Existential Meaning-Making Coping in Iran: A Qualitative Study among Patients with Cancer

This article is written on the basis of a study on meaning-making coping in Iran. The study is a part of an international project in 10 countries with different religious and cultural backgrounds. This article aims to discuss the secular existential meaning-making coping methods employed by Iranian cancer patients. Interviews were conducted with 27 participants with various kinds of cancer. Nine secular existential meaning-making coping strategies emerged from the analyses of the qualitative interviews. These coping methods are as follows: Ignoring the illness, Distraction, Altruism, Encounter with others, Nature, Discourse of the self, Visualization, Positive solitude, and Positive thinking and transformational orientation. It seems that, using these strategies, our sample of Iranian cancer patients/survivors have been denying/ignoring their illness, and/or empowering themselves. We discuss the results, considering the potential influence of cultural elements, including Iranian Islam, Persian mysticism, and Persian literature, on the selection of the coping strategies. The study contributes to our understanding of coping via elucidating how seriously ill individuals in Iran try to manage the challenges caused by a health crisis.


Introduction
Psycho-oncology research shows that cancer is associated with psychological problems such as feelings of powerlessness, despair, fear, and anxiety. When faced with stressful situations, people engage in many types of coping so as to reduce their stress. People may engage in problem-focused coping, changing the conditions that create or maintain the problem. When encountering stress, people may also resort to emotion-focused coping, which is targeted at temporarily alleviating distress by disengaging behaviorally or mentally (Dunkel-Schetter et al. 1992;Gibbons and Groarke 2018;Park et al. 2008). Meaning-focused coping may also serve as another type of coping to deal with such situations (Ahmadi et al. , 2022Park 2010aPark , 2010b. As Park and Hanna (2022, p. 94) mention: "Problem-focused coping is generally considered the most adaptive type of coping . . . , but low-control situations such as trauma, loss, and serious illness are not amenable to direct repair or problem-solving. In such low-control situations,

Meaning-Making Coping
Meaning-focused coping refers to an appraisal-based coping in which the individual draws on her/his values (e.g., "mattering"), beliefs (e.g., religious or spiritual), and existential goals (e.g., purpose in life) to motivate and sustain coping and mental health during a negative experience (Folkman 2008). The existential questions play an important role here. Davis (2015, p. 431) describes meaning-making as "an important self-regulatory process within the individual and a process of mutual regulation in relationships".
Researchers usually use the terms "religious" and "spiritual" to address meaningfocused coping strategies that are based on existential issues. To them, meaning-making process encompasses altering one's own perceptions by reappraising the situation, and in this process, some religious/spiritual explanations are found for why the stressful life event(s) has occurred or is occurring. However, several studies (e.g.,  have demonstrated that, when facing a crisis, people use other meaning-focused coping mechanisms that cannot be considered as spiritual or religious; for example, coping methods connected to nature. These coping methods are referred to as secular existential, referring to a search for meaning. Here, meaning does not have any connection to religion or any obvious connection to a sacred spiritual source. These coping strategies concern persons' efforts to find an inwardly source-in themselves, in nature or in other people; that is why they are referred to as secular existential coping. In their model,  use the term "meaning-making coping" to refer to the entire spectrum of religious, spiritual, and secular existential coping strategies. In this study, we have applied this model. According to Figure 1, there is an overlap between the concepts belonging to the spiritual and religious domains. It is the same for spiritual and secular existential meaningmaking coping. However, there is not any overlap between secular and religious concepts. This is because religion is "a search for significance that unfolds within a traditional sacred context", and spirituality refers to "a search for connectedness with a sacred source that is related or not related to God or any religious holy sources" (Ahmadi 2006, pp. 72-73). Thus, secular existential meaning-making coping does not have almost any point of connection with a traditional sacred context. It is worth noting that Lloyd (2018, p. 31) has used the term existential meaning-making in a broader way: "Existential meaning-making encompasses lived experiences leading to a fundamental sense of belonging, significance, and meaning in everyday life, as well as in relation to critical events and ultimate concerns as life and death". Secular existential meaning-making is limited to the experiences which are outside the realm of spirituality and religiosity but reflect a sense of significance, belonging, and meaning in a person's life. These senses are achieved not in a vacuum but in a broader context. As Reker and Wong (2012, pp. 436-37) suggest, "to achieve an enduring type of personal meaning [-], specific sources (i.e., situational meaning) need to be integrated into a larger and higher purpose (i.e., global meaning)". Culture is such a context. According to Marsella and Yamada (2000, p. 4), culture is: "Shared learned meanings and behaviors that are transmitted from within a social activity context for purposes of promoting individual/societal adjustment, growth, and development. Culture has both external (i.e., artifacts, roles, activity contexts, institutions etc.) and internal (i.e., values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology, etc.) representations. The shared meanings and behaviors are participant to continuous change and modification in response to changing internal and external circumstances".
It is noteworthy that in the current study, we merely focus on the secular existential dimension of meaning-making coping, and we intend to discuss the potential influence of culture on the selection of these kinds of meaning-making coping methods.
It is noteworthy that in the current study, we merely focus on the secular existential dimension of meaning-making coping, and we intend to discuss the potential influence of culture on the selection of these kinds of meaning-making coping methods.  Ahmadi (2006) mentions that coping can be regarded as "behavior chosen to face a certain stressful situation". Individuals' attitudes toward many issues such as political, sexual and family life, religion and morality, the economy, and professional life play an important role in how people deal with stressful situations: "Culture, as the framework of such views and attitudes, has hence a determining effect on the choice of coping methods in a stressful situation. In short, culture shapes coping." (Ahmadi 2006). Aldwin (2004, p. 565) believes that culture can impact the coping process in four ways: "First, the cultural context shapes the types of stressors that an individual is likely to experience. Second, culture may also affect the appraisal of the stressfulness of a given event. Third, cultures affect the choice of strategies that an individual utilizes in any given situation. Finally, the culture provides different institutional mechanisms by which an individual can cope with stress".

