Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, August 16, 2007

What Could Be Wrong with "Positive Thinking"?

  • Think happy thoughts.
  • The power of positive thinking.
  • Picture yourself getting better.
  • Mind over matter.
What could possibly be wrong with any of the above statements? Even if they do no good, they can't do any harm, can they?

From the physician's standpoint, there's nothing wrong with them at all. Some docs may even think they're a good idea in terms of "patient empowerment." Anything that gives the patient a sense that they're doing something -- anything -- will make them feel better than if they are just passive recipients of medical care.

Here's the problem: it puts a potentially painful amount of the responsibility for recovery squarely on the patient's shoulders. If they don't get better, it's because they didn't try hard enough; visualize clearly enough; want it badly enough. Because this is so often (if not always) not true, all this "positivity" has the potential to be a cruel two-edged sword.

I'm sure many oncologists and other physicians do their damndest to reassure patients that they are not to blame for their disease. I have news for them (the docs): patients don't believe you. They won't tell you; they'll come tell me. Full of shame and guilt, whispering through their tears, they confide in me. Almost all of them:
  • "If only" they hadn't smoked, they wouldn't have gotten lung cancer.
  • "If only" they hadn't eaten so much red meat, they wouldn't have gotten colon cancer.
  • "If only" they had breastfed longer, they wouldn't have gotten breast cancer.
And those are only the ones for which the popular press might provide etiological support! I would say that almost all patients, deep down inside, feel that they are to blame for their illnesses. They may not always tell us about it, though, so in addition to dealing with their disease, they are also burdened with their guilt.

Now factor in the good, empowering physician -- often one with an open mind to alternative therapies -- who encourages the patient to "think positive." Visualize that chemo killing those nasty cancer cells. The mind-body connection is powerful: harness it for yourself!

Please note that I am NOT talking about hope. Keeping the patient's spirits up by providing hope is not a problem. The issue arises when the patient perceives that hope -- or positivity -- is part of the treatment that is under his control. Now, far from being just "hope", it's another responsibility for the patient.
  • "OMG, I wasn't sure what cancer cells looked like; I must have gotten it wrong in my visualization."
  • "Oops; I was really down this week. I didn't do my part. That's why my white count is down."
I know there are studies that purport to show precisely this phenomenon. My response: how dreadful for those who "just can't keep their spirits up." Now their relapse is all their fault.

Better to say nothing than to inadvertently thrust that kind of responsibility on an unsuspecting patient. Support them in their own expressions of positivity, but don't go actively suggesting that "it might help." What patients are going to hear, if they don't get better, is that it was their fault.

The dear late Sarah said it very well in October of last year, eight months before her death from melanoma:
I'm just so tired of feeling like this is my fault or people implying that I can change it with visualization or positive thinking. Let me see you cure your next cold with positive thinking, and let me see you cure your next bout of food poisoning by visualizing an army of white blood cells attacking the bacteria! That would never occur to these people, but somehow they think that cancer is different? Ya, it's different, it is a hell of a lot more serious, powerful, sneaky and deadly! It is also incurable at late stages....

A lot of the "warriors" and "survivors" that we see on tv... we are led to believe survived because of sheer determination, positivity and strength of character. Nope, I dare say, they survived because they had itty bitty cancers in situ that have less than a 10% chance of spreading! Sure, the treatment sucks and they were scared, and lives changed forever. But the media makes them out to be these rays of hope and living testaments to the power of will and determination, when in fact, they were just damn lucky.

(I just want to make clear that this post has been gestating for months, separate in every respect from recent discussions of alternative medicine. It is not meant as a dig at CAM.)


At Thu Aug 16, 09:44:00 PM, Blogger dr. nic said...

I'm not in a position to be giving this sort of advice to a patient, but I appreciate your very interesting take on the subject. I never actually looked at it from this angle before.

At Thu Aug 16, 09:49:00 PM, Blogger Carver said...

No one could say it better than Sarah. I agree completely. I got to know her through an online Melanoma Support group and will never forget her.

The "Wellness Community" had a great article about this issue based on studies. I can't link it anymore but I saved it and these two paragraphs cover much of what sticks with me. I especially like the end, being a curmudgeon myself, it's nice to know that may be exactly what I should continue to be.

From the article:

"In a 2004 study by Penelope Schofield and her colleagues at Peter MacCallum Cancer Centre in Melbourne, Australia that involved 204 lung cancer patients, there was no evidence that a high level of optimism prior to treatment enhanced survival. However, the study underscored the importance of optimism in relation to quality of life. Those patients who were more optimistic were less depressed and more likely to adhere to treatment.

