¼ 64)
previous diagnosis (X
% ¼ 3:55; SD ¼ 1:64,
compared to a new diagnosis (X
n ¼ 189) (tð251Þ ¼ 3:51; p50.001); were Stage III
(X% ¼ 4:27; SD ¼ 1:67; n ¼ 47) or Stage IV
% ¼ 4:46; SD ¼ 1:56; n ¼ 26) compared to Stage
(X
I (X% ¼ 3:25 1.57 57) (Fð4; 241Þ ¼ 5:14; p50.001);
and had melanoma (X % ¼ 4:61; SD ¼ 1:51; n ¼ 31)
%
or ovarian (X ¼ 4:64; SD ¼ 1:63; n ¼ 26) cancer
compared to breast, (X % ¼ 3:63; SD ¼ 1:65;
n ¼ 113) or liver cancer (X % ¼ 3:05; SD ¼ 1:77;
n ¼ 18) (Fð3; 184Þ ¼ 6:37; p50.001). Other cancer
types were not included in these analyses due to the
small frequencies.
Because the association of SG with cancer type
was unexpected, post hoc analyses were conducted
to compare the four cancer groups (melanoma,
ovarian, breast, and liver) on all demographic,
medical, and religious factors to help explain this
difference. One significant finding emerged: people
with melanoma or ovarian cancer were more likely
than people with breast or liver cancer to have had
a recurrence compared to a first diagnosis. Since
recurrence was associated with greater SG this may
explain the differences in SG among these four
cancer types.
Participants reported greater SD scores if: they
were Protestant (X % ¼ 3:82; SD ¼ 1:75; n ¼ 127)
compared to being Catholic (X % ¼ 3:77; SD ¼ 1:60;
n ¼ 99) (Fð2; 249Þ ¼ 4:42; p50.01) (no differences
were found between these two religious affiliations
and a group comprised of all other religious
affiliations); and they had a 9th to 12th grade
education without a diploma or GED (X % ¼ 2:30;
SD ¼ 2:30; n ¼ 8) compared to participants who
had a high school degree or GED (X % ¼ 1:49;
SD ¼ 0:73; n ¼ 76), some college (X ¼ 1:35; %
Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
116 B. S. Cole et al.

Table 1. Spiritual transformation scale

Directions:

Whether you are or are not spiritual or religious, please indicate the extent to which these statements are true for you since your diagnosis of
cancer. Think about how you were before you were diagnosed with cancer and how you are now. Circle the number that best describes any
changes that have occurred using the following scale.
1 2 3 4 5 6 7
It is not at all true for you It is true for you a great deal

Item Factor 1

1. Spirituality has become more important to me. 0.87

2. My way of looking at life has changed to be more spiritual. 0.88
3. Because of spiritual changes I’ve been through I’ve changed my priorities. 0.80
4. I pay more attention to things that are spiritually important and forget about the little things that used to bother me. 0.81
5. I pray or meditate more often. 0.80
6. I spend more time taking care of my spiritual needs. 0.87
7. I more often experience life around me as spiritual. 0.86
8. I more often see my own life as sacred. 0.77
9. I have a stronger spiritual connection to other people. 0.87
10. I have a stronger spiritual connection to nature. 0.76
11. Spiritually I am like a new person. 0.78
12. Taking care of my body has taken on spiritual meaning. 0.73
13. My relationships with other people have taken on more spiritual meaning. 0.84
14. I have a stronger sense of the Sacred (God, Higher Power, Allah, Adonai, etc.) directing my life now. 0.82
15. I act more compassionately towards other people since my diagnosis. 0.74
16. I see people in a more positive light. 0.79
17. I more often express my spirituality. 0.83
18. I spend more time thinking about spiritual questions. 0.77
19. I am more humble since my diagnosis. 0.74
20. I more often think about how blessed I am. 0.68
21. I have grown spiritually. 0.87
22. I am more spiritually present in the moment. 0.83
23. I take part in spiritual rituals more often. 0.63
24. I more often have a sense of gratitude. 0.79
25. I more often pray for other people. 0.78
26. My spirituality is now more deeply imbedded in my whole being. 0.88
27. I am more receptive to spiritual care from others (examples: prayer, healing practices, etc.). 0.79
28. I more often look for a spiritual purpose for my life. 0.87
29. I’m finding it more important to participate in a spiritual community. 0.69

Item Factor 2

30. In some ways I am spiritually withdrawn from other people. 0.44

31. My faith has been shaken and I am not sure what I believe. 0.73
32. Spirituality seems less important to me now. 0.58
33. In some ways I have shut down spiritually. 0.74
34. In some ways I think I am spiritually lost. 0.79
35. I feel I’ve lost some important spiritual meaning that I had before. 0.63
36. My relationships with other people have lost spiritual meaning. 0.57
37. I am more spiritually wounded. 0.71
38. In some ways I am off my spiritual path. 0.64
39. I more often think that I have failed in my faith. 0.48
40. I am less interested in organized religion. 0.54
All cross loadings were below 0.20 and were not included.

