Taking positive changes seriously

Toward a positive psychology of cancer survivorship and resilience

Authors


  • Presented at Cancer Survivorship: Resilience Across the Lifespan, Washington, DC, June 2–4, 2002.

Abstract

It is a common finding that 30–90% of people experiencing serious illness and other forms of adversity report increased quality of life and other positive life changes after their experience, yet there is still considerable disagreement among scientists and practitioners about whether such changes are real or beneficial. The current article identified four pervasive assumptions about positive emotions and beliefs that may limit progress in understanding and promoting resilience among survivors of cancer, namely, that positive beliefs and emotions are absent, dangerous, delusional, or trivial among people managing life-threatening illnesses. A review of evidence on each of these points suggested instead that positive emotions and beliefs seem not only to be associated with good outcomes among people experiencing adversity, but also to play a role in realizing them. Implications for the study of positive beliefs, emotions, and life changes among survivors of cancer and for interventions to promote mental and physical health were discussed. Cancer 2005. © 2005 American Cancer Society.

The study of survivors of cancer and others who have experienced adversity provides an important illustration of both the strengths that people bring to—and seem to develop from—such experiences, and also of the major interpretational questions raised when people experiencing adversity report improved quality of life (QOL) or increased optimism as a result of their experience. The current article briefly evaluates some common life changes and positive beliefs reported after serious illness, identifies four pervasive assumptions about positive emotions and beliefs that may limit our understanding of resilience among survivors of cancer, and describes several studies that suggest that these assumptions may not be valid. Taken together, these studies offer a new perspective on resilience as efforts to maintain positive emotions and beliefs in ways that allow people to learn—and sometimes even to benefit—from adversity.

The current review is consistent with recent calls for a more positive psychology1–3 in which psychologists have questioned the field's relative neglect of positive states and beliefs (e.g., optimism, resilience, human strengths, health) compared with negative ones (e.g., depression, pessimism, vulnerability, illness). A second concern identified by these authors is that even when positive aspects of human functioning are studied, negative motives are frequently ascribed to them, resulting in some fundamental misunderstandings of positive phenomena. The current article evaluates the implications of neglecting or mischaracterizing positive emotions and beliefs for the conduct and interpretation of research on resilience among survivors of cancer, as well as for practitioners seeking to assist survivors of cancer in adjusting to the demands of the illness and its treatment.

UNDERSTANDING LIFE CHANGES AFTER SERIOUS ILLNESS AND OTHER FORMS OF ADVERSITY

It is now a common finding that large proportions of people who have experienced cancer and other life-threatening illnesses appear to find benefit in the experience, reporting such positive outcomes as improved QOL, better interpersonal relationships, and changes in values and priorities (e.g., a greater appreciation of each day, changes in spirituality) as a result of their experience. Such changes have been reported by 30–90% of most samples studied across a wide range of adverse events and have been variously termed cognitive adaptation,4 personal or posttraumatic growth,5, 6 positive illusions,7 thriving,8 and benefit finding.9

As intriguing and encouraging as these reports of positive life changes are, researchers and practitioners have not always accepted them at face value. Instead, some have suggested that perceptions of benefit from adversity, along with other positive emotions and beliefs, will ultimately be harmful because positive thoughts and feelings indicate that people do not understand the gravity of their situation. The assumptions underlying such concerns seem to fall into four groups. The first is that when negative emotions are expected, as in the case of serious illness, positive emotions should be absent, and if present, are either inappropriate or a sign of illness. As we will discuss, such assumptions have led to the omission of questions about positive aspects of functioning from many studies. The second assumption is that the presence of positive beliefs, such as optimism, among people managing serious illnesses leads people to ignore negative realities or is itself an indicator that people do not fully understand the gravity of their situation. A third, related assumption is that positive beliefs and emotions will make people see their situations and their options as more favorable than they really are, leading to risky decision making and the failure to make necessary changes in their lives in light of their illness. A fourth assumption is that positive emotions and beliefs may be pleasant, but their effects are either short-lived or trivial, and thus neither worthy of scientific study nor relevant to clinical practice.