Coping and Culture
It does not need to be emphasized that culture is not the only variable affecting coping. Other factors such as age, gender, education, socioeconomic status, and mental health all play important roles in coping. Johns et al. (2009) examined the role of culture on the process of coping, suggesting that the cultural values influence coping. When discussing meaning-making coping, we need to have a culture-sensitive approach. In our international project, we have, therefore, chosen different cultural settings. In this regard, we have focused on both the countries where religion is not an integrated part of people's life and the countries where religion plays important role in the everyday life of people. We have therefore selected countries wherein Shia Islam, Sunni Islam, Protestantism, Catholicism, or Buddhism dominate. For this study, Iran has been chosen as an example of a Shia Islam-dominated country.
According to the importance of culture in the way people deal with crises and that the present study concerns an Iranian community, an overview of the sociocultural characteristics of Iranian society is noteworthy. Iran, also called Persia, is a Middle-Eastern country with a population of around 81,672,300 people (2018 estimate). Persian is the for-  Ahmadi (2006) mentions that coping can be regarded as "behavior chosen to face a certain stressful situation". Individuals' attitudes toward many issues such as political, sexual and family life, religion and morality, the economy, and professional life play an important role in how people deal with stressful situations: "Culture, as the framework of such views and attitudes, has hence a determining effect on the choice of coping methods in a stressful situation. In short, culture shapes coping." (Ahmadi 2006). Aldwin (2004, p. 565) believes that culture can impact the coping process in four ways: "First, the cultural context shapes the types of stressors that an individual is likely to experience. Second, culture may also affect the appraisal of the stressfulness of a given event. Third, cultures affect the choice of strategies that an individual utilizes in any given situation. Finally, the culture provides different institutional mechanisms by which an individual can cope with stress".

Coping and Culture
It does not need to be emphasized that culture is not the only variable affecting coping. Other factors such as age, gender, education, socioeconomic status, and mental health all play important roles in coping. Johns et al. (2009) examined the role of culture on the process of coping, suggesting that the cultural values influence coping. When discussing meaning-making coping, we need to have a culture-sensitive approach. In our international project, we have, therefore, chosen different cultural settings. In this regard, we have focused on both the countries where religion is not an integrated part of people's life and the countries where religion plays important role in the everyday life of people. We have therefore selected countries wherein Shia Islam, Sunni Islam, Protestantism, Catholicism, or Buddhism dominate. For this study, Iran has been chosen as an example of a Shia Islam-dominated country.
According to the importance of culture in the way people deal with crises and that the present study concerns an Iranian community, an overview of the sociocultural characteristics of Iranian society is noteworthy. Iran, also called Persia, is a Middle-Eastern country with a population of around 81,672,300 people (2018 estimate). Persian is the formal language in Iran, but Turkic and Turkic dialects, Kurdish, Luri, Balochi, and Mazanderani are also spoken informally. According to the Constitution of the Islamic Republic of Iran, the official religion of Iran is Shia Islam. Iran also recognizes Christian, Jewish, and Zoroastrian religious minorities. The majority of the population (89%) in Iran is Shia Muslim, 10% are Sunni Muslim, and the remaining 1% are Zoroastrian, Christian, Baha'I, and Jewish (Statistical Center of Iran 2018). Iran is quite well-known for its longstanding history and cultural heritage. Iranian people are proud of their rich literature and love Persian poets; the poems of Hafez, Rumi, and Omar Khayyam are also well-known in the Western world for their mystical ideas. Iranians usually read and sometimes memorize the poetry by these poets; some of these poems have turned into common expressions and proverbs among people in Iran. It is showed that these points have significance for analyzing our results from a cultural perspective.

Methodology
This study was qualitative in design, and semi-structured qualitative interviews were used for data collection.

Sample
Purposive sampling was used to recruit participants. We invited the potential informants and interviewed them. We continued interviewing until no new information emerged (saturation point). Altogether, we talked to 43 potential patients, survivors, and people in hospice at a number of cancer treatment and rehabilitation centers in Tehran after their regular clinical routines; explaining the project and its objectives, we invited them to participate in the study. Sixteen people either were not interested to be an informant or did not meet the criteria of recruitment. Finally, a total of 27 (18 females and 9 males) cancer patients/survivors (16 years and older) were interviewed. Inclusion criteria were as follows: ≥16 years of age, diagnosis with cancer, being of an Iranian origin. Exclusion criteria used for the recruitment included the following: any acute condition that would limit the ability of the patient to be a participant and refusal to give informed consent. Various types of cancer were represented among the participants; as to their stage of cancer, it varied from very early to palliative care and survivors. Table 1 shows participants' demographic characteristics.

