The Importance of Mental Resilience

[timbj]

I'm Tim Cahill and I live in Stafford, UK. I have got a pancreatic NET which has metastasised to my liver.

This is an extract from a book I wrote in 2006 with the help of my wife Julie. It details our experience with cancer and what we have learned about fighting cancer. Having read many of the posts on this site, I've put it up here in the hope that it might help some folk. Please let me know if it is worthwhile.

Chapter Six – The importance of mental resilience

Outline of topics covered in this chapter

• Ordinary people can achieve extraordinary results
• Self esteem – what it is and why it is crucial in the fight against cancer
• Dealing with your emotional reaction to a cancer diagnosis
• The amazing resource between your ears
• Being a positive patient and a curious patient
• Mental resilience and the Stockdale Paradox – it isn’t enough to be optimistic


Ordinary people can achieve extraordinary results

Let us start this Chapter with a very positive note. We do believe, passionately, that “ordinary” people are capable of achieving quite extraordinary things. Throughout our respective careers, we have seen many examples of this in the workplace and in response to challenges in all aspects of life.

We want to examine the nature of this latent ability which, when circumstances are presented, can enable “ordinary” people to raise their game and face up to a major challenge. In some cases, that challenge will be life threatening. Why is it that some people exhibit that ability and others do not? Are some people just gifted in that way or is this potential within most of us?

If you were looking for the embodiment of quiet grit and persistence it would be Mick Parker. Mick is a joiner by trade and he would be the first to admit that he is not a natural athlete – he had never ridden a bike until he was in his mid-twenties. Then, encouraged by the cycling daft Cahill family, he took up cycling in the 1970s. At first, Mick’s interest was in cycle touring – covering most of the UK map between Lands End and John O’Groats. Pulling his trademark trailer behind his bike, piled up with camping equipment and every cycling tool and spanner known to mankind, Mick soon acquired the nickname “pony”.

Later, he was persuaded to ride in the British 24 Hour cycling championships so that John Cahill (Tim’s brother) and his cousin Mick Coupe (both excellent riders who had already won individual championship medals), could muster the required three riders to make up a team. Mick took up cycle racing and, through sheer determination rather than God-given ability, eventually completed the gruelling 24 Hour event. Mick suffered all kinds of pain in his legs and back to complete the course and ensure that the North Staffordshire St. Christopher’s team won the team event.

Mick persevered with his training and raced for many more years, adding to his medal collection and to his rich collection of stories which will be retold, with humour, hundreds of times during his lifetime.

How many people do you know, dear reader, who could ride a bike practically non-stop for 24 hours and cover around 460 miles?

We live in an age where the media focus on the extraordinary and the unusual; on building up heroes and superstars, then knocking them down. If we took too much notice of these media by-products in benchmarking our own abilities and potential, we might conclude that we are indeed poor specimens compared to their heroic levels of performance and achievement. Fortunately, you do not have to be a super-hero or famous or an outstanding athlete to conquer cancer.

In this Chapter, we want to examine the choice we might have to make between fighting and not fighting cancer or indeed any other potentially life threatening illness. We will look at some of the factors which future cancer patients might want to concentrate on in reaching such a decision. In doing so, we are well aware that, for some sufferers, the cancer may have progressed too far by the time of the diagnosis (according to conventional wisdom) for medical professionals to offer anything other than palliative care to make the patient as comfortable as possible for the remaining period of their lives.

Both of us have known people who died as a result of cancer just as we know people who have survived cancer. What we want to examine is the range of factors which the patient themselves can influence in order to maximise their chances of survival. There are no guarantees with cancer. We cannot guarantee that if you follow all the advice in this book that you will survive cancer. However, if you do follow all the advice, which we have distilled from many authoritative sources, we do believe that you will maximise your chances of survival.

In the recommended bibliography at the end of the Chapter, we point you to some remarkable books in this area of cancer survival which we promise will be inspirational. Whilst acknowledging that survival against the odds is always a theoretical option, many would say that there may be some merit in coming to terms with a terminal diagnosis rather than sustaining “false” hope for the patient and their dependents. It is a fact that, by coming to terms with the idea that they will soon die, experience shows that some patients can increase their life span and many can improve their quality of life in the period before they do eventually die.

We recognise that it is a fine line to tread and unless they are in that “near death” situation, no-one can be absolutely sure of how they would react to such a diagnosis. But we both think that we would want to fight to the very last and never give up. Furthermore, our research for this book has brought to our attention hundreds of cases where even terminally ill patients achieved what doctors term a “spontaneous remission” from their cancer. So who is to say that the term “terminally ill” always means what it implies. Certainly, Tim’s experience, as described in Part One of this book, is not about being diagnosed at any stage as being “terminally ill with cancer”, though it is clear that the effects of his cancer were very nearly fatal.

Lest we are accused of naivety or offering false hope, we want to make it clear what kind of situation we are addressing in this book. The normal staging of cancer is that there is a period of many weeks, sometimes many months or even years, after the cancer starts to develop and is diagnosed and before it develops and spreads in situ or by secondary growths to the extent where its impact cannot be reversed by surgery or any other medical intervention. In that period, we challenge the notion that it is right to accept that death is the inevitable outcome of cancer. Even if all the statistics for your particular type of cancer point in that direction, you can still choose to believe that you will be one of the survivors.

