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. Author manuscript; available in PMC: 2026 Jun 3.
Published in final edited form as: J Rehabil. 2026;91(4):17–29.

A Review of Acceptance Measures for Cancer Survivors: Employment, Multicultural, and Language Considerations

Kaiqi Zhou 1, Hannah Fry 2, Constance Richard 2
PMCID: PMC13227549  NIHMSID: NIHMS2145918  PMID: 42238361

Abstract

Purpose:

This review examines commonly used acceptance measures in cancer and rehabilitation research to evaluate their theoretical foundations, psychometric properties, and relevance to cancer populations. The goal is to identify measurement gaps and inform strength-based rehabilitation practices.

Methods:

A narrative review was conducted of acceptance measures used in cancer and rehabilitation research. Each measure was assessed based on alignment with rehabilitation principles, psychometric quality, cultural adaptability, and applicability to vocational outcomes.

Results:

Acceptance measures used in current cancer research reflect a predominantly medical model approach. Their language and constructs may unintentionally reinforce deficit-based views. In contrast, tools developed by rehabilitation researchers, like the Adaptation to Disability Scale-Revised (ADS-R) and the Multidimensional Acceptance of Loss Scale (MALS) emphasize psychosocial adaptation and strengths, though they have been rarely used or validated in cancer populations.

Conclusions:

Rehabilitation counseling has an opportunity to lead the development of acceptance measures that are strengths-based, culturally responsive, and applicable to vocational settings. Existing measures need adaptation or replacement to better serve diverse cancer survivors. Such tools can enhance psychosocial assessment, guide interventions, and support employment-related outcomes in cancer survivorship.

Keywords: cancer, acceptance, measurement, employment, language

Cancer is a group of diseases characterized by uncontrollable growth of body cells, invasion and destruction of adjacent tissues, and, if malignant, the spread from the organ of origin to other sites in the body (Orr & Orange, 2014). Although the exact cause of cancer is unknown, several factors have been known to increase cancer risk, such as ionizing radiation, some chemicals and pollutants, alcohol, tobacco, and suppressed immune response (e.g., Hunter, 2016; McCance, 2014). Over 100 types of cancer have been identified, classified by the origin site (e.g., lung, breast, prostate) or cell type (e.g., squamous, epithelial; National Institute of Health [NIH], 2021). Cancer staging, which assesses the extent of disease spread, is crucial for determining prognosis and treatment, typically ranging from stage I to stage IV, with the number indicating the degree of spread. Some cancers also have a stage of 0, indicating that cancerous cells remain contained within the site of origin (Falvo & Holland, 2018).

Cancer is a significant global public health issue and the second leading cause of death in the United States. For 2022, the Centers for Disease Control and Prevention reported 1,851,238 new cancer cases and, in 2023, 613,349 cancer deaths (Centers for Disease Control and Prevention [CDC], 2023). These numbers continue to grow (Siegel et al., 2022) and the American Cancer Society (ACS) estimates that by the year 2035 more than 22 million people in the United States will have a history of cancer (Wagle et al., 2025). Despite the high incidence, advances in early detection and treatment have improved survival rates for some cancers, such as lung and breast cancer since the mid-1970s (Seigel et al., 2022).

People living with cancer may experience significant psychosocial and vocational challenges (Zenger et al., 2011). Employment is often disrupted due to cancer-related symptoms, such as fatigue, physical limitations, and cognitive changes. These difficulties may lead to reduced work hours, job changes, extended work absence, or early retirement, affecting the survivor’s financial stability (Stepanikova et al., 2016; Stergiou-Kita et al., 2016). In addition, cancer survivors also experience anxiety, fear, body image issues, and low self-esteem, particularly common among patients with breast cancer (Sebri et al., 2021). These challenges can influence survivors’ confidence in returning to or maintaining employment. Negative social attitudes and internalized cancer stigma often lead to feelings of shame, guilt, and self-blame (Kang et al., 2020; Williamson et al., 2022), leading to avoidance of disclosure and workplace support. Older adults with cancer may struggle with independent living tasks, including taking medications, making lifestyle changes, and symptom monitoring (Corbett et al., 2020), which can also interfere with sustained work participation. These challenges can profoundly affect the quality of life and vocational integration of people living with cancer (Shrestha et al., 2019; Weaver et al., 2012).

Acceptance of chronic illness and disability (CID) has long been recognized as a predictor of positive psychosocial outcomes (Kennedy et al., 2012; Livneh, 2001; Livneh & Antonak, 1997; Wright, 1983; Zhou, 2024). Cancer researchers have found that this construct plays a vital role in coping with negative psychological distress and adapting to cancer (e.g., Religioni et al., 2020; Secinti et al., 2019). Acceptance-based interventions, such as acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT), have proven effective in addressing anxiety, body image, well-being, and pain perception among cancer patients (Mosher et al., 2018; Tarkhan, 2018).