Procedure
A written application was sent to the authorities in the respective rehabilitation centers and hospitals. Formal approval to conduct the research was obtained. The uninterrupted interview sessions took place at the Behnam Daheshpour Charity Organization. After the study aim was explained to the participants and confidentiality ensured, they gave their informed consent for audio-recording the interview. The interview was a semi-structured one in which the questions were asked from the informants based on a predesigned outline (see Appendix A). The interviewer also employed clarifying questions to clarify any vague answers, such as "Could you tell me more"? The interview guide included questions regarding meaning-making coping methods based on the aforementioned conceptual framework, which encompass the full range of religious, spiritual, and secular existential coping strategies. We also included some additional specific questions based on the results obtained from our previous studies concerning the secular existential coping methods such as coping methods related to nature, positive solitude, etc. In producing the final protocol, some adjustments were made based on cultural considerations.
The interviews varied in duration from approximately one hour to one and half hours. The interviews were conducted face-to-face and in Persian by a professor in sociology; all interviews were audio-recorded and, subsequently, transcribed verbatim. The interview transcripts were coded. and the codes were categorized using a thematic analysis method. When all interviews had been transcribed and analyzed, the researchers translated the core statements into English.

Data Analysis
Just as was performed in other studies included in the international project, after the transcribed interviews had been translated, the interview protocols were coded in line with the themes that emerged in the study using a thematic analysis method (Braun and Clarke 2006). The coding, based on the themes identified in the study, employed a template analysis style, i.e., a theory-driven analysis (Malterud 2014), while categorization of the themes was based on the findings obtained in the other studies included in the project Ahmadi 2015, 2018;Ahmadi et al. 2016). The categories or sub-categories were then linked to related codes in the material. Coding continued until a high inter-rater agreement level was achieved. Following completion of the coding process, we identified the fundamental characteristics of the methods used by the informants to cope with their cancer disease. To accomplish this, we began with the project aim, using previous findings of the project as a whole.

Trustworthiness
To ensure the trustworthiness of the present study, the criteria suggested by Lincoln and Guba (1985) were employed. Reliability was achieved by ensuring variation in participants' type of cancer, age, gender, occupation, and education. The researchers' commitment to the research area is long-standing. Written notes were taken during the interviews, thus contributing to the data quality. Peer examination was carried out by three experts, who verified the coding and categorization process. All research group member were involved in checking all interview drafts and verifying all codes and categorizations.

Ethical Considerations
University of Tehran's Ethics Committee reviewed and approved the research project (Approval ID: IR.UT.PSYED.REC.1397.004). The interviews were conducted and audiorecorded only after obtaining the informed consent of each participant. Participants were able to withdraw from the study at any time and during any stage; the data are being safely stored and are confidential; in the research reports, no mention has been made of the participants' name.

Results
In this section, we present the results of our investigation concerning the secular existential meaning-making coping methods employed by our informants to manage the crisis. Nine core themes emerged from our analysis: Ignoring the illness, Distraction, Altruism, Encounter with others, Nature, Discourse of the self, Visualization, Positive solitude, and Positive thinking and transformational orientation. The specific analysis results were as follows:

Ignoring the Illness
One of the meaning-making coping strategies we found is "Ignoring the illness". This is consistent with Dunkel-Schetter et al. (1992). Using this coping strategy, the patient normalizes the situation and makes the illness part of her/his daily life. In this way, the patient ignores the hardship of the illness, does not regard it as a crisis, and continues life as normal. In the three following cases, we see clear examples of this method. In the first case, an interviewee, a 16-year-old young man, says: "I was very strong and I didn't let the disease overcome me. I believe that the fear of cancer is worse than cancer itself. I didn't let cancer scare me. Cancer was just a disease for me. I would continue my life. I played music. I watched movies. I didn't bother about the illness at all".
In another case, a 75-year-old woman emphasized: "The disease is normal, if it's cured, great, if not, probably my life is finished", but I was not just sitting sadly and complaining that I'm dying. That is the worst thing one can do. It gives negative energy. If you give positive energy to yourself, you will receive the same, but if we feel defeated, we will be defeated".
Another interviewee, a 28-year-old man, explains using this method in the following way: "Cancer or any other diseases are part of life, something that can happen and you shouldn't ask: "Why should this happen to me?" I'm not the only person to get this disease . . . In fact, getting cancer enriched my experiences. I would say this disease taught me to be more realistic".