SD ¼ 0:74; n ¼ 43), or graduate or professional
degree (X% ¼ 1:28; SD ¼ 0:48; n ¼ 53) (Fð5; 247Þ ¼
3.08, p50.01). There were no significant differences
between these groups and people with either an
associates or bachelors degree.
Validity
The bivariate Pearson correlations used to assess
construct validity are listed in Table 2 along with
descriptive statistics and the Cronbach alpha for all
measures. As expected, SG was positively asso-
ciated with indicators of growth, emotional and
spiritual well-being, and coping, along with in-
trinsic religiousness. It was not associated with
indicators of emotional distress. In contrast, SD
was positively associated with indicators of emo-
tional distress and negative coping, and inversely
related to indicators of emotional and spiritual
well-being and intrinsic religiousness. Correlations

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
The spiritual transformation scale
Table 2. Correlations between the STS subscales and other measures (N ¼ 253)
Measure (Cronbach alpha) Mean (SD)
CES-D (0.78) 1.84 (0.55)
PANAS-positive affect (0.93) 3.36 (0.76)
PANAS-negative affect (0.95) 1.82 (0.71)
Daily spiritual experiences scale (0.96) 4.14 (1.16)
Intrinsic religiosity (0.91) 2.97 (0.65)
Positive brief RCOPE (0.86) 1.47 (0.79)
Negative brief RCOPE (0.84) 0.21 (0.44)
Mysticism: mystical experiencea (0.87) 2.70 (0.44)
Mysticism: religious interpretationa (0.87) 2.82 (0.44)
Posttraumatic growth inventory (0.96) 2.73 (1.18)
Spiritual growth (0.98) 3.76 (1.70)
Spiritual decline (0.86) 1.46 (0.74)
*p50.01; **p50.001.
a
N ¼ 214 due to missing data.
with the Mysticism subscales generally were not
significant for either the SG and SD.
To determine whether the STS subscales pre-
dicted adjustment (psychological and spiritual)
beyond other similar but unique scales (spiritual
coping, intrinsic religiousness, and post-traumatic
growth), a series of hierarchical regression analyses
were conducted. Each STS subscale (analyzed
independently) was tested as a predictor of adjust-
ment while controlling for background variables
and one of the related constructs of interest. The
models tested only those measures of adjustment
that had been associated with an STS subscale
based on the bivariate correlations in Table 2.
Similarly, only the background variables that had
been found to be significantly associated with the
adjustment measure in the model (based on
bivariate correlations and ANOVAs) were included
in the model}age, gender (dummy coded as
1 ¼ male), employment status (dummy coded as
1 ¼ disabled; based on no significant findings for
other employment classifications), attendance at
religious services, and self-ratings of level of
spirituality. In all but 1 of the 18 models tested,
the STS subscales predicted unique variance in the
measures of psychological and spiritual adjustment
(see Table 3).
Validity was further tested by examining the
relationship between observer (N ¼ 225) and self-
ratings on the STS subscales. Inter-rater correla-
tions were 0.52 (p50.001) for the SG and 0.24
(p50.001) for the SD.
Discussion
This study assessed the reliability and construct
validity of the STS among a sample of people
coping with cancer. Unlike other measures of
trauma-related changes, this scale focused on the
spiritual aspect of post-traumatic growth and also
included items to assess the alternative to growth
(i.e. SD). Factor analyses resulted in two subscales:
Copyright # 2007 John Wiley & Sons, Ltd.
117
Spiritual growth Spiritual decline

