Positive psychology in cancer care: safe territory or a bridge too far?

Associate Professor Lois Surgenor Psycho-oncology meeting, Christchurch 24 Sept 2012 Positive psychology in cancer care: safe territory or a bridge too far?

Outline What is positive psychology? How is it applied in cancer? What is the evidence? Implications? Not to be reproduced without permission

History of positive psychology Seligman 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. Not to be reproduced without permission

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” Not to be reproduced without permission

History of positive psychology History goes back much further: e.g., James “healthy mindedness” (1902) Maslow “hierarchy of needs” (1950s) Rogers “person-centred therapy” (1960s) Not to be reproduced without permission

What is positive psychology? Psychology traits that contribute: • Subjective well-being • Hope and Optimism • Happiness and contentment • Self-determination Not to be reproduced without permission

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 Not to be reproduced without permission

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. Not to be reproduced without permission

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 Not to be reproduced without permission

Optimism – the generalised expectancies for desirable future outcomes Carver et al., 2010 Not to be reproduced without permission

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 Not to be reproduced without permission

Self-help books: the popular (commercial) arm of positive psychology Not to be reproduced without permission

“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) Not to be reproduced without permission

The lay expectation is that a diagnosis of cancer (and living with cancer) is distressing….and something should be done to ameliorate this distress. Not to be reproduced without permission

“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 Not to be reproduced without permission

Social pressure and a desire to find answers “If it is not true, it ought to be” Coyne, 2010 Not to be reproduced without permission

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) Not to be reproduced without permission

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) Not to be reproduced without permission

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 analysis No intent to treat analysis Problems with data analysis See Coyne et al., 2007 Not to be reproduced without permission

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? 1988 Eysenck received £ 800,000 from American tobacco companies Not to be reproduced without permission

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 Not to be reproduced without permission

Reality checks Much has been learned about the study of happiness through the study of depression Not to be reproduced without permission

Reality checks The benefits of any emotional/psychological coping style are not linear. No emotion is uniformly positive or negative Not to be reproduced without permission

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 Not to be reproduced without permission

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) Not to be reproduced without permission

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” Not to be reproduced without permission

Criticisms Distracts practitioners and public from what the hard science offers (and this has resultant implications for service provision decisions). Not to be reproduced without permission

Criticisms Over-promise (of the effect of ineffectual approaches) risks public backlash generalising to other branches of psychology where there are well-validated interventions. Not to be reproduced without permission

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… Not to be reproduced without permission

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. Not to be reproduced without permission

Health science should not be a social movement, marketing, or a political manifesto Not to be reproduced without permission

Conclusion A bridge too far, although the promises are tempting Not to be reproduced without permission

Thank you for your attention Dr Lois Surgenor Associate Professor in Psychological Medicine Associate Dean (Postgraduate Studies) University of Otago at Christchurch, PO Box 4345 Christchurch 8140 New Zealand Tel 64 3 3720400 Fax 64 3 3720407

Positive psychology in cancer care: safe territory or a bridge too far?