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Journal of Sociology © 2011 The Australian Sociological Association, Volume 49(1): 22–40 DOI:10.1177/1440783311417742 www.sagepublications.com

Always look on the bright side of life Cancer and positive thinking

Jackie Youll Social Sciences and International Studies, University of New South Wales

Helen Meekosha Social Sciences and International Studies, University of New South Wales

Abstract ‘Positive thinking’ is widely advocated and encouraged, particularly in the area of serious illness. Yet what positive thinking really means for people remains elusive. Research undertaken with carers of people with cancer finds that positive thinking affects the experience of cancer. Findings suggest that positive thinking is an effort by carers to minimize stress and harm, which they perceive would follow from expressing negative feelings. However, from a Foucauldian perspective, common social values and discursive systems embedded in participants’ talk reveal institutional practices and power relations. In addition, positive thinking exists in popular discourse as a form of resistance and agency as well as a symptom of governmentality. It is found that the ideology of positive thinking reflects broader neo-liberal, capitalist culture and is therefore an example of ‘technologies of the self’ through which individuals and populations self-regulate so as to preserve health and maintain demographic norms.

Keywords: cancer, carers, governmentality, positive thinking

Introduction Moral pressure to be positive is everywhere in society, yet the authority of positive thinking has rarely been critically explored in sociological terms, even though it has a long history. Nowhere does the imperative to ‘think

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positive’ express its presence more powerfully than in the self-help genre (Held, 2002: 967). ‘Positive thinking’ is a historically popular ‘self help’ message (Woodstock, 2007: 184). As early as 1734, Franklin accentuated the positive through statements such as ‘Hope of gain lessens pain’ and later (1741) ‘let thy discontents be secrets – if the world knows of them ’twill despise thee and increase them’ (in Held, 2002: 966). In 1897, Henry Wood propagated that the health of the body is a manifestation of previous men- tal states (Woodstock, 2007: 177) and, in 1919, Emilie Cady promoted that thoughts had the power to change one’s health. From these early beginnings emerged a morality of individual responsibility in which the nature of one’s thinking is believed to affect the course of one’s life (Woodstock, 2007: 175).

Locating the contemporary fascination with positive thinking in an his- torical context goes back to the 1950s when Norman Vincent Peale, a minister of Marble Collegiate Church, New York and a famous preacher, published The Power of Positive Thinking. The book became a bestseller and, according to the publisher, was translated into over 40 languages and sold more than 22 million copies. In the introduction to the book Peale argued that ‘you do not need to be defeated by anything . . . you can have peace of mind, improved health, and a never ceasing flow of energy’ (Peale, 1996: xi). His work can, in turn, be traced back to New Thought and related ‘mind cure’ phenomena, which offered middle-class Americans relief from ‘helplessness’ at the beginning of the 20th century (Taylor, 1987: 329). Peale came from a religious background, was politically con- servative and the popularity of the book may be accounted for by the religious/therapeutic approach combined with problem-solving methods and techniques.

Susan Sontag (1991) writing in Illness as Metaphor traced historically how individuals with either tuberculosis (TB) or cancer were held to be emotionally responsible for their disease. Cancer victims had to be active in healing themselves; they had to fight the war against the colonizing tumours. In other words they had to think positively. Sontag challenged the idea that the patient was responsible for the disease and could will a cure (1991). Barbara Ehrenreich used her own experience of cancer in Bright- Sided: How the Relentless Promotion of Positive Thinking Has Undermined America. Using historical research and observation at motivational confer- ences, she explodes the myth that it is within our grasp to improve our health, happiness, wellbeing and wealth through positive thinking which, in the words of Nobel physicist Murray Gell-Mann, she asserts is simply a myth widely promoted by those who peddle what she calls ‘pseudoscientific flapdoodle’ (Ehrenreich, 2009: 68).

Promoting positive thinking, self-esteem, mental toughness, personal enhancement and self-improvement, the self-help movement is now a vast enterprise, with a growing proliferation of books, DVDs, websites, life

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coaches and courses. Yet sociology has been somewhat slow in examining this new cultural orthodoxy of positive thinking. This paper is based on small-scale fieldwork conducted in late 2008 which used semi-structured interviews to explore the role and effect of positive thinking on carers of individuals who have an experience of cancer. Although there exists a veritable genre of literature on positive thinking and cancer patients, there is little research on how carers experience the phenomenon of positive thinking. Seven people constituted the research participant group and the interviews were analyzed using discourse analysis. The seven participants, six of whom were female, had varied caring roles for their mothers, grand- mothers, fathers, partners and brothers.