We are not claiming that everyone can survive cancer just because they believe they will. But in many cases, that belief can become a self-fulfilling prophesy and can be the difference between life and death. The will to live has been demonstrated time and again to be a very powerful factor in defying the odds. Judging by what other cancer survivors and oncologists have written, what we have to say may even be applicable in terminal cases too. We believe that it is never wrong to go on believing that you can survive. It is your right as a human being to hold onto that belief no matter what anyone else says.

The Anatomy of Hope, written by Dr Jerome Groopman of Harvard Medical School, is a valuable and moving book centred on this question of hope – whether it is ethical for doctors to hold out hope in the face of overwhelming probability that death will soon occur; or whether they have the duty to sustain hope within the patient whatever the outcome. After thirty years experience as an oncologist and through his own experience with years of chronic back pain, Groopman is clear where he stands. “My place is to provide choice and understanding. To hope under the most extreme conditions is an act of defiance that … permits a person to live his life on his own terms. It is part of the human spirit to endure and give a miracle a chance to happen.”

As the powerful anecdotal evidence of his book underlines, Groopman is convinced that “miracles” do happen. We both believe that too but there does need to be something more than defiance at work. Groopman goes on to describe the biology of hope: the deep seated biochemical processes whereby our brain can summon up a molecular army which has the right equipment to attack cancer at a cellular level.

In this Chapter, we are interested in exploring the fertile conditions which must exist in our minds in order for the seeds of a miracle to be planted and to encourage them to thrive.

Self Esteem

A central theme in this book is that to maximise your chances of survival, you do need to be positive in your reaction to cancer. You have to believe that you are worth the fight as a valuable and valued member of the human race. Whether or not you have that belief is at the heart of your character, your spirituality, your personality or whatever other label you would like to attach to how you perceive yourself and hence how you are perceived by others.

This inner value system is called self esteem and we believe it is the root cause of many good and bad aspects of our lives. It determines how well we get on with ourselves as well as how well we get on with others, because of its influence on how we project ourselves and how people react to that image. Some psychologists (particularly educational psychologists in the USA) have, in recent years, rebelled against the notion of self-esteem as some kind of mental tyranny which ties us into a sense of dissatisfaction with our lives and our achievements. However, we think it is too glib to dismiss self-esteem just because some psychologists choose to see it as an inherently negative concept.

We believe that self-esteem is close to the very core of our consciousness. Being aware of ourselves and of others is more than just a physical sensation, captured mainly through our senses. As human beings, we cannot escape our ability to think about things. Our thoughts will tend to push themselves into our state of being aware - our consciousness - whether we want them to or not. Indeed, the philosopher Descartes took this awareness as the only certain proof that our existence is not illusory or a trick of our senses. “I am aware that I think: therefore I know that I exist” being a loose translation of his famous dictum “Cogito ergo sum”. He might also have added that the fact that he was having a conversation with himself (inner speech) was also a sign of consciousness.

Our awareness of our thoughts creates two levels of existence, at least in our mind. In the Hindu tradition, the concept of self comprises two parts. First, there is the basic level of thought which involves our responses to physical stimuli, including desires and needs. Then there is the deeper, real self that is concerned with reflective and introspective thoughts. We are able to think about ourselves thinking on another level. This deeper self may be at the root of our sense of spirituality.

It seems to us to be self-evident that, being aware of ourselves, we will have a view about ourselves, just as we make assessments of other people. Though we understand and accept that our self-assessment can be faulty and sometimes more negative than positive, we are content to stick with the concept of self-esteem. We recommend that you do too.

The psychologist and philosopher Nathaniel Branden has devoted over forty years of his professional life to the concept of self-esteem and it underpinned much of his clinical psychotherapy with clients. Branden believes that self-esteem has two essential components: self-efficacy and self-respect. He defines self-efficacy as the ability to cope with life’s challenges, having confidence in our abilities and hence a sense of control over one’s life. Self-respect is about experiencing oneself as deserving of happiness, achievement and love.

Branden sees self-esteem as being a self-reinforcing mechanism. When we are confident in our abilities to act and to think effectively, we will tend to act and think effectively and as a result be more successful. The exact opposite happens when we doubt our abilities to act and think effectively.

What we propose is that you accept the concept as an insight into your inner self but one which is not fixed for all time. If you have low self-esteem, you can learn to refocus and re-frame your self-assessment so that negative aspects are diminished and positive aspects are enhanced. This is not about self-delusion but more about getting a less-judgemental acceptance of who you are as a person. You may need to learn about how to challenge your immediate assessment of an outcome and to separate the feelings you have about that outcome from your beliefs about yourself. You might need help from a personal coach or counsellor to do this or you might choose to learn how to do this recalibration by yourself.

Ever since Plato had the foresight to write down the teachings of Socrates, philosophers and psychologists have accepted the reality of inner speech as a crucial component of our common humanity. It is a central process in the operation of the human mind and it helps us to conceive ideas and test future scenarios about any aspect of our lives.

Socrates: And do you mean by conceiving, the same which I mean?

Theaetetus: What is that?

