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Remaking the self : trauma, teachable moments, and the biopolitics of cancer survivorship Bell, Kirsten Oct 9, 2012

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ORI GIN AL PA PERRemaking the Self: Trauma, Teachable Moments,and the Biopolitics of Cancer SurvivorshipKirsten BellPublished online: 9 October 2012 The Author(s) 2012. This article is published with open access at Springerlink.comAbstract As numerous scholars have noted, cancer survivorship is often repre-sented in popular discourse as providing an opportunity for a physical, emotional,and spiritual makeover. However, this idea that cancer enables the self to be remadeon all levels is also increasingly evoked in the field of psychosocial oncology.Exploring cancer survivorship as a biopolitical phenomenon, I focus on two con-cepts that have become central to understandings of the disease: the ‘‘teachablemoment’’ and ‘‘post-traumatic growth.’’ Drawing primarily on representations ofcancer survivorship in the clinical literature, I suggest that cancer is increasinglyseen to present a unique opportunity to catalyze the patient’s physical and psy-chological development. In this framework, the patient can no longer be relied uponto transform him or herself: this change must be externally driven, with clinicianstaking advantage of the trauma that cancer entails to kick-start the patient intoaction. Broadening my analysis to the concepts of ‘‘trauma’’ and ‘‘development’’writ large, I go on to suggest that survivorship discourse seems to partake of a largerand relatively recent meta-narrative about development—both individual andsocietal—and the positive opportunity that trauma is seen to present to stimulatereconstruction on a grand scale.Keywords Cancer  Trauma  Lifestyle  Development  Psychosocial oncologyA survivor is a triumphant person who lives with, after, or in spite of adiagnosis or traumatic event. Survivors refuse to assume the identity of theiradversity. They are not imprisoned by the constructs of a label. Instead,survivors use their brush with mortality as a catalyst for creating a better self.K. Bell (&)Department of Anthropology, University of British Columbia, 6303 NW Marine Dr,Vancouver, BC V6T 1Z3, Canadae-mail: kibell@mail.ubc.ca123Cult Med Psychiatry (2012) 36:584-600DOI 10.1007/s11013-012-9276-9We transform our experience in order to further evolve spiritually, emotion-ally, physically, and mentally.(Carr 2008)IntroductionIn June of 2010, the biennial Cancer Survivorship Research: Recovery and Beyondconference was held in Washington DC. Sponsored by the National CancerInstitute, the American Cancer Society, LIVESTRONG: the Lance ArmstrongFoundation, and the Centers for Disease Control and Prevention, the meeting isdevoted exclusively to the topic of cancer survivorship and its stated aim is to‘‘bring together investigators, clinicians, and survivors to share and learn about themost up-to-date cancer survivorship research’’ (NCI, ACS, LIVESTRONG, CDC2010).The first day of the 2010 conference was devoted to the relationship betweenlifestyle and cancer and the line up of presenters included an impressive list of‘‘leading lights’’ in the field. Despite the generally inconclusive state of the evidenceregarding the impact of diet, weight, and exercise on cancer survival, the messagebroadcast to participants was of the need to actively encourage patients to modifytheir lifestyles (see Bell 2010; Bell and Ristovski-Slijepcevic under review). ‘‘Weneed to encourage survivors to increase their physical activity after diagnosis’’stressed one well-known dietitian. A second reiterated the need to ‘‘capitalize on theteachable moment caused by the cancer diagnosis’’ in promoting weight loss amongoverweight cancer patients. In her closing remarks, the moderator of the finalsession of the day tasked the audience with spreading this message far and wide.‘‘Talk about exercise to the survivors you come into contact with,’’ she urged.‘‘We’re charging you to get the message out’’: ‘‘spread the word.’’The remainder of the conference was more varied in content and includedsessions on topics such as rehabilitation, sexuality, fertility, and the psychologicalimpacts of cancer survivorship. Benefit Finding and Growth After Treatment forCancer was one of the most popular panels, unsurprising given the growingprominence of these concepts in the field of psychosocial oncology over the past15 years. The session focused on describing and measuring ‘‘benefit finding’’ and‘‘post-traumatic growth’’ in cancer survivors, and the permanency of their effectsover time.1 Informing several of the presentations was the assumption that there is a‘‘right’’ way to deal with cancer, a position increasingly echoed in the psychosocial1 Much of the discussion centered on the need for ‘‘objective’’ measurements of benefit finding and post-traumatic growth. The general tenor of the talks and following discussion was that the self-assessments ofcancer survivors could not be trusted as they may falsely think they have experienced growth because ofthe ‘‘tyranny of positive thinking.’’ Indeed, researchers working in this area increasingly stress the need todistinguish real growth from ‘‘pseudo-growth’’ (e.g., Lechner and Antoni 2004) because of similarconcerns. Yet, although such discussions would appear to mount a challenge to the validity of theconstruct of post-traumatic growth itself, instead it is the survivors themselves who are challenged: theconstruct is ‘‘real’’ but survivors’ reports are untrustworthy. Survivors, it appears, are ‘‘damned if they doand damned if they don’t.’’ Interventions are necessary to facilitate post-traumatic growth, but survivors’reports on whether growth has been achieved are deemed faulty.Cult Med Psychiatry (2012) 36:584–600 585123literature. In the words of one speaker: ‘‘if we respond [to cancer] in a healthy waywe can find something out of it,’’ and his talk ended with a discussion of recentefforts to develop interventions to ‘‘facilitate’’ post-traumatic growth in cancersurvivors. Significantly, the key message of the conference was that of intervention:the importance of intervening in the lives of cancer survivors, in a cost effectiveway, to make them thinner, fitter, and psychologically and spiritually healthier.In 1977 Susan Sontag (1990) wrote a searing indictment of the prevailing culturalview of cancer as a ‘‘death sentence.’’ However, in the 35 years since thepublication of her essay, the equation of cancer and death has been at least partiallysuperseded by the assertion that cancer ‘‘can be beaten’’ (Sinding and Gray 2005;Deimling et al. 2007). These developments speak to the emergence of a newdiscourse on cancer, a discourse centered on survival rather than death, which hasresulted in the production of a new category of person: the ‘‘cancer survivor’’(Saillant 1990; Zebrack 2000).Understood as a distinct clinical entity, ‘‘cancer survivors’’ are the site ofconsiderable media interest and medical attention. If cancer was unspeakable only afew decades ago, today it has become a disease to publicly lay claim to and evencelebrate. While this discursive shift can be seen as positive in so far as it moves theemphasis away from the cancer ‘‘victim’’ identity that Sontag railed against, there isalso a downside to the emergence of discourses on cancer survivorship (Deimlinget al. 2007). As a growing number of observers have noted, central to the ‘‘cancersurvivor’’ identity is the idea that cancer creates a better self. Barbara Ehrenreich(2001, 2009), writing about breast cancer, has noted that cancer is increasinglyconceptualized as a ‘‘harbinger of personal growth’’ and a ‘‘makeover opportunity.’’In this discourse, which Ehrenreich suggests has become hegemonic, the breastcancer survivor is expected to emerge from the cocoon of cancer diagnosis andtreatment as a new and improved person. Expanding on this insight, Sinding andGray (2005) have identified ‘‘spunky survivorship’’ as the dominant discourse onbreast cancer, with survival represented as both an accomplishment and opportunityfor self-transformation. Kaiser (2008) has similarly highlighted the popularemphasis on the ‘‘exceptionality’’ of breast cancer survivors.Although some analyses have suggested that these representations are gendered,with women more often depicted as transformed by the experience of cancer2 thanmen (Seale 2002), it is clear that the ‘‘new and improved cancer survivor’’ tropeextends well beyond the realm of breast cancer and pervades popular representa-tions of cancer survivorship more broadly. Today, narratives of personaltransformation and self-improvement have become ubiquitous, featuring stories of‘‘heroic struggle and psychological progress in the face of the disease’’ (Seale 2001,p. 428; see also Stacey 1997; Little et al. 2002). For example, in their analysis ofprint news coverage of cancer survivorship, Kromm, Smith, and Singer (2008, p. 3)note that the disease is depicted in ‘‘overwhelmingly positive terms,’’ with survivors2 It is also arguable whether these discourses apply equally to elderly people diagnosed with cancer,where the tragedy of cancer is seen to be less acute, coming as it does at the end of a long life. Sinding andWiernikowski (2008), in their study of older women with cancer, show that women did not see cancer asintrinsically traumatic and transformative. Rather, it was seen as an inevitable part of getting older that insome cases receded in light of other chronic diseases.586 Cult Med Psychiatry (2012) 36:584–600123represented as ‘‘energized, dynamic survivor warriors.’’ Lance Armstrong (2006)epitomizes the energized survivor warrior, having famously noted that:[P]eople have asked me what I mean when I say that given a choice betweencancer and winning the Tour de France, I’d choose the cancer. What I mean isthat I wouldn’t have learned all I did if I hadn’t had to contend with the cancer.I couldn’t have won even one Tour without my fight, because of what it taughtme. I truly believe that (p. 284).Implicit within such representations is the idea that cancer enables the self to beremade on all levels—psychological, spiritual, and physical—a view that hascrystallized in recent conceptualizations of cancer survivorship, such as the quotethis essay opened with from Kris Carr, the author of Crazy, Sexy Cancer Survivor.Yet, as the Cancer Survivorship Research conference illustrates, this trope is notrestricted merely to popular representations of cancer but infuses oncologicaldiscourses as well. As Delvecchio Good et al. (1990, pp. 55–56) have previouslyreminded us, ‘‘A nation’s practice of oncology is shaped not only by medicaltechnology and therapeutics, but by local popular and medical cultures as well.’’This paper critically examines the widespread perception that cancer enables andfacilitates self-transformation. Through an exploration of the concepts of the‘‘teachable moment’’ and ‘‘post-traumatic growth’’ and their embrace in the field ofpsychosocial oncology, I examine the growing push to intervene in the lives ofcancer survivors to ‘‘enhance’’ their lifestyles and psychological development. Inthe second half of the paper, I broaden the scope to consider the concepts of‘‘trauma’’ and ‘‘development’’ writ large, before turning to a