“I am in a Fight with My Brain”: A Qualitative Study on Cancer-Related Ruminations of Individuals with Cancer

Each individual attributes meanings toward their life that also affects existential well-being including life choices, priorities, and perspectives.1 Meaning and meaning making are important for all humans, but they are particularly salient for individuals who experience life-threatening experiences. Park's meaning-making mode has been developed to understand how psychosocial factors influence adjustment to stressful events, such as having a chronic illness. According to this model, individuals have core beliefs, global goals, and a subjective sense of purpose to build a sense of meaningfulness in their life, but the very first stage of this meaning building process is broken when the individual encounters a traumatic event.2 As a life-threatening experience, individuals with cancer face the possibilities of great suffering and a foreshortened future.3 Such traumatic experiences might lead to a vicious cognitive cycle called rumination.4 Rumination is defined as a kind of cognitive coping style that makes individuals think about the event over and over again.5,6 By repetitive thinking, individuals try to attribute a meaning toward the event they experienced as a coping mechanism.6 Coping strategies can be problem centered, emotion centered, or meaning centered; the latter strategy helps individuals leave behind impossible goals, formulate new goals in their place, become aware of what is happening, and seek possible benefits of overcoming demands.7,8 However, ruminations cannot always support coping mechanisms in line with their type. Cann et al5 described ruminations with two subtypes as intrusive rumination and deliberate rumination. Intrusive rumination occurs immediately after the event and causes emotional distress, such as helplessness, sadness, and fear. Such ruminations come to mind unintentionally and cause individuals to spend most of their time with ruminative thoughts.9,10 In fact, these ruminations, which function in making sense of the process, can affect the living spaces of individuals negatively because they cannot be controlled mostly.11 On the other hand, deliberate rumination allows the individual to comprehend the lived event, reestablish their own beliefs, and work with the emotions experienced by the individual. Therefore, the incompatibility between the person's traumatic experience and core beliefs negatively affects the individual in intrusive rumination, whereas deliberate rumination allows people to develop their coping skills.5 Thus, in addition to the commonly reported lingering fears and physical fragility, it can also help them transform their experiences and create a more meaningful life.3,12 In line with the meaning making model, the cancer of integrating the appraised meaning of a traumatic event into one's global belief system to reduce the cognitive discrepancy.13, 14, 15

Cancer is commonly perceived as a traumatic event that causes fundamental changes in the lives of individuals, which entails several uncertainties. Not only the cancer diagnosis itself but also cancer treatment is usually multimodal, demanding, and long-lasting, and many individuals experience physical and psychosocial effects. Some of these effects are life-threatening (eg, new cancers, and chronic diseases), whereas other physical and psychosocial late effects (eg, pain, lymphedema, gastrointestinal problems, neuropathies, anxiety, depression, memory, concentration, and cognitive problems) may severely impair survivors' health, quality of life, and participation in everyday life. Fatigue is often reported as the most distressing late effect because it influences all areas of life, impairs quality of life, and causes a high level of suffering and distress which trigger ruminations.16 These ruminations are closely related to the psychosocial well-being levels of individuals with cancer17,18 and intrusive ruminations might also evoke psychosocial problems such as post-traumatic stress disorder, anxiety disorders, and depression,19, 20, 21 body image anxiety,22 emotional distress, and delay in receiving health care in individuals with cancer.23 In contrast, deliberate ruminations are associated with self-awareness, psychosocial well-being, and post-traumatic growth.24,25 However, recent literature showed that the ruminations of individuals with cancer generally start with repetitive thoughts (ie, why they are sick, whether it is a punishment).9,10 which inactivate coping strategies and avoid regulating appropriate responses to the problem and cognitions generally occur with an intrusive way that individuals thinking repetitively about the causes and the consequences of cancer.9,26,27 These cognitions increase when one refuses to accept the challenge of changing values, goals, and concerns and perceives change as a threat to one's own integrity.28 Mosher et al29 emphasized that although individuals with cancer can't avoid, they try to avoid thinking, which unintentionally forces repetitive cognitions. In line with the Response Style Theory (RST), ruminations disrupt making sense processes, adversely affect coping mechanisms, and increase emotional distress.30 RST also emphasizes that rumination involves repetitively and passively focusing on symptoms of distress.31 Additionally, efforts at meaning making may influence the extent to which individuals with cancer successfully make meaning from their experience (ie, experiencing posttraumatic growth, meaning building, and restoring the beliefs), which may, in turn, influence their psychological adjustment and ruminative style. Considering the aforementioned effects of ruminations on the processes of individuals with cancer, it is very important to investigate what these thoughts are. Although a few studies have shown the impact of ruminations on individuals with cancer, there is no qualitative study in literature that investigates what these thoughts are and how exactly the ruminations affect the lives of individuals with cancer. In this context, this study aimed to interpret the meanings of cancer-related ruminations from the perspectives of individuals with cancer.

RST guided the present study by focusing on rumination as a process whereby individuals live with illness's causes and consequences.31 Repetitive thoughts force individuals to pay attention to maladaptive and intrusive cognitions that are highly ruminate with regard to negative contents, which in turn can lead to persistent thinking including rumination and worry.30 According to RST, rumination disrupts information processing, adversely affects coping mechanisms, and increases emotional distress.31 In this regard, RST presents a comprehensive and inclusive snapshot of the cognitive processes that help us consider understanding the functioning of ruminations in individuals with cancer.

Even though RST has not been generated for cancer processes in the first place, previous studies have mentioned how closely RST aligns with cancer process and serves as an informative guide to explore factors that lead to outcomes in the face of cancer.32,33 According to the RST, habitual rumination precipitates and perpetuates a vicious cycle of rumination, negative thoughts, and emotional distress through cognitively biased processing of, and attention to negative cognitive content, which results in catastrophic thoughts. In the cancer process, RST provides present a framework for studying the maladaptive and intrusive cognitions. For example, some individuals with cancer may repeatedly think about the causes and consequences of cancer, and persistent fears and concerns might explain this. Starting from this perspective, RST supported the content and dynamics of the present study and was guided by providing a wider understanding of the concept of rumination. For instance, we have developed the interview questions by focusing on the fourth of ruminations during life-threatening diseases. This way, we could develop a better understanding of ruminations and their associations with attributed meanings to cancer.

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