Socrates: I mean the conversation which the soul holds with herself in considering of anything. I speak of what I scarcely understand; but the soul when thinking appears to me to be just talking - asking questions of herself and answering them, affirming and denying. And when she has arrived at a decision, either gradually or by a sudden impulse, and has at last agreed, and does not doubt, this is called her opinion. I say, then, that to form an opinion is to speak, and opinion is a word spoken - I mean, to oneself and in silence, not aloud or to another:

THEAETETUS by Plato
Translation by Benjamin Jowett

What we need to do is to turn the power of that thinking conversation onto our current problem: cancer. In Chapter Nine, we will return to this concept of inner speech and how we can create an image of our own future in our minds which can be directed towards healing our bodies. At its simplest, it means that we can create a focus on our recovery and a belief that we will achieve that recovery. What we know from recent advances in physiology is that creating a focus and a belief can have the most profound effects on our body’s biochemistry, including stimulating our immune system, moderating our perception of pain and changing our mood from uncertainty or despair to one of optimism and energy.

If you remain sceptical about this, we invite you to consider the current understanding of the placebo effect. Time and again, controlled experiments in medical settings have demonstrated that a patient’s belief in the efficacy of a tablet or a procedure (though of no intrinsic value) can have immediate and measurable changes in their physiology and improvements in their well-being. Positive thoughts in our mind (inner speech) can lead to positive actions in our body.

There are plenty of books available which explain some of the techniques you can use to alter the nature of your conversations with yourself. We suggest some books at the end of this chapter that specifically address the issue of building your self-esteem. You will not give yourselves a fighting chance against cancer if you don’t think you are worth the fight.

Self-esteem can be the bedrock of a happy life or the shifting sand underlying a miserable existence. If we have low self-esteem, we may feel that we are not worth fighting about. “Why bother with me?” rapidly becomes a self-fulfilling prophesy. Low self-esteem probably kills more people than cancer, heart disease and road traffic accidents combined. We are sure you can bring to mind examples of people who just “gave up” or “lost the will to live”. But you will never see “low self-esteem” given as the cause of death on any death certificate.

Later in this chapter we will discuss how self esteem is a key component of self awareness and that by developing our self-awareness we can take greater control of our responses to situations. That control of our responses provides us with a stable platform for choosing how to respond to an external stimulus – perhaps to a comment by someone or to a particular type of behaviour they are exhibiting. From there, we can be more focussed and in control of the situation itself. It is well understood that having a degree of control over your situation lowers your stress levels.

If you know that you suffer from a poor self-image, you need to work on that straight away. If you have cancer, this could be crucial to your survival. If you haven’t got cancer (yet), just contemplate the fact that one in three of the population are likely to be diagnosed with one form of cancer or other at some stage in their lifetime. Don’t put off addressing this issue of low self-esteem. It might just save your life.

The September 11th terrorist attack on the World Trade Centre in New York was a disaster made all the more poignant by the many stories of heroism and courage of so many caught up in that tragic event. This ability to keep going through adversity and loss and then to learn and grow from the experience afterward is an amazing characteristic of our species. How people cope with major life challenges has always been a rich source of anecdotal data.

We read of a case in America where a patient, very ill and desperately in need of a liver transplant, was waiting in the operating theatre. She was just moments away from getting a healthy liver when the donor family changed their minds. This was the third transplant attempt that had failed for the same reason. If you had been that patient, just imagine how you might react in such circumstances. This is how that patient described her response. "It was devastating, just devastating.” Then she added “But this time, I said, ‘You know, it's just not meant to happen.’" This acceptance of how things had turned out demonstrated that she had a kind of mental toughness which allowed her to adapt quickly to the new situation, no matter that it was a very stressful one.

Now science is beginning to look seriously at the phenomenon of mental toughness. Psychiatrists and psychologists who follow the progress of patients with this attribute find that there are specific characteristics that make people mentally flexible in the face of misfortune and major disappointments. The first of these characteristics is self esteem. Many studies have shown that people who have a very positive sense of self, who feel good about themselves and have generally good self esteem, cope much better in dealing with stress and trauma than people with low self esteem.

Another characteristic of mentally tough people is the ability to retain a sense of optimism even when faced with tragedy. It has become something of a cliché in the business world to say that you should see every challenge as an opportunity and therefore change is to be welcomed and, indeed, embraced. This is sloppy thinking in our view. Not all change is good change, though ineffective leaders in organisations often fail to see that. Mental toughness is not about mindless optimism but it does involve trying to see something positive in the midst of confusion and setbacks and then building on those positive bits rather than dwelling over long on the negatives.

There have been some significant findings that individuals who are religious or spiritual in their outlook, respond more positively to stress in their life and with better outcomes. The American patient we mentioned earlier did not give up. At the fourth attempt, she had a successful liver transplant. Interestingly, she said that her strong faith was the main factor that got her through the ordeal. We will look at this question of faith and health in more detail in Chapter Ten.

There is a growing body of evidence that individuals who feel responsible for themselves and take charge of what happens in their life respond to stress in ways that minimise the impact. We can add to this that having a social support system and being willing to alter priorities also helps to build mental adaptability. Another characteristic of adaptable individuals is that they do not regard themselves as a victim in difficult situations. Instead they think and act positively in order to determine their own destiny.