Another new body of work goes beyond just looking at a positive attitude and is examining its biological underpinnings by studying immune function and stress hormones. So far, the findings are similar to the Schofield study, indicating that successful coping is not necessarily about having a positive outlook or striving for a cheery disposition. Rather, coping in a way familiar to you (which could involve anything from stress relief to exercise) can prove beneficial. In fact, if someone is a natural curmudgeon, then continuing to be a curmudgeon may be the very thing to help lower stress, bolster the immune system and, possibly, influence the success of the cancer treatment".1

The article "The Challenge of the Positive Attitude" was from the site:


At Thu Aug 16, 10:11:00 PM, Anonymous Anonymous said...

As someone whose just gone through a major medical procedure and who had to wait years, move countries, spend thousands of dollars* and gotten deeply into debt without any particular chance of success, the last thing I want to hear from my doctor is 'think positive!'.

Because 'thinking positive' and 'just relaxing' aren't going to fix my real, physical problems. They can't be fixed with medication or meditation, in fact, they can't be 'fixed' at all.

Now, medical intervention has worked for me - but the procedure could still fail. Funnily enough, because it worked, it still gives my clinic a positive record, even if the ultimate outcome is not.

I dunno, maybe I'm just too pragmatic. Or maybe I've just heard that 'positive thinking' from too many well meaning, but utterly ignorant people.

*although both my husband and I are unemployed, neither of us are eligible for any cheap health insurance whatsoever. Moreover, even if we could afford it, premiums would cost $10k a year - with a 10$k deductible.

At Thu Aug 16, 10:12:00 PM, Anonymous Anonymous said...

Gah, I meant to write 'who has' not 'whose'...

At Thu Aug 16, 11:20:00 PM, Blogger Lynn Price said...

Dino, I know you'd never believe it; but I agree with you one hundred percent. Good post.

At Fri Aug 17, 12:00:00 AM, Anonymous Anonymous said...

Dino, I've been enjoying your blog for a few months now, and appreciating your perspective on medicine, CAM and 'Traditional' (if that's the right word.)

I'm a hypnotist. With medical oversight, I help clients overcome chronic issues and/or their symptoms. Asthma, allergies, fibromyalgia, and IBS are a few examples.

I share your frustration with patients being told to 'think positively' or some such advice, without being told HOW to do so. What kind of useless advice is that?

One of the foundations of my practice is that we always make the best decisions we can -with the information available to us-. This concept, when applied, helps many patients recover fully or partially, without feeling like it was 'their fault'.

Another way to state this concept is, "Every behavior has a positive intention." Once the patient understands the idea that they can take responsibility without having to feel at fault, progress is often rapid.

'Positive thinking' is overrated. 'Effective thinking', now that's a different animal!

Jeremy Pope
128 North Broad Street
Thomasville, GA 31792

At Fri Aug 17, 06:11:00 AM, Blogger Sara said...

We all need to remember that the question most often underlying the patient's words, "Why did this happen to me?" is exactly this issue. I'm still totally new in medicine, and I can't even count the number of times a patient has asked this. I've seen answers that range from wonderful, where you see that a great burden of guilt is lifted, to horrible, where the doctor spiels off a list of risk factors.

Good post.

At Fri Aug 17, 10:31:00 AM, Anonymous Anonymous said...

This is one of the problems with prayer, as well (and I'm a major supporter of prayer . . .). When people don't get the results for which they prayed, they think they prayed wrong, did something wrong, etc. . . . which again reminds me of the often stated You can't change him/her, you can only change yourself." I know you are writing specifically about healthcare situations, but self-blame can be a problem in all areas of life.

At Fri Aug 17, 10:41:00 AM, Anonymous Anonymous said...

i never thought of positive thinking in this light before. very educational.

i suppose many practitioners believe in the "power of positive thinking." you know, the whole mind-body connection...positive thoughts can truly make you better. i don't know if this relationship is evidence based. if it is, i bet the evidence didn't take into account patient annoyance at having to "think positive" when death is at her door.

no matter what their health conditions...patients should be encourage to just be themselves, and speak freely whatever they fell in their hearts.

just my two cents. thanks for the interesting post.

At Fri Aug 17, 11:18:00 AM, Blogger Surgeon In My Dreams said...

Can you imagine (and I'm sure you can) with the stigma attached to mental illness what burden we carry?

I have fought major depression almost my entire adult life, whether things were going well in my life or not. I have only in the past two weeks been told that the fact is I am bipolar and have likely been mis-diagnosed all these years (which is not unusual at all according to all I have read).

I was brought up my entire life to believe that if you are a "good Christian" and are "trusting God enough" for your healing then you do not need a shrink much less need to take a pill.