Distraction
"Distraction" is another method we found to belong to the category secular existential meaning-making coping. Here, the issue at stake is using something as a distracting object. In this method, any selected object can help to distract the cancer patient's attention from the illness. The main consideration in this method is having an instrumental point of view on selected patterns. Each object is selected only because the patient feels it is efficient in distracting him/her from focusing on the illness. In the meanwhile, the meaning that arises for patients is actually escaping meaninglessness: to avoid facing answers to unanswered questions about existence, life, and death that have a negative impact by engaging in some activity.
In this regard, a 35-year-old woman described her use of this method in the following way: "Every time I had pain, I painted and listened to music because I didn't want to complain. Also when I had many questions in mind . . . I painted or listened to music that was very loud".
In another case, a 75-year-old woman told us: "I was spending all my time on something to be entertained. I took pottery and painted on it. Then, I started making dolls. I did a variety of artwork; for example, I made bags from old jeans. I spent all my time in this way".
In addition, a young man (22 years old) explained that playing music can serve as a distraction: "When I play a piece of music, or sing, or make songs, I become totally filled with music and I forget myself completely".
A 53-year-old woman described purposely ignoring her illness owing to other major problems: "I think one of my greatest successes in overcoming this disease was that I tried to ignore the problems caused by my disease. To do this, I focused on other problems (challenges caused by my family). This was the biggest factor that helped me. During that difficult time [caused by cancer], my challenge with my family was so intensive that my illness could not be compared with it".

Altruism
Altruism, expressed by informants as "being a good person", was one of the secular existential meaning-making coping strategies employed by some respondents. According to Ahmadi (2006, p. 139), "Human altruism is not only an act, but is interwoven with an emotion: empathy. Altruism is then a prosocial behavior, a voluntary intentional act to help others at some cost to oneself (time, effort or money)".
To explain his use of this coping strategy, a 32-year-old man told us: "One day in a magazine I saw a photo of a rider who was standing outside in a rainstorm. Next to the photo was a quote from the rider: "I want to die at age 100". I bought the English version of the book and read it. I really liked this book; it had a very positive impact on me. I imagined me as the main character of this book . . . this gave me the power to struggle [with my disease]. I was planning to begin translating the book. "If I survive, this book will help thousands of others, and if not, that's okay". I decided to translate the book. Translating it, which would impact many ill persons, had an enormous impact on me and one of the factors that helped me to be cured".
Helping others was also mentioned by another interviewee, a 22-year-old man: "When I see someone is sad, I start playing my instrument and singing. When (s)he is singing with me and laughing and clapping, it's definitely enjoyable for me. This gives me energy and motivation and of course, I project this energy to my surroundings".
A similar coping method was found in the study among Swedes (Ahmadi 2006, pp. 139-41). In both cases, Swedish and Iranian, we can see that altruism is used to improve the human condition. Here, Altruism is not a religious duty. The difference between these two methods (religious helping and altruism) is significant. According to Ahmadi (2006), study among Swedes reveals that, when the Altruism coping method is used, the focus is not on responding to stressors by receiving the help of/offering support to others or devoting oneself to others, as we see in the RCOPE coping method, Religious Helping. In other words, "the motivation here is not religious. The issue is rather an abstract transcendent feeling, a feeling of Unity with all existence and, of course, a tendency toward empathy and altruism" (Ahmadi 2006, p. 139).

Encounter with Others
Consistent with Ahmadi et al. (2016Ahmadi et al. ( , 2019, we found "Encounter with others" as a secular existential coping method among Iranian cancer patients. One of the important factors affecting individuals during a negative life circumstance is the way the people close to them deal with them and their crisis. Here, the emphasis is on the social and psychological effects of the sick role ascribed to cancer patients. The sick role changes how people view individuals with cancer, which in turn affects their perception of self and their illness and the way they cope with it. In this regard, one of the interviewees, a 22-year-old man, explained: "I always believed I was impacted only very slightly by my surroundings, which are not under my control. But when tackling this disease, I realized that my role is only 20% and my parents' contribution in terms of emotional supports is 80%".
Another informant, a 50-year-old woman, told us: "The future of my kids was important to me. It means I try to approach my illness in a way that doesn't hurt my children. My husband helped me during the illness period. He gave me hope. He told me "think about life, yourself and the children. We will live normally again. If you get depressed . . . there's no longer any hope".
In another case, we observed positive thinking on the part of a patient, a 53-year-old woman: "My motivation was to make life better for my children. Since my therapy was going well, I bought a house and arranged the weddings of my daughter and son. It was very important for me to finish the arrangements for these weddings".

Nature
One of the secular existential meaning-making coping methods used by our interviewees is Nature. This finding is consistent with Ahmadi and Ahmadi (2015) and Ahmadi et al. (2016Ahmadi et al. ( , 2019. Nature can be used as an effective coping strategy in different ways. We found two patterns which reflect these two ways:

Unity with Nature
In the international project, coping through an inner connection with nature has been found to be an important method . Here, we face a direct unintentional "spiritual" connection with nature, a feeling of being one with it and sanctifying it. In their search for significance, people sanctify different aspects of life. Searches like this become more important when people face serious problems. As pointed out by Zinnbauer et al. (1999, p. 911), almost any object can be perceived as having a divine-like character. The divine-like characteristics tied to sacred qualities include features of transcendence (e.g., holy, heavenly), ultimate value and purpose (e.g., blessed, inspiring), and timelessness (e.g., everlasting, miraculous). Individuals sanctify a particular object and attempt to approach it in ways that let them acquire the sacred qualities. By sanctifying nature, people facing a crisis such as cancer can experience a spiritual feeling that serves as therapy in their encounters with cancer.
An interviewee, a 22-year-old man, explained this as follows: "When I went to the mountain, I looked down, I discovered how small I am and how small my problems are in this world . . . I thought about it constantly. I said to myself "I'm like a particle in a sea" and I thought often that I'm part of a big unity despite playing a small role in this life".
Another participant, a 35-year-old woman, told us about her thoughts and feelings while she was ill: "I'm just like these trees. The trees, like me, 'feel cold', their leaves shake and fall down. I feel that if a tree has been able to live for years, then I can. As strong [against natural hardships] as a tree can be, I can also be against my problems . . . This kind of thinking gave me energy".