In addition to its psychological and emotional impact, acceptance of cancer may play an important role in facilitating vocational outcomes. Cancer-related changes in physical or cognitive functioning, stigma, and workplace discrimination can disrupt employment trajectories (Blinder & Gany, 2020; Mehnert et al., 2013). When individuals are able to accept their condition, they may be more likely to seek support, advocate for accommodations, or reframe their work identities, all of which can positively influence return-to-work efforts and job retention (Blinder et al., 2012; Nowicki et al., 2017).

Most existing acceptance measures were developed for broader CID populations rather than specifically for cancer patients, raising concerns about their validity in this context. In addition, the conceptualization of acceptance in these measurements assumes that having cancer is relevant to the experience of loss, neglecting other strength- and future-related experiences such as post-traumatic growth (Calhoun & Tedeschi, 2006). Further, most of the studies on cancer acceptance come from medicine (Chen et al., 2019; Cipora et al., 2018) and psychology (Secinti et al., 2019; Vargas et al., 2010). To support the psychosocial adaptation of people living with cancer and develop evidence-based interventions, researchers must ensure the feasibility, reliability, and validity of acceptance measures for this population. This review aims to evaluate existing acceptance measures for the cancer population, examine their quality, and discuss their implications for rehabilitation research, education, and practice.

Overview of Acceptance

Acceptance is a key element in achieving positive outcomes during psychosocial adaptation to CID. Somatopsychologists first introduced the construct of acceptance of CID and linked it to the acceptance of loss (e.g., Dembo et al., 1956; Wright, 1983). Wright (1983) emphasized that acceptance involves a value change, where individuals maintain self-worth by perceiving their conditions as non-devaluing. The value change process involves: (a) embracing values other than disability-related values, (b) deemphasizing the importance placed on physical appearance and physical ability, (c) limiting the impacts of disability to the impact of the actual impairment, and (d) not generalizing the limitation of disability in one area to other areas of the individual’s life.

Stage models conceptualize acceptance of CID in a similar way. These models, influenced by Kubler-Ross’s (1969) stages of mourning, conceptualize disability onset as a loss, and so framing the physical, social, psychological, vocational, and economic changes that follow. Kubler-Ross herself noted parallels between accepting a terminal diagnosis and accepting a disability, reinforcing the link between grief and disability acceptance (Allred & Hancock, 2012). Livneh (1986) synthesized different types of stage models and concluded that acceptance is the final stage of the adaptation process, wherein individuals internalize the functional limitation of CID into their self-concept and attempt to master new behaviors and social roles. This stage process, not necessarily linear, involves complex emotional responses. For example, empirical research demonstrates that anger is a common component of emotional distress among cancer patients and can meaningfully shape adjustment by influencing coping, communication, and even willingness to engage in supportive care (Barinková & Mesárosová, 2013; Mossman et al., 2024).

In cancer research, acceptance is often conceptualized as a necessary skill or strategy for adjustment, consisting of cognitive, affective, and behavioral components. Coping Theory frames acceptance as an emotion-focused coping strategy. When confronted with significant stressors, such as a cancer diagnosis, individuals use cognitive and behavioral strategies to manage these demands after appraising the situation (Lazarus & Folkman, 1984). Thus, acceptance of cancer involves acknowledging the reality of the illness, maintaining self-compassion, and adapting to new life circumstances (Carver et al., 1989; Williams & Lynn, 2010).

Third-wave approaches (e.g., ACT, DBT) argue that acceptance is not tolerating the existence of cancer but, rather, is the willingness to be present with one’s disability-related thoughts, feelings, and bodily sensations without judgment or unnecessary control attempts (Hayes, 1994; Secinti et al., 2019). In the context of cancer, acceptance can be viewed as a two-part process: (a) a willingness to experience cancer, and (b) engagement in value-based life activities despite the existence of cancer (McCracken et al., 1999). Thus, acceptance is a strategy that increases psychological flexibility and shifts from heightened emotional reactivity to cancer-related thoughts to a stance that reduces such struggles (Secinti et al., 2019).

The authors of this article would be remiss if they failed to mention that common experiences and symptoms central to many survivors’ lives after a cancer diagnosis likely influence the process of acceptance. Due to the frequent and disrupting experience of pain among people living with cancer, many cancer studies focus on pain acceptance specifically (e.g., Gauthier et al., 2009; Xu et al., 2019). Pain acceptance involves replacing ineffective pain control strategies with engagement in meaningful life activities, even with pain (McCracken et al., 2004). It has been found to be significantly associated with improved functioning and less medication use in individuals with chronic pain (McCracken & Eccleston, 2006). The definition of pain acceptance stems from self-regulation theories, in which disengagement from the attempt to control pain and re-engagement in other more attainable goals that are less impacted by pain are proposed (Eccleston et al., 2002; Lauwerier et al., 2015). Variables such as chronic pain acceptance and management, spiritual distress, psychological distress, hope, and even social support may moderate or mediate cancer acceptance. Given the complexity of the cancer acceptance experience, the authors of this article chose to focus solely on traditional acceptance measures.

