The traumatic effects of cancer treatment are not limited to the person receiving the diagnosis but also extend to their caregivers.1,2 In countries where external support resources are scarce, parents often have to take on the role of primary caregivers for their child with cancer.3,4 This involves not only providing physical care but also emotional support, closely monitoring the treatment process, and managing the side effects and symptoms experienced by their child.3, 4, 5 After the cancer diagnosis of a child, parents experience shock, denial, and anger and struggle to cope with the many difficulties associated with the psychosocial, financial, and emotional burdens of diagnosis and treatment.6 According to the literature, the conditions that most affect the mental health of parents during their child's illness and treatment include feelings of anxiety, inadequacy, fear, and guilt.7,8 These feelings may arise from thoughts of not being able to prevent the pain experienced during the cancer process or protect their child from potential harm.6,9,10 The psychosocial challenges that the disease brings are loneliness, hopelessness, grief, loss of control, and uncertainties.6,9,11 In addition to the mentioned struggles, parents also witness the initiation of long-term, painful, and dangerous implementations and side effects due to cancer treatment.3,10,12, 13, 14 These psychosocial challenges are a result of a series of dysfunctional thoughts that include an increased focus on negative events and possible risks, as well as the complexity of mental functions.15,16 The negative thoughts may be similar to the parents' cognitive focus on the negative consequences of the cancer process and their cultural understanding of cancer as a disease that is equivalent to death.15

Metacognitions, which are the structures that control, regulate, evaluate cognitions, cognitive structures, and processes, can affect the interpretations mentioned above.17 This structure allows individuals to be aware of events and thoughts in their mind and consciously direct their mental functions. However, deviations that develop in these processes can cause psychosocial problems.17 In traumatic life events, dysfunctional beliefs about oneself, the world, and other people are being activated and preventing effective coping with the traumatic event.18, 19, 20, 21, 22 As a result, dysfunctional metacognitions increase perceived stress and cause the development of anxiety, depression, posttraumatic stress disorder (PTSD), etc.21,22 All of the traumatic and negative psychosocial processes mentioned previously, along with dysfunctional metacognitions, can be more prevalent in parents with a child with cancer.15 This can cause parents to cope with the disease process ineffectively, fail to adapt to the new situation, and experience intense anxiety and fear that their child may die.15,16 It is also evident that following a traumatic life experience, individuals may experience prolonged stress and pain that distort their assumptions about the world.23

Ruminative thoughts may emerge and impact the thoughts, feelings, and sense of meaning in life.24, 25, 26 Although rumination can have positive effects, such as facilitating understanding and resolution of changing conditions, and regulating the incompatibility between the ideal self and the real self, excessively focusing on the potential causes, meanings, and consequences of life events can also cause intense stress and distort thought content.24,27 Deliberate rumination involves adaptive orientation and reprocessing of cognitions, resulting in a more positive evaluation of the lived experience. Conversely, intrusive rumination causes repetitive and involuntary recall of the experience in a nonadaptive way, leading to negative evaluations and an inability to find solutions.28,29 Intrusive rumination can cause mental health problems such as depression, PTSD, and anxiety, which can negatively affect thought content in parents of children with cancer.30, 31, 32 Thus, negative ruminative thoughts that persistently interfere with rethinking the traumatic event and focusing on real life can severely impair parents' functionality in this process.30

Metacognition and rumination can impede parents from coping with the difficulties of their child's cancer treatment process effectively, leading to psychosocial problems due to intense stress.32 However, despite the stress and trauma of this experience, individuals can emerge stronger by setting new goals, finding new meaning in life, and reviewing coping resources, a phenomenon known as posttraumatic growth (PTG).33,34 Providing appropriate support to parents of children with cancer can aid in their adaptation to the process, facilitate effective coping, and even lead to positive gains.24,35 Moreover, research has shown that traumatic life experiences do not always have negative effects, and individuals can emerge stronger from these experiences.27,33,34 Effective management of the cancer process by parents also benefits the child with cancer's adaptation to this stressful process.24,36 As primary caregivers who know and understand their child best during the treatment process, parents play a critical role in their child's disease management.24,37 Nonetheless, to support PTG, prevent mental health problems, and increase well-being in parents of children with cancer, metacognition and rumination must be addressed with appropriate and effective methods, which the literature has yet to fully explore.38, 39, 40

Resulting from the gaps in knowledge described above, this study aims to examine the association of rumination and metacognition with PTG in parents of children with cancer. In line with the proposed gap in the literature and the aim of the study, Response Style Theory (RST) implemented into the present study. Through RST, it can be understood in depth how ruminations, metacognitions, and psychological resilience interrelated.