The participants’ ages ranged from 19 to 65 years. For four of the par- ticipants, their loved one had died from their cancer. One of the individuals remains in remission and two have ‘recovered’. Interviews focused on the stories of the participant’s relationship with the loved one and their cancer journey, their understanding of the concept of ‘positive thinking’ and the role this played in their experience. The material produced was disaggre- gated into a set of categories from which findings could be drawn. All accounts of ‘positive thinking’ produced by participants were analyzed to identify significant patterns of consistency and variation (Talja, 1999: 466). Such patterns were then analyzed in view of published literature.

Discourse analysis can be considered in numerous ways from post- structural approaches to those more concerned with linguistics and remains a flexible concept. We use a discourse analysis within a Foucauldian/ post-structural framework. A discourse consists of a set of common assumptions that may be so taken for granted as to be invisible or assumed (Cheek, 2004: 1,142). Discourses both enable and constrain the produc- tion of knowledge by allowing and excluding certain ways of thinking about reality; who can speak, about what, when and with what authority (Cheek, 2004: 1,142). This paper investigates the discourse of positive thinking in individuals’ experience, where it is embedded in participants’ talk, and also within broader social values, institutional practices and power relations (Ball, 1990: 2; Talja, 1999: 459; Turner, 1987: 212).

Importantly, discourse analysis used in this research does not take the individual as the principle unit of analysis. Instead, it strives to recognize cultural regularities in participants’ accounts (Ball, 1990: 2; Talja, 1999: 459; Turner, 1987: 212). Using such an approach one does not have the impulse to replace ‘false’ truths with ‘correct’ truths, but to describe the foundation of ‘truths’ by asking ‘why’ and ‘how’ (Hazleden, 2003: 415; Rimke, 2000: 62). While the results may not be generalizable as descrip- tions of how things are, they are applicable as to how a phenomenon can be seen or interpreted (Cheek, 2004: 1,147; Talja, 1999: 472).

Illness is widely agreed to be not simply a personal condition but a social role. Social norms and expectations of behaviour affect the attitudes both

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of the person with cancer and of others with whom they interact (Turner, 1999: 104). In advanced capitalist societies pressures to contain expendi- ture on welfare are constant, and so informal caring is a socially-necessary task (Bryson and Mowbray, 1984: 271). Carers and relatives of people with cancer are therefore deeply involved in the illness experience (Kim et al., 2006; Thomas et al., 2002). By recognizing the role of carers in the cancer journey, the cancer experience is better understood as shared; as affecting the psychosocial needs of patients, carers and the family (Morris and Thomas, 2001: 87). Literature rarely explores the perceptions, use and experience of positive thinking in carers of individuals with serious illness, although from our research it is clear that carers often exhort their loved ones to think positively (Wilkinson and Kitzinger, 2000: 807).

On the individual level, positive thinking can be seen as an expression of care for the self and care for the other. It is a form of emotional work (Thomas et al., 2002) which aims to reduce the pain, fear and negativity associated with the experience of cancer. To what extent positive thinking actually achieves this remains a matter of contention. Positive thinking may allow individuals who are disillusioned with the dominant health care sys- tem to challenge conventional medical authority and exert some control thereby taking personal responsibility over their illness. Yet even as positive thinking is a form of resistance to one manifestation of authority, it also ensures that individuals comply with neo-liberal ideals of individualism and self-responsibility.

Contemporary research on positive thinking and cancer Research on positive thinking in cancer focuses on two broad hypotheses. Medical research has purported that it increases the likelihood of a good outcome, and social research suggests that it enables people to cope better with their experience of the illness and its treatment (McGrath, Montgomery, et al., 2006: 1,250). Studies such as Spiegal, Bloom, Kramer and Gottheil (1989) and Fawzy and colleagues (1993) have been interpreted to show links between interventions aimed at improving mood and cancer survival. However, the literature review by Coyne, Stefeinek and Palmer (2007) found these and other studies to be full of ‘endemic problems’ in their meth- odology.

Watson and Pennebaker (1989) countered that negativity predicts health problems by finding that more neurotic, less self satisfied and negative people are just as healthy as others when health is measured objectively rather than by self report. More recently, a large, controlled trial found no link between emotional state and disease progression in head and neck cancer patients (Coyne et al., 2004). This study has the advantage of a large and uniform sample. The authors put previous findings linking

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emotional state with a longer life down to error through variability in can- cer site and stage, poorly-measured treatment variables and variability in patients’ self-reported emotional states reflecting overall disease burden (Coyne et al., 2004).