Acceptance Measures Used in Cancer Research

The present section will describe in detail the two most widely used acceptance measures in cancer research within medical settings: the Mini-Mental Adjustment to Cancer (Mini-MAC) and the Acceptance of Illness Scale (AIS). See Table 1 for a summary of these instruments.

Table 1.

Summary of Common Acceptance Measures Used in Cancer and Rehabilitation Research

Instrument Name Author(s) Theoretical Framework Scales Total # of Items Sample items Scoring and Interpretation Psychometric Properties
ADS Linkowski (1971) Value Change Theory (Dembo et al., 1956; Wright, 1983)

  1. Enlargement of scope of values (14 items)

  2. Subordination of the physique (5 items)

  3. Containment effort (16 items)

  4. Transformation of comparative to asset values (15 items)

 50 “Because of my disability, I feel miserable much of the time.”
“Disability or not, I’m going to make good in life.”		 6-point Likert-type scale ranging from 1 (I disagree very much) to 6 (I agree very much). Reverse scaling to score some items. A total ADS score results from summing across all items. Higher scores indicate a higher acceptance of disability. 300 is the highest possible score. Low acceptance scores<175, high acceptance scores ranging from 176–300. Linkowski (1971):
Significant correlation of .81 between the ADS and the Attitudes Toward Disabled Persons Scale (Yuker et al., 1960), suggesting high concurrent validity.
ADS-R Groomes & Linkowski, 2007 Value Change Theory (Dembo et al., 1956; Wright, 1983)

  1. Enlargement of scope of values (8 items)

  2. Subordination of the physique (5 items)

  3. Containment effort (10 items)

  4. Transformation of comparative to asset values (9 items)

 32 “There are many things a person with my disability is able to do.”
“You need a good and whole body to have a good mind.”		 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Reverse scaling to score some items. Scores are summed to get scale scores. Higher scores indicate higher levels of acceptance of disability. Groomes & Linkowski (2007):
Overall reliability: very good with α = .93.
Internal consistency ranging from moderate to high.
Internal consistency coefficients of subscales ranging from .71 to .88.
RIDI Livneh & Antonak, 1990 Psychosocial Adaptation to Disability (Livneh & Antonak, 1997; Livneh, 2001)

  1. Shock (7 items)

  2. Anxiety (8 items)

  3. Denial (7 items)

  4. Depression (8 items)

  5. Internalized anger (8 items)

  6. Externalized hostility (7 items)

  7. Acknowledgement (7 items)

  8. Adjustment (8 items)

 60 “I can cope with almost all problems I face.”
“I know my limitations and have learned how to deal with them.”		 4-point Likert-type scale ranging from 1 (never) to 4 (often). Items summed for global score for each scale. Higher scores indicate higher endorsement of each scale. Livneh & Antonak (1990):
Reliability: α ranging from .64 to .89 for each of the eight scales.
MALS Ferrin et al., 2011 Value Change Theory (Wright, 1983)

  1. Enlargement of scope of values (10 items)

  2. Subordination of the physique (12 items)

  3. Containment effort (9 items)

  4. Transformation of comparative to asset values (11 items)

 42 “I think a lot about what I have lost because of my disability.”
“I can still be a responsible member of the community.”		 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Some items are reverse scaled. Sum items in each dimension gives a scale score. Higher scores indicate higher acceptance of loss. Ferrin et al. (2011):
Good internal consistency reliability (α ranging from .80 to .88 for each of the subscales)
Good construct validity
AIS Felton et al., 1984 N/A N/A 8 “I have problems with adjustment to the limitations imposed by the illness.”
“Due to the disease I am a burden on my family and friends.”		 5-point Likert-type scale ranging from 1 (strongly agree) to 5 (strongly disagree). Scores are added up to give a global score of non-AOD, thus higher scores indicate lower level of acceptance. Felton et al. (1984):
Very good reliability (α = .85)
High test-retest reliability correlation (r = .94)
Mini-MAC Watson et al., 1994 N/A

  1. Fighting spirit

  2. Helpless-Hopelessness

  3. Anxious preoccupation

  4. Fatalism

  5. Cognitive avoidance

 29 “I try to fight the illness.”
“I feel like giving up.”
“Not thinking about it helps me cope.”		 4-point Likert-type scale ranging from 1 (“definitely does not apply to me”) to 4 (“definitely applies to me”).
Higher scores on subscales indicate greater affiliation with behaviors typical of the given adjustment style.		 Zucca et al. (2012):
Adequate to very good reliability (α ranging from .62 to .88 for each domain).
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Note. ADS = Acceptance of Disability Scale. ADS-R = Acceptance of Disability Scale – Revised. RIDI = Reaction to Illness and Disability Inventory. MALS = Multidimensional Acceptance of Loss Scale. AIS = Acceptance of Illness Scale. Mini-MAC = Mini Mental Adjustment to Cancer Scale. AOD = Acceptance of disability.