In addition to this inner resolve to fight cancer, you need to draw on help from many people and form them into an effective support team. We write about support teams in Chapter Seven. “You are what you eat” is one of the great truisms and we write in Chapter Eight about the importance of diet in fighting cancer. In Chapters Nine and Ten we give more information and advice on other factors which can improve your chances of surviving cancer.

But unless you believe deep down to your boots that you are going to get better, you will dilute the impact of all the other supporting mechanisms. The Lance Armstrong Foundation believe that in the battle with cancer, knowledge is power and attitude is everything. We agree. You must become a person with attitude - and we don’t mean that in any disparaging sense.

Dealing with your emotional reaction to a cancer diagnosis

Tim’s conversations with Sheila Handley and Mavis Dean reminded him that a person’s response to being diagnosed with a serious illness is nothing to do with conventional intelligence. For example, Sheila is a very bright woman – she is a member of MENSA, the organisation for people whose IQ is in the top 2% of the population, – and yet her response to the diagnosis of her breast cancer was initial denial and then giving in to a release of overwhelming emotions. In similar circumstances, it is predictable that the person’s supporters and family will be similarly overwhelmed by their individual emotional responses, with lots of sorrow and tears but not a lot by way of practical help. Often, there will be a refusal to accept the diagnosis; a disabling fear of the course of treatment facing the patient and a brain numbing, head-in-the-sand response on the lines of “this isn’t happening to me; it will just go away”.

Contrast this with the response from our friend Mavis who is of average intelligence, like the majority of the population. Mavis was very “matter of fact” on hearing the diagnosis that she had breast cancer. Her husband Bill was more upset than she was. Mavis became very focussed about beating cancer. Clearly there was something at work in Mavis’s mind that was to do with the control of her emotions. Her determination that she was going to get better may well have been the critical factor in her being around to read these words now. She was the only survivor in her ward of six women receiving similar treatment for breast cancer. Though this happened over twenty years ago, Julie recalls that Mavis “put on make up and got on with her life”, starting on the day after her mastectomy operation.

We are not saying that displaying your emotions is wrong. It may be necessary to go through a kind of grieving process when you hear of your cancer diagnosis. To be aware of how you feel is an ability to treasure, a real strength: and giving release to your feelings is very healthy in psychological terms – provided that you don’t let that phase last too long and dominate your response. Within a matter of a few days or a few weeks, depending on how advanced your cancer is, you will have to come to terms with the facts and start to plan your fight – if you want to survive.

That is what happened in Sheila’s case. It just took a while for her to deal with her emotions and to move on to the next phase. Tim had a similar reaction when he learnt that he had a metastasis on his liver – even though he had not reacted in that way when told of the existence of the primary tumour some months previously.

Emotions are much misunderstood, especially by men! It is conventional wisdom that women are much more in touch with their emotions though some men might argue that they are, as a result, more often overwhelmed by them. Though there is a grain of truth in both these stereotypes, we need to dispel some myths about emotions; particularly that being emotional is a sign of weakness. Writing in 1997, the psychologist Dr Jeanne Segal posed an interesting test for her readers. She asked them to consider the following statements and then decide whether each one was true or false. You can try it now:

Emotion is inferior because it is more primitive than reason
Emotion is dangerous
Self-control comes from stifling feelings
There are good and bad emotions
Emotion clouds your judgement

The correct answer is that all these statements are false! For the greater part of the last century in the western world, parents were guilty of conditioning their children into believing that it was a weakness to show emotions. This was reinforced in schools too. Being emotional was undesirable we were led to understand. Boys especially were told to be “a brave soldier” rather than to cry if they were hurt. Girls too were mocked as being “babies” if they became upset or tearful. Thankfully this started to change as the psychological damage done to children and adults through suppression of their feelings became more widely recognised. But you can still hear this negative language if you stop to observe human behaviour – whether it is in the high street, a shopping mall or in an airport departure lounge.

Throughout history, emotions have played a large and important role in people’s lives. We see them as a defining characteristic of our humanity. To deny emotions any part in our decision making process would mean that we were indeed a collection of cold fish, rather like Mr Spock of Star Trek, the TV space adventure series. To deny our feelings about an incident or happening would be to diminish our value as a human being. Not many decisions in our complex lives can be reduced to just rational considerations without losing a great deal of humanity in the process.

If you are still hanging on to a vestige of doubt about the role of emotions and feelings in our lives then consider the following words from one of the 20th century’s greatest minds, Dr Albert Einstein, who said “I never discovered anything with my rational mind”. What Einstein implied was that if he had ignored his feelings, including what we call “hunches”, he would never have made the leap in logic required to unlock his many discoveries.

The amazing resource between your ears

You might not regard yourself in the same class as Einstein when it comes to intelligence or brainpower. Not many people on the planet have been blessed with his level of rational or cognitive intelligence, that is, his ability to use the process of reason and to solve complex problems. But, as the American psychologist Howard Gardner postulated in 1983, we have many different forms of intelligence. Gardener’s work has been more valued by educators than psychologists, the latter being uneasy at the lack of any empirical research to justify his conclusions. Nevertheless, even on a common sense basis, Gardner’s list of seven intelligences (which he later increased to eight) is helpful in understanding our diversity as a species and the richness of talents that people can develop.

