Emerging Finnish Adults Coping with Cancer: Religious, Spiritual, and Secular Meanings of the Experience
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The article presents empirical findings on religious, spiritual, and secular coping among emerging Finnish adults with cancer and seeks an understanding of the different meanings they constructed of their experience with cancer. Autobiographical interviews and life tree drawings of 16 emerging adults were analyzed utilizing a narrative approach. To gain a deeper understanding of the cancer-coping and meaning-making processes, the stories of Beth, Sophia, and Anna are explored in detail. An exploration of the meaning-making process of all the participants shows that over time many of the participants were able to find meaning in their cancer experience. Religious meaning was found when the disease was discovered as a calling from God, spiritual meaning was discovered within a buffered identity and important relationships, and secular meaning was found in the courage to make a career change. The theoretical discussion points out a gap between the disciplines of theology and psychology of religion. The gap is partly bridged by utilizing the concepts of lived religion and existentially oriented spirituality in the discussion of meaning-making theories.
KeywordsReligious coping Lived religion Spirituality Meaning-making Emerging adulthood Cancer
Cancer engenders a momentary need for existential, religious, or spiritual meaning-making (Hvidt 2013a, p. 134). The meaning of life and the search for a meaning of cancer are linked. If one finds existential considerations in cancer, these considerations can add a sense of meaning to the cancer experience (Seibaek et al. 2013, pp. 7–8). Research is scant on the interaction between religious, spiritual, and secular meaning-making (Park 2013, p. 373), and qualitative studies are rare in the field (la Cour and Hvidt 2010, p. 1293). Moreover, existing studies often neglect the experiences of emerging adults with cancer (Grinyer 2009, p. 2). Therefore, this paper provides an in-depth answer to two questions. First, what is the significance of religion and spirituality in the coping process of emerging Finnish adults? Second, what kinds of meanings are composed in the process?
Emerging adulthood includes elements of both potential and vulnerability; critical strengths have been identified, but dependence on others remains in many ways (Parks 2011, p. xi). When cancer occurs in emerging adulthood, emerging adults cope particularly poorly with a cancer diagnosis (Grinyer 2007; Kyngäs et al. 2000, pp. 6, 10–11; Zebrack and Walsh-Burke 2004). Religion and spirituality can provide consolation and security to a person going through the cancer process (Ausker 2012, p. 268; Hvidt 2013a, pp. 127–137; Lundmark 2010). The use of religious practices often intensifies and new practices can be found during the cancer process, but some patients do not engage in religious practices at all (Ausker 2012, p. 156; Torbjørnsen 2011, pp. 177, 185–220).
As a context for emerging adults’ meaning-making process, Finland has been characterized as having a homogenous religiosity, but this has changed rapidly in recent years (e.g., Heino 2002, pp. 23–24); 72.9 % of the population were members of the Evangelical Lutheran church of Finland as of the end of 2015 (EVL 2016). Emerging Finnish adults identify themselves as more spiritual than religious (Niemelä 2011, p. 57). Among young Finns (15–29 years), 41 % identified themselves as “Christian” and 43 % as “Lutheran” in 2012. Only 15 % of young Finns believed in a Christian God at that time (Palmu et al. 2012, pp. 40–43).
Earlier religious coping studies reported that after receiving a diagnosis of cancer, the patient’s worldview remains the same as it was before the diagnosis, but the individual’s worldview is strengthened (Ausker 2012, pp. 173, 188). Interaction with God can provide not only consolation but also difficulties when trying to understand why questions (Nielsen and Sørensen 2013, pp. 121–124). Religious rituals and conversation with a chaplain or imam are helpful when existentially and religiously reflecting on the cancer experience (e.g., Boelsbjerg 2013; Lankinen 2001, p. 132; Lundmark 2010, 2015).