0.01
0.38**
0.23**
0.23**
0.10 0.40**
0.57**
0.30**
0.52**
0.27**
0.71** 0.04

0.03 0.56**
0.12 0.07
0.16* 0.07
0.68** 0.06
}
0.03

0.03 }
SG (29 items) and SD (11 items). Both subscales
were reliable based on internal consistency and
test–retest correlations.
There were several background variables pre-
dictive of SG and SD scores. Similar to previous
studies of post-traumatic growth (for a review see
[8]), SG was associated with being more spiritual or
religious (based on self ratings or more frequent
religious behaviors). Gender has inconsistently
been related to post-traumatic growth among
cancer patients [35,36]; however, studies of non-
cancer-related traumas have found greater benefit-
finding among women [26] and this was found in
this study as well. Age and time since a traumatic
event have been inconsistently linked to benefit-
finding among general trauma and cancer patients,
but in this study SG declined with age and
increased with time since diagnosis. Findings on
the relationship between cancer stage and post-
traumatic growth have been mixed [37]. Consistent
with studies linking greater event stressfulness with
more post-traumatic growth [38] this study found
that when the illness was more threatening, either
because it was a recurrence or more advanced, SG
was higher. This finding may also explain the
unexpected finding that SG was associated with
having a particular type of cancer}melanoma or
ovarian compared to liver or breast cancer. Since
both greater SG and having a recurrence were
more likely for people diagnosed with melanoma or
ovarian cancer in this study, it may have been the
recurrence and thus increased perception of stress-
fulness, and not the type of cancer itself, that led to
the greater reports of SG.
Similar to SG, SD also declined with age. This
might indicate that as one ages, one’s level of
spirituality matures and stabilizes, and is less
impacted by traumatic events. In contrast to SG,
SD was associated with being less spiritual or
religious, having less than a high school education,
and a Protestant religious affiliation. There are no
studies of post-trauma decline with which to
compare these findings for SD. The finding related
Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
118 B. S. Cole et al.

