We still need to think critically about positive thinking in health care

Abstract

We often hear people talk about ‘fighting’, ‘not giving up’ and ‘keeping a positive attitude’ in the face of illness. These expressions are so familiar we rarely stop to think about what they really mean and, importantly, whether they are universally helpful. Almost 20 years ago in the Internal Medicine Journal article ‘Right’ way to ‘do’ illness? Thinking critically about positive thinking, McGrath et al.1 cautioned against taking this for granted. They noted how people hold different views about what positive thinking means. Perhaps influenced by the word ‘positive’ in the phrase itself, varied interpretations tend to share one assumption – that the thinking they are referring to is inherently helpful. A closer look reveals important caveats to this assumption. For example, focussing on ‘good’ thoughts or emotions while avoiding ‘bad’ ones may bring short-term comfort, but, if habitually used long term, it may delay evidence-based treatment or hinder end-of-life discussions. Further, a strong social imperative to stay positive could lead to blame and guilt for patients who struggle to maintain it. Nearly two decades later these assumptions remain, and not just for patients. A recent global survey showed positive thinking was the most popular coping strategy used by healthcare practitioners during COVID-19, ahead of peer support and exercise.2 However, they did not capture what ‘positive’ meant to study participants. Assuming ubiquity of meaning in the face of so many possible interpretations suggests we still need to think critically about positive thinking. The adaptiveness of any psychological or behavioural strategy likely depends on its sensitivity to context, including personality, illness prognosis and the social environment. Without such nuance, we risk promoting anything with the word ‘positive’ in it as an assumed universal good. It is imperative that healthcare practitioners, patients and their loved ones have effective ways of coping with the emotional burden of diagnosis and treatment. Therefore, this editorial attempts to clarify the conceptual ambiguity around positive thinking, so that we can develop research programmes and best practices that show how and when to apply it effectively. People define positive thinking in diverse ways, representing a range of strategies aimed at achieving subjectively favourable outcomes. For example, qualitative research described how patients with cancer had multiple meanings of ‘being positive’ at different stages of their illness and patients’ definitions of positive thinking differed from those of health professionals.3 So, to understand why someone regards thinking as ‘positive’, we must first understand what outcome they are trying to achieve. In the literature, these aims vary. First, positive thinking may represent focussing on good, rather than bad, outcomes.1 The Positive Thinking Skills Scale4 and a review of resilience in nursing staff5 both conceptualised the aims of positive thinking as regulating emotion, making sense of experience, engaging in problem-solving and maintaining positive expectations about the future (i.e. optimism). Together, this suggests that thinking is considered ‘positive’ when it helps a person achieve: (i) proximal psychological outcomes related to emotional regulation and making meaning of experiences, or (ii) distal outcomes, such as sustaining expectations of favourable future events. It is also important to recognise that patients' motives for staying positive may not always be entirely their own. Assumptions about the power of positive thinking can create social and moral expectations about how one should cope with illness. For example, in an experiment by Jones and Ruthig,6 participants read about a blogger with cancer who either embraced, ignored or partially followed online positivity advice. Those exposed to versions where the blogger visited a positive-thinking website but did not explicitly follow the positivity advice judged the blogger as less committed to treatment. These findings suggest that exposure to positivity norms increases attributions of personal control for patients' illness and recovery, which may exert pressure and over-responsibility. Qualitative research similarly shows that while health professionals understandably prefer positive environments, patients may feel pressure to conform to this expectation in order not to burden them.3 Thus, people may consider certain styles of thinking ‘positive’ because it pleases others. As seen, goals for positive thinking are diverse, so it is unsurprising that a range of psychological strategies is used to achieve them. These have been defined as: regulating one's beliefs, thoughts, emotions, speech and non-verbal behaviour1; noticing the need for positive thinking; interrupting, controlling, challenging or reframing thoughts; reducing negative feelings through distraction, optimistic beliefs or relaxation techniques; and breaking problems into manageable parts.4, 5 Strategies may vary depending on the outcomes people hope to achieve. A study of Irish physicians7 found that how resilience was defined affected the choice of positive-thinking strategies. Physicians defined resilience as ‘coping with adverse situations’ rather than ‘thriving’, and this led to strategies including self-awareness, reflexivity, acceptance, realism and maintaining perspective, rather than overt positivity such as ‘appreciating the good things’ and ‘believing in yourself’. This suggests that people engage in a range of positive-thinking strategies that are guided by their underlying motivations or aims and the demands of their environment. Because of this, positive thinking is likely multidimensional and contingent on many factors. Measuring it as one dimension, as done in the past,4 implies these varied strategies are all enacted in tandem towards the same aim, and that each strategy will produce the same outcomes. This flattens important nuances that could threaten construct validity and hinders communication between researchers, practitioners and patients, each of whom may be referring to something quite different when they speak of ‘positive thinking’. Table 1 outlines differences in what may be considered ‘positive’, which researchers and practitioners may wish to investigate with patients. Because there are many aims of positive thinking and many strategies to achieve those aims, it is unlikely that each positive-thinking strategy will always be ‘positive’ or effective. This likely depends on the ways strategies are applied, whether they meet individual aims and how adaptive they are to the environment. Below, we illustrate some of these contingencies with examples from the literature, to reveal the conditions under which positive thinking most likely supports or undermines well-being. Some positive-thinking strategies may be more or less adaptive, depending on the flexibility with which