The diagnosis and treatment of cancer can be a psychologically traumatic experience for many patients [1]. The effects of ambiguity during cancer treatments, the nature of the psychiatric symptoms experienced, and the ongoing and deteriorating medical condition of cancer make it a life-threatening experience. Thus, the presence of post-traumatic stress disorder (PTSD) during a diagnosis of cancer is not unusual [2]. Cancer patients develop post-traumatic stress symptoms (PTSS) including intrusive trauma-related thoughts, avoidance of trauma-related reminders, hypervigilance, and heightened arousal, at any point from diagnosis through treatment, after treatment is complete, or during recurrence of the cancer [1,3]. Cancer patients with PTSS feel sadness, fear, anger, helplessness, or hopelessness. They feel detached or estranged from other people [4]. Severe emotional distress in cancer patients results in poor compliance with treatments, an unhealthy lifestyle, and increased risk of cancer progression and death [5]. Therefore, it is important to detect and appropriately treat individuals in need of psychosocial support [6].

One of the common adaptations following a traumatic event is resilience [7]. Resilience refers to the ability to “bounce back” after trauma. Thus, after a short fallout period following a catastrophic event, an individual returns to pre-event or baseline functioning [7]. Resilience is the dynamic process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress [4]. Factors contributing to resilience include the ability to maintain an optimistic outlook in life, develop a positive social support network, face one's fears, and use active coping skills [8]. Resilient individuals are able to regulate their emotions effectively to adapt to stressful situations, find something positive in even adverse situations, and even experience personal growth from distressing events [7]. On the other hand, poorly resilient individuals go through distress and confusion when they try to understand the reason that this terrible event happened to them and the meaning of the event for their world view [8]. Molina et al. [9] described resilience in the three ways: a preexisting, baseline characteristic or trait, such as demographics and personal attributes (e.g., optimism and hope); an adaptation mechanism to promote positive outcomes, such as stress management and resilience training; and a psychosocial outcome itself. Promoting resilience is a critical element of patient psychosocial care. Nurses can facilitate resilience by recognizing and promoting certain baseline characteristics and optimizing mechanisms of adaptation [9].

Adjustment to cancer is a process. Successful adjustment occurs in patients who are able to regulate their emotional distress [5]. Emotion regulation is the process of maintaining a preferred or desired internal emotional state following an external emotion-eliciting stimulus [10]. Emotion regulation is performed in an automatic or controlled manner, either unconsciously or consciously [11].

Emotion regulation strategies are categorized as engagement or disengagement strategies [5]. Engagement strategies aim to change one’s emotions or thoughts following an emotional stimulus and include acceptance, active coping, cognitive reappraisal, problem solving, and seeking instrumental support. Disengagement strategies, on the other hand, attempt to lessen the impact of an emotion-eliciting event through avoidance or escape and include cognitive or behavioral avoidance, denial, substance use, and suppression [5]. Difficulties in emotion regulation were linked to emotional distress in cancer patients [5]. Positive emotion regulation strategies were closely associated with resilience in cancer patients [11,12]. The level of resilience is positively related to the degree of actively using adaptive cognitive emotion regulation strategies.

Cinema therapy is understood to promote a metaphorical therapeutic change in the client’s inner world, the same way as metaphors is used in traditional and contemporary forms of psychotherapy. Wilson [13] mentioned that films can be used in combination with cognitive behavior therapy and family system therapy. In cognitive behavior therapy, movies like stories, myths, jokes, fables, or even dreams are used in combination with the established modalities as a supportive device for understanding maladaptive core beliefs and for cognitive restructuring. Cognitive insights tell clients what to do but affective insights give them the motivation to follow through. Behavior modification treatment can be supported by watching movies where a character demonstrates courage in the face of a challenge [13].

Previous studies have reported that cinema or movie therapy is effective in combating PTSD, anxiety disorders, and other psychological responses commonly found in individuals suffering from chronic health conditions [14,15]. In cinema therapy, clients watch film(s) relevant to issues of personal distress and dysfunction [15]. Movies often deal with universal themes, which allows clients to view their problems from a comfortable distance [16]. By watching a movie, individuals can compare themselves to the characters in the movie, think outside the box, undergo perceptual and cognitive changes, and desire to express themselves to others through the indirect experience of positive and negative emotions and the process of encouraging to talk to others [14,17]. Movies are cost-effective and can generally be used with groups composed of persons with diverse backgrounds [16]. The benefits of using movies include compliance, accessibility and availability of modality, familiarity with movies, and the enhancement of rapport among group members [16]. Previous studies reported movie therapy reduce depression in elderly cancer patients [18], and increase quality of life in women with gynecologic cancer [19]. However, many of studies about movie therapy to date have not focused on cancer survivors.

In this study, we develop a healing movie program for cancer survivors and apply it to cancer survivors to examine their effects on PTSS, resilience, and cognitive emotional regulation.

This study investigated the effects of the healing movie program developed for cancer survivors. The program included watching a movie, conversation about a movie and the participants’ feelings, and various activities such as telling, writing, drawing, imaging, forgiving, and smiling. Through the healing movie program, cancer survivors became more aware of their negative emotions, expressed their feelings in a conversation session, and developed a positive mindset. Accordingly, this engagement reduced post-traumatic stress, and increased resilience and positive adaptive cognite emotion regulation in the statistically significant levels.