Coyne, Harris, et al. acknowledge that the belief in the role of emotions on progression and survival remains despite a lack of supporting data (2007: 3). In 2003, for example, Zhang and Siminoff (2003: 424) found that the fundamental belief that ‘positive thinking’ causes tumours to shrink and kills cancer cells existed in almost a quarter of their sample of 60 patients and their families in Ohio. Ehrenreich suggests that this is due to a tendency for research results which are publicized through the media to be spun towards positivity rather than negative or null findings (2009: 163). As such, in the broader community the general consensus remains that a positive attitude can affect the course of cancer and assist treatment to be successful (O’Baugh et al., 2008: 109; McGrath, 2004: 25). The absence of an optimistic outlook is seen to hurt one’s chances for improvement and cure (Rittenberg, 1995: 38).

Results are more consistent in regards to the benefits of positive thinking for coping with cancer. Substantial evidence exists which shows that coping strategies derived from dispositional optimism, one aspect of which is posi- tive thinking, are helpful and are related to better outcomes (De Raeve, 1997: 251; Fawzy et al., 1994; Shou et al., 2005). Small-scale randomized controlled trials show that ‘positive’ interventions, including affirmations and imagery, can be useful in enhancing coping ability and lowering distress (De Raeve, 1997: 251). Taylor (1983) identified that defining oneself as a ‘positive person’ facilitated confidence in the ability to ‘control’ cancer up to a certain point. Taylor emphasizes that such beliefs, while not supported by facts, may be essential coping techniques (1983: 1,171). Shou et al’s (2005) longitudinal survey positively correlated quality of life with a fight- ing spirit and pessimism with helplessness.

Such findings make it tempting to conclude that optimism and positiv- ity are always to be desired over pessimism or negativity (Norem and Chang, 2002: 993). Conclusions that suggest replacing negative thoughts should be a focus of intervention contribute to the suggestion that negativ- ity is dangerous and pathological (Fawzy et al., 1994; Shou et al., 2005: 725). This idea has permeated popular culture: people with cancer are reported to feel pressure both externally – from family, community and media – and internally, from their own compulsion, to find a positive way of dealing with their illness experience (Ehrenreich, 2009; McGrath, 2004: 29). Norem and Chang describe this as the ‘positivity zeitgeist’ (2002: 993). Ehrenreich argues that the pressure to be positive goes so far as embracing the cancer. She asserts that the ‘failure to think positively can weigh on cancer patients like a second disease’ (2009: 43).

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Positive thinking potentially entails significant costs. In documenting the experience of individuals receiving autologous cell transplants, McGrath and colleagues (McGrath, Jordens et al., 2006; McGrath, Montgomery, et al., 2006) explored responses to positive thinking. For some, an explicit norm of positivity applies, forbidding open displays of negative feelings, reducing open communication, ultimately adding to distress (McGrath, Jordens, et al., 2006: 667; McGrath, Montgomery, et al., 2006: 1,246). Held also contributed to this view, pointing out that one may not only feel bad about what is distressing – the illness – but also feel guilty when com- municating negative thoughts (2002: 987).

This is not to suggest, however, that the benefits of positive thinking are not both real and substantial in many cases (Norem and Change, 2002: 999). People have many different ways of facing and processing challenges; for many, positive thinking remains a reassuring attitude of confidence and action (McGrath, Montgomery, et al., 2006: 1,250). However, both Ehrenreich (2009) and Held (2002) argue that the virtues of the positive outlook have been taken to excess, both in popular culture and profes- sional/psychotherapy circles, and have become tyrannical in that we live with the demand that a ‘positive attitude’ is maintained at all times, and at all costs (2002: 967).

Two important conclusions can be drawn from this literature. First, understandings of positive thinking remain varied and contradictory (McGrath, Montgomery, et al., 2006: 1,250). Both quantitative and qualita- tive analyses suggest complex understandings and experiences. Second, a gap exists between the research literature and popular belief (Coyne et al., 2004: 2; O’Baugh et al., 2003: 268). Scholars problematize positive think- ing, yet this has largely unaffected the discourse in the broader community, and the positive thinking zeitgeist continues to have a pervasive influence in our lives. In the remainder of the paper, we will investigate this conundrum.

Discourses of positive thinking Positive thinking does not have a common accepted meaning. Positive thinking, like hope and optimism, is a term that covers a range of concepts and ideas (Norem and Chang, 2002: 994). Due to its status as a taken-for- granted piece of cultural knowledge (Holt and Drew, 1988, cited in Wilkinson and Kitzinger, 2000: 802), definitions of positive thinking are usually general and non-specific. People using the term are often simply endorsing a vague formulaic adage (Wilkinson and Kitzinger, 2000: 803). The concept positive thinking or to have a positive attitude remain diverse, fluid and contradictory. For example, Stein et al. (1997, cited in Wilkinson and Kitzinger, 2000: 800) coded ‘I’ve learned so much from this’ as a positive appraisal, while ‘trying to make self feel better by thinking posi- tively’ has been coded elsewhere as avoidance (Nolen-Hoeksema et al.,

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1997, cited in Wilkinson and Kitzinger, 2000: 800). These understandings can be seen as quite inconsistent.

