Narrative resilience: exploring the role of personal narratives in shaping self-concept and psychological resilience in cancer patients and survivors

INTRODUCTION

Cancer, a formidable adversary, has a profound impact on not only the physical health of those it afflicts but also on their psychological and emotional well-being.¹ While the emotional and psychological challenges faced by individuals with cancer are significant, among these aspects, to explore the concept of self, which includes perception, identity and other related variables, and how it evolves throughout the cancer journey is of paramount importance.² Personal narratives, the stories individuals construct about their experiences, play a pivotal role in this process as they actively contribute to the process of shaping one's identity extending beyond their function as a means to collect personal information.³ This narrative review delves into the interplay between personal narratives, self-concept, and psychological resilience in the context of cancer patients and survivors.

It's crucial to grasp the significant impact of personal narratives on the self-concept and psychological resilience of cancer survivors. The emotional challenges cancer patients face necessitate a nuanced exploration of how their stories help them make sense of life beyond illness, shaping self-concept and identity through reflective conversations about life's core aspects.³ This understanding can inform healthcare practices, interventions, and support systems for cancer survivors, ultimately enhancing their well-being and quality of life.

This study also holds implications beyond individual experiences, offering insights into broader themes of coping and adaptation in the face of adversity. By exploring this topic, we not only gain a deeper understanding of the experiences of cancer survivors but also contribute to the evolving field of psycho-oncology.

The primary purpose of this narrative review is to examine how personal narratives influence self-concept and psychological resilience in cancer survivors. It seeks to understand how narratives help individuals adapt to a cancer diagnosis and ultimately contribute to their psychological well-being.

Specific objectives include (a) analysing the impact of a cancer diagnosis on self-concept; (b) exploring how individuals construct and adapt personal narratives in response to cancer; (c) assessing psychological resilience and its measurement in the context of cancer; and highlighting the mediating role of resilience in the impact of cancer on self-concept. This narrative review focuses on narrative resilience in cancer survivors, with a primary focus on personal narratives within the context of various cancer types and stages.

Limitations include the reliance on existing research, which may vary in sample sizes, methodologies, and cultural contexts. This review cannot provide an exhaustive analysis but aspires to offer insights into the profound role of personal narratives in shaping self-concept and psychological resilience among cancer survivors. It is anticipated that the findings will inform practices that promote resilience and well-being in this population.

THEORETICAL FRAMEWORK

Understanding self-concept and resilience in the context of cancer requires an exploration of various theoretical constructs. These constructs help elucidate the psychological and emotional processes that individuals experience during their cancer journey. Here are some theoretical constructs that are relevant to self-concept and resilience in cancer as described below.

Self-concept theory

Self-concept theory is fundamental in understanding how individuals perceive themselves in the face of a cancer diagnosis. It encompasses the cognitive and emotional aspects of self-perception, including self-esteem, self-worth, and body image.⁴ This theory helps explain the impact of cancer on an individual's self-concept, which may evolve in response to the diagnosis and its implications.

Coping theory

Coping theories, such as Lazarus and Folkman's stress and coping model, are relevant for understanding how individuals manage the psychological challenges associated with cancer. They address the emotional regulation and coping strategies people employ to adapt to stressors, such as a cancer diagnosis.⁵ Effective coping can contribute to resilience and shape an individual's self-concept during their cancer journey by shifting the focus to the threats they are facing from illness and not just the illness in general.⁶

Narrative identity theory

Narrative identity theory emphasizes the importance of personal narratives in shaping self-concept. Narrative identity combines one's evolving life story, past, and future, promoting psychological adaptation and development. Research reveals that those who find meaning in adversity and emphasize personal agency experience enhanced mental health, well-being, and maturity in their life stories, in the context of cancer.⁷

Psychological resilience theory

Resilience theory explores the capacity of individuals to bounce back from adversity. In the context of cancer, psychological resilience theory helps elucidate the factors that contribute to an individual's ability to adapt and thrive despite the challenges posed by the disease. Resilience theory can explain how individuals maintain or even enhance their self-concept during their cancer journey.⁸

Attachment theory

Attachment theory focuses on early relationships and their influence on later emotional and psychological well-being. It is relevant to cancer because the diagnosis can disrupt attachment dynamics, potentially leading to changes in self-concept and coping mechanisms. Individuals may draw on their attachment experiences to navigate the emotional challenges of cancer.⁹

Cognitive dissonance theory

Cognitive dissonance theory addresses the discomfort individuals feel when faced with conflicting beliefs or information.¹⁰ In the context of cancer, a diagnosis may challenge pre-existing beliefs or self-concept. Understanding how individuals manage and resolve cognitive dissonance is important for assessing the impact on self-concept.