It should be noted that assumptions regarding the deleterious effect of positive emotions and beliefs on people's effective negotiation of reality are far from unique to the literature on adaptation to serious illness, as they appear frequently in the broader literature on positive emotions, positive beliefs, and mental health (for discussion, see Aspinwall,10 Aspinwall and Brunhart,11 Colvin and Block,12 Isen,13 and Taylor and Brown14, 15). In the following sections, we will consider evidence that challenges the validity of such assumptions and suggests that positive thoughts and feelings play a beneficial role in adaptation to serious illness and other kinds of adversity. In doing so, we will consider several different kinds of evidence, including experiments on the effects of positive emotions and beliefs, and survey and interview studies of people managing cancer. Where relevant, we will consider studies of people managing other serious illnesses and other kinds of adversity, such as bereavement. In drawing on this more general literature regarding adjustment to negative life events, we do not mean to suggest that all kinds of illness and adversity pose the same challenges, but rather that information gained from the careful study of people managing one kind of adversity may well be informative for understanding adaptation to other kinds of adversity.

Assumption 1. Positive Emotions after Adversity Are Absent (or Inappropriate or Pathologic)

Early attempts to study positive emotions and beliefs among people managing serious illness and other kinds of adversity met with considerable resistance, in part because of ethical concerns that asking people questions about positive aspects of their situation would be offensive or insensitive and in part because of assumptions that people going through such hardships could not possibly have any positive thoughts or feelings to report. Wortman and Silver16 describe great difficulty in convincing hospital personnel and study interviewers to ask basic questions about positive emotional experience in Silver's17 landmark study of young adults recently disabled by spinal cord injuries. That study found that within 3 weeks of their injuries, newly disabled young adults were reporting positive emotions (e.g., happiness) at higher levels than negative emotions (e.g., anxiety, depression, and anger). By 8 weeks, weekly reports of happiness levels were the same as those of control participants.

Similar findings concerning the presence of positive emotions over a longer time period have been obtained among parents who have lost a child to sudden infant death syndrome16 and among bereaved gay men who had been caregivers to their partners with acquired immunodeficiency syndrome (AIDS).18 In the Folkman study,18 questions about positive experiences and their role in coping with the demands of caregiving were added only after study participants told researchers that they were missing important aspects of their experience by focusing exclusively on negative experiences. After such questions were added, positive events described by respondents as meaningful to their coping efforts were reported in 99.5% of the 1800 subsequent interviews.

These studies clearly suggest that positive emotions and experiences are present among people experiencing severe forms of adversity. It is important to emphasize that positive emotions do not seem to occur at the expense of negative ones. In the studies just described, positive emotions were found to co-occur with elevated levels of negative emotions, such as depressed mood. Studies of life changes reported by survivors of cancer show a similar pattern. For example, in an interview study of patients with diverse types of cancer, most respondents (74%) reported both positive and negative life changes, for example, seeing the self as stronger but also as more vulnerable, with only 20% reporting exclusively positive changes and only 6% reporting exclusively negative changes.19 Reports of both positive and negative life changes were found for all five of the life domains evaluated in the study—views of the self, relationships, activities and priorities, views of the world, and plans for the future.

