Thinking differently about thinking positive: a discursive approach to cancer patients' talk

A narrative account of the impact of positive thinking on discussions about death and dying

GOALS OF WORK

The purpose of this study was to explore the experience of autologous stem cell transplant recipients (ASCT) and those who care for them.

MATERIALS AND METHODS

This was a qualitative prospective, longitudinal study. Ten patients who were about to have ASCT and nine carers were recruited to the study. Interviews were to be conducted at regular intervals six times over 2 years. The narratives of two widowed carers were analysed using Grounded Theory and read for themes on positive thinking and death.

MAIN RESULTS

Positive thinking has a range of meanings, and its use can have a range of consequences. It can either be a useful coping strategy or can interfere with important conversations and planning about the end of life, and subsequently add to the distress of a grieving partner.

CONCLUSIONS

It is important for patients, their partners and their health professionals to be able to discuss potential adverse consequences of illness, including death, without being hindered by the obligation to be positive or optimistic.

The focus group method: Insights from focus group interviews on sexual health with adolescents

This article concerns the manner in which group interaction during focus groups impacted upon the data generated in a study of adolescent sexual health. Twenty-nine group interviews were conducted with secondary school pupils in Ireland, and data were subjected to a qualitative analysis. In exploring the relationship between method and theory generation, we begin by focusing on the ethnographic potential within group interviews. We propose that at times during the interviews, episodes of acting-out, or presenting a particular image in the presence of others, can be highly revealing in attempting to understand the normative rules embedded in the culture from which participants are drawn. However, we highlight a specific problem with distinguishing which parts of the group interview are a valid representation of group processes and which parts accurately reflect individuals' retrospective experiences of reality. We also note that at various points in the interview, focus groups have the potential to reveal participants' vulnerabilities. In addition, group members themselves can challenge one another on how aspects of their sub-culture are represented within the focus group, in a way that is normally beyond reach within individual interviews. The formation and composition of focus groups, particularly through the clustering of like-minded individuals, can affect the dominant views being expressed within specific groups. While focus groups have been noted to have an educational and transformative potential, we caution that they may also be a source of inaccurate information, placing participants at risk. Finally, the opportunities that focus groups offer in enabling researchers to cross-check the trustworthiness of data using a post-interview questionnaire are considered. We conclude by arguing that although far from flawless, focus groups are a valuable method for gathering data about health issues.

The fight for 'health-related normality': a qualitative study of the experiences of individuals living with established inflammatory bowel disease (ibd)

This article reports on the experiences of individuals living with IBD and identifies a range of coping strategies used by them. Qualitative data from 15 individual interviews and three focus groups were analysed using a grounded theory approach. The main focus is on the emergent core concept of 'health-related normality'. A theoretical framework is proposed to explain how individuals with IBD assess their health-related normality, their fight to maintain it and their need to retain the appearance of normality to others. It is concluded that individuals maintain their health-related normality along certain time and context sensitive continuums rather than fitting into a distinct typology.

Parenting a young person with mental health problems: temporal disruption and reconstruction

The article explores the experiences of parents living with a young person with mental health problems. Qualitative interviews were conducted with 25 parents (18 mothers and 7 fathers) whose child had a diagnosed psychiatric condition. It is argued that the parents engaged in a form of narrative reconstruction of their dual roles as parents and carers as they tried to make sense of the illness in their lives by reconstructing their past, present and future experiences. The concept 'responsibility' was threaded through the parents' narratives and is discussed in relation to three key dimensions - moral responsibility; causal responsibility; and responsibility for self. It is argued that the moral imperative to care for their child was the dominant theme in the parents' narratives but that this was challenged by their lack of knowledge of psychiatric conditions; their interactions with healthcare professionals; their relationships with their child; and their difficulties in coping with the extended parental responsibility that arose from their caring role.

"Uncharted waters": the experience of parents of young people with mental health problems

In this article, the author discusses the experiences of parents of young people with mental health problems and their relations with health care professionals. She conducted qualitative interviews with 25 parents whose teenage child had a diagnosed psychiatric condition. She argues that the experiences of parent-carers can best be understood in the context of the particular relationships involved. The author contextualizes the meanings parents give to care received in wider understandings of parenting and the parental caregiving role. She argues that the parents were deskilled by the condition and by the medical profession. At the same time, parents engaged in a range of actions through which they were reskilled and their parental caregiving role was reestablished.

Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors

In a randomized controlled design, this study tested the efficacy of a theoretically based uncertainty management intervention delivered to older long-term breast cancer survivors. The sample included 509 recurrence-free women (360 Caucasian, 149 African-American women) with a mean age of 64 years (S.D.=8.9 years) who were 5-9 years post-treated for breast cancer. Women were randomly assigned to either the intervention or usual care control condition. The intervention was delivered during four weekly telephone sessions, in which study nurses guided cancer survivors in the use of audiotaped cognitive-behavioral strategies to manage uncertainty about recurrence, and a self-help manual designed to help women understand and manage long-term treatment side effects and other symptoms. Treatment outcome data on uncertainty management were gathered at pre-intervention and 10-months afterward. Repeated measures MANOVA evaluating treatment group, ethnic group, and treatment by ethnic interaction effects indicated that training in uncertainty management resulted in improvements in cognitive reframing, cancer knowledge, patient-health care provider communication, and a variety of coping skills. Results are discussed in terms of the importance of theory-based interventions for cancer survivors that target triggers of uncertainty about recurrence and in terms of ethnic differences in response to the intervention.

Denial of impending death: a discourse analysis of the palliative care literature

Terminally ill patients and their families are often referred to as being "in denial" of impending death. This study uses the qualitative method of discourse analysis to investigate the usage of the term "denial" in the contemporary hospice and palliative care literature. A Medline search (1970-2001) was performed combining the text words "deny" and "denial" with the subject headings "terminal care", "palliative care" and "hospice care," and restricted to English articles discussing death denial in adults. The 30 articles were analysed using a constant comparison technique and emerging themes regarding the meaning and usage of the words "deny" and "denial" identified. This paper focusses on the theme of denial as an individual psychological process. Three dominant subthemes were distinguished: denial as an unconscious "defence mechanism", denial as "healthy" and denial as temporary. The analysis focusses on the intertextuality of these themes with each other and with previous texts on the denial of death. Elements of the psychoanalytic definition of denial as an unconscious defence mechanism are retained in the literature but are interwoven with new themes on patient choice. The result is an overall discourse that is conflictual and at times self-contradictory but overall consistent with the biomedical model of illness. I suggest that the representation of death denial elaborated in these articles may be related to a larger discourse on dying in contemporary Western society, which both invites patients to participate in the planning of their death and labels those who do not comply.

The role of humor for men with testicular cancer

In this article, the authors examine how 45 men talked about "pure" and "applied" humor in qualitative interviews about their experience of testicular cancer. Most described using applied humor in work and social settings to challenge assumptions about the disease, and in health settings to manage feelings, hide embarrassment, reduce tension, share a sense of solidarity with others, or encourage others to examine themselves. Men also described their usually positive reaction to jokes made by others; jokes helped to dispel tension and reassured men that they were being treated as normal. In a few accounts, men revealed how humor was hurtful. They were sometimes upset about jokes made by others, or by the idea of jokes being made, fearing humiliation and stigma. Humor might ease difficult interactions, but our results suggest that clinicians and others should be careful not to initiate humor without a clear lead from the patient.

The journey towards a cancer diagnosis: the experiences of people with cancer, their family and carers

This small-scale study aimed to provide an insight into the time between first noticing a symptom, attending a healthcare provider and obtaining a cancer diagnosis. Previous research showed that the pre-diagnostic moments on the illness trajectory were important to people with cancer and could influence levels of satisfaction with subsequent care. This article provides an overview of the qualitative component (phase 2) of a three-pronged study that involved a workshop, a literature review and focus groups and interviews with people affected by cancer. Results highlighted some of the difficulties encountered during the complex journey towards a diagnosis of cancer. These included fear of what might be found, communication of symptoms to healthcare practitioners, the influence of family on decisions to attend a primary care practitioner and the importance of a person's gender on perceptions of health-seeking behaviour. Results presented warrant further investigation and suggest the importance of viewing the 'cancer journey' as including the journey leading up to a diagnosis of cancer.

Expressions of loss of adulthood in the narratives of people with colorectal cancer

The diagnosis and treatment of colorectal cancer entail detailed discussions of bodily functions, invasive procedures, and a reorientation of life around bowel habit. Furthermore, people with stomas undergo a second experience of toilet training in adulthood. For these reasons, colorectal cancer is sometimes considered an embarrassing disease. Narrative interviews with colorectal cancer patients indicate the inadequacy of the concept of embarrassment in describing the loss of dignity, privacy, independence, and sexual confidence as well as a compromised ability to work, travel, and socialize. The link between bowel control and the constitution of adult identity must be acknowledged if health professionals and carers are to offer the most appropriate forms of information and support to people affected by colorectal cancer.