After the cancer diagnosis, social relations become more important. The psychosocial support given by healthcare providers promotes a feeling of well-being (Seibaek et al. 2012, p. 367). From the perspective of informational support, awareness of the truth with access to all possible information is highly important (Mattila 2002). Emotional support occurs when the patient is listened to in an empathetic atmosphere and is able to share feelings and emotions (Hvidt 2013b, pp. 617–632; Nielsen 2005, pp. 102–104). Moreover, the meaning of religion becomes vivid through social relations (Ausker 2012, pp. 173, 188). Close relationships are significant sources of meaning (Nielsen and Sørensen 2013, pp. 121–124).
Religious, spiritual, and secular meaning-making
This study embraces two complex theoretical discussions. First, defining the phenomena of religion and spirituality is difficult; the only common understanding seems to be that they are multidimensional concepts (Corrigan 2004, p. 4; Hermans 2014, pp. 113–126; Oman 2013, pp. 23–27; Pargament 1999, pp. 3–16; Zinnbauer and Pargament 2005). Second, the theoretical discussion on meaning-making is constantly expanding. Next, I will introduce some key issues related to meaning-making and place them in the narrative context. I will also specify how I am defining “religion” and “spirituality” in this study.
Finding meaning in life and in a crisis is a primary need for human beings. This meaning itself can change over time and varies between individuals (Frankl 2010/1959, pp. 90, 99). Meaning-making refers to the process by which an individual “attempts to restore global meaning when it has been disrupted or violated” (Park 2013, p. 360). A crisis of meaning occurs when an individual’s sense of coherence and continuity is violated. Usually, this crisis is followed by a search for meaning (Schnell 2009, p. 488). In this meaning-making process, people try to make sense out of the world and of themselves (Bruner 1990, p. 2). From the perspective of narrative identity, the storyline of an individual is shaken when a crisis occurs; nevertheless, after a favorable coping process, the storyline can return to a stable state (Ganzevoort 1998b, p. 284). Stories have the ability to unite life events and provide a feeling of continuity (e.g., McAdams 1988, 2008, 2009).
This sort of coherence of a story could be defined in Schnell’s (2009) terms as meaningfulness, which is grasped when an individual appraises his or her life as coherent, significant, directed, and belonging. Sources of meanings combine human cognition, behavior, and emotion, and they are ultimate meanings. The Sources of Meaning and Meaning in Life Questionnaire includes 26 orientations of meanings that form four dimensions: self-transcendence, self-actualization, order, well-being and relatedness (pp. 487–488). Both Park (2013) and la Cour and Hvidt (2010) suggest that religious, spiritual, and secular meanings can be found in the meaning-making process. I agree with la Cour and Hvidt (2010) that there must be an awareness of each of these three concepts. Unfortunately, their theoretical grid does not include studies of “lived religion” found in sociology of religion or theology. I will complement the idea of la Cour and Hvidt (2010) with theological views and the literature of sociology of religion and, in addition, introduce other notions from the field of psychology of religion.
The recent definitions of “religion” within the field of practical theology build on sociology of religion and examine religion through the concept of “lived religion” (Ammerman 2013; McGuire 2008, on lived religion). Religion is a phenomenon that includes both traditional and nontraditional actions and meanings that are related to the sacred/God. Classical definitions of religion must be extended in order to grasp the religious context of today (e.g., Ganzevoort and Roeland 2014; Hermans 2014). From the narrative perspective, people bind their personal stories with stories that are related to God and religious rituals (Ganzevoort 2013).
Religiosity can become visible in different ways. A story’s author can be religious or the story itself can be religious when it is motivated by hope, trust, and openness. A religious audience can be found when the author includes listeners of the story in the transcendent. Moreover, the religious purpose of a story refers to religion that provides meaning when an individual is adjusting a life experience into perspective with transcendence (Ganzevoort 1998a, pp. 278–279). The awareness of the religious orientation of an individual can be helpful when trying to determine how religious, spiritual, and secular experiences can be defined. A person’s religious orientation is defined in terms of three categories: as a believer, an unbeliever, or a nonbeliever. Both believers and unbelievers have a religious orientation that can range between positive and negative. The third category of nonbelief is defined as nonreligious, since transcendence is absent (Ganzevoort 1998b, p. 279; Ganzevoort builds on Scobie 1994).