Since Gardner's original description of these intelligences in his book “Frames of Mind” (1983) he looked at three possibilities which might be added to the list, namely a naturalist intelligence, a spiritual intelligence and an existential intelligence. He concluded that only the first of these merited adding to the original list.

Gardner’s forms of intelligence can be summarised as follows:-

Linguistic intelligence involves the ability to learn languages, and the capacity to use language to achieve certain goals. This intelligence includes the ability to use language effectively to express oneself rhetorically or poetically.

Logical-mathematical intelligence consists of the capacity to analyse problems logically, carry out mathematical operations, and investigate issues scientifically. It includes the ability to detect patterns in number sequences, to reason deductively and to think logically.

Musical intelligence involves skill in the performance, composition, and appreciation of music. It includes the capacity to recognise and compose musical pitches, tones, and rhythms.

Bodily-kinaesthetic intelligence entails the potential of using one's whole body or parts of the body to solve problems. It is the ability to coordinate complicated bodily movements, as in ballet or sport.

Spatial intelligence involves the potential to recognise and use the patterns of wide space and more confined areas.

Naturalist intelligence enables human beings to recognize, categorize and draw upon certain features of the environment, for example patterns in nature.

Interpersonal intelligence is the capacity to understand the intentions, motivations and desires of other people. It allows people to function effectively with others.

Intrapersonal intelligence entails the capacity to understand oneself, to appreciate one's feelings, fears and motivations. In Gardner's view it involves having an effective working model of ourselves, and to be able to use such information to regulate our lives.

Some of our most important decisions in life are not reached by what we might call our thinking or cognitive brain. For example, one of the most basic decisions in a sudden dangerous situation is the so-called “fight or flight” reaction. In the face of the danger, say a snarling dog, do we move quickly away or stay to fight it off? In milliseconds, our survival mechanism kicks in from our brainstem - the “primitive” brain – before any cognitive or rational thinking process reaches any conclusion about the pros and cons of alternative courses of action. Similarly, we have an emotional response to many situations that triggers powerful reactions, possibly overwhelming alternative and rational suggestions coming from the cognitive brain.

Let us consider the resources that we have available to us in making that “fight or not fight” decision in relation to cancer. We are a remarkably intelligent species by comparison with the other creatures on the planet and even in comparison to that remarkable product of mankind’s creativity, the computer.

The computational capacity of the human brain is estimated at 20 million billion calculations per second. If you want to see that as a number, it is 20,000,000,000,000,000 calculations per second. That is twenty times greater than the world’s biggest supercomputer currently can achieve. We suspect that for many of us, a lot of those zeroes in the number are rarely brought into full effect. In other words, each of us has a huge untapped potential sitting between our ears! The next time you catch yourself saying “That’s too difficult for me” or “I could never master that”, just remember those unused zeroes!

One of the widely accepted theories on how the brain works is that there are three distinct regions. This is the so-called Triune Brain Theory first described by Dr. Paul McLean of the National Institute for Mental Health in the USA. In descending order of evolutionary appearance, these are the Neo-cortex, the Limbic System (or Midbrain) and the Reptilian Brain (or Brain Stem). The Neo-cortex, with its highly convoluted surface, accounts for 80% of the brain mass, oversees higher order skills like language and constitutes what we refer to as the “rational” part of the brain. It is in the neo-cortex that we build our maps and models of the world and create “meaning” from external stimuli.

The Limbic System deals with our emotions, belief and value systems and is possibly the centre for our long term memory. Experiments have shown that emotional “tagging” of events makes them more memorable. Receiving a “copy” of the external stimulus at the same time as the neo-cortex, the mid-brain attaches emotional significance to it and sorts and passes on what is considered important to conscious attention. It is estimated that the limbic system works 80,000 times faster than the conscious brain – giving us an “instantaneous reading” on believability and trust, for example when we recognise a face.

The primitive or reptilian brain is centred in the brain stem and is the oldest evolutionary part of the brain. It controls all routine body functions and our instinctive behaviour. It is our ‘survival’ manager and takes over control if conditions are threatening.

So, in brief, we have an astonishing piece of apparatus between our ears but we need to understand that it is only partially under our direct or rational control. If it offers a decision to us based on a reaction to events, we should be suspicious of which part of the brain is dominant. In our ‘reaction to cancer’ scenario, we can discount the contribution of the primitive brain, apart from ignoring the initial urge to run down the corridor screaming, after the doctor has delivered his diagnosis.

The struggle is between the rational brain and the emotional brain. Philosophers and faith healers have been observing that struggle since Plato’s first commentaries two thousand years ago. In the last fifty years, an ever increasing number of psychiatrists, psychologists, neurologists and other scientists have brought their formidable intellects to this area of study.

It is pertinent to be reminded that the separation of emotions from physical symptoms of disease is a 20th Century phenomenon or “development”. In their book “Getting Well Again”, written by Carl and Stephanie Simonton with James Creighton, the co-authors review the history of the connection between the emotions and cancer. One of the references is to the writings of the physician Galen who noted (about eighteen hundred years ago) that depressed women were more likely to succumb to cancer than were cheerful women.