Contemplation and Purification
The other pattern is seeing nature as a place for contemplating, being alone and clearing away thoughts that cause stress. According to Berto (2014): "Exposure to natural environments produces positive mood chances; actually exposure to natural stimuli can mediate the negative effect of stress, reducing the negative mood state and at the same time enhancing positive emotions. In particular, natural settings have restorative influences on three affective dimensions: positive effects, anger/aggression, and fear".
One 30-year-old man explained this method as a way to cleanse the soul: "After being hit by cancer, being in nature has always been one of my favorite things . . . It's not an exaggeration to say that when I'm in nature, I feel harmony within myself. I feel a rhythm inside me. My mental state improves. After being in nature, I feel a harmonic feeling for a week and then, I feel once again I need to return to nature, go to a desert, or by the sea or a forest. It's incredibly enjoyable and it gives me a lot of mental relaxation. The impact it has isn't so much physical, but its effects are mainly psychological".
A 35-year-old woman also pointed out how being in nature helped her cope with stressors caused by her illness: "When I look carefully at the nature around me, everything is based on order. Nothing in the world exists in vain. I enjoy this ordering, it makes me feel good. For instance, when I walk on the grass or on sand it is just like injecting new blood into my body".

Discourse of the Self
In the present study, "Discourse of the Self" was found to be a secular existential meaning-making coping method. Discourse of the Self is considered the mental picture one has of oneself and consists of things that have been learned through personal experiences and by internalizing the judgments of others. Discourse of the Self is related to an individual's understanding of themselves socially (as a member of different groups) and individually (as a unique person) and, therefore, of their personal and social roles. Accordingly, Discourse of the Self results from (a) how an individual sees themselves and their personal and social roles, (b) how others see the individual and her/his personal and social roles, and (c) how the individual perceives others' views of her/him.
Having faced a severe disease such as cancer, the individual is forced to assume a new role, the sick role, to use Parsons's (1951) term. Parsons treats health as a normal condition and as reflecting a person's optimal ability. Disease, on the other hand, is seen as a deviating condition that causes the person concerned to be dependent on others. However, it is important to emphasize that Parsons's analysis of the sick role is not based on a medical discourse but on a social and political perspective. Disease is seen as a threat to the social order. In the present paper, we emphasize the social and psychological effects sicknesses have on cancer patients. The sick role changes the way the disease victim is seen, which in turn affects how the person is perceived. This affects how the person faces her/his illness and copes with it. We found three patterns concerning the Discourse of the Self as secular existential meaning-making coping method.

Personal Strength Discourse
The first pattern involves using a Personal strength discourse as a self-protection mechanism. To explain this mechanism, for instance, a 22-year-old man says: "I say that I rely on myself and myself alone in this world and do not depend on anything or anybody. I know that if I want and try, I will win and get what I want. I know that whatever would happen in my life, it could not be as difficult as this disease, and it was this disease that made me believe that I could overcome the other difficulties in the future . . . This disease taught me how to deal with the problems of life. And in the meantime, my inner power made me believe that I would recover, and I believed these conditions were not lasting, and that everything would not end here and life would continue".
In another case, a 35-year-old woman says: "I have controlled my entire life so far and I have almost done everything I wanted and I do not need anyone . . . I hate my life as a routine. I enjoyed my period of illness because I was in a position where I could prove to myself and others that they are thinking in the wrong way about many things. I want to find a world that's worth keeping anyway".
Regarding having the power to cope with a crisis through personal strength, together with considering life itself precious and worth fighting for, these interviewees found it important to face their disease and cope with it, the first one through his strong will to live and the second by aiming to control everything in her life.
One of the meaning-making coping methods found in the study in Iran  was spiritual connection (one of the RCOPE methods). Using this method, the person looks for a stronger connection with God or a spiritual person. In the case of the coping method Discourse of the self, one does not seek spiritual connection with God or some other celestial spiritual source, but looks for a spiritual connection with themselves. This involves a search for an inner power, which may help them cope with the stress associated with illness.

Having a Mission
The second pattern is "Having a mission". In this regard, a 22-year-old man who had overcome the disease told us: "I used to think that every human being has a mission in this world, and I believed that if I have to leave this world, I had to accomplish my mission first. I didn't know when I would die, but I did know that I would live for a long time, because I had to accomplish the mission that I had been born to accomplish, but I hadn't yet done it. This disease made me aware of this mission and enhanced my ability to influence and motivate others".

