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Coping with Cancer Interventions for the Family
Cancer & Family continuing education psychologist CEUs

Section 16
Defining Beliefs and Meaning in the Cancer Experience

CEU Question 16 | CE Test | Table of Contents | Cancer
Psychologist CE, Counselor CEUs, Social Worker CEUs, MFT CEUs

Defining attributes of personal beliefs
Beliefs are a person's existing attitudes, expectations and values. They are determined by the individual's previous experiences as well as by the experiences of other members of their family. These beliefs can be readily elicited or described, and are part of the cognitive structures of an individual. Situated at a conscious level, beliefs are rational and concrete representations that may change readily with information or after particular events. Relatively circumscribed, they affect how individuals see both positive and negative events and how they cope with them.

Defining attributes of existential meaning
Existential meanings or schemas are global representations that influence individuals' perceptions of their place within the world. Determined by past experiences, they are also influenced by personal beliefs and by the beliefs of other members in the family. Situated at both the conscious and unconscious levels, existential meanings are cosmic, abstract representations that have a pervasive impact on many facets of human experience. Relatively enduring, they evolve slowly and are most likely to change in response to major life events.

Defining attributes of situational meaning
Situational meanings or appraisals are a set of expectations generated by the individuals' perception of a new event and their capacity to handle it. Determined by preexisting beliefs and by existential meanings, they have both cognitive and emotional elements. Shaped by the current situation, they change actively as events unfold. Ultimately, beliefs, existential meanings and situational meanings will influence each other. During crisis situations, all three are important factors in determining each individual's behavioural and emotional responses.

Model Case
Elizabeth, a 45-year-old woman of Greek origin, lives with her husband, Dimitri, who operates a successful printing company. They have one daughter aged 20 and two sons aged 15 and 13. Early in her marriage, Elizabeth worked as a model for a fashion magazine. She is very active in her community and now works part-time as a teacher. After finding a malignant lump in her right breast, she underwent a radical mastectomy, and is receiving chemotherapy that has resulted in the loss of all her hair.

During the treatments, the nurse noticed many photos of herself and her family that Elizabeth consistently placed on a nearby table. Elizabeth stated ‘I am very different now’. In exploring this comment, the nurse learned that since the onset of her illness, Elizabeth had cancelled her manicure sessions, a monthly routine that she had followed all of her adult life, because she believed that it was wrong to take care of one's appearance while sick. Her mother had told her that when sick or mourning the death of a family member, one should appear bleak and dreary. Elizabeth believed that she had developed cancer because she had been too proud of her appearance, and that if she continued to focus on her physical attributes, the cancer might recur. She recognized that her disease had stopped her from doing things for herself that had made her feel useful and important to her family and her community. These discussions made Elizabeth consider the possibility of purchasing a wig, something she refused in the past, and re-awakened her interest in her appearance and grooming. As she and the nurse discussed this belief, Elizabeth spoke for the first time about feeling guilty for bringing bad luck not only to herself, but also to her family.

Situational meaning
During the chemotherapy sessions the nurse frequently sat down with Elizabeth and spoke with her about how she was managing. They talked about specific concerns related to fatigue, tingling and changes in sensation in her limbs, and how she was handling housekeeping demands at home. However, Elizabeth would not ask her husband for help, nor did she want her sisters to know that she was finding it hard to manage, because she said they were busy with young children of their own. These discussions helped Elizabeth to see her symptoms as real, but temporary. They also helped her to consider that her sisters' frequent calls were requests to be helpful, and that allowing them to help would give them a feeling of being useful. Elizabeth ultimately spoke with her sisters and gave up the grocery shopping and the laundry during the remainder of the time she was on chemotherapy.

Existential meaning
During the period of her surgery, neither Elizabeth nor her husband had spoken about what the cancer, its treatment or prognosis meant to each of them. During the chemotherapy, Elizabeth found that her decreased energy level made it difficult to complete tasks or follow through on problems that arose at home. This disturbed her because she felt she was ‘not all there’ for her children. The nurse used this opportunity to encourage her to talk about how she felt about the illness in general, and to relate what she had accomplished as a mother, a teacher and a wife. Elizabeth described a vision of herself as a cancer survivor who intended to see her children marry and have grandchildren. She spoke about how her cancer was giving her a different view of her career; about feeling that if she could touch the life of only one of her students, then it was all worth it. Elizabeth also spoke about her relationship with her husband, describing how he had never liked to talk about emotionally laden experiences like illness or death, and that it would be impossible for her to share with him the fears of pain and death which she associated with recurrence. Over the years of their marriage she had come to accept that this would not change and generally did not speak with him about her own feelings of sadness or anxiety. These discussions with the nurse allowed Elizabeth to speak about feelings that she could not share with her husband. The nurse noted that her own attempts to encourage Dimitri to share his feelings about his wife's illness usually resulted in brief responses in which he said that he was pleased that she was doing so well, and was sure that everything would be fine once the treatments were over.

As beliefs, existential and situational meanings are closely related and frequently circular phenomena, the antecedents of one may be the same as the antecedents for another. Consequently, antecedents are best described as the global context in which all three elements evolve. Understanding the nature of the antecedents is therefore important for nursing practice as the goals are to explore beliefs, work with how patients and families perceive and handle an illness event, and help them to regain purpose and meaning in life.