In the eighteenth and nineteenth centuries, it was commonplace for medical books to ascribe emotional states as being the cause of tumours. The authors of these books, separated by many hundreds of years, were not stupid people; they were physicians who in their time were the world’s best and they were not theorists. They wrote their conclusions based on the evidence of their own eyes and long experience of treating people with cancer. We might wonder, from our perch a little higher up the knowledge mountain, at their lack of knowledge of biochemistry and other modern sciences but as observers of the emotional states of patients, we venture to suggest that they were at least as well attuned as many modern day oncologists.

With the rapid development of medical knowledge and technologies at the end of the nineteenth century, following physicians like Louis Pasteur, the diagnosis and treatment of illnesses started to be dominated by the physically observable evidence. The fuzzy relationship between one’s emotional or mental state and the physical symptoms of disease sadly was lost altogether in the more rigorous application of scientific method. It was only towards the end of the 20th century, with advances in biochemistry, neurology, psychiatry and psychology that physicians were willing to reintroduce emotions into the “whole patient” picture.

Being a positive patient and a curious patient

At the heart of the approach we are encouraging is the idea of being a positive patient and a curious patient too! You need to make good use of some of those unused “zeroes” we referred to earlier! What we mean by “curious” is taking responsibility to find out as much as possible about the challenge facing you and your loved ones. We can contrast this to what we call the passive patient syndrome.

Rachel, one of the nurses at St. James’s, described some of the symptoms of the passive patient syndrome as “walking into the hospital ward, changing into your pyjamas and dressing gown, then lying down on the bed, as if waiting for the doctors and nurses to bring about a cure for your condition.” She told Tim “we have to smile at that, we see it so often”.

It is a powerful image to bear in mind, the idea of lying down and waiting to get better. You might but there again you might not. Are you comfortable with that? Is that your idea of a fighting chance? We hope not. The very fact that you are reading a book such as this means that you are likely to be looking for ways and means to improve your chances of survival. It shows that you have taken some positive steps already to influence the course of events. It shows that you have a degree of optimism about your situation.

However, an optimistic attitude is not enough. Some researchers claim to have shown that having a positive mental attitude does not improve a cancer patient's chances of survival. This conclusion was based on a review carried out by the Glasgow-based Social and Public Health Sciences Unit and published in November 2002. They had looked at 28 previous studies that investigated the way in which people cope with their illnesses. The researchers claim to have “scoured medical databases for all research published in the field …. that investigated a link between psychological coping and survival, or looked at recurrence of the cancer”. Of the 28 studies reviewed, ten investigated the impact of a "fighting spirit". Of these, only two small studies were said to have produced positive evidence of a link with survival.

This whole question of “mind over matter” sparked quite a long and controversial debate in the 1990s. It started with the results of a study, which startled the “cancer community” when it was published in the journal ‘The Lancet’ in 1989. Undertaken by Dr David Spiegel of Stanford University School of Medicine in California, this was a 10-year study indicating that group support not only had positive effects on quality of life for metastatic breast cancer patients, but also lengthened survival time by almost two years on average. Those patients in the psychotherapy support group met weekly to explore issues related to living with cancer, including fears surrounding death and the dying process, family adjustment, and communication with physicians. It was a focussed programme of discussion, the scope of which was determined by the patients themselves.

More recently‚ a larger study in this field was conducted by Dr Pamela Goodwin‚ an oncologist at Mount Sinai Hospital in Toronto. Again, the study made headlines in the cancer community not only for what it disproved‚ but for its other conclusions. Dr. Goodwin concluded that while group therapy does not prolong survival in women with metastatic breast cancer‚ it does improve “mood and the perception of pain‚ particularly in women who are initially more distressed”. Observers commented that the research showed that we do not extend life just by patients joining support groups‚ “but we surely do improve the quality of life”.

What are we to make of this? Can Spiegel’s and Goodwin’s studies have been measuring the same effect? When we dig a little deeper into Goodwin’s conclusions, we find a comment by Dr Jimmie Holland‚ of the Memorial Sloan–Kettering Cancer Centre in New York‚ that “such findings are connected to survival in that women who are very depressed might not go for treatment‚ which will have an impact on survival”. Ah! So there might after all be a very good reason in having support groups because they do have an impact on the survival chances of depressed women otherwise reluctant to undergo treatment!

Twenty five years on from Spiegel’s famous study on support groups, he was asked “How much of a role do you believe state of mind plays in dealing and moving through the cancer experience, and do you think a really positive state of mind is enough to ward off the possibility of recurrence?

Spiegel answered “I wish I did but I don't. There is no magic talisman. The problem with that point of view is that it can lead you to avoid dealing with natural reactions to the illness and also to blaming yourself if the disease progresses. I think there is a difference between being rigidly upbeat, which my patients call the prison of positive thinking, and being realistically optimistic - seeing what lies ahead of you and what is happening but finding the best life you can with this disease. It is more a matter of being optimistic about life but not giving yourself false hope, and also not giving yourself false despair.”

The conclusion we draw from this “mind-body” debate is rather different from the Glasgow reviewers. We conclude that they and many before them were looking at the wrong kind of characteristics from which to draw conclusions about the impact on cancer survival of having the right mental approach. We would draw a clear distinction between optimism (and what one could characterise as a “positive mental attitude” or a “fighting spirit”) on the one hand and, on the other hand, the dogged, dour determination to hang onto life, stemming from what we recognise as mental resilience. Mental resilience is not to be confused with staying bright and cheerful or determinedly displaying a bright smile for the benefit of your visitors.