Human developmental theories

The theories of human development, such as Erikson's psychosocial development stages, can be relevant to understanding self-concept in cancer. These theories examine the evolving nature of self-identity throughout the lifespan ¹¹. A cancer diagnosis may prompt individuals to revisit and reevaluate aspects of their self-concept, particularly in stages related to identity and generativity.

Existentialist theories

Existentialist theories, including those of Jean-Paul Sartre and Viktor Frankl, delve into the search for meaning and purpose in life. Cancer can prompt individuals to confront existential questions about life's meaning, mortality, and values, which can significantly shape their self-concept and resilience.^12,13

Social identity theory

Social identity theory explores how individuals define their self-concept in relation to various social groups. In the context of cancer, individuals may identify with the ‘cancer survivor’ social group, which can influence their self-concept and sense of belonging.¹⁴

Self-concept theory from the Indian philosophical background, when applied to the context of cancer, offers a unique and profound perspective on how individuals perceive and adapt to their self-concept in the face of a life-altering diagnosis. The rich traditions of Indian philosophy provide insights into the interconnectedness of self and the universe, the impermanence of the ego, and the pursuit of self-realization. Here's how these ideas are relevant to understanding self-concept in the context of cancer as described below.

Interconnectedness and compassion

Indian philosophy, particularly in Vedanta and Buddhism, teaches that all beings are interconnected, and the individual self (Atman) is interconnected with the universal self (Brahman or Nirvana). Recognizing this interconnectedness can foster compassion, as individuals acknowledge the shared human experience of suffering and healing, in the context of cancer.¹⁵ This recognition can positively influence self-concept by emphasizing empathy and support from a broader perspective.

Impermanence and coping

Indian philosophy, through the concept of Maya, underscores the transient nature of the material world and the ego. Individuals can draw strength from the understanding that all experiences, including illness, are impermanent.^15,16 This awareness can lead to a more adaptive self-concept by helping individuals cope with the uncertainty and changes brought about by cancer.

Self-realization and personal growth

Indian philosophy places a strong emphasis on self-realization and self-knowledge. In the context of cancer, this perspective encourages individuals to view the cancer journey as an opportunity for profound self-realization and personal growth. Through introspection and self-awareness, individuals may develop a deeper and more resilient self-concept, acknowledging the potential for inner transformation.^17-19

Detachment and psychological resilience

The teachings of detachment and non-attachment can be applied to coping with the emotional challenges of cancer. By cultivating detachment from the fear of suffering, the uncertainty of the future, and the identification with the illness, individuals can enhance their psychological resilience. This shift in self-concept allows them to embrace their true nature beyond the ego, fostering a sense of inner strength and resilience.^20,21

Karma and responsibility

In the face of cancer, the concepts of dharma (duty) and karma (action) in Indian philosophy can guide individuals in understanding their responsibilities. Recognizing the karmic consequences of their actions may help individuals accept their circumstances and take responsibility for their health and well-being.¹⁵ This sense of approach can positively impact self-concept and motivate proactive engagement in their cancer journey.

Mind-body practices

Many Indian philosophical traditions advocate practices like yoga and meditation. These practices can enhance self-awareness, reduce psychological distress, and promote a sense of inner peace. Such practices are not only relevant to managing the physical aspects of cancer but also to the emotional and psychological dimensions of self-concept and resilience.^22,23

CANCER DIAGNOSIS AND ITS PSYCHOLOGICAL IMPACT ON SELF-CONCEPT

A cancer diagnosis is a life-altering event that reverberates beyond the physical implications, profoundly affecting an individual's psychological and social well-being.²⁴ Cognitive and emotional responses to such a diagnosis are diverse, ranging from shock and disbelief to anxiety and fear.^25,26 The psychological impact extends beyond the immediate emotional reactions, influencing how individuals perceive themselves and their roles in various aspects of life.²

The journey through cancer disrupts self-concept and role identities, challenging the individual's sense of identity and stability. The ‘self’ functions as an intra-psychological structure, shaping life experiences and understanding in a continuous, chronological sequence. Maintaining the continuity of the ‘self’ is pivotal for finding meaning and ensuring psychological well-being. However, the traumatic encounter with cancer disrupts the normal flow of life stories, challenging coherence. Chronic illnesses, like cancer, alter daily actions, erode control, reshape the relationship with one's body, and force a confrontation with mortality. Cancer patients often face unmet social support and emotional needs, impacting their identity and self-perception shaped in social relations.²⁷ Cancer experiences impose profound changes, with aspects like uncertainty and aggressive treatments making patients vulnerable to alterations in self-views. Mages and Mendelsohn specifically contend that cancer treatment-induced physical damage can compel shifts in self-perception.^2,27