Table 3. Hierarchical regression analyses summary: the to level of religiousness is inversely comparable to
unique contributions of the STS subscales in predicting the relationship found between SG and religious-
adjustment to a cancer diagnosis ness. However, the relationship between SD and
Model Variable DR2 DF either level of education or religious affiliation
needs further investigation to determine if the
Spiritual growth predicting PANAS-Positive Affect Scale
First Step 1: Background variables 0.05 2.47*
findings are simply spurious.
Step 2: Intrinsic religiousness 0.00 0.16 The validity of both subscales was strongly
Step 3: SG 0.05 12.75*** supported by consistently moderate to high corre-
Second Step 1: Background variables 0.05 2.47* lations with constructs expected to be related to SG
Step 2: Positive RCOPE 0.00 0.03
or SD. SG was positively associated with: spiritual
Step 3: SG 0.06 15.99***
Third Step 1: Background variables 0.05 2.47*
well-being, positive spiritual coping, intrinsic re-
Step 2: Post-traumatic Growth Inventory 0.03 7.43** ligiousness, post-traumatic growth, and positive
Step 3: SG 0.01 3.36 affect. SD was positively associated with negative
Spiritual growth predicting Daily Spiritual Experiences Scale spiritual coping, depressive symptoms, and nega-
First Step 1: Background variables 0.46 42.32*** tive affect. It was negatively associated with
Step 2: Intrinsic religiousness 0.18 122.66***
intrinsic religiousness, spiritual well-being, and
Step 3: SG 0.03 19.78***
Second Step 1: Background variables 0.46 42.32***
positive affect. Further support for the validity of
Step 2: Positive RCOPE 0.09 47.49*** the SG subscale was found in correlations between
Step 3: SG 0.02 11.36*** self- and observer-ratings on this scale. However,
Third Step 1: Background variables 0.46 42.32*** inter-rater correlations for SD were low. While this
Step 2: Post-traumatic Growth Inventory 0.05 25.97***
finding does not support the SD subscale’s validity,
Step 3: SG 0.04 19.44***
it also may not call it into question. It may be that
Spiritual decline predicting PANAS-Positive Affect Scale
First Step 1: Background variables 0.05 2.47*
cancer patients are less likely to confide in loved
Step 2: Intrinsic religiousness 0.00 0.16 ones, or perhaps anyone, when they are experien-
Step 3: SD 0.04 10.01** cing SD. This is consistent with clinical case reports
Second Step 1: Background variables 0.05 2.47* of participants in a spiritually integrative interven-
Step 2: Negative RCOPE 0.02 3.85*
tion for cancer patients (Cole et al., 2005,
Step 3: SD 0.02 5.54*
Third Step 1: Background variables 0.05 2.47*
unpublished raw data) and calls for further
Step 2: Post-traumatic Growth Inventory 0.03 7.43** investigation.
Step 3: SD 0.04 10.67*** The exploratory analyses of relationships be-
Spiritual decline predicting PANAS-Negative Affect Scale tween spiritual transformation and mysticism were
First Step 1: Background variables 0.08 4.44*** weak or non-existent, suggesting little overlap
Step 2: Intrinsic religiousness 0.00 0.16 between these two constructs. As a cautionary
Step 3: SD 0.14 43.41***
Second Step 1: Background variables 0.08 4.44***
note, however, several participants complained
Step 2: Negative RCOPE 0.11 32.34*** about the mysticism scale, possibly indicating that
Step 3: SD 0.05 16.16*** this 1970s scale developed with college students
Third Step 1: Background variables 0.08 4.44*** may not accurately capture the language used by
Step 2: Post-traumatic Growth Inventory 0.01 1.38 older adults today to describe mystical experiences.
Step 3: SD 0.13 40.07***
Construct validity for the STS subscales was also
Spiritual decline predicting CES-D (depression)
supported in all but one of the 18 hierarchical
First Step 1: Background variables 0.08 4.39***
Step 2: Intrinsic religiousness 0.01 1.82
regression models testing the unique predictive
Step 3: SD 0.10 31.21*** properties of these subscales. The results indicated
Second Step 1: Background variables 0.08 4.39*** that SG and SD assess an aspect of spirituality that
Step 2: Negative RCOPE 0.09 26.83*** is distinct from intrinsic religiousness or spiritual
Step 3: SD 0.04 12.84***
coping. SD, but not SG, also seems to be unique
Third Step 1: Background variables 0.08 4.39***
Step 2: Post-traumatic Growth Inventory 0.00 0.00
from the construct of post-traumatic growth. This
Step 3: SD 0.11 33.14*** along with the high zero-order correlation between
Spiritual decline predicting Daily Spiritual Experiences Scale the SG and the PTGI suggest that these latter two
First Step 1: Background variables 0.46 42.32*** instruments assess a common underlying tendency
Step 2: Intrinsic religiousness 0.18 122.66*** to find positive meaning and benefit within trau-
Step 3: SD 0.01 5.20*
matic situations. SD, on the other hand, seems to
Second Step 1: Background variables 0.46 42.32***
Step 2: Negative RCOPE 0.01 3.10
assess a construct unique from both spiritual and
Step 3: SD 0.02 8.67** secular aspects of post-traumatic growth.
Third Step 1: Background variables 0.46 42.32*** The distinctions found in this study between the
Step 2: Post-traumatic Growth Inventory 0.05 25.96*** STS subscales and spiritual coping subscales
Step 3: SD 0.03 15.74***
contribute to the understanding of the spiritual or
*p50.05; **p50.01; ***p50.001. religious aspects of trauma experiences. Based on
Background variables included: age, gender (dummy coded as 1 ¼ male), Pargament, Murray–Swank, Magyar, and Ano’s
employment status (dummy coded as 1 ¼ disabled, based on no significant
findings for other employment classifications), attendance at religious services, [39] theoretical model, when a trauma occurs, the
and self-ratings of level of spirituality. spiritual aspects of the individual’s world view and