We do not suggest that having an optimistic or positive mental attitude will have an impact on your long term survival. That is only part of the mental attitude you need. You need to have mental resilience.

Mental resilience

But what exactly is mental resilience? It can be confused with stubbornness but being stubborn isn’t enough. Often, stubborn people close off their minds to new information and other perspectives on a situation and persist on holding onto their own opinion or interpretation of events, even when all the facts indicate that they are wrong. Stubbornness may prevent a person facing hard facts head on. Indeed, it can deepen their resistance to outside help which could improve their situation.

One of the clearest statements of the term “mental resilience” is captured in the Stockdale Paradox, a term coined by Jim Collins in his excellent book “From Good to Great”. Collins’ book is a masterly piece of research about the factors which differentiate those companies which far exceed the performance of those who merely achieve average performance (as measured by rise in stock exchange value over twenty or so years). Whilst writing his book, it was Collins’ good fortune to meet a remarkable man named James Stockdale, for the latter embodied the meaning of “resilience”, which was one of the key factors identified in Collins’ “great” companies.

What can this example from the world of business tell us about surviving cancer? First, you need to know a bit about Admiral James Bond Stockdale. He was the highest ranking US military officer captured by the Vietcong during the Vietnamese war.

After his aircraft was shot down, he was held in the notorious Hoa Lo prison, ironically renamed the “Hanoi Hilton” by the POWs. He was tortured over 15 times during his 7 years as a prisoner. The torture techniques included beatings, whippings, and near-asphyxiation with ropes. He spent 4 years in solitary confinement and two of those years in leg irons. He was under-nourished and there was not a chance of his receiving medical care for his injuries. It left him with horrific scars on his body and a permanent limp.

Just imagine the mental strength it would take to survive that sort of experience.

Explaining to Jim Collins how he survived those years as a prisoner of war Stockdale said “I never lost faith in the end of the story. I never doubted not only that I would get out, but also that I would prevail in the end and turn the experience into the defining event of my life, which, in retrospect, I would not trade.”

Collins: “Who didn’t make it out”?

Stockdale: “The optimists. They were the ones who said ‘we’re going to be out by Christmas’. And, Christmas would come and Christmas would go. Then they’d say, ‘We’re going to be out by Easter.’ And Easter would come, and Easter would go. And then Thanksgiving, and then it would be Christmas again. Then they died of a broken heart.”

“You must never confuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”

Source: “From Good to Great” by Jim Collins

This last sentence is the essence of the Stockdale Paradox. The key to Stockdale’s survival (and that of 600 other POWs who looked to him for leadership) was the ability to hold these two seemingly contradictory notions in the mind simultaneously. You have to believe that your objective can be achieved and you have got to do everything in your power to make it happen. But you must never let your belief and faith cloud your judgement about the facts facing you. It is a question of balancing belief with reality. So it is with cancer.

Does this example suggest that you have to be a heroic kind of person in order to display mental resilience? If it does, we apologise for having planted that misleading fiction in your mind. We have only used the story because Stockdale was so clear in his articulation of what constituted mental resilience.

Many people who have shown similar gritty determination in adversity are not spectacular personalities, often being rather reserved by nature. What they share is an ability to hold onto an idea or a belief and grind away relentlessly day by day, doing unspectacular things very well, to turn that belief into reality. That is what you are going to have to do to defeat cancer. We believe many “ordinary” people can summon up this mental resilience and thereby achieve extraordinary outcomes.

Stockdale’s source of inspiration was a former Roman slave, Epictetus, born in 55 AD in the city of Hierapolis in Phrygia, now part of Turkey. Epictetus later moved to Rome and became a free man and a teacher of philosophy. What we found interesting in following this connection from the teachings of Epictetus, through two millennia to the present day, is how often his maxims have been recycled by other writers. Epictetus said: “We must ever bear in mind that, apart from the will, there is nothing good or bad”. We find this same Zen-like acceptance of events being repeated by Shakespeare’s Hamlet “for there is nothing either good or bad but thinking makes them so.” We will return to this notion that “thinking makes them so” shortly. It is a central issue in our recommendations for maximising your chances of surviving cancer.

First let us relate Stockdale’s adaptation of stoic philosophy to our context of illness and express the concepts in plain language. We would say that there is a preferred mental attitude to adopt towards illness of any kind. First of all you have to accept the illness as the way things are. There is nothing to be gained from an over-emotional reaction to it, even though others may think that to do so is perfectly understandable and justifiable. If you want to create your “fighting chance” of recovery, you have to move on to an acceptance of the facts. This may take some time but don’t let it take more than a day or so otherwise there is the danger that you will remain stuck there.

Then you have to decide that this is not how things will be in the future. Faced with the shock onset of an illness or a doctor’s diagnosis, we have observed how some people respond by denying its seriousness or the diagnosis itself. Denial is not helpful. Many people waste a lot of time and energy in that reaction. Nothing but nothing must get in the way of your recovery and to deny that there is a need for a recovery process will obviously prevent it starting. This is where Tim’s fellow patient Craig’s mind was stuck (see the Introduction) and it had remained stuck for eight months.

