When patients are diagnosed with cancer, or a terminal illness of any kind, they report that there are a couple of near universal reactions by the people around them. First, everyone has advice for them. Everyone thinks they know what caused their illness and what will cure it. The floodgates of free advice and misinformation open.
Everyone also wants them to stay positive. A positive attitude will get them through their illness. Many patients internalize this advice, as in this patient discussing her diagnosis of brain cancer:
“It hasn’t been sunshine and rainbows since getting my diagnosis, but I still believe in the law of attraction. I believe that if I think more positive thoughts, I will attract more of the positive things I want in life. I can’t do this 100% of the time, but in my experience, thinking this way as much as possible has yielded positive results.”
But when the diagnosis of cancer was confirmed she also had this reaction:
“At first, it was hard to believe that our positive intentions hadn’t worked. I even blamed myself for not being positive enough.”
It is easy to see the attraction of believing in a positive attitude, for patients and for everyone around them. It’s uncomfortable and difficult to deal with a serious and potentially fatal diagnosis. People struggle to find something positive to say, to take some of the emotional sting out of the situation. Patients themselves want to believe they have some degree of control over their situation. Belief in the power of positive thinking does the trick, so people reach for this.
There is also an entire cottage industry of alternative medicine gurus who are essentially selling the snake oil of positive thinking. Throw in a little dietary and lifestyle advice, maybe some magic energy, and you have the whole package. Anything, it may seem, is better than the stark reality of biology. Patients with serious diagnoses like cancer are extremely vulnerable, and make easy targets for selling false hope.
But most people advising positive thinking mean well, and they may really believe it. It’s one of those folk wisdoms that many people believe but happen to be wrong. There is a legitimate scientific question here – is there any measurable effect from having a positive attitude in terms of survival or perhaps quality of life? It’s not entirely implausible that there would be. Attitude may affect compliance with treatment, a better appetite and therefore nutrition, and improved sleep. More speculatively it’s possible that increased emotional stress releases corticosteroids that suppress immune function.
But this question has been asked and answered years ago. Here is one review from 2010:
“Claims about these areas of research routinely made in the positive psychology literature do not fit with available evidence.”
Perhaps the definitive study involved over 1000 patients with head and neck cancer, and found:
“No statistically significant univariate or multivariate effects were observed for emotional well-being, and there were no effects limited to subgroups. These results stand in sharp contrast to the prognostic value of a variety of demographic and clinical variables.”
The study was able to see the effects of demographics and clinical variables, but not attitude or emotional outlook. Some studies, however, show a positive effect on quality of life, but this, of course, is more subjective. It’s also a bit circular – people who are happier seem to be happier.
But the pressure to be positive can also have a profoundly negative effect on patients. They feel guilty when not being positive, and they blame themselves when things go poorly because they were not positive enough.
Sometimes a positive attitude is formulated as a specific intervention. But these don’t work either. As the American Cancer Society summarizes:
“Research has not shown that techniques like guided imagery, relaxation, or meditation can control cancer growth.”
Further, what I find when looking through the literature for the last decade is that researchers have essentially stopped looking at the question – meaning the effects of attitude on survival or disease course. All of the studies are of subjective outcomes, like anxiety, symptom management, or some measure of quality of life. Even there the results are mixed and modest.
Given this reality, it is arguably important not to burden patients with what has been termed “the tyranny of positive thinking”. This is just a setup for false hope, disappointment, and self-blame. It’s also a setup for exploitation, which can sap people and their loved ones of limited time and resources.
This is not to say there is no value in counseling or helping people with terminal diagnoses to make the best of the time they have. But I would further argue that having a realistic view of the medical reality, whatever that is, is helpful. It helps people accept their situation and make the best of it, or react in whatever way they want. Belief in magic is counterproductive, and leads to poor decision-making and often self-blame.
Patients do not need you to tell them everything will be alright, that they can beat their cancer if they stay positive, and they don’t need you to tell them how to respond to their diagnosis. They just need your love and support. You don’t have to offer a solution, especially a false one.
Don’t Blame the Patient