Such findings suggest two important points about positive emotions among people experiencing adversity. First, the thoughts and feelings of people undergoing severe forms of stress are rarely exclusively positive or exclusively negative. Second, the presence of positive emotions and beliefs after adversity cannot be taken as an indication that people are not confronting or understanding the negative aspects of their situation. Further, with respect to the question of whether the experience of positive emotions among people confronting adversity is pathologic, longitudinal studies of bereavement find no evidence that people who experience positive emotions after a loss subsequently experience greater adaptational problems (e.g., a delayed grief reaction16, 20; see also Bonnano et al.21), and some evidence suggests that early positive reactions are associated with better subsequent adjustment.22

Assumption 2. Positive Beliefs Lead People to Ignore Negative Realities and Thereby Compromise Coping and Adjustment

How are positive beliefs and emotions related to adjustment to cancer and other chronic illnesses? A second common set of assumptions holds that positive beliefs, like optimism (defined here as positive expectations about the future23), should interfere with adjustment to serious illness, because people may maintain positive beliefs by tuning out or distorting negative information. However, prospective survey studies of people adjusting to cancer and other illnesses consistently find that optimism predicts better psychological adjustment over time. For example, among women adjusting to breast cancer surgery, optimism predicted lower levels of psychological distress at the 3, 6, and 12-month follow-ups; greater acceptance of having had the surgery; higher levels of constructive forms of coping, such as positive reframing; and lower levels of denial and disengagement.24 Similarly, in a large-scale study of gay and bisexual men who were human immunodeficiency virus seropositive, those who were optimistic about not developing full-blown AIDS reported greater perceived control over their risk of developing AIDS and greater efforts to maintain their health through diet and exercise.25 In addition, men who were optimistic in general reported fewer intrusive thoughts about AIDS and lower levels of psychological distress than men who were pessimistic.

Although these findings clearly suggest that optimism is associated with good reported adjustment to serious illness, these studies, and indeed all self-report studies of adjustment to illness, are vulnerable to alternative interpretations. For example, it is possible that optimists report better adjustment because of a positivity bias, in that the same things that make one provide positive or favorable responses on an optimism questionnaire also make one provide positive responses on an adjustment inventory. Worse, these findings could be taken as evidence of denial, in that one could argue that the reason optimists report better adjustment and fewer intrusive thoughts about their illnesses is that they do not understand the full extent of their situation and its implications.

Prompted in part by these alternative explanations, the first author and her students undertook a series of controlled studies of the relation of dispositional optimism to attention to negative information. We reasoned that if optimism functioned like denial, optimists would show lower levels of attention to negative information about themselves and their health, especially as the information became more negative and more personally relevant. In all of our studies to date, however, optimism predicted greater attention to negative information, especially as the information became more negative and/or more personally relevant. For example, we found that optimistic college students who were frequent users of vitamins spent more time reading information about the risks of vitamin use (e.g., overdose, masking serious illness) from a computer menu of topics and remembered more of this information at a subsequent testing session than did pessimistic college students.11

We found similar results in a study of attention to information about melanoma risk among young adult women who were frequent sunbathers or users of tanning salons.26 One-half of the participants were randomly assigned to a proximal threat condition (they were told that the average melanoma patient was a 25-yr-old woman) and one-half were assigned to a distal threat condition (participants were told that the average patient was age 55 yrs). We found that optimists in the proximal threat condition were more likely than pessimists to engage in cognitive elaboration of risk information presented via computer. That is, during a stimulated recall interview after their online session in which participants were shown a videotape of their online session and asked to think aloud at various points in the tape, optimists were more likely to discuss the melanoma risk information in ways that indicated that they thought about the risks presented and how they applied to them personally. Of particular interest, these optimistic young women showed no evidence of counterarguing or otherwise downplaying the risk messages. Taken together, these studies are highly inconsistent with the idea that optimism functions like denial, in that optimism was associated with greater attention to and greater veridical (as opposed to defensive) processing of health risk information, especially as the information became more negative or more personally relevant.