Mini-Mental Adjustment to Cancer Scale

Measurement Properties

The Mini-Mental Adjustment to Cancer Scale (Mini-MAC) is a widely used tool globally, designed to measure common reactions to cancer, refined from the original Mental Adjustment to Cancer (MAC) Scale. Developed to assess psychological dimensions of adjustment, the Mini-MAC reduced the original 40 items to 29 and expanded the Cognitive Avoidance subscale (Watson et al., 1994; Watson & Homewood, 2008). The Mini-MAC includes five subscales corresponding to common cancer adjustment styles: Fighting Spirit (e.g., “I try to fight the illness” and “I see my illness as a challenge”), Helplessness-Hopelessness (e.g., “I feel that life is hopeless” and “I feel like giving up”), Anxious Preoccupation (e.g., “I feel completely at a loss about what to do” and “I am apprehensive”), Fatalism (e.g., “At the moment I take one day at a time”), and Cognitive Avoidance (e.g., “I can’t handle it” and “Not thinking about it helps me cope”). The scale also offers positive and negative summary scales. Responses are rated on a 4-point Likert-type scale from 1 (“Definitely does not apply to me”) to 4 (“Definitely applies to me”), with higher scores indicating stronger identification with a given adjustment style.

Psychometric Properties

Many studies support the reliability and validity of the Mini-MAC and its subscales (e.g., Anagnostopoulos et al., 2006; Boyes et al., 2011; Hulbert-Williams et al., 2012) For example, Boyes et al. (2011) found that the Mini-MAC demonstrated acceptable to very good internal consistency, with Cronbach’s alphas ranging from .62 to .88, among adult cancer survivors six months following diagnosis (Boyes et al., 2011). Hulbert-Williams et al. (2012) found the Mini-MAC has good test-retest reliability over a three-month interval (.52 to .76) and showed significant correlations with quality of life, anxiety, and depression, with the exception of the Fighting Spirit subscale. However, Some of these researchers have also proposed different factor structures to replace the original one. For instance, Anagnostopoulos et al. (2006) proposed a two-factor structure with adaptive and maladaptive subscales. Ho et al., (2004) suggested combining Fatalism and Fighting Spirit into a Positive attitude subscale.

Application to Cancer Context

The Mini-MAC provides valuable insights into coping and adjustment responses to cancer. It has been widely used across various cancer types, including breast, ovarian, stomach, colorectal, and more (Czerw et al., 2016; Kulpa et al., 2014; Pereria et al., 2014; Sowa et al., 2018). It has been adapted in numerous languages, including Portuguese (Pinto Pereira & Vilaca de Brito Santos, 2014), Arabic (El Amine Ragala et al., 2021), Greek (Anagnostopoulos et al., 2006), Spanish (Vaillo et al., 2018), Persian (Patoo et al., 2015), Chinese (Ho et al., 2004), Italian (Grassi et al., 2005), Korean (Kang et al., 2008), among others (Vaillo et al., 2018). Given the different understanding of cancer and the variation in factor structure of this scale across cultures, ongoing psychometric validation remains necessary.

Acceptance of Illness Scale

Measurement Properties

The Acceptance of Illness Scale (AIS), developed by Felton et al. (1984), is another commonly used acceptance measure in cancer research. It consists of eight questions designed to assess acceptance of any illness, with a focus on the negative aspects such as functional limitations, dependency, poor self-esteem, and lower self-sufficiency. The scale does not include subscales and measures non-acceptance of disability. Items were drawn from Linkowski’s (1971) Acceptance of Disability Scale and are rated on a 5-point Likert scale from 1 (“Strongly agree”) to 5 (“Strongly disagree”), with higher scores indicating lower levels of acceptance. Examples of items include “I have problems with adapting to limitations imposed by my illness” and “My illness makes me sometimes feel unwanted.”

Psychometric Properties

In earlier studies, the AIS demonstrated strong reliability, with Cronbach’s alphas ranging from .81 to .83 and a test-retest reliability of .69, in middle-aged and older adults with cancer (Felton et al., 1984; Felton & Revenson, 1984). A Chinese version of AIS validated in 2018 yielded a three-factor structure and showed good internal consistency (α = .754) and good content validity of .925 (Zhao, 2018). Additionally, Leong et al. (2021) translated and validated the AIS for a Malaysian oncology population, also reporting good internal consistency (α = .84). The test-retest reliability with a two-week interval was significant and notably strong, with a correlation of 0.94 (p < .001).

Application to Cancer Context

In cancer research, the AIS provides the opportunity to explore the relationship between acceptance and a wide variety of psychosocial outcomes. It has been widely used among different cancer populations, such as women with breast cancer (Carver et al., 1999; Ośmiałowska et al., 2022), patients with gastrointestinal cancers (Czerw et al., 2020), and people who had pancreatic cancer surgery (Martin et al., 2023). The AIS has been translated and adapted to multiple languages. Cancer researchers in China (Han et al., 2018), Poland (Czerw et al., 2020), and Turkey (Uslu-Sahan & Gulcan, 2023), have used this scale to conduct psychosocial studies.