Hermans (2014) amplifies that “religion” cannot be defined without defining “spirituality,” moreover; in Western society people tend to describe themselves as being more spiritual than religious (Ramshaw 2010, p. 171). Spiritual experiences “are related to ultimate meaning, which are existentially relevant, unexpected, and sometimes (but not necessarily) objectively strange” (Hermans 2014, p. 118). Spiritual experiences are contingent: “(1) in an epistemic sense, there is [sic] no sufficient grounds to explain what happened; (2) no human action that can transform the situation into such an (necessary) order; (3) the situation is experienced as having an existential value, and (4) this unexpectedness can give people to think (about fullness beyond what is contingent)” (Hermans 2014, p. 119; Hermans builds on Wuchterl 2011).
Spirituality includes elements of ethics of love and compassion, an accepting attitude toward self and world, spiritual practices, and experiencing transcendence. Furthermore, spirituality can be subdivided into two concepts. Vertically transcendent is often identified among religiously orientated people and includes concepts of an eternal, supernatural god or higher power. Horizontally transcendent emphasizes the existence of the immanent absolute but avoids references to a supernatural reality and therefore is often seen in spiritual atheism. Atheist theology resonates with spiritual atheism, which includes spirituality without having a god in the sense of a beginning or an end, the transcendent or the eternal (Schnell 2009; 2012, pp. 35–36; Schnell and Keenan 2013, pp. 102–108). In addition, there are normal experiences that are so ordinary that we do not knowledge them in any specific way (Hermans 2014, p. 118). In the meaning-making context of this study, ordinary experiences relate to secular meanings.
Scholars of theology Nolan et al. (2011) define spirituality in the context of European palliative care as follows. The existential questions of spirituality refer to “identity, meaning, suffering and death, guilt and shame, reconciliation and forgiveness, freedom and responsibility, hope and despair, love and joy.” Value-based considerations of spirituality address what the individual holds as most important, such as “relations to oneself, family, friends, work, things, nature, art and culture, ethics and morals, and life itself.” In addition, the religious considerations of spirituality consist of a personal relationship with God/the ultimate, faith, belief, and practices (p. 88).
The concepts of “religion” and “spirituality” do not need to be forced to be hierarchical; rather, the concepts are linked to each other (see Hermans 2014). La Cour and Hvidt (2010) suggest that the concepts should be understood as overlapping. In this paper, “religion” is understood to include both an individual’s relations to God/a higher power and to practices of lived religion (e.g., Ganzevoort and Roeland 2014; McGuire 2008). Religious meanings are appraisals and outcomes of religious experiences. Spiritual meanings are strongly related to experiences of ultimate meaning and to what is the most important for an individual. Religion and spirituality as phenomena are partly intertwined with each other, but neither is superior to the other. In addition to these two concepts, there are normal experiences that do not catch our attention but can lead to secular appraisals of an event and the formation of secular meanings. I have found these viewpoints useful in grasping the worldview of Finnish emerging adults with cancer. In the results, the theories are compared to the stories of these emerging adults. The next section explains the analysis in more detail.
Conducting the research
The vulnerability of the participants was taken into consideration in all stages of the research. To ensure the study was ethical, I followed the following procedures. At the beginning of the research project, the Faculty of Theology at the University of Helsinki accepted the research plan. Before I started interviewing, I presented my plans in a narrative study group and at a narrative conference. Both of these groups advised me to design the interview questions carefully. In particular, probing the participants’ views of their future needed to be delicately handled. From these premises, I wrote an open interview guide that addressed some basic themes.