Positive thinking has been seen by some as a deliberate effort to enter- tain only the possibility of good outcomes (McGrath, Jordens, et al., 2006: 666), and a mental strategy to overcome unpleasant thoughts (De Raeve, 1997: 250). McGrath simply defines ‘being positive’ as a way of talking and acting that reflects an optimistic or positive attitude and feeling state (2004: 26). Her research found a difference between optimism and what her participants labelled the ‘RA RA’ positive: the arbitrary imposition of pressure to be positive during the challenge of serious illness (McGrath, 2004: 27). The concept has also been articulated as a performance that is required of people living with a serious or chronic illness. According to this interpretation of positive thinking, people should manage their thoughts by planning and rehearsing, striving to accentuate the ‘capable self’ rather than the ‘disabled self’ (Corbin and Strauss, 1991, cited in Barnes et al., 1999: 53; McGrath, Jordens, et al., 2006: 666). Being opti- mistic, having faith, making an effort to maintain hope, appreciating each day as it comes and viewing death as a transition are all part of this same performance (Zhang and Siminoff, 2003: 423).

Nurses have defined the concept of a positive attitude as one of a ‘fighting spirit’, where the patient is determined to live, and looks on the ‘bright side’ of their situation (O’Baugh et al., 2008). Negative patients were non- compliant, angry, and questioning (O’Baugh et al., 2008: 113). Conversely, others have argued that this non-compliant attitude is actually a manifesta- tion of positivity (Collinge, 2002), further demonstrating the variability in the definition and manifestation of positive. While positive thinking serves to encourage patient compliance with treatment, and can therefore assist medical practitioners who wish to avoid emotional work with patients, it is not always antithetical to medical discourse. More progressive medical and health practitioners may use it to reinforce a sense of agency in patients and their carers, a similar approach to that of complementary and alternative medicine.

Taking a discursive approach, Wilkinson and Kitzinger suggest that positive thinking is used as an idiom (2000: 803). Its frequent appearance in conversations around illness may be a consequence of speakers’ need to lighten talk, keep the conversation moving, or shift talk from the personal to the general. Wilkinson and Kitzinger also suggest that the idea of positive thinking may be so popular because it reinforces a sense of belonging to a common culture in which such ideas are widely shared (2000: 803).

Thus positive thinking can be used as a bulwark against hopelessness in life-threatening illnesses, it can also support or deny the medical ‘facts’ or help maintain social roles in the full knowledge of the ‘facts’. Different actors may have varying rationales for utilizing the discourse and different conflicts may emerge. However, our research is largely concerned with the

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carer’s experience. This paper does not seek to specifically examine the role of emotions in positive thinking, but we acknowledge that positive thinking can be used to police emotions and this aspect therefore requires more detailed empirical research.

Positive thinking as an expression of care The carers in this research felt that their positive attitude helped their families. Some even felt that overt expression of sadness, pain and fear could weaken the patient’s ability to fight the cancer. Jennifer felt ‘being negative did nothing for him. It didn’t help him at all . . . It’s hard to explain, but we felt being positive helped him, in some way’. Participants articulated a desire to protect the ones they loved from the stress and harm they perceived would follow from expressing the truth about their feelings. Thomas et al. (2002: 538) explain that this emotional work is fundamentally about managing feelings in order to sustain a sense of con- trol over events, and stave off the fear of death and loss. Yet, with the benefit of hindsight, most participants wished that they had shared more, conceding that being more emotionally engaged in the experience may have helped with their coping. Katie’s father died from cancer during her adolescence: ‘I don’t actually know how long he was sick for because my parents sort of tried to keep everything running . . . I felt we were kept a bit away from it all. And I don’t think that was a good way’. Dana echoed Katie’s opinion: ‘I feel incredibly regretful that I didn’t make the effort to try and talk earlier’.

Several previous studies have found that, in the event of serious illness, avoidance of family communication is a common phenomenon (Hilton, 1994; Shields, 1984; Thomas et al., 2002; Zhang and Siminoff, 2003). Carers frequently feel that they have to be, and want to be, ‘strong’ and ‘positive’ for their loved one (Thomas et al., 2002: 538). Zhang and Siminoff suggest three reasons for this: first that emotional expression is personally confronting; second because of concerns about upsetting oth- ers; and third because positivity may impact upon the clinical outcome (2003: 424). Evidence supporting these reasons emerged in this research. Participants used positive thinking as denial or evasion, facilitating the construction of a reality, which was intended to be more tolerable for the person with cancer and other family members.

