Cancer Survival and the Tyranny of Positivity
By Jeff Tirengel, Psy.D., MPH
I was diagnosed and hospitalized with an aggressive form of lymphoma, a type of blood cancer, in December 2009. While still in the hospital, I began to hear from family members, friends, and colleagues, including fellow psychologists, that I was the kind of individual who was likely to do well under these circumstances. After all, they said, you are generally a positive and optimistic person, and you have the fighting spirit that characterizes those who are most resilient when dealing with cancer.
Although I fully understood that these messages were intended to be caring and supportive, it was clear to me immediately that they reflected a particular cultural viewpoint, “the triumph of character and attitude over biology” (Coyne and Tennen, 2010, p.17). As I continued to hear similar sentiments expressed by physicians, nurses, and even other cancer patients, I began to sense the shadow side of these same messages, i.e., they discouraged open communication about the uncertainty, distress, and pessimism that were part of my actual mix of thoughts and feelings. I also wondered whether others might blame me for not being positive enough, or as psychologically resilient as they had believed me to be, if the cancer eluded effective treatment.
As a psychologist with a prior degree in public health and 20-plus years of professional experience at Cedars-Sinai Medical Center’s Preventive and Rehabilitative Cardiac Center, I have had a career-long interest in health psychology and its commitment to understanding “how people stay healthy, why they become ill, and how they respond when they do get ill” (Taylor, 2009, p.3). I knew that there had been many studies related to how health might be affected by “positive” dimensions of experience such as hope, gratitude, and spirituality, as well as “negative” dimensions such as anger, stress, and fear. In the aftermath of my own diagnosis, however, I realized that I knew relatively little about these studies as they pertained to cancer and specifically to cancer survival. What I discovered when I reviewed the literature on this topic surprised me.
Although I had anticipated that the research findings might be inconclusive, the spirited level of debate among serious-minded health psychology researchers exceeded my expectations. A series of thoughtful and thought-provoking “pro” and “con” articles evaluating the health implications of positive psychology appeared in the Annals of Behavioral Medicine in 2010 and exemplifies the passion evoked by this topic. The papers stem from a debate first conducted at an annual meeting of the Society of Behavioral Medicine (SBM), sponsored by the SBM Cancer Special Interest Group, and highlight recent advances in our understanding of the health implications of positive psychology as well as some of the limitations and problems associated with this line of inquiry.
The titles of the articles themselves are indicative of the current level of controversy. For example, a “pro” article entitled, “The Value of Positive Psychology for Health Psychology: Progress and Pitfalls in Examining the Relation of Positive Phenomena to Health” (Aspinwall and Tedeschi, 2010) is followed by one from the “con” perspective focused in part on the relationship of positive factors to cancer incidence, survival time, and mortality. The latter article has a more provocative title: “Positive Psychology in Cancer Care: Bad Science, Exaggerated Claims, and Unproven Medicine” (Coyne and Tennen, 2010). The authors of the initial “pro” article respond; they agree that many significant issues remain unresolved, but claim “it is premature to dismiss optimism and other positive phenomena as potentially important predictors of health outcomes” (Aspinwall and Tedeschi, 2010, p.27). Rather, they suggest, we should build on promising lines of scientific evidence related to positive phenomena to help cancer patients now, arguing that “we do not always have to understand the exact mechanisms before moving forward or using an approach that improves health or well-being” (p.33).
This, in turn, leads to a final “con” response with yet another provocative title: “Positive Psychology in Cancer Care: A Story Line Resistant to Evidence” (Coyne, Tennen, and Ranchor, 2010). The authors’ conclusions about the research findings to date include this: “If appeals to scientific evidence are to continue to be made, it is high time that there be wider acknowledgement of (a) the lack of evidence connecting positive psychological states to the biology of cancer, (b) acknowledgment of the consistent evidence that psychological interventions do not prolong survival, and (c) that any causal links remain to be established between the parameters of immune function studied in relation to positive psychological states and psychological interventions” (Coyne, Tennen, and Ranchor, 2010, p.40). The authors add that, relative to other chronic diseases, the evidence is weakest for any link between positive psychological factors and biological markers of cancer. For now, at least, even the authors of the “pro” articles appear to agree with these conclusions (or are unable to refute them) as they pertain to individuals diagnosed with cancer.
