Finding the middle ground in psychological appraisal of illness

I read Dixon et al.'s insightful editorial with great interest – where the authors called for a re-think on common medical advice for patients to engage in ‘positive thinking’ in the face of illness, which can have life-changing implications.1 As with most things in life, humans have a tendency towards dichotomous (‘black-and-white’) thinking that forces perceptions of events to be either inherently positive or negative. This is a common cognitive distortion given that reality is mostly filled with grey areas and uncertainty. Likewise, patients with chronic disease are bound to face several ups and downs in their illness journey and be subject to many uncertain elements beyond our control. As the authors mentioned, over-emphasis on positive thinking in illness appraisal, while well meaning, can lead to unintended consequences such as creating unrealistic expectations, maladaptive thought-action fusion, undue pressure to conform to social expectations and, eventually, unwise health-related decision-making.1 On the other hand, excessive negativity and pessimism lead to loss of hope, amplification of stress responses and maladaptive behaviours such as unhealthy lifestyles and non-adherence to medical treatment and advice.2 In both instances, fixation on extreme attitudes leads to undesirable consequences. Instead, a ‘middle-ground position’ that balances optimism and pessimism, embedded with practical realism, is perhaps the better and more ethical approach to clinical care.3 In my humble opinion, psychological support for patients should ultimately revolve around helping them live with illness – which involves managing natural emotions experienced in the course of the illness journey, focussing on the controllables, coping with uncertainties and letting go of what is beyond their control. According to the ‘Let Them’ theory popularised by Mel Robbins,4 which has psychological grounding in psychologist Julian Rotter's locus of control theory,5 inner peace and reduced anxiety can be attained when there is acknowledgement and acceptance of our external circumstances, followed by a shift from an external locus of control (helplessness towards external events) to an internal one (that focusses on self-agency). In this regard, encouraging mindfulness practice, defined as ‘meta-awareness and acceptance of present moment thoughts, emotions, and sensations’,6 can help patients in the first step of illness appraisal to acknowledge their condition and accept natural emotions that occur. Physicians can simply ‘hold space’ for these patients to narrate their thoughts and feelings in a safe environment free from judgement whenever there is a new event that occurs (e.g. new diagnosis, complication or treatment response/lack thereof). After this phase, rather than tell patients what they should feel, gently guide them away from focussing on the external situation to instead look at what they can do within their control to live meaningfully and purposefully with the disease – and in this process, offer practical support to help them achieve this. After all, we do not want our patients who live with disease to be defined by it. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.