Moreover, it was felt that a visual element could capture a person’s life experience of cancer without forcing the element of the uncertain future. A tree as a symbol of life is well known, and trees have often been used in different therapeutic settings. The use of drawing, in particular, has been confirmed to be valuable in conjunction with delicate research topics (see Katz and Hamama 2013, pp. 877–882; Lev-Wiesel and Liraz 2007, pp. 65–75; Pain 2012, pp. 303–319). Therefore, the creation of drawings of a tree representing each participant’s life was selected as a visual element of the study. A tree as a symbol is a uniting vision of life (see Burns 2009); moreover, drawings of trees are visual sign sets. I understand the drawings as narrative representations of life with cancer. These drawings incorporate the temporal and causal constructions of the cancer experience at the specific moment they were drawn by the participants (see Esin and Squire 2013).
Participation in the research was voluntary, and the participants were given an opportunity to withdraw from the research at any stage of the work. At the beginning of the interviews, I explained the participants’ rights and my responsibilities as a researcher. I asked for permission to use their drawings and interviews for academic purposes and teaching material. The consent forms were made in duplicate, and my contact information was printed on the forms.
In the interviews, the participants were given an opportunity not to answer any questions they felt uncomfortable with. At the end of each interview, the participants were asked about their current feelings. It was understood that they could have an emotional burden caused by the interview that needed to be shared or that they would need help in seeking emotional support. In the end, all questions were answered, most of the participants described feeling relieved after sharing their stories, and every participant continued to be part of the research project and permitted their data to be used for this purpose.
I took notes about the atmosphere of the interviews and described my personal thoughts in a research diary. The diary helped me to remember nonverbal details from the interviews and assisted me in finding a suitable position within the research. Since I was working on my own, it was crucial to consult with others and present papers in multiple seminars, study groups, and conferences. A pastoral psychology and theology seminar offered me regular feedback on my data gathering, analysis, and writing process. In addition, a study group on narrative research was of great help in identifying the analytical tools needed to grasp this particularly sensitive research topic.
Moreover, it was considered that the cancer stories of emerging adults could include both elements of coherence and fragments of stories. Therefore, the definition of “narrative” needed to be broad enough in order to grasp the cancer experience as a whole. “Narrative” was defined to include aspects of “big stories” as a form of a coherent story with a plot and also “small stories” that can include “ongoing events, future or hypothetical events, and shared (known) events. .. allusions to (previous) tellings, deferrals of tellings, and refusals to tell” (Bamberg 2011a p. 381; see also Bamberg 2011b). I believed that by combining the perspective of “big” and “small,” a rich territory of narratives would be found (see Freeman 2010, 2011; Patterson 2008).
Recruiting the participants and collecting the data
The recruitment of the participants was done through advertisements posted in Internet chat rooms and by an email circulated through a Finnish cancer organization’s email list. The age of the participants varied between 18 and 34 years. The age distribution was based on the Finnish Cancer Society’s official age parameters of 18 to 35 for young patients (Sonninen 2012). In my research, I am referring to this age group of patients as emerging adults (e.g., Parks 2011, about emerging adulthood). No religious conviction was necessary to be able to participate. The time between the treatments and interviews varied from a few weeks to five years. One respondent wanted to participate shortly after being diagnosed, so she was interviewed for the first time during her treatment and the second time after the treatment.
Autobiographical interviews with 16 emerging adults with cancer were conducted after their cancer treatment. At the beginning of each interview, the participants were asked to draw a tree representing their life. Only simple instructions were given: “I ask you to think about your life, thus far, as a tree. What does your tree look like?” The task elicited various reactions, but in the end, the participants felt that the drawing provided a new tool they could use to examine their cancer experience. If they had doubts about their personal drawing ability, I would tell them that the drawings were not going to be judged by their appearance. After the drawing task, they were asked: “Where would you like to start?” They were asked about the elements, colors, and symbols of the tree. This task was followed by an autobiographical interview that consisted of story-eliciting questions considering the past, present, and future. In addition, three of the participants were writing a blog about their cancer experiences, and all three contributed the contents as research material. In addition, one interviewee had written a letter about her cancer experiences. These textual materials were analyzed alongside the interviews.