There is also fundamental agreement in the professional literature about the dangers of promoting positive thoughts, feelings, and expectations as ways to prevent or manage serious illness. Specifically, there is concern about the “seemingly relentless emphasis on mandating optimism, individual happiness, and personal growth no matter the circumstances,” and a related concern that “the general public may come to believe that one can conquer cancer by thinking positively and that if one is not getting a good response, one is not thinking positively enough, not laughing enough, or not being spiritual enough. Indeed, the explicit blame of people with serious illness for their failure to cure themselves in best-selling popular treatments of positive thinking is shocking and reprehensible” (Aspinwall and Tedeschi, 2010, p.10).
In Bright-Sided: How Positive Thinking is Undermining America, writer Barbara Ehrenreich comments on another significant problem that arises from a focus on the psychological disposition of the individual cancer patient: “This focus shifts attention from the larger social, political, and economic forces behind poor health care, poverty, (and) unemployment.” It also shifts attention away from other social injustices that increase cancer-related mortality and morbidity in population subgroups. As one contributor to the literature on theory, measurement, and controversy in health psychology and cancer has concluded, “comprehensive theory and measurement will need to address the social context within which positive adaptation to cancer may arise…Ultimately, interventions will need to address multi-level approaches, from the policy to the biology” (Gorin, 2010). I would add that it will be important to tailor these future interventions with cultural differences in mind.
My conclusion from my own experience with cancer and the tyranny of positivity is similar to a perspective that I have heard expressed by others, including Ehrenreich, who has herself been an oncology patient: Somewhere between “positive thinking and feeling” and “negative thinking and feeling,” there is space available for “realistic thinking and feeling.” In this “realistic” space, there is room for optimism and pessimism, hope and despair, gratitude and anger, courage and fear, gain and loss, certainty and uncertainty, etc. As I suspected when I was first diagnosed, the most evidence-based practice for supporting family members, friends, and colleagues with cancer is to allow them to express a full range of thoughts and feelings rather than require them, explicitly or implicitly, to be positive, deny their distress, or engage in particular behaviors for which there is no empirical evidence.
Jeff Tirengel, Psy.D., MPH, is a Professor at the California School of Professional Psychology at Alliant International University-Los Angeles Campus. He also directs psychological services for the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Medical Center.
Aspinwall, L.G., and Tedeschi, R.G. (2010). The value of positive psychology for health psychology: Progress and pitfalls in examining the relation of positive phenomena to health. Annals of Behavioral Medicine, (39), 4-15.
Aspinwall, L.G., and Tedeschi, L.G. (2010). Of babies and bathwater: A reply to Coyne and Tennen’s views on positive psychology and health. Annals of Behavioral Medicine, (39),27-34.
Coyne, J.C., and Tennen, H. (2010). Positive psychology in cancer care: Bad science, exaggerated claims, and unproven medicine. Annals of Behavioral Medicine, (39), 16-26.
Coyne, J.C., Tennen, H., and Ranchor, A.V. (2010). Positive psychology in cancer care: A story line resistant to evidence. Annals of Behavioral Medicine, (39), 35-42.
Ehrenreich, B. (2009). Bright-Sided: How positive thinking is undermining America. New York: Henry Holt and Company.
Gorin, S.G (2010). Theory, measurement, and controversy in positive psychology, health psychology, and cancer: Basics and next steps. Annals of Behavioral Medicine, (39), 43-47.
Taylor, S.E. (2009). Health psychology. (7 ed.). New York: McGraw-Hill.
The Los Angeles Psychologist – www.lapsych.org – reprinted with permission.