Individuals carry a unique 'pre-cancer self-concept,' which evolves with its content and structure when transitioning into the 'cancer self.' The self-concept at diagnosis differs from that during treatment or relapse, and it can also transform into a 'post-cancer self' in survivorship phase while some may face a transient ‘self-disappear’ phase in between.^2,27 Thus, self-concept plays a pivotal role in determining coping strategies individuals may employ to navigate the emotional turmoil, including seeking social and emotional support, engaging in positive reframing, acceptance, planning or adapting a resilient mindset.²⁸

Understanding the cognitive and emotional responses to a cancer diagnosis, acknowledging the disruption of self-concept, and recognizing the role of self-concept in coping strategies is crucial for healthcare professionals. Tailoring support and interventions to address the psychological impact of a cancer diagnosis can enhance the individual's overall well-being, resilience, and ability to navigate the complex journey of cancer survivorship.

NARRATIVE IDENTITY: THE POWER OF PERSONAL NARRATIVES

Narrative identity represents an individual's internalized and evolving life story, combining the reconstructed past and imagined future to offer life a sense of coherence, purpose, and meaning. Developing a narrative identity involves learning to share stories within cultural norms, among various groups like families and peers. Early parent-child dialogues lay the groundwork, enabling children to extract meaning from personal events. This process, integral to narrative identity development, moves beyond event details to articulate personal beliefs about oneself. In meaning-making, the storyteller draws conclusions about the self from the episodic information conveyed in the story.⁷ Reconstructing narrative identity involves crafting an agentic identity, viewing illness as merely one facet of a complex, evolving-self capable of actively pursuing well-being in recovery. This transformative process, marked by personal growth and adaptability, aligns with a narrative constructivist perspective. Here, individuals are seen as ever-changing, continually adapting to internal and external demands, with storytelling serving as a fundamental process of human functioning. As individuals evolve, their stories may undergo changes, rendering their narrative identity open to transformation.²⁹ The concept of narrative identity delves into the profound influence of personal narratives on an individual's life. Understanding how individuals construct their personal narratives is essential in unravelling the complexities of human experience.³⁰ These narratives contribute significantly to the shaping of self-concept, influencing how individuals perceive themselves, their resilience, and their ability to navigate adversity. The stories individuals construct about their illness, treatment, and survival contribute to a unique narrative identity.³¹

By exploring the intricate relationship between personal narratives, narrative identity and coping mechanisms, healthcare professionals gain insights into the emotional landscapes of individuals dealing with cancer. Acknowledging and supporting the construction of positive and empowering personal narratives can foster a sense of agency, resilience, and a more adaptive self-concept, ultimately enhancing the overall well-being of those facing the challenges of cancer.

PSYCHOLOGICAL RESILIENCE IN THE FACE OF CANCER

Psychological resilience, a dynamic trait, is crucial for individuals facing the formidable challenges of cancer. Psychological resilience in cancer refers to individual’s modifiable protective attributes aiding successful adaptation to cancer including meaning of life, self-coherence, optimism, emotions, self-esteem, self-efficacy, cognitive flexibility, coping, social support and spirituality. Resilience, a dynamic mechanism, evolves with time and is influenced by a range of factors, including sociodemographic and personal attributes, certain cancer-related variables (such as time since diagnosis, cancer type, and stage), the social context, and coping strategies.

Despite varied coping responses among cancer patients, there's an increasing recognition that resilience in life-threatening situations, like cancer, is more common than believed. Many navigate this stress with minimal impact on daily functioning, even experiencing positive emotional and personal growth. Moreover, psychological resilience acts as a mediator in the impact of cancer on self-concept. As individuals grapple with the disruptions caused by cancer, a resilient mindset can mitigate the negative effects on self-perception.⁸ Resilience becomes a buffer, helping individuals maintain a positive self-concept and adaptively integrate the experience into their broader life narratives.