We have extended these findings to other positive thoughts and experiences.27 Young women who were frequent caffeine consumers and who were randomly assigned to complete a 3-minute affirmation procedure in which they were asked to recall past acts of kindness to others subsequently engaged in more constructive (i.e., less defensive) processing of information about the link between caffeine consumption and fibrocystic breast disease. This finding is intriguing because it suggests that bringing to mind positive attributes in one domain (kindness) can help people manage negative information in another, unrelated domain (health; see also Sherman et al.28). Similar findings have been reported in experiments in which success on an initial task made participants more willing to evaluate weaknesses or failures on subsequent tasks unrelated to the initial task.29, 30

Researchers have not yet identified the exact mechanism(s) involved, but these studies suggest that positive beliefs and states, far from interfering with the acquisition and understanding of negative information, seem instead to serve as resources that allow people to manage the emotional costs of considering negative information, such as health risks and personal failures.10, 30 In considering the relevance of these findings for survivors of cancer, it is important to acknowledge that studies in which healthy young adults are presented with information about health risks and personal failures are clearly not equivalent to the experiences of patients with cancer or others managing serious adversity. Nonetheless, these results are consistent with those of survey studies of survivors of cancer and others managing serious illness in that they suggest that positive beliefs, experiences, and emotions may help people engage in constructive ways of coping with the task at hand, even when that task involves managing negative information about the self.

Assumption 3. Positive Beliefs and Emotions Lead People to See Things as More Favorable than They Really Are and to Make Poor Decisions

A third common assumption is that positive beliefs and emotions, like the proverbial rose-colored glasses, lead people to see things (decision-making options, life circumstances, future events) as more favorable, feasible, and likely than their situation warrants. If this is the case, people with positive beliefs, for example, should be more likely to take bad risks and more likely to devote effort to projects that are unlikely to succeed. In the case of cancer survivorship, the concern would be that positive beliefs and emotions would lead people to make poor decisions about their illness, its treatment, lifestyle changes, and other issues.

It is noteworthy that in experiments on mood and risk taking, the assumed link between positive mood and risk taking seems to hold true only for risks that are hypothetical. When presented with hypothetical risks, people in a positive mood may take more chances, but when the stakes are real (involving cash, points, or other resources), people in a positive mood become risk averse and more conservative.31 Similarly, studies of coping and problem-solving find that optimists are not more likely to persist on problems that cannot be solved. Instead, they are more likely than pessimists to disengage from unsolvable problems, both in reports of their own coping32 and in controlled experiments of problem-solving.33 In this latter study, optimists disengaged more rapidly from initial problems that could not be solved and went on to solve more subsequent problems correctly within the time limit than did pessimists. These results suggest that positive beliefs and states foster greater selectivity in the allocation of effort to problems, based on whether they are controllable or solvable. Underlying this selectivity may be the ability to recognize that some problems are beyond one's abilities or the resources (e.g., time, energy) available, and to move on to other, more doable tasks (see Aspinwall et al.34 for a discussion).

These studies are suggestive in their implications for understanding resilience among survivors of cancer, as people must often make professional, personal, and other life changes in light of their illness and its demands. Interview data with patients with cancer seem to support this selective application of effort to controllable aspects of their situations. In the Collins et al.19 study described earlier, positive changes outnumbered negative ones in life domains that seemed to be the most amenable to personal control, namely, the priority given to personal relationships and one's choice of daily activities. These findings are noteworthy because they suggest that people may be actively making the best of their situations by creating or perceiving beneficial changes in life domains that are amenable to personal control. Importantly, these findings are also inconsistent with the idea that perceiving positive life changes from serious illness leads people to misapply their coping efforts to situations that are unlikely to improve.

Assumption 4. Positive Beliefs and Emotions Are Pleasant, but Have Few Lasting Effects

The last set of assumptions we wish to address is that positive beliefs and emotions, while pleasant, have effects that are trivial or ephemeral and are thus unworthy of scientific study and irrelevant to clinical practice. The view that positive beliefs and emotions are somehow less important or impactful than negative ones has limited the scientific attention given to them, but this view is changing in light of evidence regarding the effects of positive states on problem-solving, social behavior, immune function, and health (see Aspinwall and Staudinger,1 Fredrickson,35 Isen,36 Salovey et al.,37 and Taylor et al.38 for reviews).