Limitations of Current Acceptance Measures in Cancer Research

The Mini-MAC and AIS have both contributed to the knowledge base of cancer acceptance. However, these measures need to be critically examined to ensure they reflect the needs and experiences of cancer survivors and are held in the spirit which measures the construct without bias or priming. One concern with the Mini-MAC is its utility across languages and cultures, as it has been shown to demonstrate varying factor structures across such differences (Hulbert-Williams et al., 2012). The different factors may be indicative of differences in cultural understandings and reactions to cancer. Language around cancer, even in the U.S., has changed drastically in the past century (Schattner, 2023). Around the world, cancer is understood and talked about differently and, thus, the adjustment styles of the Mini-MAC must be adapted to the cultural context in which research is conducted. Furthermore, the scale’s terminology, particularly “fighting spirit,” aligns with the “battle language” around cancer prevalent in the US, which may not resonate with all individuals or cultural contexts (Mayer et al., 2017). The very term “fighting spirit” frames cancer as a “battle” and implies that there are winners and losers in the “war on cancer.” This language could influence responses and skew results, especially since “fighting spirit” is the only positively connoted adjustment style (Hauser & Schwarz, 2015; Hendricks et al., 2018).

Regarding concerns about whether a measure assesses a construct without bias, there are concerns around the priming nature of the AIS. Namely, all items in the AIS are negatively framed, reflecting the conceptual framework of stress and coping. Examples include statements like “I have problems with adjustment to the limitations imposed by the illness” and “Due to the disease I am a burden on my family and friends.” The language of the AIS may prime individuals to perceive their illness as intrusive, burdensome, limiting, and capable of erasing worth which contrasts with strength-based approaches to acceptance. This critique reflects the present authors’ analysis of the AIS item structure, as the uniformly negative phrasing may inadvertently bias respondents toward problem-focused interpretations of their illness.

Acceptance Measures Used in Rehabilitation Research

Although the acceptance measures mentioned above are used in cancer research, their utility is compromised. To better reflect the uncertainty of cancer and its varying cultural understandings, there is a need for measures that can hold varying truths about the experience of cancer acceptance without leading respondents’ one way or another. Together with the concerns regarding the application to other languages and cultures and bias towards a deficit-oriented approach, the authors present existing acceptance measures commonly used in rehabilitation research with general disability populations and their applicability in cancer research. See Table 1 for a summary of these instruments.

Acceptance of Disability Scale/Adaptation to Disability Scale-Revised

Measurement Properties

Linkowski (1971) developed the Acceptance of Disability Scale (ADS) based on the value change theory of Dembo et al. (1956) and Wright (1983). The 50-item scale assesses four dimensions of value change: (1) enlargement of the scope of values, (2) subordination of the physique, (3) containment of effort, and (4) transformation of comparative values to asset values (Groomes & Linkowski, 2007). It uses a 6-point Likert-type scale, with higher scores indicating greater acceptance of disability (AOD). Some items are reverse-scored, and the total ADS score reflects overall acceptance.

In 2007, Groomes and Linkowski revised the scale to modernize its language and address psychometric concerns raised by Keany and Glueckauf (1999) and renamed the scale as the Adaptation to Disability Scale-Revised (ADS-R). The revision reduced the scale to 32 items while retaining the original four-factor structure: Transformation, Enlargement, Containment, and Subordination.

Psychometric Properties

Linkowski (1971) reported that factor analysis suggested the four subscales measure a unidimensional construct. The original ADS demonstrated high concurrent validity with the Attitudes Toward Disabled Persons Scale (r = .81; Yuker et al., 1960) and good split-half reliability (.92). However, beyond the initial study, psychometric validation of the original ADS is limited.

Groomes and Linkowski (2007) maintained the original four-factor structure in the ADS-R while reducing it to 32 items. Groomes and Linkowski (2007) reported excellent internal consistency, with a Cronbach’s alpha of .93 for the full scale and .71 to .90 for the subscales. Unlike the original ADS, the ADS-R has been psychometrically validated across various populations. For instance, Lin et al. (2013) validated an abbreviated version of the ADS-R on individuals with spinal cord injury in Taiwan, confirming a four-factor structure and demonstrating good internal consistency (.71 to .88). It also showed significant correlations with functional independence (r = .25 to .35) and life satisfaction (r = .34 to .37), indicating concurrent validity.

Commentary

The items’ language reflects the theoretical underpinnings of the ADS-R within value change theory (Wright, 1983). The Transformation, Containment, and Subordination subscales point to a preoccupation with physicality, limitations, and perceived worth. The subscales questions each have negative connotations, which make up over two-thirds of the revised measure. Examples that are emblematic of items in the Subordination subscale include “You need a good and whole body to have a good mind” and “Physical wholeness and appearance make a person who s/he is.” Examples that are emblematic for the Containment subscale are “My disability in itself affects me more than any other characteristic about me” and “When I think of my disability, it makes me so sad and upset that I am unable to do anything else”. Examples from the Transformation subscale are “Having my disability, I am unable to do things like people without disabilities do” and “Because of my disability other people’s lives have more meaning than my own” (Groomes & Linkowski, 2007). The Enlargement subscale items are sprinkled throughout the scale to, perhaps, undercut some of the negative connotation. Examples of items from the Enlargement scale include, “There are many things a person with my disability is able to do” and “There are many more important things in life than physical ability and appearance.”

