Live each day, each second, each morsel, to the fullest. Do what you want to do. What a gift, at twenty-nine, to have had to face myself and ask: What do you regret, now that your life may be over? I live now in a manner that will allow me to answer the same question-at forty-nine, sixty-nine, eighty-nine, whatever age – “Nothing!” I’ll tell you the honest truth: I would not undo this gift of perspective, even to have my breast back. I know, now, what is important and what is not. – Tanya.
There is something powerful about this statement that reminds me that out of the most difficult experiences comes transformation, growth, strength and benefits. Throughout the years, I have had patients talk to me about their experiences with cancer and how it has changed them in a positive way. For many years clinicians have observed and accepted this notion, but research psychologists are now more seriously exploring this concept. In professional literature it is often called “posttraumatic growth” (PTG) or benefit finding. Patients sometimes use the words “blessings” or “gifts of cancer.” While early research relied on patients’ general reports of these experiences, more interest in this area has generated assessment tools that standardize the evaluation of the concept and allow researchers to understand more specific aspects of it. There is a growing body of literature documenting the frequency of occurrence and the parameters by which it can be categorized. Much of the early research involves the largest survivorship population, women with breast cancer. It is estimated that 53% to 83% of women reported that their lives had changed in positive ways after their breast cancer diagnosis. Research with other populations of patients with cancers (e.g., colon, lung, prostate, melanoma, testicular, etc.) has shown similar benefits to traumatic events associated with the disease and treatments. Men and women alike seem to have the same probability of developing PTG.
The concept of PTG (post-traumatic growth) is not new. It has been studied with many groups of people who have endured traumatic events – victims of terrorist attacks, natural disasters and sexual assault, veterans of combat, caregivers and the bereaved. However, its application to personal medical illness, and particularly to understanding the cancer experience, has been more recent. Researchers presume that PTG follows an initial period of turmoil and distress as patients and family members adjust to the impact of cancer on their daily life. Over time, however, many individuals develop a growing sense of enrichment and satisfaction that appears to exceed prior levels.
There is a growing consensus from the literature that there are some specific domains of life that seem to be enhanced by the experience of cancer. The most commonly reported benefit is that interpersonal relationships are perceived as being enriched after the experience. For example, patients report that their relationships with friends and family are stronger or they feel more connected emotionally with a greater feeling of closeness. Improvements in the quality of marital relationships are also common as well as an awareness of one’s importance to others. The literature has also documented increased feelings of compassion for others and noted that compassion is more deeply felt.
Patients often report that the cancer experience brings a renewed appreciation for life. Tanya, as noted in the quote above, expresses how she feels different after her cancer experience and shares that she has gained a new perspective or outlook on life. Many patients report these shifts in perspective as a result of their cancer experience and feel that they have a new set of priorities or changes in their goals. The shift can include a variety of changes related to work life, school, family life and how they relate to themselves. Many feel that they have grown stronger and that this process has also given them new resources and skills to tackle life’s problems. As a result they feel more competent. My patients and the research in this area documents that many individuals feel empowered to make changes.
Patients also note that they frequently feel a greater connection to their spiritual selves. For some, it may be a return to previously held religious beliefs or practices. For others it is not in relation to a specific religious practice or belief, but may be internally oriented in terms of their own path in the world. Also, cancer can make individuals more conscious of their health and promote changes in their lifestyle, such as an increased attention to and awareness about cancer screening, diet or lifestyle―all of which can bring a sense of benefit and growth.
These findings suggest that the cancer experience is a powerful one. It challenges the psychological, physical and spiritual self, and it creates opportunities for change. There is some evidence to suggest that the level of trauma that an individual experiences must be great enough to create a perception of threat in order to produce a PTG experience. It may be that as the level of challenge increases for the person, they are more likely to be forced to review their experiences and search for meaning in them. However, there is also some evidence that if the threat becomes too great, the ability to find benefit may be diminished.
The research on PTG moves away from the perspective that trauma only creates stress and negative effects for the individual. It raises questions for individuals about how they cope with the experiences of cancer and what they want in their future. While the literature on PTG is still in its infancy, there are some interesting findings related to coping. A finding that has been reproduced over several studies is that individuals who use coping strategies that engage them with the stressful event and involve problem-solving are more likely to develop PTG. Similarly, patients who actively accept the cancer trauma and utilize cognitive styles that help them re-appraise the cancer experience are more likely to develop PTG. In addition, active involvement with spiritual coping strategies can be associated with the facilitation of PTG.