Thematic-holistic narrative analysis and visual-narrative analysis
The textual data were analyzed with a narrative approach utilizing both a narrative holistic analysis and a thematic perspective (Lieblich 1998, pp. 62–87; Riessman 2008, pp. 53–76). First, I transcribed all the interviews in detail by myself. After the raw transcription, I wrote down other details such as laughter and tears, and I counted the length of pauses since I wanted to create accurate descriptions of the interviews. Second, I read the material through several times without any specific aim. I looked for changes in the storyline, unfinished thoughts, disturbing matters, and central themes and noted these in the margins of the paper. I kept in mind that the dialogue between the researcher and the author of the story is an important part of the reading process (see Lieblich 1998, p. 62). Third, I kept track of the appearances and ends of the themes as well as the way the themes were connected to each other. I used colored markers and short codes to be able to follow each theme in the text. For example, themes that suggested religious coping were underlined with a red pen and marked by “RC” written on the margin of the paper. I continued reading thematically and followed specific characters and changes. Fourth, when the central themes were identified, I created theme lists. In the lists, I wrote down which subthemes formed each main theme and was able to follow the connections between the themes. First, I analyzed the cases one by one, and later I discovered features shared between the cases (see Riessman 2008).
The content of the blogs included much more detail about the treatment practices. In the interviews, several more personal themes emerged, such as negative events with significant others, fear of dying, and thoughts about God and/or a higher power. From an ethical point of view, I wanted to ensure the anonymity of the informants. Therefore, the blogs are not referred to with codes or names, nor are the quotations based on the blogs.
The textual analyses were followed by an analysis of the drawings. First, each picture was examined, and at the same time, the tree narration was read. I wrote down general findings about the drawing, such as “the tree seems vital” or “no roots.” I followed the participants’ self-understanding and documented their descriptions of their drawings. By combining the tree-related narration with the image, I was able to identify which themes emerged in the drawing and what meanings the participants described in their life trees. The use of colors, symbols, and paper was also documented. Secondly, I compared the themes found in the drawings with those discovered in the interviews. The visual analysis showed that each participant utilized the tree as a metaphorical representation in an original way (for the visual analysis, see Riessman 2008, pp. 141–182; Saarelainen 2015; Tamboukou 2010).
The next section introduces the findings from Beth’s and Sophia’s interviews and drawings. Anna’s story is constructed from her letter (2007) and the interview (2011) during which she made her drawing. These stories were selected to provide a more in-depth view of the personal cancer experience and the meaning-making process.
Selection of example cases
Most of the 16 participants were found to be believers; a few of these described themselves as Christian, and more than half reported having a belief in a higher power. A few identified themselves as having some kind of atheistic thoughts. Among these, only one could be clearly identified as a nonbeliever, and a couple had such strong negative thoughts about God that their worldviews seemed appropriate to be categorized as unbeliever (see Saarelainen 2016). No specific gender differences were found from the data; therefore, I chose cases that would provide the most variables and represent different worldviews among the participants in a comprehensive way. In addition, the selection was based on the fact that within these stories, a range of different meanings can be found. The stories of Beth, Sophia, and Anna are followed by an exploration of the meaning-making experiences of all the participants.
At some point [after the second diagnosis] I began to think that the disease was a trial I had to endure so that I could find some new insights into my life and rethink my values. I began to think about God and pray, even though I was unsure about my personal faith. . . . I prayed when I was scared. Then I realized that it was too selfish to pray just to get better. So I started praying every time I thought that there was something to be grateful for. If there were a God, I wanted to be fair and remember the positive things, too.
This description shows that she wanted to make sure that she was answering God’s calling to rethink her life. Still, she was uncertain about her conviction. Before the diagnosis, Beth described herself as “having a Christian upbringing.” After her religious seeking, she stated that she found “a universal God who combines all the world’s religions” and defined herself as a “neutral believer” and “a member of the Lutheran Church of Finland.”
