How human beings cope with bereavement, loss, extreme adversity, and life-threatening illness has dominated the research interests of George A. Bonanno, PhD, Professor of Clinical Psychology, Teachers College at Columbia University, New York, for more than 20 years. In his book, The Other Side of Sadness: What the New Science of Bereavement Tells Us about Life after Loss (Basic Books, 2009), Dr. Bonanno reported on his studies of grief and loss.
Nearly 50 years ago, Elisabeth Kübler-Ross, MD, advanced the theory that people suffering a traumatic event such as the loss of a loved one (or their own impending death) go through five stages of grief: denial, anger, bargaining, depression, and acceptance. Despite this long-held perspective, Dr. Bonanno’s research on loss and bereavement found no evidence that these stages are relevant in the grieving process (although he has not studied dying patients).
According to Dr. Bonanno, the bereaved exhibit different patterns of grief reactions across time, ranging from overwhelming feelings of loss for long periods of time (more than 2 years) to less pronounced feelings of sadness over a year or less. However, most people rebound from loss fairly quickly, experiencing intense periods of sadness for several weeks, which then taper off. It is this natural resilience to trauma and loss that allows people to regain their equilibrium and return to their day-to-day lives even though they may still experience moments of anguish and sadness.
The ASCO Post spoke with Dr. Bonanno about how human resilience factors into how well people deal with a life-altering event like a cancer diagnosis.
Understanding Resilience
What is resilience in the context of your research?
I take a scientific approach to resilience, so I define resilience exclusively as the stable trajectory of healthy adjustment after a highly aversive event, like getting a cancer diagnosis or being in a disaster.
Are people born with a certain amount of resilience, or can we learn to become more resilient?
There isn’t much scientific research on this issue, but my personal view is that we are born with the tools to be resilient. Resilience is predicted by a lot of different factors. It isn’t a simple matter of either you are or you aren’t resilient. There is evidence showing that the type of person we are makes us more or less resilient, but there are many other factors that also come into play, including economic, social, and health resources available to us and the amount of stress we have in our lives.
Personality traits such as optimism or hardiness predict resilience, but that’s only a little piece of it, like a slice of the pie. You can have the healthiest personality in the world, but if everything else in your life is negative—you live in poverty or lack access to adequate education—you are less likely to be resilient.
Other personality factors that have been shown to affect resilience include self-enhancement, which is actually a kind of narcissistic self-serving trait that has to do with the positive reframing of a bad situation. Another factor is self-confidence in one’s ability to cope, which is called hardiness, but you can also call it optimism—these traits are all related. Resilient people have the sense that they’ll be able to deal with any adversity. Most of us will respond to a cancer diagnosis with fear, but ultimately you have to decide to somehow deal with the disease, as opposed to saying, “I can’t deal with it.”
Long-term Stress
How does experiencing long periods of ongoing treatment and the potential for relapse affect a person’s ability to remain resilient?
With cancer and diseases that require long-term treatment, patients face repeated challenges and stressors, and how well they are able to cope is not well understood. We know that people are able to bounce back fairly quickly from acute events and get on with their lives. But when they experience repeating events, or when there is a long, long period of rehabilitation, that can be really tough to overcome.
There are different types of resilience. Minimal-impact resilience is when a person takes a blow and keeps going. Emergent resilience is when a person struggles for a long time, and everything is in flux. When people are going through chemotherapy and a prolonged physical assault, they are going to be emotionally up and down a lot.
In our study of women diagnosed with breast cancer, one of the variables that predicted a better outcome was less difficulty with treatment decision-making.1 Another predictor was the patient’s confidence in the treatment choice. That finding seemed to suggest the patient was saying, “I have to deal with my cancer. I am going to consider my options, make the best choice, and do my best to survive.” And you can imagine that with recurrent cancer, there comes a point when people decide to give up.
Patterns of Outcome
What has your research found on peoples’ ability to cope after a traumatic event or the death of a loved one? How long does it take to recover from these situations?
What I found across all kinds of events, including people dealing with a cancer diagnosis and bereavement, is that there isn’t one pattern of outcome. By the same token, it is not random either. We have repeatedly identified a set of prototypical outcome patterns.
Some people are completely overwhelmed by an event in their life and take years to regain their footing. Between 5% and 25% of people show this pattern and will be debilitated psychologically for a long time. In another pattern, which we call the recovery pattern, people struggle for a number of months, and then it takes a year or two for them to gradually come back to where they were before the event took place.
The most common pattern of resilience is that in which people are disturbed for a little while—a few days to a few weeks—but then they are okay and resume their life. When people lose a loved one, they have intense emotional reactions, but the reactions are not encompassing, they are episodic. The grieving person may be intensely sad for a short period of time and then have flashes of sadness over a longer period of time, coming in and out of that state, but he keeps functioning and has positive phases in which the sadness is replaced with laughter and being connected to other people. I think that’s why we are able to cope so well after a loss; we are hardwired to deal with loss efficiently.
Healthy Response
What is the healthy response to a serious illness or the realization of impending death from the illness?
The healthy response to an illness you can recover from is different from a healthy response to an illness that you can’t recover from. A healthy response to an illness you can survive is to accept the situation as a challenge and do your best to cope with it.
I have not studied how people respond to terminal illness. But my understanding from anecdotal evidence of hospice caregivers is that when people realize their death is imminent, the healthiest response is to come to terms with this fact and to do what they can to live as comfortably as possible—and to do that with the people with whom they are closest. ■
Disclosure: Dr. Bonanno reported no potential conflicts of interest.
Reference
1. Lam WW, Bonanno GA, Mancini AD, et al: Trajectories of psychological distress among Chinese women diagnosed with breast cancer. Psycho-Oncology 19:1044-1051, 2010.