Positive thinking for the individual experiencing cancer may not involve the same mix of feelings, thoughts and conflicts as the carer. In fact, the raison d’être for positive thinking may not be the same. The self suste- nance required by the individual is different than that needed by the carer. Connie did not tell her daughter the true extent of her partner’s illness ‘so she didn’t know until quite late in the piece . . . and that meant that she wasn’t really able to say goodbye’. Veronica’s parents kept the seriousness

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of her Grandmother’s prognosis a secret: ‘at first my parents didn’t tell me [that the cancer was terminal] . . . I actually said to her “why didn’t you tell me that” and she said “because it is going to affect the way you think about it, so we didn’t want you to know”’.

Other carers may have simply wanted to avoid the pain of talking openly, in addition to avoiding being negative in front of their loved one. Dana, for example explained: ‘we were all avoiding talking about her dying . . . we were acting like it wasn’t going to happen even though in our hearts we knew’. Veronica demonstrates the function of such a silence between her and her mother: ‘I don’t want to go to her and tell her exactly what I’m feeling because I know she’s feeling pretty crap about it too. So it’s better to keep that sort of positive momentum going’. Positive thinking thus may be seen to allow carers to protect their families and themselves from the discomfort of negativity. Participants have recognized that accentuat- ing the positive through eliminating the negative is not ideal, particularly in terms of the effect this has on communication, yet there remains a com- pulsion to continue coping in this way, indicating that positive thinking is a persuasive phenomenon. Ehrenreich refers to this phenomenon as ‘near universal bright siding’ (2009: 28).

Positive thinking as resistance and agency From a Foucauldian perspective, how an individual responds to illness is closely associated with power relations in society; how individuals and populations are enmeshed in processes which accord with the ideologies of the elites and the ruling classes (Crossley, 2005: 23). This section will dis- cuss current conceptions of medical hegemony and will argue that, while the classification of disease is predicated on a medical model, individuals, families and communities have developed forms of resistance through which they may remain more in control of their cancer experience. Positive thinking may be seen as one such form of resistance alongside the use of alternative and complementary therapies.

Medical power functions by making the body a visible and predictable collection of matter, which is amenable to scientific analysis (Crossley, 2005: 26; Price and Shildrick, 1999: 147, cited in Titchosky, 2007: 91). So long as doctor and patient are willing to conform to a set of taken-for- granted beliefs informed by medical sensibility, both may believe in and expect a straightforward equation between illness and life (Titchosky, 2007: 91). The power of this discourse was evident among participants: medical knowledge emerged as a way of feeling more in control, or having a more realistic grasp of their situation. For carers, it felt good employing the medical perspective in their appraisal of the quality and length of life remaining because this understanding makes the experience more man- ageable than uncertainty. Jennifer argued: ‘You don’t want to hear “oh this

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might happen and that might happen”, you do want numbers’. However, the discourses of medical knowledge and professionalism tend to exclude the ideas and understandings of individuals and their carers who are expe- riencing serious illness. The dominance of this discourse was demonstrated in the ‘us versus them’ mentality inherent in the carers’ talk. Carers referred to doctors’ as ‘they’ and ‘them’. In the majority of cases, there were no personal, reciprocal relationships with medical professionals:

they said that ‘we are going to have to see some improvement in his blood cell count before we can do anything else’ . . . They said ‘we’ve done as much as we can’. . . And they said ‘if there is a change overnight, great, but we don’t think there will be’. (Jennifer)

Medicalized understanding of disease and illness only ever produces a partial perspective of the reality of the illness experience (Cheek, 2004: 1,145; Turner, 1987: 224) and the enduring dominance of medical ideolo- gies has become increasingly subject to distrust and cynicism (Archibald, 2007: 49). In liberal democracies people are resistant to feeling powerless, deviant or unproductive. Alternative discourses have challenged the nature of the relationship between the doctor and patient (Turner, 1987: 49).

Participants and their families were sceptical of the medical care provided to their loved ones, many of them frustrated with slow or inappropriate treatment, second guessing decisions and diagnoses. Katie, for example felt that her Mother’s doctor ‘made a few mistakes, actually. I thought about getting the medical file and really checking it out’. It took many weeks for Veronica’s Grandmother to be diagnosed, leaving her ‘quite sick for a long period of time’, which was painful for the entire family network.

Thus the ‘new’ medical consumer, who is acutely aware and critical of scientific definitions of health, disease and illness, and about the monop- oly held by doctors, has emerged. These consumers are to some extent dependent on medical knowledge for clarity in the form of statistics and probability of life expectancy, but they are also open to alternative and complementary medicine which ‘empowers’ the self to take back some control and agency over their life chances (Van Krieken et al., 2000: 379). Patients and their carers resisted accepting mainstream medicine as the only option, and to being passive recipients of medical attention. There was no way Connie’s partner ‘was going to hand over her life to a doctor’. Dana’s partner ‘needed to be in control, because that being in control was strengthening’.