Two important coping themes appeared as intertwined in Beth’s story: her individual inner power that helped her to cope and her family as an emotional support provider. Beth narrated: “I’ve seen what kind of strength a shy and kind girl can have. I am so proud of myself for making it through the cancer process.” Beth saw that her own power and actions were highly important when she had cancer, but she was also conscious of the importance of family. She linked her inner power to the support she received from her family, and she illustrated her individual strength through her drawing. Her tree was balanced, and she commented, “The tree has a strong base, and it [the strength of the tree] continues to the trunk.” She drew strong roots on her tree and described in detail how important significant others were during her experience with cancer. She said, “I made the trunk strong, since everything that is in the roots has had an impact on my emotional survival.” The strong roots represent the metaphor of support. The cancer was depicted as leafless small branches; as she stated, “The cancer stripped me. Therefore, the branches are stripped.” This indicates that she utilized the drawing as a metaphor of self.
A counternarrative to the support from her family appeared as the need to remain independent. Beth noted, “It was emotionally difficult to move back to my parents’ house.” She kept her rental apartment in the city of her university as “a safe haven” for when she needed time for herself. The apartment represented “a promise that I will return.” Her experiences reflect her need to preserve her independence in a time of reliance on others. The promise to return reflected her hope to get better. Her shock about the relapse and thoughts of “returning” reflected her thoughts of surviving cancer.
It was important for Beth to maintain her relationships with her friends and have a normal life. As she put it, “The first thing [after each treatment] was to contact my friends and plan something to do.” Wearing a wig made it possible to “do stuff without other people realizing the issue [her cancer].” Losing her hair made the disease visible and made her feel different. These descriptions reflect Beth’s desire to live a normal life but contain a counternarrative of the cancer and her fear of stigma. They also illustrate how emotionally demanding the situation is; one has to have something else to think about in order to cope.
The importance of peer support became clear from two perspectives. Beth received peer support for herself and became a supporter of herself. The connection between the peer support and the significance of volunteering (herself as a support person for other young people with cancer) was indicated in Beth’s narration as follows: “So that there would also be a meaning for all the bad days and experiences. .. so that someone else could get help from my experiences, even from the worst ones.” These words reflect her process of discovering a meaning for her suffering. Beth had a strong urge to “share all the good I have had myself.” This was visible in her drawing as blooming foliage that is not fully visible. She envisioned her future through the possibilities for work, and stated: “I wanted to leave it like that. You cannot know all the growth it will reach.” This indicates her bright view of the future and thoughts of staying healthy.
Sophia was an adolescent when she experienced pain in her ankle. After several doctor’s appointments, she was diagnosed with a malignant tumor, and chemotherapy was started. “No one said anything about cancer. .. I was quite shocked when I realized that my hair was falling out and that it meant cancer.” Her narrative points out that it would have been important to her to have been given detailed information when she was diagnosed.
The physical changes were the most difficult for Sophia, and she noted, “It was not the cancer that I was afraid of, rather, it was the fear of losing my leg that terrified me.” She had seen some young patients who limped after their operation. She did not want to be “left like that.” Her expressions hint at the fear of stigma. The feeling of being different and stigmatized emerged in different phases of Sophia’s story. She described, for instance, that when going out in a wheelchair, “I pulled up my hood to cover my head” so that no one would recognize her. These expressions illustrate the emotional difficulties that arose from her physical condition. The stigmatization was reflected in her relationship with her parents, as she described that it was “humiliating to be so dependent on my parents.” Sophia shared that she had just gained more independence, but the diagnosis made her “like a baby again.” These notions show that she felt as if she were going backwards in her identity development.
Sophia’s parents provided support for her daily life, but the impact of her mother is visible in this description: “We [Sophia and her mother] wanted to get all the help we could. So we went there [church]. I don’t know what religion [revivalist movement] it was, but I was given a blessed linen cloth. And I carried the cloth with me to treatment.” This experience was the beginning of her personal faith, and she narrated: “I felt God’s presence for the first time in my life.” These excerpts point out that the mother had a significant role in Sophia’s attending church. The cloth seemed to provide tangible religious support, as Sophia carried it with her.