I've heard I need to pick myself up by my bootstraps so many times I could hurl if I hear it again. People act as if we want to be this way or we enjoy having these depressive thoughts. Who would wish it on themselves?

I enjoyed this blog and you are so right. Give them hope, yes, but try not to make it their personal faliure if they don't get better.

At Fri Aug 17, 02:53:00 PM, Anonymous Anonymous said...

Thank you!

At Fri Aug 17, 10:18:00 PM, Anonymous Anonymous said...

You're on the mark with this one.

I suppose it's human nature to try and find some reason why something bad has happened, especially something as serious as cancer. It reminds me of a conversation I had with my friend Barb, when I was telling her about another woman our age (40) who'd been diagnosed with Hodgkins disease. Barb peppered me with questions: did the other woman spend too much time in front of a computer, was she exposed to radiation, was she around chemicals, what could have caused this to happen???

My reply was none of the above. It was simply bad luck. A reason that is a lot more difficult to accept, since bad luck can happen to anyone at anytime, and for reasons that we are powerless to hold off.

I believe it adds insult to injury to tell a person with a serious or chronic problem to just think 'Positive'! As if the person needs one more platitude.

At Sat Aug 18, 11:36:00 PM, Anonymous Anonymous said...

I really enjoyed this post, Dino. People desperately want to control their illnesses and will resort to any number of evidenceless therapies for psychological comfort. But this comfort can do more harm than good when (as you describe) guilt and fear surface as the outcome isn't influenced by all these positive thoughts or magical therapies. Self flagellation can result (if I had only thought MORE positively, or if I had only taken this supplement at this time...) and I don't see much benefit in that. It's absolutely natural to want to feel in control - and there are some things people can do to influence how they live with and through illness - but magical thinking is not helpful in my view. Stay positive, be realistic, do the best you can under the circumstances, enjoy life to the fullest... but don't beat yourself up about things you can't change. The Serenity Prayer sums it up nicely...

At Mon Aug 20, 10:39:00 PM, Blogger Drew Rosielle MD said...

Dino this is one of my favorite subjects. Barbara Ehrenreich (a breast cancer 'survivor' who actively and eloquently rejected the cult of the pink ribbon, hope, and positivity) wrote a fantastic editorial about this in Harper's earlier this year which I discussed when it came out on my blog Pallimed. She frames it as being 'against hope' although it is really against 'positive thinking.'

Her last paragraph (the full essay is available at her website):"

"I got through my bout of cancer in a state of constant rage, directed chiefly against the kitschy positivity of American breast-cancer culture. I remain, although not absolutely, certifiably, cancer-free down to the last cell, at least hope-free. Do not mistake this condition for hopelessness, in the beaten or passive sense, or confuse it with unhappiness. The trick, as my teen hero Camus wrote, is to draw strength from the "refusal to hope, and the unyielding evidence of a life without consolation." To be hope-free is to acknowledge the lion in the tall grass, the tumor in the CAT scan, and to plan one's moves accordingly."

At Tue Aug 21, 02:27:00 PM, Anonymous Anonymous said...

Hi, stupid med stu here. I just wanted to know, what should you say in response to the patient who says "I wouldn't get lung cancer if only I hadn't smoken"?

At Tue Aug 21, 03:25:00 PM, Blogger #1 Dinosaur said...

fh: "You don't know that. Many people get lung cancer without having ever smoked. Now that you have it, though, let's concentrate on treating it instead of wasting time and effort worrying about where it came from."

(Oncology colleagues: feel free to chime in with your spiel)

At Fri Aug 24, 05:58:00 PM, Blogger Radioactive Tori said...

Now we need to figure out a way to make all medical professionals aware that patients did not cause their cancer. I had to go to a cardiologist (relating to my thyroid cancer if you can even believe that) and the nurse repeatedly asked me why I had cancer. It took me a while, but I finally figured out she was trying to find out what "bad" thing I did that gave me cancer. I told her she was lucky that I am not easily offended, told the doctor what she had said, and hopefully she will never do that again to someone who would believe her that it was their fault. It boggles my mind that a nurse would say something like that!

I love Sarah, she was an amazing person. She is absolutely right. I am terrified to watch the tv special crazy sexy cancer, or whatever it is called because I fear it is going to make people believe the results of cancer are an effect of how they deal with it. Positivity is great, but it doesn't cure cancer!

At Sat Sep 29, 06:50:00 PM, Blogger Synchronicity said...

Thank you so very much for this post! I do not have cancer but I do have MS and there is such a determination of people to force the rose colored glasses down your throat. People with illness have to grieve. They get sad and angry and everything in between. Thank you so much for giving patients the right to feel as they feel. You rock doc!


Post a Comment

<< Home