Fleeing the Fire: Transformation and Gendered Belonging in Thai HIV/AIDS Support Groups

By the turn of the millennium, HIV had infected nearly one million people in Thailand. A large number of support groups now exist throughout the country. These groups have emerged as the primary forum through which having HIV is negotiated and normalized in Thai society. This is done by allowing members to publicly refashion their sense of self and its appropriate place in the world. However, the moral and social space created by support groups is not without its own structuring principles. The discursive strategies that shape support groups are embedded within local moral economies and frameworks of meaning. Gender and social identity are significant factors that influence the benefits to be gained from belonging. To date, women markedly outnumber men in most groups, and many members regard masculinity as a constraining factor on male participation. Within support groups, unwillingness to join is considered one reason for the perception that men with HIV seem to die sooner than do women with HIV. Clinically true or not, this belief has major ramifications.

‘Being positive’: perceptions of patients with cancer and their nurses

BACKGROUND

A review of popular literature reveals a constant message about the healing power of 'being positive'. While there are studies that have examined the link between psychosocial factors such as attitude and cancer survival, very little has been reported about the perceptions of patients and nurses on the meaning of 'being positive'.

AIM

To explore the meaning of 'being positive' for patients undergoing cancer treatment and for nurses who care for them.

METHODS

A qualitative, descriptive approach within the paradigm of constructivist inquiry was used. Semi-structured interviews were conducted with a self-selected convenience sample of 11 patients and eight nurses. The interviews addressed the following key concepts: definitions of 'being positive' and being negative; how these attributes are manifest in cancer patients; and factors influencing patient attitudes.

FINDINGS

Patients defined 'being positive' as maintaining some sort of normality without letting cancer have a detrimental effect on daily living. Nurses identified hope, acceptance, fighting spirit and looking on the bright side as definitions of 'being positive'. Nurses and patients identified environment and support of family, friends and health professionals as factors that influence patient attitudes. Patients also identified other peoples' attitudes as important.

CONCLUSIONS

'Being positive' must be acknowledged as central to being able to cope with cancer and its treatment. The ability of nurses to care for patients with cancer and help them to remain positive will be improved if they develop a better understanding of the meaning of 'being positive' for patients, and how other peoples' attitudes affect their state of mind.

Language use as Social Strategy: A Review and an Analytic Framework for the Social Sciences

Language use as a social strategy is reviewed and a new interdisciplinary taxonomy developed. Four categories are suggested for using language: to get people to do things, to get people to say things, to keep people's attention, and to maintain social relationships. Within these categories, all of the discourse and conversational analysis literatures are reviewed, allowing a common framework within which to make more systematic analyses. Reinterpretations of psychological theories are suggested, and fresh avenues for interdisciplinary research are created. A major imperative from the review is that some form of ethnographic data collection is needed for all analyses of conversations and texts to incorporate more of the social, economic, historical, and cultural contexts into both our observations and theorizing.

A new approach to eliciting meaning in the context of breast cancer

A semistructured measure was developed from early descriptive work by Lipowski to elicit the meaning of breast cancer using eight preset categories: challenge, enemy, punishment, weakness, relief, strategy, irreparable loss, and value. This measure was applied in two studies: a cross-sectional survey of 1012 Canadian women at various points after diagnosis and a follow-up study 3 years later of 205 women from the previous study who were close to the time of diagnosis at the first testing. The majority of the 1012 women chose "challenge" (57.4%) or "value" (27.6%) to describe the meaning of breast cancer, whereas fewer chose the more negative "enemy" (7.8%) or "irreparable loss" (3.9%). At the 3-year follow-up assessment, 78.9% of the women who had indicated positive meaning by their choices of "challenge" or "value" did so again. Verbal descriptions provided by the women were congruent with those reported in previous qualitative studies of meaning in breast cancer with respect to the two most prevalent categories: challenge and value. At follow-up assessment, women who ascribed a negative meaning of illness with choices such as "enemy," "loss," or "punishment" had significantly higher levels of depression and anxiety and poorer quality of life than women who indicated a more positive meaning. The meaning-of-illness measure provides an approach that can be applied in large surveys to detect women who ascribe less positive meaning to the breast cancer experience, women who may be difficult to identify in the context of small, qualitative studies.