Finding Self-Esteem
Finding self-esteem is the third pattern found in the Discourse of the Self coping method. In this pattern, the individual finds themselves valued and significant. This happens when someone faces a crisis that threatens their existence and life. In this regard, one interviewee, a 50-year-old woman, explained:

Visualization
One of the holistic health methods used by informants that can be considered secular existential meaning-making coping is visualization. As Shafer and Greenfield (2000) explain, visualization is the language used by the mind to communicate and make sense of the inner and outer worlds. As Ahmadi (2006, p. 145) points out: "This technique, which is also called guided imagery, is supposed to promote physical, mental and emotional health by having the patient imagine positive images and desired outcomes of specific situations. . . . The aim is to incorporate the "power of the mind" in order to help the body heal, to maintain health or to relax by way of inner communication involving all of the senses".
One interviewee, a 35-year-old woman, describes her coping using this method as follows: "I'm a daydreamer and it was exactly one of the factors that helped me so much . . . For example, I visualized that I would be treated and I would establish a charity, or I would do the work, or I would do something in another country.
Then, all this happened to me. This is the power of the mind. Visualization helped cure me".

Positive Solitude
Positive solitude is another secular existential meaning-making coping method our informants have used to cope with their illnesses. In the present study, preferring to be alone and having a chance to contemplate was recognized as one of the methods mentioned by the Iranian informants as a coping method with the anxiety and stress caused by cancer. Several informants mentioned that, during their being sick, they were willing to be by themselves. The term Positive Solitude refers to this attitude. It implies an appreciation of being alone. A 52-year-old woman describes this method as follows: "I often tried to manage being alone. I walked alone in the park or I sat alone at home and then reviewed things for myself, what I had done, what I had not done and what I could do. This was positive for me".
In another case, a 35-year-old woman says: "I wanted to be alone from the time I got the diagnosis . . . I felt it was better to be alone and think. My revelations occurred when I was alone, and that loneliness helped me a lot".
Sometimes becoming seriously ill gives individuals the opportunity to look into their inner self and search for questions they have rarely had time to ponder. Positive solitude is not only a way to avoid exhaustion and promote feelings of tranquility but also, as our informants explained, a way to review events and reconstruct one's view of life.

Positive Thinking and Transformational Orientation
As Naseem and Khalid (2010, p. 42) maintain: "Positive thinking is looking at the brighter side of situations. It makes a person constructive and creative. The authors explain "positive thinking is related with positive emotions and other constructs such as optimism, hope, joy, and wellbeing". McGrath (2004) defined positive thinking as a generic term referring to an overall attitude that is reflected in thinking, behavior, feeling and speaking. Positive thinking is a mental attitude that admits into the mind; thoughts, words and images that are conducive to growth, expansion, and success".
We find several studies (Carver and Scheier 2001;Khodayarifard et al. 2016;Khodayarifard et al. 2017) in the coping literature that have explained positive emotions and thinking. According to Naseem and Khalid (2010, p. 47), "Dispositional use of positive emotions inducing coping strategy was mostly associated with positive aspects of wellbeing. Positive Emotional Granularity (PEG) is the tendency to represent experience of positive emotions with precision and specificity. This exerts an important influence on coping by making the individual more attentive to the situation at hand".
Our study in Iran and also our studies in other countries have revealed that the painful journey cancer patients undergo can make them feel more grateful in their present life and bring about 'a turning point' in their life-a new positive attitude toward life. In this respect, a 22-year-old man explained: "I learned to deal with hardship and use its positive aspects to continue my life, because I believe that when it comes to one's life, experiences can be beneficial. It's not important how difficult the situations are, the personality growth caused by these harsh situations is important and valuable. If anyone understands this, (s)he can rebuild a new life on this basis".
In another case, a 35-year-old woman told us: "[After getting the diagnosis] everything really became very beautiful for me . . . everything became enjoyable. With this new view, I began to live in a way so that if I die, I have no regrets and aspirations for me because I am full of pleasure and I have enjoyed everything around me".

Discussion
In this study, we examined the secular existential meaning-making coping methods employed by Iranian cancer patients. We found that our participants deal with the crisis through nine secular existential coping strategies: Ignoring the illness, Distraction, Altruism, Encounter with others, Nature, Discourse of the self, Visualization, Positive solitude, and Positive thinking and transformational orientation. In this section, we classify these coping strategies into two general categories: Denying/Ignoring and Empowering. Then, we discuss the existential coping methods found in this study, bringing forth some dynamic aspects of Iranian culture.

Denying/Ignoring
This group of secular existential coping methods includes methods that seem to emphasize diminishing the role and effect of the cancer disease and even ignoring it. This is consistent with Dunkel-Schetter et al. (1992). The focus here is not on empowering the patient and attempting to transform her/him from a passive victim to an active actor. Here, instead of finding the power resources for coping, the strategy is to direct attention to diminishing the importance of the "physical world", i.e., the illness. By using the coping methods belonging to this group, the patient tries to reduce the position of her/his illness as a crisis and to normalize it. We discussed two secular existential meaning-making coping methods that belong to this group: "Ignoring the illness" and "Distraction".

Empowering
This category includes two groups of secular existential coping strategies: - The first group of existential coping methods involve trying to find power resources by connecting or uniting with an 'eternal entity', which is always there and persists. This 'entity' can be multidimensional or simple. It can also be physical or metaphysical in nature. The power resources identified in the present study were Nature, Science, and People. We discussed three secular existential meaning-making coping methods that belong to this group: "Altruism", "Encounter with others", and "Unity with Nature". - In the second group, the focus is on convincing the patient that (s)he is powerful enough, based on inner power resource, to overcome the threat brought about by cancer. This is consistent with Dunkel-Schetter et al. (1992) and Ahmadi et al. (2019).
In the present article, we discussed the secular existential meaning-making coping methods that belong to this group: "Contemplation and Purification" in Nature, "Discourse of the self", "Visualization", "Positive solitude", and "Positive thinking and transformational orientation".