Once you have decided that this is not how things will be in the future, you have to stay committed to that decision, through thick or thin. You have to become utterly single minded and focussed about recovery. You have to use your ability to think about things as they are now and then how you want them to be in the future. You will have used these inner reflection skills throughout your life to learn from your experiences and mistakes.

Now you must put those skills to further use. You have to learn very quickly about what you need to resolve to do and then move on - without feeling guilty about what has led up to the current situation. You may have been a heavy smoker, you may have eaten the wrong foods, you may have been a complete couch potato as far as exercise was concerned and you may have denied the early symptoms of your illness. It does not matter – you cannot do anything about that now. What matters is what you decide to do from now on.

"The person who says it cannot be done should not interrupt the person doing it."

Chinese proverb.

What might be useful in cementing your resolve? Well, think through the consequences of your illness. What will be the impact on those around you, perhaps your spouse, your children and other people, like elderly relatives or work colleagues, who might be dependent upon you? It might be more productive to spend some time thinking about how sorry you would be for them if you died, rather than just feeling sorry for yourself. To quote from Epictetus again “What disturbs men's minds are not events but their judgements on events”. If you let your judgement of events be based solely on how they affect yourself, you will feed the torment in your own mind instead of quelling it.

Let us turn to the second part of Stockdale’s Paradox – facing up to the harsh facts of your current reality. You will need to find out as much as possible about the type of cancer you have been diagnosed with. There is a huge amount of information on different types of cancer available through the internet. You also need to understand the statistics about survival for your particular form of cancer. There are over two hundred forms of cancer and survival rates range from less than 5% to over 95%. Even within the 5% survival group, you will want to fight to be one of that 5% rather than not. The less optimistic the prognosis, the more likely you are to need every ounce of mental resilience you can muster.

Knowledge is power. In Chapter Three of the 2,500 year old classic text on “The Art of War”, the soldier Sun Tzu includes the saying “If you know the enemy and know yourself, you need not fear the result of a hundred battles”. It is a piece of wisdom as relevant today in the battle against cancer as it was then in battles between neighbouring Chinese kings.

What will determine whether we resolve to keep learning and stay in control of the situation or submit to feelings (emotions) of self-pity is our level of self-esteem. Will self-esteem act as our anchor or will we be inundated by the waves of emotion crashing over our heads? We cannot over emphasise the vital role which self-esteem and mental resilience will play in your fight against cancer.

Summary of key learning points

• Beating cancer is not a job you can delegate to doctors and nurses. You have to be a positive patient and a curious one too!

• In being a positive patient, you take responsibility for and control of your situation. Being a curious patient means you have to become well informed about your illness and proposed treatment and open to learning and new ideas.

• The statistics of cancer survival favour those who display mental resilience.

• Mental resilience is not to be confused with optimism or fighting spirit. It involves facing up to the harsh facts of your illness, deciding never to give up the fight and grinding away relentlessly day by day to turn your focus on your survival into reality.

• At the root of all this is self-esteem. You have to believe you are worth fighting for.


Useful books for further reading

The Anatomy of Hope, by Dr Jerome Groopman, published by Simon and Schuster, 2004 ISBN: 0-7422-6390-1

Fighting Cancer from Within, by Dr Martin L. Rossman, published by Henry Holt & Company, 2003 ISBN: 0-0850-6916-X

How to Raise your Self-Esteem, by Nathaniel Branden, published by Bantam Books, 1987 ISBN: 0-5532-6646-2

Getting Well Again, by Carl and Stephanie Simonton with James Creighton, published by Bantam Books, 1980 ISBN: 0-5532-8033-3

It’s Not About the Bike, by Lance Armstrong, published by Yellow Jersey Press, 2001
ISBN: 0-2240-6087-2

Cancer Battle Plan, (second edition) by Anne and David Frahm, published by Tarcher / Putnam, 1997 ISBN: 0-8747-7893-X

Some useful web sites

www.cancerbacup.org.uk
www.livestrong.org

[phullon]

Hi,Timbj
I really want to thank you for opening my eyes. I think when I received those words "you have cancer" it seemed that my mind and body separated. My mind understood what was going on and reacted in a positive way but I allowed my body to react in a passive way. However, by reading the information you shared from your book. I realize that the way I have approached dealing with my diagnois has been wrong. I never gave up on my survival but I allowed my mind and body to separate and to deal with the problem separately. Now I realize if I really intend to beat this thing. I have to use my mind and body as one. To get as much strenght as I can to deal with whatever comes my way. Not to anticipate bad things but to be ready to deal with them should they come my way. I have been on the RCA site since April 2010. This is the first time I ventured to the area where you wrote about Mental resilience. I would like to purchase your book. I know that you did not write the information on this website to make book sales. However, it sounds like a book I need to read. Please forward me the title of your book. You stated you wrote the book with help from your wife. It's nice to see that married couples can work together as one.
Look forward to hearing from you soon.


Phullon

[sharon]

Phullon,

The book mentioned in the first post of this topic is not, in any way, affiliated with me or the Rare Cancer website. It is something that a forum member has written and it is that forum member who has posted the excerpted info here. I just wanted to clarify that.