by Barbara Ehrenreich
Smile of Die: The Bright-Side of Cancer
There was, I learned, an urgent medical reason to embrace cancer with a smile: a “positive attitude” is supposedly essential to recovery. During the months when I was undergoing chemotherapy, I encountered this assertion over and over—on web sites, in books, from oncology nurses and fellow sufferers. Eight years later, it remains almost axiomatic, within the breast cancer culture, that survival hinges on “attitude.” One study found 60 percent of women who had been treated for the disease attributing their continued survival to a “positive attitude.” In articles and on their web sites, individuals routinely take pride in this supposedly lifesaving mental state.
“Experts” of various sorts offer a plausible-sounding explanation for the salubrious properties of cheerfulness. A recent e-zine article entitled “Breast Cancer Prevention Tips”—and the notion of breast cancer “prevention” should itself set off alarms, since there is no known means of prevention—for example, advises that:
A simple positive and optimistic attitude has been shown to reduce the risk of cancer. This will sound amazing to many people; however, it will suffice to explain that several medical studies have demonstrated the link between a positive attitude and an improved immune system. Laughter and humor has [sic] been shown to enhance the body’s immunity and prevents against cancer and other diseases. You must have heard the slogan “happy people don’t fall sick.”
No wonder my “angry” post was greeted with so much dismay on the Komen site: my respondents no doubt believed that a positive attitude boosts the immune system, empowering it to battle cancer more effectively…
… One of the early best- selling assertions of this notion was Getting Well Again, by O. Carl Simonton, an oncologist; Stephanie Matthews-Simonton, identified in the book as a “motivational counselor”; and psychologist James L. Creighton. So confident were they of the immune system’s ability to defeat cancer that they believed “a cancer does not require just the presence of abnormal cells, it also requires a suppression of the body’s normal defenses.” What could suppress them? Stress. While the Simontons urged cancer patients to obediently comply with the prescribed treatments, they suggested that a kind of attitude adjustment was equally important. Stress had to be overcome, positive beliefs and mental imagery acquired.
The Simontons’ book was followed in 1986 by surgeon Bernie Siegel’s even more exuberant Love, Medicine, and Miracles, offering the view that “a vigorous immune system can overcome cancer if it is not interfered with, and emotional growth toward greater self-acceptance and fulfillment helps keep the immune system strong.” Hence cancer was indeed a blessing, since it could force the victim into adopting a more positive and loving view of the world.
…You can see its appeal. First, the idea of a link between subjective feelings and the disease gave the breast cancer patient something to do. Instead of waiting passively for the treatments to kick in, she had her own work to do—on herself. She had to monitor her moods and mobilize psychic energy for the war at the cellular level.
…It could be argued that positive thinking can’t hurt, that it might even be a blessing to the sorely afflicted. Who would begrudge the optimism of a dying person who clings to the hope of a last-minute remission? Or of a bald and nauseated chemotherapy patient who imagines that the cancer experience will end up giving her a more fulfilling life? Unable to actually help cure the disease, psychologists looked for ways to increase such positive feelings about cancer, which they termed “benefit finding.” Scales of benefit finding have been devised and dozens of articles published on the therapeutic interventions that help produce it. If you can’t count on recovering, you should at least come to see your cancer as a positive experience, and this notion has been extended to other forms of cancer too. For example, prostate cancer researcher Stephen Strum has written: “You may not believe this, but prostate cancer is an opportunity.… [It] is a path, a model, a paradigm, of how you can interact to help yourself, and another. By doing so, you evolve to a much higher level of humanity.”
But rather than providing emotional sustenance, the sugarcoating of cancer can exact a dreadful cost. First, it requires the denial of understandable feelings of anger and fear, all of which must be buried under a cosmetic layer of cheer. This is a great convenience for health workers and even friends of the afflicted, who might prefer fake cheer to complaining, but it is not so easy on the afflicted. Two researchers on benefit finding report that the breast cancer patients they have worked with “have mentioned repeatedly that they view even well-intentioned efforts to encourage benefit-finding as insensitive and inept. They are almost always interpreted as an unwelcome attempt to minimize the unique burdens and challenges that need to be overcome.” One 2004 study even found, in complete contradiction to the tenets of positive thinking, that women who perceive more benefits from their cancer “tend to face a poorer quality of life—including worse mental functioning—compared with women who do not perceive benefits from their diagnoses.”