The scale ends on a positive question, which is important; the tool allows the final impression of disability as something that matters but does not limit active engagement in life. This result is especially true for the unique challenges faced by cancer population. Cancer survivors’ active engagement in life facilitates the value shift to no longer centralize cancer because they integrate the cancer into their identity (Drury et al., 2017; Ore & Foli, 2020). There is life and acceptance of the experience of cancer in survivorship, which creates a sense of optimism and hope for the future. This strengths-focused view is underscored in the measure with its final question. In essence, the measure leaves the individual on a disability-positive note aligning with the strengths-based philosophy of rehabilitation counseling.

Application to Cancer Context

The application of the ADS-R to the study of cancer is relatively new, with emerging research focusing specifically on breast and rectal cancer, predominantly led by researchers in China over the past decade. Zhang et al. (2013) found that acceptance scores of participants with rectal cancer were significantly lower than those with Ehlers-Danlos Syndrome, likely due to the severe physical changes and challenging prognosis associated with the condition. Less than 50% of participants exhibited high acceptance levels, with the Subordination subscale scoring the lowest, possibly due to Chinese cultural norms emphasizing collectivism. In breast cancer research conducted by Zhang et al. (2019), the ADS-R was used to identify psychosocial predictors of disability adjustment, with significant correlations found between acceptance and factors such as social relational quality, age, and coping styles. Breast cancer patients had higher acceptance scores than those with ischemic attacks but lower than those with colorectal cancer. Both studies underscore the sensitivity of acceptance as a construct to cultural environments, where social perceptions may impede the acceptance process.

Reaction to Impairment and Disability Inventory

Measurement Properties

The Reaction to Impairment and Disability Inventory (RIDI), developed by Livneh and Antonak (1990), reflects the stage model of disability. Kubler-Ross’ (1969) stages–denial, anger, bargaining, depression, and acceptance– are mirrored in the RIDI. Like Kubler-Ross’ model, Livneh and Antonak’s stage model reflects the reactions that occur in response to the onset of CID: shock, anxiety, denial, depression, internalized anger, externalized hostility, acknowledgement, and adjustment (Livneh & Antonak, 1990). The stages were operationalized by the eight subscales for the RIDI. The RIDI is a multidimensional scale designed to capture different levels of reaction to disability, with acceptance being measured with a combination of the seventh and eighth subscales (acknowledgement and adjustment; Livneh & Antonak, 1990).

Psychometric Properties

The designers of the sixty-item scale reported that the scales have “good item properties, are easy to administer and score, are reliable, and have adequate construct validity” (Antonak & Livneh, 1995, p.1,101). Thus, each of the items in their respective subscale are unique and do not apply to other scales. Additionally, the developers of the RIDI used factor analysis to establish construct validity: Cronbach alphas ranged from .63 to .89 and .70 to .92; inter-item correlations were low (.15–.36), and mean inter-items were .48 to .49. Using Linkowski’s (1971) Acceptance of Disability Scale, criterion validity was evaluated using the acknowledgement and adjustment subscales and an r = .68 was found (Livneh & Antonak, 1997).

Commentary

The language of the RIDI items also reflects a strengths-based philosophy that may also point to the influence of Beatrice Wright’s (1983) definition of acceptance. Item examples from the acknowledgement and adjustment subscales tend to acknowledge limitations, but also strengths. Examples from the acknowledgment subscale are: “I am interested in getting socially involved with other people” and “I know my limitations and have learned how to deal with them.” Examples from the adjustment subscale are “Although, I am restricted in certain ways, there is still much I am able to do” and “Everything in my life is coming together again” (Livneh & Antonak, 1990).

While the original intent of the creators was to recognize the fluid nature of acceptance and that people with CID can and do move between stages, jump stages, and cycle and repeat stages, many people interpret the stage model as linear. Thus, simply because an individual scores high on one or two stages (e.g., internalized anger and externalized hostility), it does not necessarily imply that said person will “move on” to the “next” stages of acknowledgement and acceptance. It is important to understand the fluid nature of such stages.

Application to Cancer Context

While the RIDI was originally created using a heterogeneous population of people with CID, including those with cancer, use of the RIDI in cancer populations is limited. One example comes from Fry (2023), who used the RIDI to explore psychosocial adaptation among cancer survivors and its influence on satisfaction with labor market participation. Another study, based in China, validated the RIDI for individuals with physical disabilities, including a small number of people with cancer (Siu et al., 2022). Out of the 224-sample population with various disabilities, 15% were noted as having cancer. The validation study found satisfactory to good internal consistency for the RIDI subscales. The subscales were significantly positively correlated to resilience and mental well-being, which provided support for convergent validity. Criterion-related validity was supported through significant negative relationships between the adjustment subscale and measures of symptomatology and illness.