they are applied. As a systematic review of studies of patients with advanced cancer found that avoiding or suppressing negative feelings is helpful for short-term emotional regulation (e.g. controlling emotions before surgery, preventing overwhelm), this is less effective as a long-term strategy to avoid habitually distressing experiences.8 This is especially true if the prognosis becomes more serious, where long-term avoidance or denial may delay decision-making or important discussions with loved ones.2 Paradoxically, making meaning of experiences through acceptance may sometimes regulate emotions better than using positive emotions. Accepting rather than judging mental experiences was associated with a reduction in negative emotional responses to stressful situations, which led to greater long-term psychological health.9 This is akin to psychological flexibility – being able to notice flexibly and adapt one's mindset or behaviour to one's needs and situation – which has also been shown to be related to overall psychological health and resilience.10 Thus, the flexibility with which thinking strategies are able to be adapted to the situation plays an important role in producing positive outcomes. Some thinking strategies are aimed at more distal positive outcomes. In these cases, there are several contingencies to consider. Thinking strategies that aim to sustain hope, perceived control and self-efficacy represent goal-oriented expectations that one can get from where they are, to where they want to be. According to Karademas et al.,9 patients with cancer who have resilient traits reported higher quality of life 3 years later because of higher self-efficacy. In another study, positive thinking was found to enhance self-efficacy and coping in nurses.4 Thus, positive thinking can boost or maintain a patient's belief in their ability to achieve goals, which is likely to build resilience, coping and quality of life. For example, it may help patients persist with arduous treatment plans and maintain optimism in the face of setbacks. When positive thinking extends beyond sustaining motivation to predicting or expecting favourable outcomes, results may become more uncertain. While an optimistic sense that things will turn out well can improve well-being, it is often considered a dispositional trait and thus automatic or habitual. When applied uncritically to judging the likelihood of uncertain outcomes, it could bias decision-making. A review has suggested that whether optimism contributed to better post-surgery psychosocial functioning depended on whether pre-surgery expectations were aligned with surgical outcomes.11 Positive thinking that is poorly calibrated to realistic treatment expectations (perhaps reflexively, due to one's disposition) may lead patients to choose interventions they might otherwise avoid and experience greater disappointment afterwards if results fall short. Thus, practitioners need to balance supporting optimism while ensuring expectations remain realistic. Sometimes the aims of positive thinking go beyond raising expectations of treatment success, to viewing thoughts and emotions as causal agents in illness or healing. Thought–action fusion (TAF) is a symptom of obsessive-compulsive disorder that causes patients to believe a thought will cause an equivalent event to happen. Interestingly, TAF has also been linked to greater adoption of alternative therapies, perhaps because they reinforce similar category errors between mind and body connections.12 A culturally relevant form of TAF is manifestation, popularised in the self-help book The Secret,13 which claims that thoughts cause illness and health outcomes through a metaphysical ‘law of attraction’. In studies developing a scale to measure manifestation belief by the first author of the editorial,14 one-third of participants endorsed manifestation beliefs. While higher belief was associated with optimism, hope and self-efficacy, manifestation belief also predicted overoptimism, risk-taking and financial losses. In unpublished data from the same studies,14 it was also associated with belief that thoughts cause illness and health and use of alternative therapies. The American Cancer Society states that while optimistic thinking can improve quality of life, it does not change a person's chance of survival.15 Therefore, it is important for researchers and practitioners to understand the degree to which patients are engaging in positive thinking with the belief that it may cure their illness. This could affect their motivation to seek medical intervention or affect how patients explain their treatment progress, potentially contributing to self-blame when experiencing setbacks in treatment. It also points to the importance of interventions that help patients remain flexible and responsive to evidence, rather than being driven by rigid, socially reinforced expectations to ‘stay positive’. The evidence reviewed here highlights that positive thinking is not a single process but a diverse set of strategies that serve different purposes, depending on the person and their context. Future research should therefore move beyond measuring positive thinking as a single dimension and instead examine contingencies – psychological, social and contextual factors that moderate the relationship between positive thinking and patient outcomes. For practitioners, Table 2 offers a set of questions that might be helpful for eliciting communication with patients and loved ones about positive-thinking styles and contingencies in outcomes. This may also help researchers to examine critically positive thinking in future studies. Deliberate: May increase self-efficacy. May cause emotional strain if not authentic. Automatic: May represent optimistic or resilient traits, enhancing positive emotions. May risk reflexive overoptimism or rigidity, biasing judgement. Authentic: Identity-supporting because actions are aligned with values. Perceived outcomes may not align with reality. Performative: May be interpersonally beneficial if congruent with own needs. May cause strain or hinder processing of experiences, if not. Flexible: Adaptive psychological and situational flexibility. May hinder developing consistent identity or narrative about illness. Fixed: May represent optimism as a trait, aiding self-efficacy and resilience. May cause strain and hinder processing of experiences, decision-making or interpersonal communication if used for long-term avoidance. Idealised: May maintain hope, optimism, pleasant emotions. Socially desirable. Risks being unrealistic, hindering decision-making. May cause strain and hinder processing of experiences and interpersonal communication if used as avoidance. Evidence-based: May be more realistic, providing accurate evidence for decision-making. Enabling processing of experiences. Does not guarantee pleasant emotions or outlook. May cause interpersonal issues if loved ones are idealised. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.