Besides, it takes effort to maintain the upbeat demeanor expected by others—effort that can no longer be justified as a contribution to long-term survival. Consider the woman who wrote to Deepak Chopra that her breast cancer had spread to the bones and lungs: “Even though I follow the treatments, have come a long way in unburdening myself of toxic feelings, have forgiven everyone, changed my lifestyle to include meditation, prayer, proper diet, exercise, and supplements, the cancer keeps coming back. Am I missing a lesson here that it keeps reoccurring? I am positive I am going to beat it, yet it does get harder with each diagnosis to keep a positive attitude.”
She was working as hard as she could—meditating, praying, forgiving—but apparently not hard enough. Chopra’s response: “As far as I can tell, you are doing all the right things to recover. You just have to continue doing them until the cancer is gone for good. I know it is discouraging to make great progress only to have it come back again, but sometimes cancer is simply very pernicious and requires the utmost diligence and persistence to eventually overcome it.”
But others in the cancer care business have begun to speak out against what one has called “the tyranny of positive thinking.” When a 2004 study found no survival benefits for optimism among lung cancer patients, its lead author, Penelope Schofield, wrote: “We should question whether it is valuable to encourage optimism if it results in the patient concealing his or her distress in the misguided belief that this will afford survival benefits.…If a patient feels generally pessimistic … it is important to acknowledge these feelings as valid and acceptable.”
Without question there is a problem when positive thinking “fails” and the cancer spreads or eludes treatment. Then the patient can only blame herself.
Whether repressed feelings are themselves harmful, as many psychologists claim, I’m not so sure, but without question there is a problem when positive thinking “fails” and the cancer spreads or eludes treatment. Then the patient can only blame herself: she is not being positive enough; possibly it was her negative attitude that brought on the disease in the first place. At this point, the exhortation to think positively is “an additional burden to an already devastated patient,” as oncology nurse Cynthia Rittenberg has written. Jimmie Holland, a psychiatrist at Memorial Sloan Kettering Cancer Center in New York, writes that cancer patients experience a kind of victim blaming:
It began to be clear to me about ten years ago that society was placing another undue and inappropriate burden on patients that seemed to come out of the popular beliefs about the mind-body connection. I would find patients coming in with stories of being told by well-meaning friends, “I’ve read all about this—if you got cancer, you must have wanted it… .” Even more distressing was the person who said, “I know I have to be positive all the time and that is the only way to cope with cancer—but it’s so hard to do. I know that if I get sad, or scared or upset, I am making my tumor grow faster and I will have shortened my life.”
Clearly, the failure to think positively can weigh on a cancer patient like a second disease.
I, at least, was saved from this additional burden by my persistent anger—which would have been even stronger if I had suspected, as I do now, that my cancer was iatrogenic, that is, caused by the medical profession. When I was diagnosed I had been taking hormone replacement therapy for almost eight years, prescribed by doctors who avowed it would prevent heart disease, dementia, and bone loss. Further studies revealed in 2002 that HRT increases the risk of breast cancer, and, as the number of women taking it dropped sharply in the wake of this news, so did the incidence of breast cancer. So bad science may have produced the cancer in the first place, just as the bad science of positive thinking plagued me throughout my illness.
Breast cancer, I can now report, did not make me prettier or stronger, more feminine or spiritual. What it gave me, if you want to call this a “gift,” was a very personal, agonizing encounter with an ideological force in American culture that I had not been aware of before—one that encourages us to deny reality, submit cheerfully to misfortune, and blame only ourselves for our fate.
Reprinted by arrangement with Metropolitan Books, an imprint of Henry Holt and Company LLC.