The findings we have reviewed suggest that positive beliefs, like optimism, and positive emotions do not seem to impair adaptation to serious illness by leading people to ignore useful negative information or to persist on unsolvable problems. Instead, positive beliefs and emotions seem to promote increased attention to useful negative information and the selective allocation of effort to problems that are amenable to personal control. How might these ways of managing problems and information about them lead to lasting benefits? One set of pathways we have evaluated is that active problem-solving and the ability to attend to negative information may work hand in hand to increase people's knowledge about the problems they face10, 39 (see also Aspinwall and Taylor40). Specifically, holding favorable expectancies has been shown to lead to more active forms of problem-solving, such as trying different ways of approaching a problem and asking others for help and advice. These more active ways of approaching one's problems, even if unsuccessful, are more likely to yield information about one's situation than are passive ways of coping. To the extent that one can maintain attention to such information, especially when it is negative, one may achieve a more informed understanding of one's situation and its challenges, leading to more effective problem-solving in the future. In this way, the presence of positive beliefs and states may help people to learn from adversity.

These gains in coping skill and knowledge may be enduring. In addition, the kinds of information-seeking, problem-solving, and social behavior fostered by positive emotions and beliefs may create an upward spiral in which people facing adversity not only learn more about the problems they face, but also act in ways that preserve problem-solving resources by more effectively focusing their efforts on aspects of their lives that are amenable to change. In turn, the experience of successful coping should sustain the positive beliefs and emotions that gave rise to this coping sequence (see, for example, Aspinwall and Richter,33 Aspinwall and Taylor,40 and Aldwin et al.41). These sustaining properties of positive beliefs and emotions should be especially important to people managing situations with chronic demands, such as their own or a loved one's serious illness.18 This analysis is consistent with other evidence suggesting that different positive emotions, such as joy and curiosity or interest, may put in motion a variety of processes, such as play and exploration, that lead to the development and refinement of skills and knowledge.35 Thus, instead of being short-lived and trivial, positive emotions and beliefs may potentiate a series of behaviors that lead to enduring gains in knowledge, skill, and social resources and may thus themselves be an important resource for people managing serious illness and other stressors.

DISCUSSION

Taking Positive Beliefs, Emotions, and Life Changes Seriously: Conclusions and Recommendations for Future Research and Intervention

Positive beliefs and states appear to fuel resilience

In contrast to commonly held assumptions, there is increasing evidence that positive beliefs, emotions, and life changes among people experiencing adversity are common, that they facilitate attention to useful negative information, and that they do not lead to maladaptive ways of coping. Increasingly, researchers are assessing ways in which positive emotions and beliefs foster patterns of information seeking, coping, and social behavior that may have lasting benefits for mental and physical health. In this final section, we discuss the implications of these findings for the conduct and interpretation of research on resilience among survivors of cancer, as well as for interventions to promote well-being and health.

Implications for Research: Giving Positive Emotions and Beliefs a Fair Test

If the goal of research among survivors of cancer is to understand the full range of adaptational processes and multiple aspects of QOL, questions about positive emotions, experiences, and life changes should be routinely included in research protocols, ideally through standardized measures and open-ended questions that allow people to share both positive and negative aspects of their experience. Although a complete understanding of the effects of positive beliefs and emotions on the many challenges of cancer survivorship awaits future research, our analysis suggests that an important part of the effort to understand such phenomena would be to jettison the four common assumptions about positive beliefs and emotions that we have discussed here. Instead of assuming that positive changes are absent, harmful, or trivial, it will be important to submit positive beliefs and emotions to an even-handed scientific test of their impact on multiple aspects of cancer survivorship.

Such tests might profitably focus on three issues: 1) the effects of positive emotions, beliefs, and life changes on mental and physical health outcomes over time, 2) the multiple pathways through which such effects may be realized, and 3) the psychological and social processes that support resilience. First, longitudinal studies of how positive beliefs, emotions, and life changes are sustained (or not) and how they are related to coping, medical adherence, and mental and physical health outcomes over time will be especially important. To date, we know much more about the kinds of life changes reported by survivors of cancer than we do about how and whether such changes are maintained, their specific functions, and their relation to the ongoing challenges and demands of cancer survivorship (see also Park42).