Positive attitude in cancer: patients' perspectives

PURPOSE/OBJECTIVES

To describe what being positive means for patients undergoing treatment for cancer.

RESEARCH APPROACH

Qualitative, descriptive approach.

SETTING

Specialist cancer clinic in a large metropolitan hospital in Sydney, Australia.

PARTICIPANTS

11 patients with cancer currently being treated at a cancer clinic for a variety of cancers.

METHODOLOGIC APPROACH

Semistructured interviews that were audiotaped, transcribed, and thematically analyzed for content related to being positive.

MAIN RESEARCH VARIABLES

Patients' definitions of positive and negative attitude, their perceptions of the importance of attitude during their cancer journey, and any factors that influenced their perceived attitude.

FINDINGS

For patients, positive attitude was defined as optimism for the day and getting though everyday events of the journey by taking control rather than focusing on the future. Factors that affected patients' positive attitude were their relationships with their specialists, people around them being positive and supportive, and having a pleasant environment at home and at the treatment center. Patients found expectations of them to be positive as being detrimental.

CONCLUSIONS

Patients with cancer must be positive for the present rather than the future.

INTERPRETATION

Nurses need to inspire and support patients' positivity while undergoing treatment for cancer. Nurses should not force their own value system on them nor treat them differently if they do not conform to societal expectations to be positive and optimistic for the future.

Beyond the "fetishism of words": considerations on the use of the interview to gather chronic illness narratives

The author explores the technique of interviewing chronic illness patients to obtain narratives of their illness experiences. It is argued that the perspective that interview responses are accurate reflections of experience (the "fetishism of words") hampers the understanding of patient voice and agency. Discussions of chronic illness and narrative are followed by an examination of the interview based on the work of Charles L. Briggs. The author then uses the concepts of self-presentation and social support to examine what interviewers and interviewees contribute to the coconstructed discourse that is produced by the interview and addresses the question of how these concepts contribute to the beneficial outcomes of constructing narratives. The author offers specific suggestions for future research.

Gender schema and prostate cancer: veterans' cultural model of masculinity

Coming to terms with disease, chronic illness, and aging may be challenging for men who adhere to an inflexible gender schema. In this study of elder U.S. veterans' ideas about masculinity, we find that prostate cancer patients reaffirm a strongly moral normalizing discourse about "being a man" yet tend to separate roles and values from male physical and sexual attributes. Using systematic data collection methods taken from cognitive anthropology, we map veterans' schema of masculinity and examine the relative importance that cancer patients and non-patients give to gender attributes. The results demonstrate the complementarity between cognitive and narrative approaches in medical anthropology. This research also suggests the hypotheses that (1) coming to terms with iatrogenesis may involve a subtle reformulation of masculinity and that (2) men with a fixed view of masculinity may have worse health outcomes than do those who accept the changes accompanying their treatment for prostate cancer.

The patient's perspective: a qualitative study of acute myeloid leukaemia patients' need for information and their information-seeking behaviour

In recent years there has been an increased focus on cancer patients' information needs. The majority of the studies have led to the conclusion that most patients want as much information as possible about their disease and treatment. These studies have been large survey studies, and most of the patients enrolled in them have been out-patients. Very little is known about the information needs of severely ill cancer patients being treated as in-patients-such as those with acute myeloid leukaemia (AML). As part of a larger study dealing with AML patients' illness narratives, this work describes the information needs from the patients' perspective and their information-seeking behaviour. In-depth ethnographic interviews were conducted with each of 21 patients on two occasions: at the time of diagnosis and again 2-5 months later. Most patients did not recall much information from the time of diagnosis, except the diagnosis itself and the feelings it had aroused in them. All patients had basic medical knowledge about their disease. However, many patients-especially the elderly-expressed no need to receive further medical details about their disease. Avoiding information, in particular about the prognosis, was explained as a strategy to maintain hope. Most patients attached more importance to information about problems affecting their everyday life and how other persons had coped with their illness. They did not seek medical information on their own, although especially younger patients expressed the feeling that they "ought" to do this. There was a discrepancy between their expressed attitudes regarding the need for medical information in general and their actual information-seeking behaviour. Being informed and seeking information are discussed as society's expectations of today's cancer patient.