Cultural Perspective
In this section, we discuss the secular existential coping strategies found in this study from a cultural perspective. Before addressing the question of what role culture may have played in use of these coping methods, we should remember that the culture of a nation includes a wide range of subcultures and different cultural settings/ways of thinking. This does not call into question the notion that certain cultural settings are more dominant than others. We consider the cultural contexts that may have shaped the narratives (the participants' answers), as one of the most important aims of our international project is to provide reflections on the potential role of culture in meaning-making coping.
It should be noted that in this section, we have also speculated about the potential influence of some well-known Persian poetry on the pattern of results found in this study. As Ahmadi and Ahmadi (1998, p. 60) mention: "The poems of Hafez and Jalaluddin Rumi, well-known in the Western world for their mystical ideas, are so prevalent among Iranians that it is no exaggeration to claim that there are only a few Iranians who have not read or listened to a recital of at least one of these poems. One of the many reasons why mystical poetry survived among Iranians during so many centuries is the fact that Iranian children used to memorize these poems. Even today, the students read and memorize the poetry of Hafez, Rumi, and others. It is therefore not surprising that "to this day, there is hardly anyone in Persia, even among the so-called illiterate people, who does not remember a number of verses of this poetry". Additionally, Nicholson has classified Mathnawi-a book of Persian mystical poems in rhyming couplets, mainly with didactic, romantic, and heroic themes written by Jalaluddin Rumi-as "a work so famous and venerated that it has been styled «The Koran of Persia»", indicates the extent to which the reading of mystical poetry has been a tradition among Iranians".
Concerning the potential role of culture in the secular existential meaning-making coping methods discussed in the present article, the following four points may be remarkable: (1) "Ignoring the illness" and "Distraction" are both secular existential meaningmaking coping methods focused not on empowering the patient but on denying the importance of the illness and the person's suffering. In Persian culture and Iranian ways of thinking, we find an approach to suffering we believe may pave the way to use of these coping methods. A remarkable part of the Iranian cultural heritage is related to the inability to resist one's destiny, the necessity to delimit the suffering by enjoying available pleasures and ignoring problems we cannot overcome-in other words, by living in the moment: 'Dam'. For example, the works of some Persian poets, which are loved by Iranian people, convey such messages. In a quote by Omar Khayyam, we read: "Drink wine. This is life eternal. This is all that the youth will give you. It is the season for wine, roses and drunken friends. Be happy for this moment. This moment is your life". (FitzGerald 1995, p. 26) Additionally, in a poem, written by Hafez: "With wine make the fabric of the heart. Since this evil world is bent on that, it may make a brick of our dust in the grave". (Clarke 2014, p. 79) The idea of living in the moment may be partly a result of the historical situations Iranians have faced over the centuries. Here, we are referring to invasions of the country by different nations-invasions that have dissuaded the people from planning and thinking in the long term.
(2) "Unity with nature" is one of the meaning-making coping methods identified in the present study. In this case as well, we find the footprint of a Persian cultural feature, namely, the idea of the "Unity of Existence" (Vahdat-e-Vojod) (Nasr 1989;Ahmadi and Ahmadi 1998), which is highly prevalent in Sufism. This method can be classified as belonging to the coping methods that empower the patient. The patient takes paths that are somehow connected to something that is sacred and has a transcendent quality; in this connection, we find an experience of unity of existence through the sanctification of nature. The patient does not merely discover a feeling of connectedness but also sees her-/himself and her/his disease in a new light. This, in turn, helps her/him cope with the disease.
"Altruism", in the form of helping others, and "Encounter with others", as accepting the support of the people in one's life, can be regarded as another secular manifestations of the idea of the "Unity of existence". Here, the patient empowers her-/himself and protects against the illness by "disappearing in others" or better "surviving in others". Here, love is the keyword for unity. In the Persian literature, we see the same idea. Hafez says: "Never dies the one whose heart is alive with love. On the world's record, is written the everlasting existence of ours". (Clarke 2014, p. 11) Sa'di mentions: "Sa'adiya! Well-known never dies . . . . Dead is someone who people don't remember their name as a good person". (Katouzian 2016, p. 417) (3) In the present study, "Positive solitude" and "Contemplation and purification" are recognized as two secular existential meaning-making coping methods for handling the psychological problems caused by cancer. Although here these meaning-making coping methods are regarded as secular existential in nature, we cannot deny the possible impact of the internalization of some ideas, which have their roots in religious teachings, by the Iranian interviewees in the study. Here, we refer to the idea of 'purification by solitude' (for instance, Chilla) advocated by Islam and Persian mysticism (Sufism). Chilla is " . . . caring about heart and waiting for revelation. One should not be afraid of whatever has happened for them and empower themselves by inner power resources [that God has given to them]" (Razi 1994, pp. 275-88). Islam and especially Persian Sufism emphasize the discovery of inner powers through positive solitude and contemplation. "Positive solitude" is regarded as an important way of discovering new aspects of the self and of releasing us from the divergent chains that keep us in the cage of worldly desires. Here, it is worth noting that according to many scholars (Ahmadi and Ahmadi 1998;Lewisohn 1999;Nicholson 2009;Schimmel 2011), from the ninth century onward, Sufism underwent considerable change. Islamic asceticism passed over into the pantheistic religious enthusiasm that forms the true essence of later Sufism. The key notions of the new Sufism were not about suffering in the ascetic sense but the ideas of Love and Light. Weber (1978, pp. 555-56) took into consideration the Persian Sufis' strong tendency toward mysticism instead of asceticism. He says: "The inner-worldly order of dervishes in Islam cultivated a planned procedure for achieving salvation, but this procedure, for all its variations, was oriented ultimately to the mystical quest for salvation of the Sufis. This search of the dervishes for salvation, deriving from Indian and Persian sources, might have orgiastic, spiritualistic, or contemplative characteristics in different instances, but in no case did it constitute «asceticism» in the special sense of that term which we have employed".
(4) In addition to the above-mentioned coping methods with denial characteristics, we found two methods-"Discourse of the self" and "visualization"-that have an empowering function by helping patients rely on their inner power resources. Here, the crisis is not totally denied or ignored, but the individual tries to overcome it by playing the role of an active actor.
Discourse of the self: Transforming a threat into an asset and creating a new meaning for the illness do not actually constitute denying it but are better characterized as coping with it. We can find such ways of thinking in the most important and beloved Persian poet, Rumi. He argued that a human being's inner immortal world is superior to the physical mortal world. According to him, human beings have a mission, which is much more significant than their daily life: "O thou who art the whole sea, what wilt thou do with dew? And O thou who art the whole of existence, why art thou seeking non-existence?" (Nicholson 2007, p. 339) In his doctrine, the importance of terrestrial aspects of human existence, including the experience of being struck by disease, is secondary: "O, brother! You are all thought, and the rest of you are just bones and veins". (Nicholson 2007, p. 275) Visualization: Concerning the cultural interpretation of using 'Visualization' by our interviewees, there is a belief among Iranian people that if one wishes something heartily and believes that one can achieve it, this wish will be realized. For example, the expression "to wish is to get" is a very common proverb among Iranians.