Multidimensional Acceptance of Loss Scale

Measurement Properties

The Multidimensional Acceptance of Loss Scale (MALS) is also founded on Beatrice Wright’s (1983) definition of disability acceptance. Ferrin et al. (2011) developed the scale to address the shortcomings in the ADS. As noted previously, the ADS lacked psychometric evidence and received criticism that the global scale does not systematically measure the four value changes. Ferrin et al. noted the importance of Wright’s coping and succumbing paradigm on rehabilitation counseling philosophy and the general understanding that acceptance is tied to adaptation. Thus, Ferrin et al. (2011) decided to create a new measure that, in their view, would be more empirically sound. Wright and a panel of experts reviewed the initial item pool and requested six to be deleted and several to be reworded. The MALS is a 60-item scale with four subscales, reflecting the four value changes from Wright’s framework. Items use a 4-point Likert-type scale with anchors from 1 (“Strongly disagree”) to 4 (“Strongly agree”). Some items are reverse scaled. Items for each scale are summed, providing a scale score, with higher scores indicating higher acceptance of loss. Ferrin et al. found three clusters of types of respondents: high, medium, and low disability acceptance styles.

Psychometric Properties

The subscales of the MALS (subordinating the value of physical abilities to other values, expanding the range of values, transforming values from comparative to asset, and containing the effects of disability) were found to have a high internal consistency reliability (Cronbach’s alphas ranged from .80 to .88) and good construct validity (Ferrin et al., 2011).

Commentary

Like the language of the ADS-R, the sixty-item MALS uses items with negative connotations for two of its subscales (Enlarging the scope of values and Transforming) with Transforming having a mixture of positive and negative items. Examples of items from the Enlarging subscale are: “I think a lot about what I have lost because of my disability” and “When comparing myself to other people, I perceive I am not as good as them.” Examples of Transformation subscale items are “Because of the disability, everything about me is subaverage,” and “I can still be a responsible member of the community” (Ferrin et al., 2011). The mixture of items with negative and positive connotations reflects the value change theory and acknowledges that reactions to loss can be complex.

Application to Cancer Context

The MALS is perhaps the least-used scale of those reviewed. Much of the literature using the MALS is on spinal cord injury, which makes sense given its allegiance to Wright’s Coping vs. Succumbing model (Wright, 1983) that focused on physical disabilities (Aaby et al., 2021; Ferrin et al., 2011). While there would need to be psychometric validation for the cancer survivor population, the MALS holds promise to investigate the fit of Wright’s model in the cancer context. Having a strong theoretical understanding tied to this measure provides avenues of intervention, support, and understanding of where an individual is on their acceptance journey.

Discussion

Acceptance is a construct that has long been studied in the rehabilitation field. However, the absence of rehabilitation researchers in cancer acceptance literature reveals a significant oversight. While some acceptance of CID measurement tools grounded in psychosocial adaptation frameworks that emerged from rehabilitation counseling and rehabilitation psychology have only begun to be utilized in the cancer acceptance realm (e.g., ADS-R), there is a lack of measures from a rehabilitation counseling perspective that have been developed or used with the cancer population. This oversight limits the field’s ability to provide strength-based, holistic support to cancer survivors.

Most of the widely used measures in cancer research, such as the AIS and the Mini-MAC, were developed in fields outside of rehabilitation counseling (clinical psychology and medicine, respectively). As such, these tools reflect a predominantly medical model of CID that is pathology-oriented in nature. The language used in the scales is an extension of this pathological viewpoint and must be addressed. The medical model constrains the understanding of strengths found in loss and adversity and creates a negative and positive polarity out of the complex, multidimensional experience of cancer.

Another consideration in the creation of such measurements is the attention, or lack thereof, to the numerous intersections of social identities that each individual holds. Research that holds multiculturalism and intersectionality as a key component can lead to best practices to support those who have historically been marginalized in clinical practice settings and research.

Language

The language used in acceptance measurements reflects the theoretical models on which they are based. In the case of medicine and clinical psychology, the medical model has been and continues to be a widely used approach to understanding CID, which emphasizes pathology, deficit, and dysfunction. This model is oriented to what is “wrong” or “lacking” in a person’s life rather than originating out of a strengths-based philosophical tradition, such as the field of rehabilitation counseling. As reviewed, many of the items used in measuring acceptance of cancer, and even the order in which the items are presented, could prime or bias the individual to fixate on the negative. Importantly, the strengths-based approach does not attempt to ignore or minimize the negative impact of cancer, which many people do experience; rather, it recognizes that there can be growth alongside the negative aspects of a cancer diagnosis.