Researching experiences of cancer: the importance of methodology

This paper draws on contributions to and discussions at a recent MRC HSRC-sponsored workshop 'Researching users' experiences of health care: the case of cancer'. We focus on the methodological and ethical challenges that currently face researchers who use self-report methods to investigate experiences of cancer and cancer care. These challenges relate to: the theoretical and conceptual underpinnings of research; participation rates and participant profiles; data collection methods (the retrospective nature of accounts, description and measurement, and data collection as intervention); social desirability considerations; relationship considerations; the experiences of contributing to research; and the synthesis and presentation of findings. We suggest that methodological research to tackle these challenges should be integrated into substantive research projects to promote the development of a strong knowledge base about experiences of cancer and cancer care.

Men, women, gender and cancer

This paper argues for a gender relational approach in the context of cancer care bearing in mind that conceptual problems are intertwined with methodological approaches. Hitherto, research in the field of psycho-oncology has used a positivist methodology that separates sex from 'gender'. Men's and women's biological difference dictates their sexual destiny. Moreover, adjustment to cancer is conceptualized as lying within the patient, usually women. A contextual framework of a person's experience is negated. A 'gender relational' approach to cancer care underpins the ways in which people enter into a set of socially constructed relationships produced and reproduced through actions with each other and in institutions but never in a vacuum. It is suggested that, by using differing methodologies, such an approach will illuminate the similarities and differences within and between men and women with cancer. It may also help to demystify the conceptual stance that often pathologizes and medicalizes people, especially women, as has been the case in mainstream research. This will pave the way for a clearer understanding of how patients experience cancer in terms of gender and how medical institutions may be contributing to that experience as they too, gender their practice.

Influence of psychological coping on survival and recurrence in people with cancer: systematic review

OBJECTIVE

To summarise the evidence on the effect of psychological coping styles (including fighting spirit, helplessness/hopelessness, denial, and avoidance) on survival and recurrence in patients with cancer.

DESIGN

Systematic review of published and unpublished prospective observational studies.

MAIN OUTCOMES MEASURES

Survival from or recurrence of cancer.

RESULTS

26 studies investigated the association between psychological coping styles and survival from cancer, and 11 studies investigated recurrence. Most of the studies that investigated fighting spirit (10 studies) or helplessness/hopelessness (12 studies) found no significant associations with survival or recurrence. The evidence that other coping styles play an important part was also weak. Positive findings tended to be confined to small or methodologically flawed studies; lack of adjustment for potential confounding variables was common. Positive conclusions seemed to be more commonly reported by smaller studies, indicating potential publication bias.

CONCLUSION

There is little consistent evidence that psychological coping styles play an important part in survival from or recurrence of cancer. People with cancer should not feel pressured into adopting particular coping styles to improve survival or reduce the risk of recurrence.

Comorbid depressive symptomatology: isolating the effects of chronic medical conditions on self-reported depressive symptoms among community-dwelling older adults

Advances in medical technology and surgical knowledge have greatly extended the life expectancy of older individuals with chronic disabilities. Among the older adult population the prevalence of comorbid chronic illness and depressive symptoms has often been investigated. Yet there continues to be a lack of understanding about the consequences of specific chronic illnesses on depressive symptoms. Using cross-sectional data while simultaneously controlling the effects of various socioenvironmental, demographic, and other factors, this study analyzed the prevalence of self-reported depressive symptoms in relation to chronic illness. The cumulative effect of medical comorbidity and the specific effect of individual chronic illnesses were examined. The sample consisted of 359 older white Americans aged 55-93. Overall, the findings show that self-reports of depressive symptoms were greater among those individuals who also reported digestive disorders, respiratory ailments, and heart problems. These results suggest that for older white Americans these three chronic conditions may present a greater mental health burden than other chronic illnesses.

Replacing Catharsis and Uncertainty Reduction Theories with Descriptions of Historical and Social Context

Many explanations in psychology rely on notions of catharsis, drive reduction, or uncertainty reduction. This article criticizes such notions and suggests 3 ways that such theories can be replaced to make the phenomena events of social life rather than “inner” events: They have hidden social events as their conditions for occurrence; they are the result of conflicting social demands; and they function as good conversational rhetoric. Seven examples are given in detail, including the reduction in anxiety about life through religion, the cognitive psychology assumption of uncertainty reduction through categorization, and the reduction in anxiety resulting from making rumors. Relying on descriptions of historical and social context rather than on theories of catharsis provides a better basis for applied interventions and integration into the social sciences but requires that psychologists pay much more attention to measuring such details.