The supportive roles of spirituality and mindfulness in patients’ cancer journeys

KEYWORDS:

• Spirituality
• mindfulness
• cancer
• coping
• resilience

‘Cancer is a tremendous opportunity to have your face pressed right up against the glass of your mortality.’ (Jason Shinder, New York Times, 24 December 2008)

While people in many parts of the world are increasingly declining to label themselves ‘religious,’ those considering themselves spiritual (with or without also identifying as religious) have remained virtually constant (e.g. 75% of Americans label themselves ‘spiritual’) [1]. Even for those who do not consider themselves spiritual in the abstract, facing a cancer diagnosis may lead to consideration of many questions traditionally considered spiritual, such as the meaning of existence with its brevity, uncertainty, and suffering; connectedness; and possibilities for redemption and transcendence.

Perhaps not surprisingly, then, a great deal of research has studied the roles that spirituality (i.e. ways of relating to the sacred) [2] may play in the context of cancer. Much of this work has focused on religiousness, a subset of spirituality – institutionalized or culture-bound – through which most individuals express their spirituality [2]. More recently, mindfulness has received increasing attention and application in psycho-oncology, sometimes overlapping with research on spirituality. In this commentary, we review research regarding spirituality and mindfulness in the journeys of those with cancer. We then suggest directions for future research and clinical applications to better understand and integrate spirituality and mindfulness into this sojourn.

Spirituality can play many different roles across the cancer continuum from diagnosis through treatment and into survivorship or palliative care [2]. For example, following diagnosis, spirituality can inform the types of cognitive appraisals individuals make regarding their cancer, and these appraised meanings influence not only their coping and subsequent adjustment but also their treatment-related decisions and their well-being. Cancer patients often make both religious and secular attributions regarding why they got cancer as well as whether they – or God – are in control of the course of their illness. For example, in a sample of young- to middle-aged cancer survivors, both religious (‘God causing cancer’) and secular (‘oneself causing cancer’) causal appraisals were negatively associated with well-being, while both religious (‘God having control’) and secular (‘oneself having control’) appraisals of course/cure positively related to well-being [3]. Further, attributing the cancer to an angry or punishing God was associated with more anger at God and poorer psychological adjustment [4]. Thus, spirituality can be deeply involved in individuals’ understanding of their cancer.

Spirituality also offers myriad coping resources on which individuals can draw to deal with their cancer. Spirituality may serve as a source of hope and strength as patients cope with the rigors of treatment and its adverse side effects as well as the fears and uncertainties of their situation. In addition, those who are spiritual or religious are often part of a faith community, which can serve as a tremendous source of social support for people with cancer and their families [5].

Spirituality can also provide many specific coping activities that can help individuals to deal with their cancer and that may be particularly helpful in low-control situations. For example, cancer patients often turn to prayer and meditation to help them cope, although studies of people dealing with cancer have generally indicated that religious or spiritual coping relates only weakly to well-being in the context of cancer [6]. However, different types of spiritual coping may differentially relate to well-being depending on the particular phase of the cancer continuum under study. For example, during the diagnostic phase, personal spirituality may be particularly relevant. One study found that use of different spiritual coping strategies by breast cancer patients changed from pre-diagnosis to two years post-surgery: during particularly high stress points such as pre-surgery, spiritual coping strategies that provided comfort, such as active surrender of control to God, were highest and closely related to well-being at that point, while spiritual coping processes reflecting meaning-making increased over time into survivorship and related favorably to longer-term psychological adjustment [7].

Spirituality may help cancer patients and survivors frame their experience in ways that provide meaning and redemption of their suffering. For example, Gall and Cornblat summarized qualitative results from breast cancer survivors: ‘When used in the creation of meaning, relationship with God allowed some women to reframe the cancer from a disruptive, crisis event to a “blessing” and a “gift”. These women believed that the cancer served some Divine purpose in their lives and so they were better able to accept it’ [8, p. 531].

One distinct aspect of spirituality is associated with survivors faring worse emotionally: spiritual struggle, which refers to individuals feeling angry at God or that God is angry with them or has abandoned them. Sometimes termed negative religious coping, it is reported at low levels relative to more positive aspects of spirituality, but tends to have much stronger adverse effects than the more positive aspects have salutary ones [4,9].

Changes in spirituality following cancer are commonly reported [5]. Survivors often report that they have become more spiritual and have a stronger sense of the sacred directing their lives, while some believe less strongly in their faith or feel spiritually lost because of their cancer. In a sample of survivors of a variety of cancers, positive and negative perceived spiritual changes were unrelated, but positive spiritual transformations corresponded to higher levels of emotional well-being and quality of life, while negative spiritual transformations related inversely to well-being and quality of life [10].

Increasingly, researchers have focused on a concept associated with Eastern spiritual traditions, mindfulness, and much of this research has been in the context of cancer. Mindfulness is a state of consciousness that includes being self-aware and attentive in an open, nonjudgmental manner [11]. Research has consistently demonstrated positive links between mindfulness and physical and psychological well-being across the cancer continuum, including stress reduction; lower depression, anxiety, and pain; and even better immune functioning [12,13]. As cancer patients often struggle with anxious thoughts surrounding what caused their cancer, how their treatment will proceed, and possibilities of recurrence, living in the present moment in a nonjudgmental manner may be particularly helpful [14].

In some contexts, mindfulness may be overtly secular, while in others, spirituality may be explicitly related to mindfulness. This connection between spirituality and mindfulness is most apparent in intervention research, where studies sometimes incorporate spirituality into the mindfulness intervention [15]. Other studies have examined the effects of mindfulness on spirituality. For example, one study of cancer patients found that changes in cancer patients’ self-reported mindfulness mediated effect of mindfulness-based stress reduction (MBSR) on spirituality [16]. Developing mindfulness skills through MBSR may facilitate a sense of meaning, peacefulness, connectedness, and personal growth in cancer patients [16]. Although mindfulness-based interventions demonstrate efficacy in promoting well-being for cancer patients and survivors, it is important to note that this is only one of the many potentially beneficial intervention approaches to promote states of well-being and enhanced meaning and spirituality [17].

1. Future research and intervention directions

We briefly reviewed only some of the many complex ways that spirituality can play a part in the journeys of those with cancer. Although knowledge is accumulating, much remains to be learned about these parts that spirituality plays. For example, studies have yet to track the spiritual and secular meanings that cancer patients give their illness experiences over time and phases of survivorship, and we know little about the coping processes and other determinants of the changes in those meanings. In addition, most researchers who have focused on spiritual aspects of meaning making in cancer survivorship have relied on cross-sectional, correlational designs, limiting our understanding of temporal or causal relationships. Future research examining spirituality and mindfulness in cancer patients and survivors must use more sophisticated approaches, including longitudinal designs and thoughtful assessment of the constructs under study.

In addition, researchers should attend to the differences among people with cancer, including their personal characteristics, disease, and context. For example, spirituality may have very different influences depending on the specific aspects of that spirituality, such as religious traditions and affiliation and perceived closeness to God. The centrality of spirituality relative to other influences for a given individual might also influence its effectiveness in coping with cancer.

Spirituality is clearly an important aspect of the journey of many cancer survivors around the world. Although much remains to be learned, research evidence is already strong enough to demonstrate that researchers and clinicians must attend to the spiritual aspects of cancer patients’ and survivors’ experiences. Such an understanding will likely lead to more effective and individualized interventions for cancer patients and survivors, some of which may be based in mindfulness approaches. More importantly, such attention may lead to increased awareness of, sensitivity to, and understanding of the myriad and meaningful ways spirituality is part of the lives of those living with or beyond cancer.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

No funding to declare.