Second, in conducting such research, it will be especially important to evaluate multiple pathways through which positive beliefs and emotions may influence resilience. Although we have focused our review on attention to negative information and coping, there are many additional, complementary pathways through which positive beliefs and positive emotions may influence resilience, such as social support. For example, optimistic young adults were found to have established more friendships on arriving to college and were more likely to maintain these friendships over the course of the academic term.43 As a result, they were less distressed during finals week than were their pessimistic counterparts. Given the well documented physical and mental health benefits of social support, understanding how positive emotions and beliefs among survivors of cancer are related to the tasks of mobilizing and maintaining social support throughout the demands of treatment represents an important area of study. Another intriguing pathway is through the association of positive beliefs and states with immune function (see Salovey et al.37 and Taylor et al.38 for reviews). Continued attention to these multiple pathways and their interrelation (for example, how different ways of coping with cancer are related to the availability and use of social support over time) will yield a more complete portrait of how positive beliefs and states contribute to multiple aspects of resilience in the face of adversity.

A third important area for future research will be the continued evaluation of the psychological and social processes that support resilience. In addition to describing the presence of positive emotions and changes, researchers should continue to evaluate the psychological and social processes (e.g, changes in self-evaluation and coping) that support positive emotions, life changes, and other efforts to find meaning and benefit in one's experience (see Taylor,4 Tedeschi et al.,5 Affleck and Tennen,9 Folkman,18 Aspinwall,39 Armor and Taylor,44 McFarland and Alvaro,45 and Holman and Silver46 for reviews).

Implications for Intervention and Clinical Practice

At the very least, the findings we have reviewed suggest that it may be harmful to base clinical practice or interventions on the assumption that people who experience or express positive emotions and beliefs after adversity are adjusting poorly. Instead, such experiences and expressions of them may be healthy aspects of coping and adjustment. The continued development of personal and group-based interventions that support positive outcomes, such as benefit finding,47 may be valuable in their own right, as well as contribute to our understanding of resilience among survivors of cancer.

In designing both research and interventions in this area, there are at least two temptations to be avoided. First, it will be important to avoid generating new assumptions about positive emotions and beliefs that may limit future research and intervention efforts to promote resilience among survivors of cancer. Just as it seems limiting to assume that all positive beliefs and reported life changes are harmful or delusional, it would be limiting of scientific inquiry—and dangerous from an intervention standpoint—to assume that all positive emotions and beliefs are beneficial. Instead, researchers should evaluate how different kinds of positive emotions and beliefs are related to the QOL of survivors of cancer, their medical adherence, social behavior, and mental and physical health over time.

Second, although a good outcome of the research we have reviewed would be for practitioners and lay people to avoid criticizing survivors of cancer who seek positive experiences or who report finding benefits in adversity, it will be especially important not to use these findings to mandate positive changes and beliefs in this or any other group of people experiencing adversity. Careful longitudinal studies in the area of bereavement have indicated that adaptation to loss is both individual and varied, with several different patterns of emotional responses over time, none of which is more “normal” than others.16, 20, 21 It is likely that there is similar variability in response to the diagnosis and treatment of cancer, and it would be a disservice to survivors of cancer to suggest that they should be experiencing mostly or uniquely positive changes in their lives as a result of their illness. Further, people with cancer should not be made to feel deficient if they do not find some specific set of positive life changes at a prescribed time and sequence. Instead, research that is focused on understanding the full range of adaptational outcomes and processes, as well as the resources and skills that promote adaptation and resilience among survivors of cancer, is most likely to lead to effective interventions to develop and sustain these resources for those who seek them.

Acknowledgements

The authors thank Samantha Leaf for helpful comments on an earlier version of the current article.

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