consideration of theimpacts of these discourses on cancer survivors themselves. My overarching goal isto demonstrate that discourses on cancer survivorship are linked with much largercultural shifts in the ways that psychological, social, and societal development areconceptualized.Cancer and the Teachable MomentIn recent years, the concept of the ‘‘teachable moment’’ has become a cornerstone ofthe health literature to describe naturally occurring life transitions or health events(e.g., cancer diagnosis, hospitalization, pregnancy) that have the potential tomotivate individuals to adopt health-protective behaviors (McBride et al. 2003;Ganz 2005). However, the widespread embrace of the concept has not been drivenby empirical research demonstrating its validity, which is notably lacking (Lawsonand Flocke 2009). Rather, it is generally treated as a self-evident truism, suggestingthat much of its appeal stems from an underlying model of human nature andselfhood that appears to intuitively make sense to oncology care professionals.This underlying model of human nature crystallizes in attempts to describe theelements constituting the teachable moment. Here, the work of McBride et al.(2003) is instructive. They suggest that for cueing events to become teachablemoments, three interrelated elements are necessary. The event should (1) increaseperceptions of personal risk and outcome expectancies, (2) prompt a strong affectiveCult Med Psychiatry (2012) 36:584–600 587123or emotional response, and (3) redefine self-concept or social role. In other words,the concept of the teachable moment suggests that the more scared a patient is, themore fundamentally their prior sense of self is undermined, the higher theirmotivation is to change their lifestyle—as long as they perceive the change to havesome potential benefit.3 That fear is central to this model becomes explicit instatements such as ‘‘Negative affect, i.e. fear, may be particularly impactful becauseit increases vigilant attention and prompts the survival instinct’’ (McBride et al.2003, p. 163).It was initially thought that people diagnosed with or ‘‘at risk’’ for cancer wouldnaturally improve their lifestyle because of the exemplary ‘‘teachable moment’’such events present; however, clinicians are increasingly of the view that thediagnosis of cancer alone cannot be relied upon to stimulate behavior change. In thewords of Demark-Wahnefried et al. (2006, p. 5126):Until recently, there was a degree of optimism among oncologists andresearchers because descriptive studies suggested that individuals improvedtheir lifestyle behaviors after being diagnosed with cancer…. [M]ore recent,robust research… reveals that there may be comparatively fewer lifestyledifferences between individuals with or without a cancer history thanpreviously thought, especially among long-term cancer survivors. In fact, insome survivor subgroups, the practice of healthful behaviors may even beworse. Thus, although adjusted analyses indicate that survivors may besomewhat more likely to meet physical activity guidelines, the majority aremuch like the population at large—a population marked by sedentarybehavior; overweight or obesity; and suboptimal fruit, vegetable, and fiberconsumptions, and high intakes of saturated fat.Here, the attitudes of those who resist injunctions to modify their lifestylebehaviors are pathologized, deemed to be ‘‘marked’’ by fatalistic attitudes andmisconceptions that need to be dispelled by clinicians. As Martha Balshem (1993,p. 67) observes, ‘‘The magic bullet is the health-education message, delivered to thetarget population through an appropriate strategy, preferably at a teachablemoment.’’In this framing, teachable moments can be actively created and exploited ratherthan simply waited for (Lawson and Flocke 2009, p. 27). Consequently, as theCancer Survivorship Research conference attests, among oncology care providersthere has been a growing interest in ways to facilitate and exploit the teachablemoment that cancer presents via active interventions that promote adherence torecommended lifestyle behavioral guidelines (Blanchard, Courneya and Stein2008). According to Demark-Wahnefried et al. (2005, p. 5827):3 In the words of Humpel, Magee, and Jones (2007, p. 622), ‘‘Positive lifestyle changes are more likely tooccur if the cancer survivor believes that these changes will improve their health and prevent cancerreoccurrence.’’ There is clearly a sales pitch that occurs, whereby survivors need to be convinced (in theface of inconclusive evidence) of the tangible benefits of making this change (Bell and Ristovski-Slijepcevic under review). As Balshem (1993) has pointed out, many of the ‘‘myths’’ about cancer thathealth educators are expected to dispel are actually valid and logical interpretations of the existingevidence.588 Cult Med Psychiatry (2012) 36:584–600123For decades the cancer diagnosis has been acknowledged as a life-changingevent. It is time for oncology care providers to not only lead their patientsaway from disease but also to capitalize on the teachable moment that cancerprovides and guide their patients to better health.Others similarly argue that formal interventions should be introduced to ‘‘takeadvantage’’ of the ‘‘underused’’ ‘‘window of opportunity’’ presented by cancerdiagnosis and treatment and patients’ ‘‘heightened receptivity’’ during this period(see McBride et al. 2003, 2008; Gritz et al. 2005).Trauma and GrowthUnderlying these discussions of the teachable moment is the assumption that acancer diagnosis is deeply traumatizing for those who experience it.4 Indeed, the useof the term ‘‘survivor’’ to refer to people diagnosed