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
The spiritual transformation scale
related resources (e.g. practices and relationships)
may be threatened. This threat initiates a spiritual
struggle (i.e. spiritual coping) in order to either
‘conserve or transform’ one’s sense of the spiritual
or sacred aspects of life. Following their model, the
success of coping efforts directed toward transfor-
mation would be reflected by measures such as the
STS subscales and in adjustment measures. The
results of this study support this theory and further
suggest that the level of spiritual transformation
uniquely predicts adjustment to the event beyond
the coping efforts themselves.
There are several limitations to this study. First,
care must be taken in interpreting the SG and SD
scores as these measure change rather than levels of
spiritual development. Because of this, people who
were either highly spiritual or not at all spiritual at
pre-diagnosis could have the same score on the STS
subscales at a later time point. Neither person
might have grown or declined spiritually: the
former, because he/she was already highly spiritual
with little opportunity for growth and the latter,
because spirituality was not relevant to his/her life.
This is not a problem if the scores are correctly
interpreted as change scores. As such, these scores
are meaningful as regression data indicate that
even when level of spirituality and religious
attendance are controlled, the amount of change
(SG or SD) is predictive of adjustment. This
suggests something unique about spiritual
change(s) that contribute to adjustment beyond
whether or not one is a highly spiritual person.
Doan [40] suggests that people coping with cancer
may turn to alternative health practices as part of a
‘heroic stance’ in which personal transformation is
pursued. The results of the current study suggest
that this process, embracing the heroic journey
itself, may buffer the deleterious impact of a cancer
diagnosis, independent of whether one begins the
journey with high or low levels of spiritual
involvement. However, this would also suggest,
based again on Pargament and colleagues’ [39]
model, that efforts to transform one’s spirituality
are more promising than efforts to conserve what
one already has. Additional studies, using long-
itudinal designs, are needed to verify this possibility
and further examine the associations between levels
of spirituality prior to diagnosis and subsequent
spiritual transformations and their effects on
adjustment. This could have implications for
clinical interventions.
The STS can be easily adapted for longitudinal
use by adjusting the directions to refer to different
time points. That is, the first scale administration
could refer to changes since diagnosis. The next
scale administration could refer to the time lag
between the first and second administrations of the
STS. Whether the scale scores would vary long-
itudinally is an empirical question needing investi-
gation and currently being assessed (Cole et al.,
Copyright # 2007 John Wiley & Sons, Ltd.
119
2007, study in process). While items referring to
world views may be more stable across time, most
of the STS items assess more fluid dimensions of
spiritual life (e.g. changing one’s priorities). If
longitudinal use is substantiated, the scale could
help elucidate points along the disease time line
during which spiritual transformation is more
likely, or when it is likely to be characterized as
more positive or negative.
Other limitations include that the sample was
comprised primarily of Caucasian, middle-aged,
married women who were Judeo-Christian in
religious orientation. Thus, the results may not
generalize to people more diverse in regard to these
characteristics. And finally, the correlational design
of this study precludes determining the causal role
that SG or SD might play in the adjustment to
cancer. Again, prospective studies with the STS are
needed to establish causality.
Despite these limitations, the findings have
important implications for future research and
clinical work with people facing cancer. The
identified independent nature of SG and SD
further contributes to an understanding of post-
trauma reactions as reflecting growth and/or
decline. As Almedom [41] has called for regarding
other post-trauma changes, work is now needed to
identify variables that predict these alternative
trajectories. Along this line, longitudinal studies
are needed. While SD may be deleterious in the
short term, it is unknown how often this decline is a
time-limited process that may lead to a richer,
fuller, and more spiritually centered life [42].
Moreover, other researchers have pointed out
the need to extend trauma research to clinical
applications [3,7]. To contribute to this work, the
four domains assessed by the STS (world view, life
goals/priorities, relationships, and sense of self)
and consistently identified in both general trauma-
outcome [9] and cancer-outcome studies [14,15]
suggest potential intervention targets. This work is
particularly critical for cancer patients who may be
in the midst of a SD. The SD items provide a
means by which people experiencing such decline
can be identified and referred for clinical services.
While general therapeutic practices that integrate
spiritual components [43] might be adapted to meet
the needs of this population within clinical practice,
outcomes might be enhanced by the development
and testing of specific interventions for this
population targeted to address SD and enhance
SG. Preliminary work in this area is promising (e.g.
[20]; for a review see [39]) but larger studies with
more rigorous methodology are needed.
In conclusion, the results indicate that the STS
subscales offer a reliable and valid method for
assessing SG or SD following a cancer diagnosis.
Moreover, SG and SD seem to be important
components of post-traumatic changes that have
implications for adjustment to cancer. The
Psycho-Oncology 17: 112–121 (2008)
DOI: 10.1002/pon
120
presence of SD appears to especially warrant
clinical attention and further investigation.
Whether playing a direct causal role in the
development of depression and negative affect, or
simply co-occurring as an aspect of the cancer
experience, further clinical and research attention is
needed to understand the trajectory of SD and
develop appropriate and effective interventions.
Acknowledgements
This work has been funded by The Spiritual Transformation
Scientific Research Program, sponsored by the Metanexus
Institute on Religion and Science, with the generous support
of the John Templeton Foundation. We would also like to
acknowledge the extensive contributions and dedication of
Deborah Brower who coordinated recruitment and data
management. We thank the medical staff, faculty, and
physicians at the University of Pittsburgh Medical Center,
who gave generously of their time and efforts to make this
study a success, especially: Drs Victor Vogel and Joseph
Kelly at Magee Women’s Hospital; Drs. John Kirkwood,
Robert Redner, and Kenneth Foon at the Hillman Cancer
Center; and Dr Andrew Baum at the University of
Pittsburgh.
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