Sophia talked about her personal relationship to a higher power. “Of course I prayed; I prayed before each treatment. I was constantly talking to my friends and parents. In my mind, I was having this dialogue with someone else. I don’t know if it has a name.. .. In a difficult situation, you reach out for a higher power.” Her description shows that sharing emotions and thoughts was important to Sophia. Besides significant others, Sophia needed to turn to God.
Emotional changes followed the physical phases of her story, as she narrated that at the beginning of the cancer process “my spirits were high,” but she shared that “after the operation I was depressed. .. during my darkest moments I hoped to die.” When a physiotherapist came to their house and started her therapy, she always found the motivation to do the exercises, which she explained as follows: “Somehow I had the spark inside me. I just decided that I am going to walk.” Her physical rehabilitation was good, which is how she described it: “The process was surprisingly fast, and I felt emotionally better too.” These excerpts show that her physical changes were strongly linked to her emotional wellbeing. She felt that it was her own willpower that pushed her through the rehabilitation.
The importance of emotional support becomes clear in Sophia’s explanation of peer support education. “Those camps [the peer support education camps] are for education, but at the same time, it is peer support for myself. It is really easy to be there since all the people have a similar background.. .. The atmosphere is different because we all had that same thing [cancer]. It is like going to therapy; besides education, you get support for yourself.” Along these lines, Sophia mentioned the long-term need for support; it had been five years since she had cancer, and she still received support from these meetings. Among her peers, it was possible to feel a sense of belonging through having “a similar background.”
Overall, Sophia was “grateful for the cancer experience,” and if she could choose whether or not to be diagnosed, she would choose cancer. It was important to her “not to forget it,” since it changed her “attitude to life” and led her to become “more independent.” Her identity story goes back and forth, and the outcome reflects this; she felt that she is “the same age as her schoolmates,” who are actually one year younger than Sophia; however, she considers herself “more mature.” This points out that the cancer had an impact on her identity in many ways. The disease is also strongly vivid in her tree; half of the branches seem dead. She narrated that “it [cancer] is in the tree, but it does not control the tree.” Sophia drew an apple that depicted that “something is mellowing there,” which represented her hopes for the future. Green leaves representing “the hope of growth” surround the apple. This indicates that she utilized the tree as a metaphor of self. By telling me that “everything in my life has led me to the point where I am now,” Sophia pointed out that cancer is an important part of her life story. The meaningfulness of the disease became apparent to Sophia through her “new relationships that developed as a result of it.”
I have a natural view on life and death. I used to think that after dying people go to somewhere bright, above the clouds, where the angels are. Now I think or at least I hope that there is no pain after dying. I think that the place after death is more like the underworld in Finnish folklore: dark and misty, a bit harsh, but close to nature. I’d like to believe in a Christian heaven, but after my experiences, I just can’t.
This description shows how cancer changed her view of death from the Christian heaven of her childhood to a misty folk description. She longs for a Christian heaven, but the agony in her life made it impossible for her to believe in it. The cancer diagnosis was a clear sign that God cannot exist. Anna explained: “An omnipotent God would not allow such things to happen.” Later, in 2011, she clarified: “I have seen so much suffering around me.. .. I don’t want to believe in such a God—I don’t mean a Lutheran God, I mean any God who would allow these things to happen.” In her case, the religious activation shifted her attitude in a negative direction over the years. Seeing various people suffering around her intensified her unbelief and her will not to believe. However, she remains a member of the Lutheran Church of Finland.
A positive shift in Anna’s religious story occurred when she started to describe her general views on religion. In 2011, she narrated, “I understand that religion can be good for some people, but religion is not my preoccupation at the moment. .. you can never know the future.” Anna defines her boyfriend as “a Christian believer,” and if they were to have children, she would “allow him to teach them an evening prayer.” These excerpts show that she also found a positive attitude towards religiosity at some point after her diagnosis. When facing cancer and evaluating the situational meaning of religion, she came to the conclusion that “at that moment” there was no place for religion in her global meaning system.