NARRATIVE RESILIENCE IN CLINICAL PRACTICE

Narrative resilience is a powerful concept in the field of psycho-oncology, particularly in the context of cancer care and survivorship. These ideas are crucial in clinical practice because the care of the ill revolves around narratives. From symptom onset to treatment completion, illness must be expressed: first by the patient to themselves through symptoms, then to family and friends, and ultimately to healthcare professionals who share this information. Each illness or care episode produces numerous accounts: patient concerns, clinician reports, provider comments, and responses from all involved. Despite their textual diversity, they collectively form a multi-perspective narrative of illness, vital for its management. Amidst this multitude of accounts, the pivotal event in clinical care unfolds when the patient conveys their experience, and a trained caregiver comprehends and acknowledges it. Clinical practice increasingly recognizes the role of narrative resilience in improving patient outcomes, overall well-being, and communication between healthcare providers and patients.³²

NARRATIVE-BASED INTERVENTIONS IN PSYCHO-ONCOLOGY

Narrative-based interventions involve the use of storytelling and personal narratives as therapeutic tools to help cancer patients cope with their diagnosis, treatment and altered-life. Narratives serve as the pathway to self-expression and self-understanding. A narrative approach provides an alternative to psychosocial oncology's pathologizing of negative affect into psychiatric categories. Allowing patients to tell their own stories, reconstructing their narrative, offers a distinct mode of coping, emphasizing the process of meaning-making over coping outcomes. The therapeutic act of narrating experiences, being listened to, and heard is performative, actively shaping and reshaping one's self.³¹

Lately, there is a growing sense of immediacy in the act of sharing one's self. This urgency is not limited to memoirs; it extends to a wide array of narrative forms, including fiction, poetry, drama, essays, and journalism, which unveil aspects of the self.³²

Mindfulness-based narrative therapy (MBNT) employs mindfulness and a blend of verbal and non-verbal methods to elicit fresh meanings by disrupting the depressive narrative.³³

Art therapy, a potent approach using artistic expression, aids physical and mental healing, enhancing perception and cognitive functions. It serves to confront life and death in serious diseases like cancer, visually conveying deeply buried emotions like fear and hope, by stimulating memory. Patients and their families often experience emotional strain due to concern, fear, anxiety and existential questioning during the challenging phases of cancer- diagnosis, treatment and post-treatment. Through art therapy, they can articulate themselves without the need for talent when words fall short. Art therapies encompass various forms like music, painting, drawing, collage, sculpture, dance, creative drama, or writing.³⁴

Narrative coaching, a transformational person-centred intervention, centres around personal identity. It's pragmatic, employing literary metaphors, models and tools for personal change. A serious game, like a board game, could be effective in narrative identity reconstruction, employing metaphors, focusing on identity and enabling players to experiment with responses to challenges and explore potential identities. These games simplify complex concepts effectively.²⁹

In Systems-centred therapy (SCT), ‘experience’ is used as the key theme which differs between the ‘there-and-then’-what's known, felt, and encountered- and ‘here-and-now’-the unknown and unencountered narratives. SCT mandates discussing the ‘here-and-now’ experience via ‘functional subgrouping,’ fostering listening, reflection, and building on shared experiences.³⁵

These interventions encourage individuals to share their experiences, fears, and hopes, providing a safe space for emotional expression and reflection. By acknowledging and validating patients' narratives, healthcare professionals can promote resilience and emotional healing, which is particularly vital in the often daunting and emotionally charged world of cancer care.

THE ROLE OF NARRATIVE MEDICINE IN SUPPORTIVE CARE FOR CANCER PATIENTS

The patient's narrative and the physician's documentation are crucial for patient care. In 2001, Dr. Rita Charon of Columbia University coined the term ‘narrative medicine’ (NM), which involves recognizing, comprehending, interpreting and responding to the stories and challenges of patients.³⁶ Its goal is to tackle the relational and psychological challenges intertwined with physical illness, endeavouring to treat patients not solely based on symptoms but as individuals with unique stories.³⁷ In supportive care for cancer patients, narrative medicine in support group can aid in comprehending the patient's journey, experiences and emotions as the individuals rehearse and refine their evolving stories of illness and survival. It enables healthcare providers to offer more personalized and empathetic care understanding their difficulties in transition to old ways and efforts in renegotiation with the reconstructed identity, ultimately promoting resilience and improved overall patient outcomes.³⁸

IMPROVING COMMUNICATION BETWEEN HEALTHCARE PROVIDERS AND PATIENTS

Effective relation and communication between doctor-patient is a cornerstone of cancer care and narrative resilience can enhance this. Healthcare providers who acknowledge and validate patients' narratives create an environment of trust and collaboration, ultimately leading to better-informed decision-making, emotional well-being and resilience in the face of cancer with an effective therapeutic alliance using person-centred approach.^32,37