with cancer shows how centraltrauma is to conceptions of the disease, given that the label initially described thosewho had experienced traumas such as attempted genocide, war, natural disasters, orrape. In contemporary formulations of the teachable moment, the trauma of thecancer diagnosis is deemed to have positive utility in transforming the cancerpatient’s lifestyle.The positive role of trauma is articulated even more explicitly in the concept ofpost-traumatic growth, which suggests that trauma may lead to ‘‘a greaterappreciation of life and changed sense of priorities; warmer, more intimaterelationships with others; a greater sense of personal strength; recognition of newpossibilities or paths for one’s life; and spiritual development’’ (Tedeschi andCalhoun 2004, p. 6). Coined in the 1990s, ‘‘post-traumatic growth’’ was explicitlyconceptualized as the antonym of ‘‘post-traumatic stress,’’ representing the upside oftrauma: the silver lining to its dark cloud5 (Tedeschi, Park and Calhoun 1998).Although the concept did not relate specifically to cancer in its initial formulation, ithas certainly flourished in the fertile soil of psychosocial oncology and over the pastdecade it has gained increasing prominence in the field.In many respects, post-traumatic growth is the psychological counterpart to theteachable moment, whereby the psychological self is transformed along with thephysical self. This becomes evident in discussions of the conceptual underpinningsof post-traumatic growth, which is seen to result from a ‘‘seismic event’’ that‘‘shatters an individual’s assumption system, forcing reconfiguration of theirschemata’’ (Aldwin and Levenson 2004, p. 19). Compare this with McBride et al.’s(2003) description of the teachable moment as a ‘‘cueing event’’ that prompts a‘‘strong emotional response’’ and ‘‘redefines self-concept.’’4 However, this assumption is not necessarily accurate. As pointed out in note #2, not all of those whoexperience cancer find the experience equally traumatic. This, of course, speaks to some of the limitationsof existing ways of thinking about trauma, a category which serves to universalize and normalizeexperience and erase difference (see Young 1995; Pupavac 2001; Fassin and Rechtman 2008).5 The cover of the first book on this topic actually depicts a cloud with a silver lining.Cult Med Psychiatry (2012) 36:584–600 589123Indeed, in some conceptualizations, the teachable moment collapses into post-traumatic growth, with increases in health-promoting behaviors seen to be anintegral manifestation of such growth (see Lechner and Antoni 2004). Moreover,like the teachable moment, post-traumatic growth is posited to happen spontane-ously, but it is also something that can purportedly be triggered throughinterventions that ‘‘take advantage of the trauma-induced disruption to the person’slife’’ (Lechner and Antoni 2004, p. 35; Garland et al. 2007, p. 950). In both of theseframings, trauma has an instrumental role to play in remaking the self. By forcingthe cancer patient to re-evaluate his or her life, and by shattering taken-for-grantedassumptions about the self, trauma allows the self to be remade from the ground up.However, as Alan Young (1995) and Didier Fassin and Richard Rechtman (2008)have shown, although the concept of trauma is understood to describe a natural anduniversal phenomenon, it represents a very particular way of thinking about the self.In this conceptualization, trauma does something to the self: either the self becomes‘‘stuck’’ and unable to progress (as in post-traumatic stress disorder) or trauma‘‘kick-starts’’ the self, positively transforming it (as in post-traumatic growth). Thisis evident in some of the language used to talk about cancer survivors, where thosewho have not experienced growth are deemed to be ‘‘stuck’’6 in earlier phases of thetrajectory and unable (or unwilling) to move toward the ‘‘light’’ at the end of thetunnel (e.g., Utley 1999; Taylor 2000). Clearly, in this conceptualization, aparticular manifestation of ‘‘growth’’ is naturalized.In this framework, trauma thus gives grounds for the intervention of psychol-ogists and psychiatrists (Fassin and Rechtman 2008, p. 276). Indeed, it could beargued that the psychic trauma that cancer is seen to entail was central to thelegitimization of psychosocial oncology as a distinct sub-specialty in the 1990s.7Thus, in an editorial published in the inaugural issue of the journal Psycho-Oncology, the emotional response of patients and their families to cancer wasidentified as a central concern of the subfield, with ‘‘controlled trials ofpsychotherapeutic, behavioral and psychopharmacologic interventions’’ deemed tobe one of its primary goals (Holland 1992, p. 6).Today, one of the most influential of such interventions is ‘‘Cancer Transitions:Moving Beyond Treatment,’’ which was created in 2006 by the Cancer SupportCommunity and LIVESTRONG (both community-based organizations), although itis increasingly being offered at a number of cancer treatment centers in the USA andCanada.8 The program is designed to help cancer survivors ‘‘redefine how we live6 As noted above, this framing is very similar to the ways that PTSD is represented. For example, onewebsite on PTSD describes it in the following terms: ‘‘sometimes the trauma is so overwhelming that youfind that you can’t move on. You feel stuck…. If you went through a traumatic experience and are havingtrouble getting back to your regular life…you may be suffering from post-traumatic stress disorder’’(Smith and Segal 2011).7 Although psychosocial oncology (also known as psycho-oncology) emerged in the late 1960s/early1970s, and was the