Conclusions
The current qualitative study among cancer patients in Iran, concerning meaningmaking coping methods, provides evidence that our participants make use of a variety of secular existential coping methods. According to our findings, to deal with their illness and worries, Iranian informants may benefit from ignoring their illness, distracting themselves, doing altruistic acts, encountering with others, sanctifying nature, using visualization, training positive solitude, and having positive outlook. Proceeding from a cultural perspective, we have attempted to explain the findings by taking into consideration the possible impact of certain cultural features and elements that would influence on or be reflected in the selection of coping methods by Iranian cancer patients during fighting their illness. It should be taken into consideration, however, that some religious teachings may have played an indirect role in the secular existential meaning-making coping strategies observed. However, these teachings, advocated by writers and poets, are hardly regarded as religious by some people; this is because over the centuries, they have been integrated into people's ways of thinking and are considered primarily as a part of Iranian culture.

The Strength and Limitations of the Study
The present study sheds light on the ways our sample of cancer patients may manage and endure their conditions. It may also help us to better understand the possible role of culture on using certain secular existential meaning making coping methods. The main strength of our research is that, to our knowledge, it is the first study of its kind to discover secular existential meaning-making coping in an Iranian group struck by cancer. By presenting and discussing about the results of our study, we hope to contribute to an increase in scientific knowledge in meaning and coping field. One of the limitations of this study considers the sampling and that our sample skewed female. Thus, generalization of the present findings to different populations and settings should be done with care. Furthermore, we did not attend to patients' biopsychosocial distress, which may play a role respect to coping.

Directions for Future Research
Conducting similar research on coping among other groups with different chronic illnesses paves the ways for intergroup comparisons of the patterns of results. This may generate valuable knowledge regarding the interaction of human beings and health crises.
Through nationwide or large-sampled quantitative surveys, future research could investigate the extent to which the existential coping methods found in this study are widespread in Iran. Cross tabulations by sociodemographic (gender, age, education, etc.) and clinical characteristics (e.g., phase of illness) will make these quantitative efforts more informative and the applied statistical analyses stronger. Considering the respondents' phase of illness and survivorship in future studies on meaning-making coping processes and strategies seems to be important, as cancer survivorship spans a continuum from diagnosis through treatment and far beyond and because survivors' experiences of cancer change across this survivorship spectrum (Park and Hanna 2022).
For a more rigorous scrutiny of the coping patterns in patients, we encourage future researchers to also consider biopsychosocial states of informants in their comprehensive research attempts in the field.

Practical Implications and Policy Recommendations
We recommend that health psychologists, psycho-oncologists, physicians, anticancer therapists, social workers, palliative care professionals, hospice care providers, and nurses on cancer care make use of the present findings when giving advice to patients with cancer.
We encourage health administration officials and cancer support service providers to provide evidence-based educational classes and self-study materials for cancer patients to inform them of the possible ways to face their situation.
The patients and survivors themselves are also recommended to adopt a wider range of adaptive coping strategies to deal with their challenges in managing their illness and distress.