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的反應，但過度的焦慮仍是有礙於PTG的產生，因為焦慮會使個體高估事件的威 脅性、低估自己的因應能力，導致認知與行為上過多逃避的反應（Riskind, Williams & Joiner, 2006），由於PTG需要反覆審慎的思考，焦慮會讓個體把資源 於都投注在自我保護與防衛上，錯失尋找意義與發現益處的機會。
最後本研究發現承認癌症對個人的負面影響、認知到個人的脆弱性與 PTG 的經驗是有關的，而且癌後最佳適應的狀態必頇要帄衡於接受自己的脆弱性，並 從困頓中獲取正向意義、找尋益處，因此，如何於癌後降低患者對癌症負面影響 的否認，而非一味地只關注正面想法或找尋癌症經驗中的益處是重要的。一些協 助患者整理癌症經驗與生命故事的介入方式，例如書寫表達治療、社會支持與述 說等等，應該讓癌症患者有機會同時表達癌後正、負面的改變。
第五節、 研究限制與未來研究方向
針對本研究的限制與無法解決的議題，整理如下，並提出未來可行的研究方 向。
首先，本研究只以乳癌患者為研究對象，然而已經有許多研究指出各種類型 的癌症患者都有相當高的比例報告PTG（e.g., Sears et al., 2003），因此未來研究 應納入其他類型的癌症患者，尤其是男性的癌症患者。因著這樣的研究，才能說 明本研究的發現是否可類推到其他的癌症類型。
第二，針對PTGI的部分，Ho等人指出，PTG可以包含個人與人際兩種層次 的成長，目前對於不同面向的PTG與心理沮喪的關係並不清楚，但已有一些學者 強調探討PTG的不同面向之重要性（Curbow et al., 1993; Ho et al., 2004; McMillen et al., 1995），並認為不同面向的PTG之變化是不同的，有些面向的改變是比較 迅速的（例如，人際關係、同理心的增加）、有些面向的改變則比較緩慢（例如，
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瞭解到自己的能耐、人生哲學關的改變（Affleck et al., 1987; Frazier et al., 2001;
Weaver et al., 2005）。因為PTG不同面向的變化，及其與心理適應的關係可能不 同，因此瞭解PTG不同面向的差異可以探索癌後調適最有利的臨床介入重點及關 鍵的介入時機，未來的研究可以繼續探討PTG不同面向之軌跡及其與心理適應的 關係。
第三，關於如何區辨四組不同的PTG組別之患者，尤其是對PTG上升組與中 度維持組的區分，從本研究的結果證據是較缺乏的，未來應進一步探索這兩組之 間有何差異。此外，為何PTG下降組的人的危機反應較低且隨時間下降？這一組 的患者雖然焦慮感受最低，但憂鬱程度卻不低於PTG上升組與中度維持組，為何 如此？PTG下降組乳癌患者之心理素質如何？其『不投入』的心理狀態之意涵為 何？都值得於未來加以探討，另外，本研究追蹤的時間範圍內，雖然PTG下降組 的患者沒有延宕心理症狀的證據，但他們的負向心理反應是否在後續重返生活期 或存活期（survivalship）才上升，是可以繼續探討的議題。
第四，若推論PTG下降組為一組未知覺重大危機的患者，那麼她們是否仍屬 於本研究所討論的對象，亦即，本研究既然將重點放在『創傷』後成長，是否應 排除PTG下降組的患者？本研究認為，於癌症期數、輔助治療、手術方式等醫療 變項，及主觀癌症衝擊性，PTG下降組都為顯著低於其他組，且其主觀癌症衝擊 性量表中，每一題的帄均分數介於3.07－3.69（量尺為1－5分），代表PTG下降 組知覺到的癌症衝擊不低於其他組，且有中度以上的衝擊感受，因此沒有理由認 為他們不具心理上的創傷性質，但未來研究需繼續釐清為何這群患者並未投入於 癌症的因應與調適？其面對壓力的心理特性為何？
第五，PTG高度維持組在本研究中各種正向的相關變項（自尊、適應性因應 策略、深思反省、PA）上都表現最高分，憂鬱程度也最低，PTG可能只是其正 向反應偏向的一種展現？不過，PTG高度維持組在一些負向的PTG相關變項上亦 具有較高的分數（例如，自覺脆弱性、苦惱自責），且其社會期許性並未顯著高
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於其他三組，因此，正向反應偏向對本研究在推論上的威脅應不大。
最後，PTG的理論在爭辯PTG的本質上有相當多的討論，主要分為兩大類，
一類將PTG視為真實、有建設性的成長，另一類將PTG視為自我保護的因應策略，
或正向錯覺。本研究的結果並無法推掄PTG的本質抑或PTG與心理適應的因果關 係。但本研究採用PTG作為自我覺知的正向成長，與Davis等人（1998）及Tennen 與Affleck（2002）對益處發現的定義一致，他們認為由於探討PTG的本質仍是一 條很長遠的路，目前研究多先假定PTG是個體報告或覺知的創傷後正向改變，這 種自我察覺的PTG本身尌是創傷後／癌後促進健康與心理適應之正向調適的一 環。
雖然有上述限制，本研究的突破在於提出PTG的異質性是探討PTG與適應關 聯的阻礙因素之一，因此本研究於時間序列研究中，突破過去探討PTG的軌跡變 化及其與心理適應的關係之限制，提出PTG異質性變化軌跡對瞭解乳癌患者癌後 適應歷程的重要性。
本研究以客觀的統計分析方法－群體軌跡模型（Group-based trajectory;
TRAJ）分析PTG異質性的變化軌跡，並以過去文獻提出的相關變項考驗PTG軌 跡組別的效度，為過去文獻所缺乏的。此外，將因應策略、認知投入、自覺脆弱 性以動態的方式，探討他們與PTG隨時間變動的關係，亦為一項突破。最後，本 研究將PTG下降組排除後，發現PTG與心理適應的關係呈現過去學者期望得到的 結果，亦即乳癌患者的創傷後成長愈高，其心理沮喪愈少，且正向情緒愈高，並 與適應性因應及深思具有顯著的正相關，以實徵證據回應Carver（2009）的觀點，
亦為本研究之貢獻。總而言之，排除PTG下降組後，本研究支持PTG可視為癌症 正向適應的一環。此結果於實務上提供了重要的依據，對『PTG中度維持組』與
『PTG上升組』兩組患者需提供心理介入，提升PTG、增加適應性因應策略，以 期降低其心理沮喪，提升癌後心理適應與生活品質。
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