focus of a specialty journal (Journal of Psychosocial Oncology) from the mid 1980s;arguably, it was not until the early 1990s that it was recognized as a mainstream subspecialty (see Holland1992).8 Such alliances are a good example of the public–private–NGO partnerships that have arisen over thepast two decades around the issue of ‘‘cancer survivorship’’ (see Klawiter 2008), where a growing amountof survivorship ‘‘care’’ is managed by dispersed and decentralized community organizations.590 Cult Med Psychiatry (2012) 36:584–600123our lives from this point forward,’’ and to ‘‘support and empower survivors as theytransition from active treatment to post-treatment’’ (Cancer Support Community2011). Running over 6 weeks, the program aims to encourage cancer survivors to‘‘take charge’’ of their survivorship through information and training in a variety ofareas, including exercise, emotional health and well being, nutrition, and how tomanage their follow up medical care.There is considerable demand for such programs among cancer survivors, manyof whom feel abandoned following the completion of treatment and are looking forways to maximize their chances of avoiding disease recurrence (Magee and Scalzo2006). However, through such interventions and programs cancer survivors are alsorecruited into their responsibilities as ‘‘good’’ biological citizens and therapeuticsubjects9 (Rose 2007). This obligation becomes quite explicit in the ‘‘patient active’’concept, which lies at the heart of the Cancer Transitions program. This conceptstates that ‘‘Patients who participate in their fight for recovery along with theirhealthcare team, rather than acting as hopeless, helpless, passive victims of theillness, will improve the quality of their lives and may enhance the possibility ofrecovery’’10 (Golant and Thiboldeaux 2010, p. 474, emphasis added).There is an underlying neoliberal logic to this framing, whereby the cancersurvivor is called upon to enter into the process of his or her own self-governancethrough ‘‘endless self-examination, self-care and self improvement’’ (Petersen 1996,pp. 48–49; see also Rose 1999). Contemporary oncological discourses on cancersurvivorship appear to be premised on this neoliberal logic of privatized riskmanagement, whereby the ‘‘good’’ subject/citizen is expected to take responsibilityto manage his or her risks of cancer recurrence, to alleviate the financial burdenotherwise imposed upon the tertiary healthcare system.However, what I want to particularly emphasize about such conceptualizations ofcancer survivorship is that the radical biographical disruption and discontinuity(Bury 1982; Little et al. 2002) caused by the disease is increasingly seen to present aunique opportunity to catalyze the patient’s physical, psychological, and spiritualdevelopment. In this framework, the patient can no longer be relied upon totransform him or herself—this development must be externally driven, withclinicians taking advantage of the ‘‘trauma-induced disruption’’ to the person’s life.Trauma, Intervention, and DevelopmentAt the heart of the trauma narrative detailed above is a story of individualdevelopment: of development forestalled or development enhanced. Thus, althoughdevelopment assumes a progressive form of temporality, which trauma clearly9 Indeed, evidence suggests that identifying with the ‘‘survivor’’ identity leads to taking a more ‘‘active’’approach to dealing with cancer (Deimling et al. 2007).10 Interestingly, Cancer Support Community now uses a modified (and less loaded) definition of ‘‘patientactive’’ on their website: ‘‘People with cancer who actively participate in their fight for recovery alongwith their physicians and healthcare professionals will improve the quality of their lives and may enhancethe possibility of their recovery,’’ although the original version of the concept is still evident in many oftheir materials.Cult Med Psychiatry (2012) 36:584–600 591123disrupts (Burman 2008), I would argue that trauma is increasingly being understoodas a precipitant to development. Moreover, in my view, this perceived relationshipbetween trauma and development resonates well beyond the field of psychosocialoncology and permeates contemporary politics and biopolitics more broadly.Following Fassin and Rechtman (2008, p. 22), I would, therefore, like to considerhow thinking about experience in terms of ‘‘trauma’’ transforms our understandingof human development on a collective as well as individual level.As noted above, the concepts of ‘‘trauma’’ and the ‘‘survivor’’ bring radicallydifferent groups, such as rape victims, cancer patients, war veterans, survivors of theHolocaust, and major natural disasters, into relation. Thus, under contemporaryconceptions of trauma,There is no difference between the survivor of genocide and the survivor ofrape… the notion of ‘trauma’ has become a general way of expressing thesuffering of contemporary society, whether the events it derives from areindividual (rape, torture, illness) or collective (genocide, war, disaster) (Fassinand Rechtman 2008, pp. 19–20, emphasis added).Bearing in mind Erica Burman’s (2008) note of caution that it is ‘‘as problematicto attempt to read social processes back on to the development of the individual as itis to treat individual development as the prototype and site of manipulation forsocial development’’ (p. 9), there appear to be important links between the conceptsof ‘‘trauma’’ and ‘‘development’’ writ large that warrant further examination.The concept of development implies, by definition, potential growth (Castan˜eda2002) and is generally used to denote either a state or a process associated withmaterial wellbeing, progress, social justice, economic growth, and personalblossoming (Rist 2006). As Burman (2008, p. 1) notes, ‘‘claims to the term‘development’ inextricably link psychological, cultural and international (social andeconomic) models and practices.’’ Thus, models of individual and internationaldevelopment share central key features, assuming that change occurs according to apre-established pattern, the logic and direction of which is known (Pieterse 1991;Castan˜eda 2002).Others before me have explored in detail the shared features of models ofindividual and international development (e.g., Castan˜eda 2002; Burman 2008), so Iwill not repeat their arguments here. However, like models of psychosocialdevelopment, models of international development are based on the notion ofprogression toward a clearly defined endpoint—in this case, a transformed societythat shares central features of capitalist modernity (Escobar 1995; Duffield 2001a,2001b); according to an early iteration of the concept, ‘‘ancient philosophies have tobe scrapped; old social institutions have to disintegrate; bonds of cast, creed andrace have to burst’’ (quoted in Escobar 1995, p. 4). As Burman (2008, p. 10) notes,stage-based models of international development ‘‘not only institute culturallyspecific norms as if they were universally applicable but also open up strategies formanipulation and intervention.’’ For my present purposes, it is these strategies thatare of particular interest.Mark Duffield (2001a) suggests that until the mid-1990s the transformational aimof official development policy was generally regarded as something that would592 Cult Med Psychiatry (2012) 36:584–600123emerge naturally through supporting economic growth. In other words, thedominant view was that economic growth would inevitably lead to social changein a desirable direction: i.e., an open market economy, liberal democratic politicalsystem, and the breakdown of ‘‘backward’’ forms of custom and practice. However,in the 1990s a new development paradigm emerged which radically altered themeaning of the concept. Key to this ‘‘new’’ conception of development was the ideathat social change could ‘‘no longer be left to the hoped-for synergies ofmodernizing projects and market reform’’ (Duffield 2001a, p. 39). Instead, effectingsocial transformation became a direct and explicit policy goal. This moreaggressively interventionist model of development linked aid policy to conflictresolution and societal reconstruction, leading to the emergence of new strategicnetworks and complexes involving governments, non-government organizations,military establishments, and private companies (Duffield 2001a, p. 2).Particularly important are Duffield’s insights into the incorporation of war andconflict (i.e., trauma, although Duffield does not use this term) into developmentdiscourse. Duffield argues that although the destructiveness of conflict wasdeplored, its wider effects were not construed as wholly negative. Central to thisnew view of development was the idea that conflict situations present a positiveopportunity for radical social reconstruction on a grand scale, based on theassumption that the social institutions of a given society had been destroyed by theconflict. It is worth quoting Duffield at length here to provide a sense of the tenor ofhis argument, and the parallels I seek to draw out between conceptions of traumaand conflict in individual and international development. In Duffield’s (2001a)words:Although violence can destroy development, a common strand within liberalgovernance is that is also erodes the cohesion of a society’s culture, customsand traditions. Given that a radicalised development now seeks to transformsocieties as a whole, including the beliefs and attitudes of the peopleconcerned, this Hobbesian outcome of violence has a certain utility. Inideological terms, it makes the process of transition easier. While the rollingback of development and the deepening of poverty provide the urgency tointervene, the destruction of culture furnishes the opportunity for aid agenciesto establish new and replacement forms of collective identity and socialorganisation (p. 123, emphasis in original).The positive utility of ‘‘seismic events’’ such as conflict and warfare indevelopment discourse appears to paradigmatically connect to the positive utility oftrauma in psychosocial oncology—a field that is rife with its own militaristicmetaphors (Sontag 1990; Penson et al. 2004; Reisfield and Wilson 2004). In bothcases, destruction (whether of the self or society as a whole) and the trauma itengenders provide both the grounds for intervention and the opportunity to stimulate‘‘development.’’The centrality of trauma to international development discourse becomesparticularly evident in the focus on post-traumatic stress disorder. Thus, psycho-social interventions are now a key activity of a variety of international aid agenciesworking in conflict zones, and range from trauma counseling to initiatives toCult Med Psychiatry (2012) 36:584–600 593123develop life skills and build self-esteem (Pupavac 2001; Fassin and Rechtman2008). Indeed, as Fassin and Rechtman (2008) have shown, the rise of trauma as an‘‘unassailable moral category’’ was central to the emergence of humanitarianpsychiatry as a legitimate field. Today, psychological care has thus become anintegral part of international aid, with psychologists as likely to be sent intoemergency situations as doctors. However, although the impetus for intervention isalleviating ‘‘post-traumatic stress disorder’’ rather than facilitating ‘‘post-traumaticgrowth,’’11 the focus on self-realization and the