Fraas highlighted the significance of narratives in the treatment journey. In the diagnosis phase, narratives foster empathy and mutual understanding between healthcare providers and patients. Throughout treatment, they offer valuable insights for decision-making and disease management. Additionally, narratives prompt reflection on behaviour and thoughts, enhancing mutual understanding not only from the medical side to patients but also from patients to their caregivers.³⁷ Narrative, inherently disruptive, stands apart from neat, predictable and obedient lists or formulas. However, the benefits of employing narratives in medicine are manifold. They forge connections between healthcare providers, patients and communities, thereby mitigating the inevitable complexities in healthcare.³⁹

Overall, narrative resilience is a vital component of clinical practice in psycho-oncology, emphasizing the significance of personal narratives, storytelling and narrative-based interventions in cancer care. It contributes to improved patient outcomes, better communication and enhanced psychosocial support for cancer patients and survivors, making it an invaluable aspect of cancer care.

CULTURAL AND CONTEXTUAL INFLUENCES ON NARRATIVE RESILIENCE

Life narratives play a crucial role in capturing individuals' cultural sense-making. Therefore, narrative resilience is valuable for revealing how cultural factors influence the expression of resilience, especially in the context of cancer.⁴⁰ In examining resilience within the context of culture, the interaction variable becomes highly significant. However, it's worth noting that environmental factors tend to explain more variance in models compared to individual differences when both are measured in studies.⁴¹

Culture encompasses a society's values, beliefs, language and behavioural norms, shaping perceptions, emotions, and illness views. Cancer experiences are inseparable from culture; societal beliefs influence how illness is perceived, treated and its potential outcomes. Cross-cultural distinctions can create ethical quandaries concerning communication, decisions, treatments and end-of-life choices which influence the themes, values and emotional tones within these narratives, impacting how individuals cope.⁴²

Cultural beliefs, such as the meaning ascribed to cancer, can affect the content and direction of the narrative, and the availability and nature of social support networks too culturally determined.³¹ These cultural influences are vital considerations for cross-cultural and multicultural cancer care, where healthcare providers must be sensitive to diverse coping mechanisms and narratives. Acknowledging these influences is crucial for delivering effective, empathetic and culturally competent support to cancer patients and survivors from various cultural backgrounds.

FUTURE DIRECTIONS AND RECOMMENDATIONS

Moving forward, research should prioritize developing and testing personalized narrative interventions tailored to individual cancer survivors. Going forward personalised medicine will form an integral part of cancer care. Examining the effectiveness of innovative approaches, such as virtual support groups and technology-mediated interventions, would contribute to evolving practices. Longitudinal studies tracking the trajectory of narrative resilience over time can provide a deeper understanding of its dynamic nature.

Additionally, investigations into the inter-sectionality of narrative resilience with cultural and socioeconomic factors can enhance cultural competence in interventions. Integrating narrative resilience principles into medical education is crucial, fostering empathetic communication and enhancing healthcare professionals' ability to provide patient-centred care. Furthermore, interdisciplinary collaborations between psychologists, healthcare providers and technologists can facilitate the development of user-friendly tools that promote narrative expression and resilience. By addressing these future directions, the field can advance its understanding of narrative resilience and translate these insights into more effective and culturally sensitive interventions for the psychosocial well-being of cancer survivors.

CONCLUSION

In conclusion, this narrative review significantly advances knowledge and understanding in the field of psycho-oncology by unravelling the intricate interplay among personal narratives, self-concept, and psychological resilience in the context of cancer. The exploration, deeply rooted in theoretical frameworks from Western and Indian philosophical traditions, sheds light on the transformative influence of personal narratives on evolving self-concepts throughout the cancer journey. By emphasizing the pivotal role of narrative resilience, the study not only contributes practical insights for personalized and empathetic healthcare strategies but also enriches the theoretical landscape of psycho-oncology. The findings underscore the need for tailored interventions that recognize the nuanced dynamics of personal narratives, self-concept, and psychological resilience, offering a comprehensive understanding of the intricate psychological processes involved. This nuanced perspective paves the way for future research endeavours, advocating for longitudinal studies and interdisciplinary collaborations to further refine and implement narrative resilience principles into clinical practice. Ultimately, the study positions narrative resilience as a cornerstone in reshaping healthcare practices, fostering healing, personal growth, and resilience in the challenging and transformative journey of cancer survivorship.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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