Participants and their families used independent research and inquiry to improve their sense of power and hold their own with medical professionals:

Mum was really into looking up stuff online . . . my older brother was the same, every drug he was taking they wanted to know everything about it, the ins and the outs of it. I think what it was for Mum, because she was the Mum . . . she likes to ask the questions. They were going to give him this drug, and she could

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say ‘oh but what about the side effects, I was reading this’. . . maybe it was a sense of having control, to be able to use the drugs’ names. (Jennifer)

Confidence in the possibility of medical truth delivering on its promises has faded. People continue to surrender their bodies to medicine, but increas- ingly hold on to their own stories (Frank, 1997: 16). In a postmodern world, the dominance of medicine is being unsettled as people search for their own power, agency, control and truth.

Positive thinking as governmentality While positive thinking can be understood as a process of resistance and agency, it can also be seen as complicit in the medicalization and dominant discourse of cancer therapy and treatment. This section will explore Foucault’s theory of governmentality, and suggest that positive thinking is influenced by political rationalities, which encourage responsibility, independence and self-reliance. Foucault defines ‘government’ loosely as the ‘conduct of conduct’, both in the practices of government, and in the practices of self-regulation and self-guidance (Dean, 1999: 10). Such a definition presumes a set of standards of conduct which act as an ideal towards which individuals can and should strive (Dean, 1999: 10). Foucault’s ‘governmentality’ therefore is a methodical and rational way of influencing possible fields of action, so as to shape, guide, correct and modify the ways in which individuals conduct themselves (Burchell, 1996: 19; Dean, 1999: 12; Philip, 2009: 5; Rose, 1990: 5). Foucault’s interest lay in how certain types of knowledge are used to rationalize particular gov- ernmental practices, and how governmental rationality becomes operational via certain ‘technologies’ (Philip, 2009: 6).

Foucault’s technologies of power, self, and of the market are all useful ways of analyzing the growth of positive thinking. Technologies of the self are linked with technologies of power and domination through positive thinking. Governmentality helps us link patient/carer submission to medical hegemony to capacity for self control. Although in the final analysis few people suffering from cancer are likely to reject medical authority in a bid for complete self-control.

The expanding market of self-help products and services is part of the neo-liberal ideology, which brings the ideals and aspirations of individuals into alignment with wider political objectives such as consumption, profit- ability and efficiency (Hazleden, 2003; Philip, 2009: 3; Rimke, 2000). Market strategies have long been trying to convince us that books, CDs, courses and diets should be purchased in pursuit of positive identities and attitudes. Positive thinking has become part of our collective consciousness, a subtle yet influential trend of thought integral to self-help and the ‘psy’ discourses (Rose, 1996). The objectives of liberalism, as suggested by Foucault (1994: 74), are based on the constant suspicion that one is being

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governed too much. Liberalism therefore limits direct state intervention into individual lives. Citizens of a liberal democracy are expected to ‘self govern’; they are considered responsible for regulating themselves, and for the social consequences of their acts (Rose, 1990: 223). Jennifer stated ‘you just felt that you had to keep doing it, and the only way you are going to be able to keep doing it was to stay positive’. However, there is nothing personal about self government (Cruikshank, 1996: 231).

Private spaces, such as the family, are important because they define what exists beyond the formal powers of the state; they define what is to be protected from ‘too much government’ (Rose, 1996: 99–100). They present a challenge for liberal governmentality: how, without threatening personal autonomy, to ensure that subjects act virtuously in the private sphere, in order to protect the public sphere (Philip, 2009: 22; Rose, 1996: 100)? As a solution, thoughts, feelings and actions, while appearing to be the very constitution of the intimate self, have become socially organized and man- aged (Rose, 1990: 1). Veronica remarked:

Mum is really big on it, even if you’ve got a cold or whatever. She’s sort of like, ‘oh you know, don’t let it worry you, and say to yourself, I can’t be sick, I’ve got things to do’ or whatever, just so, that’s what she’s been like . . . for everything.

This stoical attitude may not be just a product of self-regulation. It may also be a result of particular cultural, philosophical and historical factors.