connections made betweenemotional literacy and good citizenship (see Pupavac 2001) sound strikinglyfamiliar. In both cases, there is a growing reliance on interventions to stimulate‘‘development’’ that exploit the opportunities trauma and conflict provide, parceledout through a network of alliances that span the public and private and governmentand non-government sectors.Survivors’ Responses to Dominant Discourses on Cancer and GrowthDespite the questionable ethics of intentionally intervening at moments of ‘‘trauma-induced disruption’’ to stimulate a particular developmental arc, such approacheshave received minimal critical scrutiny in the field of psychosocial oncology—orthe other disparate arenas where similar ideas appear to be playing out. As NikolasRose (1998, pp. 169–190) observes:In political life, in work, in conjugal and domestic arrangements… and in theapparatuses of medicine and health, human beings are addressed, represented,and acted upon as if they were selves of a particular type: suffused with anindividualized subjectivity, motivated by anxieties and aspirations concerningtheir self-fulfillment, committed to finding their true identities and maximizingtheir authentic expression in their lifestyles.Although people treated for cancer undergo diverse transformations that fitpoorly into a positive or negative mold marked by either post-traumatic growth orpost-traumatic stress disorder (Kahana et al. 2011), in the dominant framework,those who do not experience or desire ‘‘growth’’ are rendered abnormal andpathologized. As Little et al. (2002) note, ‘‘The spectrum of socially legitimateresponses to the existential state of survivorship is therefore narrowly defined’’(p. 176). This narrowing of acceptable responses is illustrated in the quote at thebeginning of this essay from Kris Carr, where she emphasizes that survivors are11 Interestingly, although discussions of ‘‘post-traumatic growth’’ and ‘‘post-traumatic stress’’ occur inboth bodies of literature, the concepts are not equally weighted: post-traumatic growth dominatesdiscussions of cancer and post-traumatic stress dominates discussions of the effects of war and conflictsituations. Invoking post-traumatic growth to speak of the aftermath of civil war seems inherentlyproblematic, because of the concept’s implications (explicit or not) that the trauma is, at the end of theday, a good thing. These implications are very much a part of dominant cancer narratives (Segal 2010).This speaks to the moral economy of trauma and differing valuations placed upon it depending on wherethe responsibility for the trauma is seen to lie (Fassin and Rechtman 2008).594 Cult Med Psychiatry (2012) 36:584–600123‘‘not imprisoned by the constructs of a label,’’ but then goes on to do exactly that,suggesting that survivors use their cancer as ‘‘a catalyst for creating a better self.’’Cancer survivors themselves are often all too aware of the expectations attachedto this identity. For example, Judy Segal (2010), in her newspaper editorial ‘‘Cancerisn’t the best thing that ever happened to me,’’ points to the coercive dimensions ofcancer survivorship narratives: ‘‘If, as a person with cancer, you violate the code ofoptimism, or if cancer somehow failed to improve you, you’d better be quiet.’’Barbara Ehrenreich (2001, 2009) has similarly criticized the ‘‘relentless brightsid-ing’’ of cancer and invocations of the ‘‘redemptive powers of the disease.’’ Agrowing body of qualitative research also speaks to the coercive dimensions ofdominant cancer narratives. For example, in their study of thirteen cancer survivors,Little et al. (2002) juxtapose the stories of Bill and Robert, who responded verydifferently to the experience of colon cancer. While Bill continued to express asense of restlessness, alienation, anger, and bitterness about his cancer and resultingcolostomy, Robert embodied the attributes of the enlightened, gracious, andaccepting cancer survivor. As Little et al. note, ‘‘Neither Robert’s nor Bill’sresponse is ‘right’ or ‘wrong’, but the social acceptance of and admiration for one ismirrored by the social distaste for the other’’ (p. 176).Breast cancer survivors in Sinding and Gray’s (2005) and Kaiser’s (2008) studieshighlight the ways that prevailing discourses on cancer survivorship obscure theongoing presence of cancer in women’s lives, especially the uncertainty and worrythey continue to experience, and the sense of burden placed upon them to stay well.Despite inhabiting this liminal space between the well and the sick, a space thatArthur Frank (1991) has termed ‘‘the remission society’’ and Lochlann Jain (2007)has called ‘‘living in prognosis,’’ survivors spoke of the pressure to hide cancer’songoing effects from public view (Sinding and Gray 2005). As Sinding and Gray(2005) observe, ‘‘Survivors are required to act as if cancer is over, and at the sametime they are required to act to prevent recurrence. The first requirement rejects orpathologizes an ongoing sense of vulnerability to cancer; the latter is premised onit’’ (p. 157).As I have previously documented, cancer survivors are often highly susceptibleto messages about the role of lifestyle in tertiary cancer prevention, and tend to seethis as a way of exerting some individual control over the possibility of diseaserecurrence (Bell 2010). However, this need for vigilance around lifestyle invariablyleads to a sense of guilt when survivors experience a lapse in will power or fail tolive up to what they see as a healthy lifestyle (Bell 2010). As a woman in Sindingand Gray’s (2005) study commented, ‘‘Every time I put something in my mouth I’maware and vigilant—if I have (fast