The importance of culture in shaping beliefs and meanings has long been recognized. Culture is reflected in specific behaviours and activities of individuals such as dietary practices, religious observances and bereavement rituals and in how people define their place in the world. Culture is communicated through the multigenerational transmission of myths and legends, books, film and the mass media, powerfully shaping and reflecting the values of our times — what it means to be a man or a woman, a family, a father or a mother, to be successful or to fail (Walsh 1998). Culture has also been found to have an impact an certain beliefs pertaining to health and illness. Rolland (1987) suggests that ethnicity, race and religion are major determinants of a family's beliefs regarding health and illness. As an example, he explains that it is customary for Italians and Jews to describe physical symptoms freely and in detail, and individuals or families from Irish or white Anglo-Saxon descent to deny or conceal ailments. Wright et al. (1996) cite the importance of year of birth in the Chinese culture in influencing one's fate or survival following serious illness. Donnelly (1995) suggests that it is important for the nurse to understand culture in terms of models of reality for the patient. She considers cultural models as ‘the pool of meanings fashioned within and available to a community to make collective sense of a shared experience’ (p. 7).

Past experiences are also strong determinants of how individuals will respond to an illness event. Certain factors will influence both the specific beliefs that individuals hold as well as the two types of meanings that they will ascribe to events as they occur. Specifically for cancer, histories that are heard or past experiences of success or failure with the illness will influence both cognitive structures and emotional responses to the diagnosis of the disease in a family member. The timing of crisis events in the individual and family life cycle will also contribute to determining the meaning of an event. For example the onset of serious illness is expected in late adulthood when the anticipation of death is considered as a normative, universal experience. Off-time events such as the death of a child with cancer, do not fit prevailing beliefs about the expected trajectory of life and its meaning. Such events challenge individuals' existing beliefs, their views of the controllability of life, as well as their ability to handle the situation (Neugarten 1976, Sorenson 1995).

Implications for Practice and Research
A clear differentiation between concepts of belief and meaning helps clinicians to generate questions that explore each of these related concepts and leads to more focused interventions. It is important that nurses create an environment conducive to the exploration of beliefs as well as the situational and existential aspects of the cancer experience for both patients and their families.

As beliefs are rooted in the cognitive world of the individual and often inspired by personal experiences or culture, a nurse can assist patients to explore beliefs by inviting them to relate personal histories about their families, culture and their perception of illnesses. A conversation about patients' and families' general attitudes, expectations and values and about previous experiences with, or specific beliefs about cancer is an important part of the nursing assessment. Questions that may be helpful in exploring beliefs include: Before you were diagnosed, what images did the word ‘cancer’ evoke for you? What other experiences have you had that you think affect the way in which you see this situation? What do you believe is the cause of your illness? How do you perceive that these beliefs will impact on your everyday life or on your recovery? What do you believe will help you get through this experience? In identifying constraining and facilitating beliefs the nurse can belp individuals or families focus on their strengths, correct or inaccurate information behind constraining beliefs as well as reframe events in order te create a more positive emotional environment in which adjustment can take place.

Nurses must also work with the situational and existential meanings of the cancer experience for the patient. Examples of nursing interventions that directly address situational meaning include: giving general information about the disease that helps patients feel in control of the situation; exploring specific concerns about hair loss, fatigue or nausea during chemotherapy; making concrete suggestions for managing acute or chronic pain; and exploring alternatives that mitigate the impact of the illness and the treatments on patients' day-to-day activities. Generally, nurses recognize the importance of addressing these issues. However, the more global impact of the illness on an individual's identity and purpose in life is more easily overlooked or neglected, particularly in busy acute care settings. Nurses need to recognize the best time for raising these issues, and create a climate of acceptance and legitimacy that will allow patients to share their existential concerns. It is worth recognizing that addressing patients' concerns related to handling the immediate situation, helps build a relationship of trust and confidence that will enable patients and their families to speak about the overall meaning of the illness. Nonetheless, the responsibility rests with nurses to raise these issues in the course of caring for the patient and family and to recognize that one major roadblock in this process may be their own reluctance to address the issue of existential meaning. Questions or comments that may help open the subject of existential meaning include: You have had a lot to deal with since you first learned you had cancer. … How have you been dealing with it emotionally? Sometimes, patients and the people around them talk about how the cancer has made them re-examine what they think is important in life. Have you ever found yourself thinking about that?

- Richer, Marie-Claire; Ezer, Hélène; Understanding Beliefs and Meanings in the Experience of Cancer: a Concept Analysis; Journal of Advanced Nursing, November 2000, Vol. 32, Issue 5

Personal Reflection Exercise #2
The preceding section contained information regarding the definition of beliefs and meanings relating to the cancer experience. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Schäfer, A., Pels, F., & Kleinert, J. (2020). Effects of different coping strategies on the psychological and physiological stress reaction: An experimental study. European Journal of Health Psychology, 27(3), 109–123.

Vail, K. E., & Soenke, M. (2018). The impact of mortality awareness on meaning in life among Christians and atheists. Religion, Brain & Behavior, 8(1), 44–56.

Van Tongeren, D. R., Green, J. D., & Richmond, T. (2021). In the valley of the shadow of death: The existential benefits of imbuing life and death with meaning. Psychology of Religion and Spirituality. Advance online publication.

Wadlington, W. (2017). Review of Pragmatic existential counseling and psychotherapy: Intimacy, intuition, and the search for meaning [Review of the book Pragmatic existential counseling and psychotherapy: Intimacy, intuition, and the search for meaning, by J. L. Shapiro]. The Humanistic Psychologist, 45(2), 183–185.

Online Continuing Education QUESTION 16
What is the definition of existential and situational meaning? Record the letter of the correct answer the CE Test.

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