Foucault’s definition of government assumes that there are agents whose responsibility is ensuring that self-regulation occurs. Pluralities of such governing agencies exist, all of which preside over various sets of behavioural norms (Dean, 1999: 10). The self, therefore, is not governed centrally, rather by a proliferation of complex and heterogeneous ‘tech- nologies of power’, which utilize expertise such as psychology, social work and other ‘psy-professions’. Many of these human services are profit- making entities and constitute, in Foucauldian terms, ‘technologies of the market’. Expertise remains grounded in a claim to authority and objectiv- ity, creating the distance between self-regulation and the state necessary in liberal democracies (Rose, 1996: 156), at the same time as fostering ‘useful’ obedience (McHoul and Grace, 1993: 68). Self-help has been recognized as one such ‘technology of the self’ (Hazleden, 2003; Rimke, 2000). The findings of this research support the argument that positive thinking, in part, is responsible for the management of individuals because it encour- ages the changing of bodies, souls and ways of being with the aim of opti- mizing the forces of the population in order to mould them towards certain goals and particular ends (McHoul and Grace, 1993: 71).

Positive thinking is generally assumed to have gained popularity through the vehicle of ‘psy’ professions (Rose, 1996), and has gained momentum through its relentless promotion in the media and self-help industry

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(Ehrenreich, 2009). The application of ‘solution focused’ therapy, which uses constructive theory in social work and psychology through a focus on reframing language and thinking in order to build on the positives in people’s lives and experiences rather than focus on negatives or ‘problems’ (Payne, 2005: 172), provides an example of this type of professional inter- vention. These trends have, according to Held (2002: 971), lent professional legitimacy to popular self-help practitioners’ unsubstantiated ‘be positive and focus on yourself’ messages. The following quotes reveal the alignment of ‘political, social, and institutional goals with individual pleasures and desires’ (Rose, 1990: 213, 257) among carers of people with cancer. This involved suppressing negativity in favour of a more participatory positive attitude. Participants revealed that the expectation to be positive was pri- marily social by indicating that this pressure did not exist in private:

the negative stuff seems to set in when you’re sort of by yourself and you don’t have the other person to reaffirm you . . . (Veronica)

as it did in public:

Mum said once, she felt like she was high because she would go in there and she’d be like ‘this was a horrible thing that is going on, but we’ll go in there [to the hospital] and we’ll talk and laugh . . . (Jennifer)

The self-help discourses of positive thinking emphasize the concept of responsibility. We are told that, as individuals, we possess the ability to choose happiness over unhappiness, success over failure, and even health over illness (Rimke, 2000: 73). Such pronouncements of morality provide a good example of how government of the self occurs (Rimke, 2000: 63). The rewards promised to those autonomous, productive and efficient people engaging in self-help projects such as ‘thinking positively’ are appealing in their promise of health, prosperity and inner fulfillment. These virtues are all strongly aligned with the ideal liberal citizen (Hazelden, 2003; Philip, 2009; Rimke, 2000).

Foucault argues that the power of governmentality works at a very basic, preconscious level (Crossley, 2005: 24). The present research pro- poses that the extent we are governed to be positive is a technology of the self, a ‘policing’ of one’s emotions, which is deep-seated and complicit. We are urged to ‘look on the bright side’ because it is part of our collective consciousness (Rose, 1990). Even where self-help was not explicitly involved in participants’ coping they were directed by its values. Participants embodied the idea of positive thinking as it influenced many aspects of their cancer experience:

Women have died at the age of 30 in that group, with three young kids, of breast cancer. She’s 72, and she’s seen her seven grandkids, and she has three kids, and she has actually lived her life, whereas these women haven’t. So she’s still reaf- firmed that she is in a great position. So that’s quite good. (Veronica)

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Youll & Meekosha: Always look on the bright side of life 35

Carers were even positive about things which would in many other situations be regarded as negative, such as the lead up to and subsequent death of their family member:

She died in the hospital. And I was really happy that kind of spontaneously we were all there, my brothers and me . . . I think we were really positive, like if I think back we were really happy the way we were saying goodbye to her. (Katie)

These technologies of self are evidence of individuals being constantly engaged in the processes of self-regulation. Techniques such as positive thinking have seeped into everyday life, becoming unnoticed but remaining effective in the mechanics of reproducing liberal order and objectives (Dean, 1999).

Conclusion The aim of this research was to examine the role of positive thinking in the experience of carers of cancer patients. We asked whether positive thinking is an influence on the experience of cancer for carers and families of patients. The answer is an unequivocal yes. This research explored positive thinking as an expression of care, as a form of resistance and agency and as governmentality. Each of these ways of interpreting positive thinking, while seemingly contradictory, showed that this phenomenon plays a role in participants’ experiences. These discourses function as governmentality regardless of participants’ reflective awareness of employing them, and are integral to carers of people with cancer in interpreting and understanding their experiences (Cheek, 2004: 1,145; Talja, 1999: 4,222). This has been described as the ‘positivity zeitgeist’ (Norem and Chang, 2002: 993).