food), I need lots of salads after. I keep a littletally of good things, bad things…’’ (p. 152). Similarly, in Broom and Tovey’s(2008) study of cancer patients’ experiences of CAM therapies, they found thattherapeutic regimes often created a form of governance of the self whereby patients‘‘…felt bad if they slept in, ‘missed an enema’ or had negative thoughts’’ (p. 1655).In the context of an actual cancer recurrence, this sense of self-blame andresponsibility is likely to be dramatically intensified.Should the fear that surrounds cancer, still the most culturally loaded of alldiseases despite some heavy competition from HIV/AIDS, be used to encourageCult Med Psychiatry (2012) 36:584–600 595123survivors to fit into a particular vision of what the self should be and aspire to?While undoubtedly well intended and ostensibly designed with the best interests ofthe patient in mind, prevailing interventions to promote physical and psychologicalhealth serve to naturalize a problematic set of assumptions about trauma and theself, while simultaneously assigning the responsibility for regaining and maintaininghealth to the patient. While there are those for whom such discourses areempowering, providing a means of gaining something positive out of whatotherwise seems like a senseless and destructive illness, in light of the groundswellof critique from survivors themselves their underside demands further attention.ConclusionsPopular notions regarding the transformative dimensions of the cancer experienceclearly infuse oncological discourses on cancer survivorship, crystallizing mostexplicitly in concepts such as the ‘‘teachable moment’’ and ‘‘post-traumaticgrowth’’—which suggest that cancer diagnosis motivates survivors to transform notonly their lifestyles but their psychological selves as well. Increasingly, however,these concepts have become not merely descriptions of the experience of cancersurvivorship but prescriptions for how survivors should conduct themselves.Indeed, I have argued that the trauma a cancer diagnosis is seen to entail isincreasingly understood to have positive, instrumental value. In shattering closelyheld illusions about the self, it is deemed to present an invaluable opportunity toestablish new and replacement forms of identity in those patients who have notspontaneously re-evaluated their lifestyles and selves.I have suggested that these assumptions are not confined to the field ofpsychosocial oncology; indeed, as previously outlined, the concepts of the‘‘teachable moment’’ and ‘‘posttraumatic growth’’ have a wide degree of currencyin the fields of health promotion and health psychology. Moreover, by paradig-matically linking together individuals and collectivities, these conceptions of‘‘trauma’’ and ‘‘development’’ have implications for an array of disparate contexts.They speak to a larger ideological shift in contemporary forms of governance,particularly a growing cynicism about whether development (physical, psycholog-ical, or social) will occur ‘‘naturally’’ if individuals and societies are left to theirown devices, and an attendant appetite for intervention. Trauma and conflict—within the self or external to it—are central to this new strain of interventionism,seen to create a kind of tabula rasa that allows selves and societies to befundamentally remade.Prevailing frameworks and interventions rely on a set of assumptions about thenature of selfhood (and statehood) that have become thoroughly naturalized today.These assumptions presuppose the desirability of the autonomous, responsiblesubject/citizen obliged to make his or her life meaningful through acts of choice thatmaximize emotional, physical, and economic health (Rose 1998; Miller and Rose2008) and attendant social and political systems aligned with the rationalities ofliberal modernity (Escobar 1995; Duffield 2001a, 2001b). However, the hegemonicdimensions of this discourse and its codification in the various subfields of596 Cult Med Psychiatry (2012) 36:584–600123psychosocial oncology deserve critical scrutiny in light of the narrow range ofacceptable responses to cancer they imply.Acknowledgments This paper was prepared for a workshop funded by a Canadian Institutes of HealthResearch Meetings, Planning And Dissemination Grant titled Critically Interrogating Cancer Survivor-ship: Social Science and Humanities Perspectives (Principal Investigators: S. Ristovski-Slijepcevic andK. Bell). The research on which this paper was based and was funded by a Social Sciences andHumanities Research Council Operating Grant titled Between Life and Death: the Contradictions ofCancer Survivorship (Principal Investigator: K. Bell). Some of the content that appears in this paper wasfirst presented at the Australian Anthropological Society conference in Geelong, Australia, in 2010 andthe feedback of the participants in the Biosocial Communities and Emerging Identities session encouragedme to further develop several lines of thought. Thanks are also due to Svetlana Ristovski-Slijepcevic,Darlene McNaughton, Vinay Kamat, and the anonymous CMP reviewer for providing invaluablecomments on this manuscript and I also benefited enormously from feedback from Jackie Stacey and theother participants in the Critically Interrogating Cancer Survivorship workshop.Open Access This article is distributed under the terms of the Creative Commons Attribution Licensewhich permits any use, distribution, and reproduction in any medium, provided the original author(s) andthe source are credited.ReferencesAldwin, Carolyn, and Michael Levenson2004 Post-Traumatic Growth: a Developmental Perspective. 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