The studies that look at coping and the relationship to PTG raise interesting questions. Can you influence your experience of cancer and structure it in such a way as to create greater personal growth? It may be worth pondering, but only with a significant cautionary note; we must not expect that everyone will develop PTG. Further, I would like to remember that we must be careful not to hold this as a criterion or definition of “good coping” or a marker of a “successful cancer experience.” This would be a disservice to the many individuals who do not experience PTG and yet are actively coping with their illness. The expectation could backfire and create unnecessary and unwarranted pressure. I have had patients tell me that they were told there would be a silver lining to their cancer experience and later felt disappointed that they had not found it. It is also important to recognize that people experience fluctuations in the cancer experience. There may be difficult times, but it does not necessarily take away from the benefits that may have been experienced previously. Finally, I would like to note that PTG does not equal having a “positive attitude” about cancer either. In fact, I would argue that having a positive attitude is less relevant than experiencing your true feelings, positive and negative. If these experiences could be understood or interpreted into strengths and or benefits, this would be an additional plus. Allowing real feelings to surface is, by definition, actively engaging with the stressor.
The above cautions noted, I still believe that structuring the cancer experience to create personal growth is a concept that has merit. I believe it is possible to shape your coping strategies and possibly the cancer experience. Below are some suggestions that may be helpful for patients and family members dealing with cancer.
- Know that it is possible to come through the cancer experience with some changes that may reflect benefits or greater satisfactions. The degree will vary for each individual and family.
- Throughout the experience look for opportunities to identify benefits, no matter how small they might seem at the time. Consider keeping a journal of these benefits as they come. It may be helpful to be able to remind yourself of these experiences as time passes or in difficult times. As an example, one patient told me that her daughter took her to her chemotherapy appointments and they sorted through old pictures while she received her infusion. This led to some warm memories and good experiences in the face of the trauma of cancer.
- Write about your experiences and thoughts. Allow yourself time to process your experiences through the written word. These writings can be unstructured entries in a journal about any feelings along the way. If you prefer to have more structure, think about writing about different emotions, possibly using a stem such as “I was so ___________ (fill in the emotion– e.g., angry, upset, exuberant, thankful) because ____________.” Allow yourself to write down your hurts and sorrows as well as your joys.
- Allow yourself to talk to others who also are undergoing cancer events. Sometimes saying things out loud in a support group, as an example, can help you unburden and may also bring insights. In addition, hearing how others process and manage similar experiences can be reinforcing and enlightening.
- Many individuals find that meditation can be a useful tool to increase awareness of experiences and to find increased connection to their spiritual life. Prayer may be another source of a meditative experience and can enhance your connections to spirituality.
- Share your experiences with family and friends who you feel are interested and want to engage in a dialogue with you about your experiences. Sometimes opening up to those around you leads to a greater depth of experience and can help enhance your connection to others. They may express their deeper feelings for you and in the process you may have the opportunity to know how much they care for you.
- Engage in activities that help to mitigate stress. Participate in mind/body workshops or trainings that teach relaxation skills such as those offered here in the Center. Learning how to use guided imagery or mindful meditation practices can help you to reduce your stress and increase your ability to manage difficult events.
- Look for ways to alter your lifestyle or well-being through practices such as exercise and diet. There is a growing body of literature that suggests that both aerobic and strength-training exercise helps improve your physical and psychological quality of life.
I know that cancer creates a variety of stresses, losses and traumas for different individuals. One should not ignore these nor diminish their power, but I do encourage patients and family members to confront them and look for ways to transform them into opportunities for change. These opportunities are all highly individual; there is no clear way to predict your personal journey, which must be respected and honored as your own.
I am reminded by a published poem that describes what cancer can and cannot do. I have had many patients tell me that it is hopeful and inspiring and I have had some patients tell me it was not helpful. I respect these varying opinions, but offer it nonetheless in the hope that more of you will find it more helpful than those who do not.
Cancer is so limited.
It cannot cripple love.
It cannot shatter hope.
It cannot corrode faith.
It cannot eat away peace.
It cannot destroy confidence.
It cannot kill friendship.
It cannot shut out memories.
It cannot silence courage.
It cannot invade the soul.
It cannot reduce eternal life.
It cannot quench the spirit.
— Unknown Author
Anne Coscarelli, Ph.D.
Wallis Annenberg Director’s Initiative in Psychosocial Oncology
© Anne Coscarelli, Ph.D. All rights reserved. 2007.
For reprint authorization, contact SimmsMannCenter@mednet.ucla.edu.