Understanding of acceptance in the disability and rehabilitation literature is still developing to account for the complexity and diversity of experiences that people with CID may experience. For example, there is still discussion as to whether acceptance is a single moment in time or an ongoing process. Groomes and Linkowski (2007) acknowledged the advancement of our understanding of acceptance with a name change of their scale from “Acceptance of Disability” to “Adaptation of Disability-Revised” (ADS-R). This change reflected a shift in understanding that successful adaptation does not necessarily require acceptance. Furthermore, Groomes and Linkowski posited that adaptation does not necessarily imply an active choice, but acceptance does. Researchers must continue to develop and refine understanding of acceptance with engagement from CID communities, including cancer survivors. It is critical that counselors continue to seek professional development activities around acceptance as the field progresses, so they develop a current and accurate approach supported by the evidence.

Multicultural Considerations

Aside from the Mini-MAC, which has been translated into many languages and psychometrically validated for diverse cultures internationally, many of the measurements and psychometric validation data have been on primarily White samples (Hulbert-Williams et al., 2012). The focus for many research teams is on the specific type of cancer (e.g., breast cancer). While some cancers are more common in certain populations than others (e.g., breast cancer in people assigned female at birth or leukemia in children), leading to samples needing to reflect the specific cancer demographics rather than demographics, there remains a need for greater understanding of psychosocial outcomes, including acceptance of cancer, in minoritized groups. People’s experiences of acceptance are shaped by the intersections of race, gender, class, and other identities. Damaskos et al. (2018) concluded that health care practices “overlook the many overlapping racial, socioeconomic, sexual and gender issues that comprise an individual’s identity” (p.31). Existing acceptance measures often fail to capture these culturally nuanced experiences, as they are typically developed and validated with predominantly White, Western samples. The use of uniform, decontextualized items may miss key cultural values (e.g., collectivism, spiritual coping) or assumptions (e.g., the importance of the role of family in decision-making) that influence how individuals come to terms with their cancer diagnosis. Acceptance research, like health care practices, needs to consider the interaction between identities and the implications for individuals’ adaptation to and acceptance of cancer.

Work and Cancer Acceptance

Work is one of the many life domains that are impacted by a cancer diagnosis. A significant number of people diagnosed with cancer are in their prime working years (45% between the ages of 20 and 64; Howlader et al., 2019). Breaks from work due to cancer and its treatment are common, and returning to work is a well-researched area in cancer literature. Many barriers have been associated with the return-to-work process, including health-related quality of life, cancer-related fatigue, cognitive dysfunction, and depression and anxiety (Ahn et al., 2009; Johnsson et al., 2011; Sun et al., 2017). Acceptance of disability has been found to be associated with higher levels of quality of life (Elfström et al., 2005) and lower levels of depression (Kennedy et al., 2000) and anxiety (Kennedy et al., 2012).

Implications

This review highlights the need for further rehabilitation attention to the language of acceptance measurements, the populations with whom they are validated, and the extent to which they reflect work-related outcomes. Although existing research has linked acceptance to quality of life, there is a need for more studies examining the relationship between cancer acceptance and work-related outcomes, such as job satisfaction and return-to-work readiness.

Regarding teaching and practice, the field of rehabilitation counseling needs to prepare counselors-in-training to understand and apply acceptance measures relevant to individuals living with cancer. Cancer is considered a disability under the Americans with Disabilities Act (1990) and could be the primary diagnosis under which someone receives state vocational rehabilitation services. In this case, rehabilitation counselors must be equipped to assess their psychosocial adaptation and vocational goals using appropriate tools. Training programs should introduce students to commonly used measures, such as the Mini-MAC, AIS, and ADS-R, and encourage critical evaluation of their theoretical underpinnings, language, and cultural relevance. By gaining familiarity with these tools, students will be better prepared to integrate evidence-based assessment into their practice and support cancer survivors in both psychosocial adjustment and vocational goal setting.

Conclusion

Cancer is a major global public health issue and the leading cause of death worldwide (World Health Organization, 2022). Fortunately, cancer survivorship has increased and there is estimated to be 20 million people living with a history of cancer by 2026 (American Cancer Society, 2016). As people transition into survivorship, it is the imperative of rehabilitation professionals to provide support in the adaptation process. To facilitate this process, it is paramount to have appropriate and relevant measurement tools to assess this construct that are congruent with the strengths-based philosophical underpinnings of rehabilitation counseling. Much of the acceptance of cancer research has been realized by fields complementary to rehabilitation. Rehabilitation has a long and rich history of researching and supporting people with CID through the psychosocial adaptation process. It is appropriate that rehabilitation professionals extend this expertise to support those with cancer in the process of acceptance to ultimately improve quality of life.

Acknowledgments

The authors have no acknowledgments.

Funding

Dr. Hannah Fry’s effort on this project was supported, in part, by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,000,000 with 100 percent funding by ACL/HHS (Grant Number 90AREM0008). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by ACL/HHS, or the U.S. Government.

Dr. Constance Richard’s effort on this project was supported, in part, by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $1,000,000 with 100 percent funding by ACL/HHS (Grant Number 90AREM0005). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by ACL/HHS, or the U.S. Government.

Footnotes

Conflict of Interest

The author(s) declared no conflicts of interest with respect to the research, authorship, and/or publication of this article.

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