These findings support previous research, which indicates that there is a belief in the wider community that negative thoughts are deviant and pathological for individuals with serious illness (Fawzy et al., 1994; Shou et al., 2005: 725). On the level of personal experience, ‘being positive’ is part of the emotional work carers do in order to manage their own feeling states and those of the person with cancer (Thomas et al., 2002: 542). There is no evidence available that it affects the progress or outcome of ill- ness. Positive thinking doesn’t cure cancer, prevent or postpone death (Coyne, Harris, et al., 1997; Watson and Pennebaker; 1989). This research, and that of Zhang and Siminoff (2003), found that restricted communica- tion and suppression of feelings are consequences of positive thinking. Such thinking has failed to actually reduce pain and fear, and maybe only tempo- rarily suppresses them. Yet carers insist that positive thinking makes them feel better and their experience easier. This research suggests that being positive allows carers to ‘survive’ and function in an otherwise overwhelm- ing situation. This complex phenomenon can help to maintain hope, and allow carers to protect their families and themselves from the discomfort of emotional pain and negativity. Carers are aware of the potential harm such

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36 Journal of Sociology 49(1)

coping may cause, but in their experience, it is a necessary counterbalance to a fearful situation. It remains unclear whether positive thinking or being positive are cognitive states as well as tools for interaction. Respondents in this research implied that positive thinking is in fact a ‘way of thinking’, but how it is carried out remains unclear (Wilkinson and Kitzinger, 2000).

The application of positive thinking is understood in these findings as the utilization of largely taken-for-granted, ‘social feeling rules’ which are part of larger discursive systems (Duncombe and Marsden, 1998; Wilkinson and Kitzinger, 2000). Findings show that modernist, medical- ized understandings of cancer only produce partial perspectives of what is being experienced by family members and carers (Cheek, 2004: 1,145; Turner, 1987: 224), and thus such understandings became subject to distrust and cynicism (Archibald, 2007: 49). Carers utilized sources of resistance and agency through which they remain more in control of their experience. Positive thinking can be seen as one such form of resistance and agency. Alternative therapies that promoted positive thinking for partici- pants led them to perceive that they were able to challenge institutional medical authority. Participants were then able to become agents in the healing or treatment of their loved one, taking back control some of the probability of life.

A second related discursive system emerged from the research. From the perspective of Foucault’s theory of governmentality, positive thinking as a ‘technology of the self’ is a way of governing subjectivity toward dominant political rationales (Rose, 1990). Positive thinking might be understood from this perspective as a manipulation by a neo-liberal gov- ernment. Carers and families are channelled by the discourse to respond to illness in a certain way, with the aim of moving patients from depen- dence and maladjustment to autonomy and self-responsibility (Rose, 1990: 214).

Positive thinking as an alternative therapy appears to be the epitome of anti-authoritarianism in which medical power is doubted and distrusted. It allows participants to take control of their experience. However, their very resistance to medical power keeps them within the logic of neo-liberal politics: striving for a ‘better’ and healthier lifestyle and being personally responsible for their welfare. Indeed, positive thinking is about accentuat- ing the capable rather than disabled self (Barnes et al., 1999: 53; McGrath, Jordens, et al., 2006: 666).

In a period of neo-liberalism, both medicine and complementary thera- pies see health as the personal responsibility of individuals. Resistance to medical power is in fact a form of governmentality through self-regulation consistent with neo-liberal morality. Positive thinking exalts the view that people can exercise control and mastery over themselves and their lives (Rimke, 2000: 62) and create their body in the manner preferred: healthy, efficient and effective (Crossley, 2005: 26). Positive thinking is widely socially approved of for these reasons, and we are, in turn, products of the

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Youll & Meekosha: Always look on the bright side of life 37

discourses with which we live (Little and Sayers, 2004: 1,336; McHoul and Grace, 1993: 75).

Acknowledgements This paper is taken in part from a thesis submitted in fulfilment of the requirements for the BSW Hons degree of Jackie Youll in the School of Social Sciences at the University of New South Wales. We wish to thank the anonymous reviewers of this article for their constructive criticism and ideas.

Funding This research received no specific grant from any funding agency in the public, com- mercial, or not-for-profit sectors.

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Biographical notes Jackie Youll completed the Bachelor of Social Work degree in 2009 in the School of Social Sciences and International Studies at UNSW. This paper is partly based on research conducted in the Social Work Honours Programme. Jackie is now working in the non-government sector in foster care. [email: [email protected]]

Helen Meekosha is Associate Professor in the School of Social Sciences and International Studies at UNSW. She is a leading social scientist in the area of disability studies and chronic illness. Address: UNSW Sydney Sydney New South Wales, 2052, Australia. [email: [email protected]]

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