The PTSS score of the intervention group significantly decreased after the intervention of the healing movie program. The healing movie therapy encouraged the participants to freely talk to other participants about their feelings regarding the movie and express their own emotions recalled by the movie. The participants expressed their long-suppressed feelings to other participants in a relaxed manner. This exposure helped the participants reduce their tendency to avoid traumatic memories associated with cancer diagnosis and treatment in a negative manner. Frueh [30] reported a significant decrease of PTSS in Vietnam veterans by using exposure therapy that included a variety of means, such as reading and talking about the war, reflecting on traumatic war experiences, and sitting near a helicopter pad as well as watching Vietnam war movies. Self-exposure was a useful way for patients who experienced traumatic events to resolve their emotional issues [31]. Based on the results of this study and previous studies, it is thought that exposing cancer survivors' emotions while watching movies in this study reduced PTSS in cancer survivors who experienced trauma events.

The resilience score of the experimental group significantly increased after the healing movie program intervention. The results of this study were consistent with the results of Loprinzi et al. [32] that showed that individual resilience could be improved by training. In their study, breast cancer survivors’ resilience significantly increased at the end of a 12-week training program that focused on attention and interpretation to decrease stress and enhance resilience. To enhance the resilience of cancer survivors, our program included various activities such as filling one’s self with happiness, writing thank-you letters, developing a graph of his or her life facing challenges, planning positive activities, imagining a happy life after 1 year, practicing forgiveness, finding sources of happiness in daily life, planning a happy and healthy future, and practicing smiling. Through these activities, the participants promoted a positive mindset and realized that happiness is not beyond their reach, and eventually promoted resilience. Moreover, by forgiving those who hurt them in the past and ending unhealthy relationships with them, the participants felt at ease, took a load off their mind, gained positive emotions of self-satisfaction and happiness and thus, increased their resilience.

The score of the adaptive cognitive emotion regulation of the intervention group increased after the intervention. The effects of this intervention lasted for 2 weeks. Adaptive cognitive emotion regulation plays a key role in individual’s growth by encouraging positive refocusing and reevaluation, wider perspectives, review of plans, and acceptance, and by contributing to the reconstruction of the existing belief systems [25]. In our program, by watching movies of protagonists with cancer and listening to their stories, the participants stopped blaming themselves for causing cancer and repeating negative thoughts from their past experiences. The program encouraged the participants to explore ways to positively change their current situation through the protagonists of movies who courageously challenged themselves. Thus, the program contributed to the improvement of adaptive cognitive emotion regulation such as positive refocusing and reevaluation.

The score of the maladaptive cognitive emotion regulation of the intervention group decreased after the intervention. Previous studies presented a decrease in maladaptive cognitive regulation after the similar intervention. Massah et al. [33] reported that the emotion regulation strategies of their training program reduced anger symptoms of drug-dependent individuals. As one type of maladaptive cognitive emotion regulation, cancer survivors tend to blame themselves or other individuals for developing cancer. According to the study by Park and Kim [34], when asked about the factors that caused their cancer, female cancer survivors blamed other individuals, such as their spouse and mother-in-law, whereas male cancer survivors blamed themselves for not taking care of their own health. In this study, participants had time to share their feelings with other participants while watching a movie to reduce maladaptive cognitive emotion regulation. The participants expressed emotions, such as the fear and horror of recurrence, guilt, and depression. However, they did not fully express their own feelings or feelings toward people who were associated with causing their cancer. This means that it is necessary to develop intervention strategy to reduce negative emotion in cancer survivors.

This study had several limitations. First, because the participants were recruited from four healthcare centers, the findings of this study were limited to this population. Second, the participants who enrolled in the intervention program of this study might be highly motivated to learn and practice the skills provided in the program. This might influence the results of this study. Third, all the participants were over 50s although the researchers did not intend to recruit those participants. Studies involving participants of various ages are needed. Forth, follow-up tests were not planned and conducted to test the lasting effects of the healing movie program. The effectiveness of movie therapy requires validation with a randomized control group with long term follow-up tests. Thus, the results of this study provide the preliminary evidence of the effectiveness of an audiovisual intervention, such as movie therapy. Lastly, the skill set of the researcher (Kong JH) who conducted the healing movie program with the intervention group might play a role in the positive results of this study. Future program results can be affected by the skill set of the movie therapists who conduct such programs and this should always be considered when studying the use of such programs.

In this study, the healing movie program for cancer survivors was developed and applied for 5 weeks to confirm the effect on changes in PTSS, resilience, and cognitive emotion regulation strategies. The healing movie program developed in this study was found to have the effect of reducing PTSS and increasing resilience by allowing cancer survivors to express their emotions in words or in writing through the experience of the protagonist in the movie.

Since the above research results have confirmed that the healing movie program has a positive effect on the PTSS and resilience of cancer survivors, it is suggested to use it as a community program for cancer survivors who have experienced and recovered from cancer. As a suggestion for further research, first, based on cognitive behavior theory, it is suggested to develop a program that not only promotes the adaptation to the life of cancer survivors but also returns to the community and second, to develop customized health programs focusing on specific cancers and to identify their effects.