Positive psychology in cancer care: safe territory or a bridge

too far?

Associate Professor Lois Surgenor

Psycho-oncology meeting, Christchurch 24 Sept 2012

Outline

What is positive psychology?How is it applied in cancer?

What is the evidence?Implications?

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History of positive psychologySeligman and Csikszentmihalyi (2000) take credit for the revolution, and coining term “Positive Psychology”

Though part of a wider movement, including the increased demand from people who are not severely psychologically unwell but want to increase their well-being.

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History of positive psychology• Criticisms of conventional psychology as

“negative psychology”

(focusing on psychopathology)

• Focus on mental health has “developed a distorted view of what normal- and exceptional- human experience is like”

• “It is not enough to help those who suffer”

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History of positive psychologyHistory goes back much further:

e.g., James “healthy mindedness” (1902)Maslow “hierarchy of needs” (1950s)Rogers “person-centred therapy” (1960s)

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What is positive psychology?

Psychology traits that contribute:

•Subjective well-being•Hope and Optimism •Happiness and contentment•Self-determination

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What is positive psychology?

Positive personality traits at an individual level:•capacity for love and vocation•courage•interpersonal skill•aesthetic sensibility•perseverance•forgiveness•originality•future mindedness•spirituality•high talent•wisdom

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Fighting Spirit

Cancer is a challenge, be optimistic, the cancer is controllable, take an active role in recovery, and attempt to live life as normal as possible.

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Post-traumatic growth

Experiencing improved relationships, increased inner strength, deepening spirituality from having undergone a traumatic or life-threatening experience.

People overly link (attribute) change to a traumatic experience

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Optimism – the generalised expectancies for desirable future outcomes

Carver et al., 2010

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Benefit-finding

Exactly what this is has not been clearly spelt out in the literature? positive illusory process (bias, selective recall)? positive self-narratives Benefit-finding researchers has not been able to consistency show that this is linked to adjustment

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Self-help books: the popular (commercial) arm of positive psychology

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“Can the Mind Cure Cancer? Several studies we have examined show that there is a definite correlation between emotional stress and the development of disease, including cancer. Likewise, we can conclude that a positive outlook, lowered anxiety and depression, a sense of control, and improved mood increase the survival times of cancer patients. There is solid evidence that stress and mood negatively affect the status of the immune system”

http://curezone.com/diseases/cancer/psychology.asp(downloaded 13.09.12)

The lay expectation is that a diagnosis of cancer (and living with cancer) is distressing….and something should be done to ameliorate this distress.

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“Received wisdom is what we know to be true, because it is said often enough (with enough gravitas by such senior people) that it would seem like heresy to think otherwise”

Waller, 2011

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Social pressure and a desire to find answers

“If it is not true, it ought to be”Coyne, 2010

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Reality checks

Studies claiming that psychological interventions improve immune functioning have been found to be seriously flawed in their conclusions

(See Coyne et al., 2010)

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Reality checks

It has not been demonstrated that psychotherapy promotes survival in people with cancer.

(the view that it does mainly rests on 2 studies [Fawzy et al., 1993; Spiegel et al, 1989] that have been found to be seriously flawed)

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Reality checks

How so?

Fawsy et al (1993) and follow-up (2003)Never intended to study survival…only decided to look at this later

Statistically under-powered for survival analysisNo intent to treat analysisProblems with data analysis

See Coyne et al., 2007

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Time to air our dirty laundry in public:

A famous historical example

Eysenck co-published a study ‘demonstrating’ that personality was related to smoking, and personality was related to lung cancer, and thus any direct relationship between smoking and lung cancer was illusionary.

When do you think this study was published?

1988Eysenck received £ 800,000 from American tobacco companies

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Reality checks

Straw man argument used:Positive psychology falsely depicts clinical psychology as not taking into account the positives (in assessment and interventions)

Clinical work is routinely assessing protective factors

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Reality checks

Much has been learned about the study of happiness through the study of depression

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Reality checks

The benefits of any emotional/psychological coping style are not linear.

No emotion is uniformly positive or negative

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Reality checks

Context is important: studies show that psychological traits such as forgiveness, optimism, hope etc can be beneficial or harmful depending on the context.

‘Negative emotions’ can be helpful: Anger can help avoid depression in some contexts

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Reality checks

Context is important: studies show that psychological traits such as forgiveness, optimism, hope etc can be beneficial or harmful depending on the context.

(optimism in a gambler is problematic; forgiveness in a victim of domestic violence may be dangerous)

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Reality checks

Context is important: studies show that psychological traits such as forgiveness, optimism, hope etc can be beneficial or harmful depending on the context.

Optimists are less likely to disengage from an unwinnable task and are more likely to overspread their resources (Norem & Chang, 2002)Not to be reproduced without permission

Criticisms

• “Saccharine terrorism”

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Criticisms

Distracts practitioners and public from what the hard science offers (and this has resultant implications for service provision decisions).

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Criticisms

Over-promise (of the effect of ineffectual approaches) risks public backlash generalising to other branches of psychology where there are well-validated interventions.

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Challenges

• How do we, as health workers, make the buyer beware?

• How do we utilise the coping mechanisms that patients bring but not collude with beliefs that are ill-founded?

Why is this such an uphill battle? Social psychology theory helps us out…

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The goal has to be…

- applying specific psychological technologies for conditions where there is evidence that these technologies are effective

- early detection of clinically significant psychological problems and conditions

- avoiding a ‘waiting list’ situation for those who deemed to require treatment.

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Health science should not be a social movement, marketing, or a political manifesto

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Conclusion

A bridge too far, although the promises are tempting

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Thank you for your attention

Dr Lois SurgenorAssociate Professor in Psychological MedicineAssociate Dean (Postgraduate Studies)University of Otago at Christchurch, PO Box 4345 Christchurch 8140New Zealand Tel 64 3 3720400 Fax 64 3 3720407