Anna described the positive significance of cancer as part of her career change, and she highlighted how “the disease gave me the courage to follow my own instincts and change my field of studies.” This shows that the cancer affirmed Anna’s identity and offered a meaningful opportunity “to think about how to live my life.” This was made visible in the flourishing foliage of her tree, which she described in this way: “The foliage would have suffered without the change of career.” Anna drew an owl living in the tree trunk. In this image, she captured the idea that at first the owl was an odd creature “coming from the outside to live in the tree,” but with time the cancer became a natural part of the self. The description of cancer (the owl) coming from the outside into the body (the tree) suggests that she utilized the metaphor of a body when drawing the tree. Anna talked about the importance of the disease by saying, “I would not give it away.” Her story indicates that she felt that cancer also had a positive impact on her identity. Two small sprouts are emerging from the owl’s burrow; one is dead, and one is starting to grow. These descriptions illustrate the metaphor of self in her tree.
I received great peer support when I got to know Linda. She was a bit older than me, had the same diagnosis as me, but her treatments were a few months ahead. I felt that it was enough. . . . The other support . . . I received social support from my family and friends. Also, I had a great personal nurse who took care of me. She was a great person.
In Anna’s recollections, the hospital staff had the important role of providing informational support and helping her achieve a daily rhythm. In addition, a peer patient offered information, since Linda was a doctor herself. Moreover, seeing Linda’s progress, Anna could imagine herself progressing. Anna also wanted to volunteer as a peer support person for other young patients to “provide all the knowledge and support I can.”
Doing normal stuff was like an energy boost. It was like having a reminder from a more normal life . . . that it was possible to get a grip from a [whispering] life that was more than cancer.
This excerpt shows that the reality of living with cancer can be overwhelming, and it filled Anna’s life. The reminder of a normal life provided the hope of living a life without cancer. In Anna’s drawing, the sun was drawn to symbolize “things bringing a good spirit. .. besides, the tree needs the sun to be able to photosynthesize.” This finding deepens the understanding that Anna needed to have “energy boosts” in order to emotionally survive her cancer.
Constructing a meaning for cancer
In Beth’s story, religious meanings were the most vivid; following God’s will become visible in her relationship with God and in her prayer habits. Beth can be defined as a believer, in other words, as a religious author of a story. The story itself had religious aspects; it was open to transcendence and included elements of hope. Discovering a personal relationship with God can be seen as a religious meaning for the cancer and as a religious purpose of the story.
For Sophia, her conversion experience was described as finding God/a higher power and in her way of approaching transcendence. Attending church and carrying the blessed linen cloth changed Sophia’s means of approaching and experiencing transcendence. Lundmark (2015) suggests that prayer cloths are utilized as transitional objects in religious coping during the cancer process. The cloths provide a sense of fellowship and security by reminding the patients of God’s healing powers. The prayer cloths support their faith when it is contested (pp. 68–78). Concurrently, religion became part of Sophia’s global meaning system. In her case, religion played a strong and empowering role. This could be interpreted as a religious purpose of the story since the cancer experience was examined through Sophia’s relationship with transcendence. Sophia herself, like most of the participants, did not mention that cancer had an actual religious meaning.
Like Beth and Sophia, many of the participants narrated having “a normal Finnish religiosity” as part of their childhood upbringing. Often, this religiosity became positively more important and personal after their diagnosis. For some, such as Anna, the negative image intensified. Anna, who was identified as an unbeliever, wondered about God’s role in her cancer process. These kinds of negative God appraisals appeared in half of the stories of the 16 participants. They wondered, “Why God would allow” such a horrible thing to happen. Only a few participants did not have this kind of existential question. These negative appraisals often became positive during the treatment process. As Torbjørnsen (2011) has found, a negative image of God is a burden, but the image may become more positive during the cancer process (pp. 177, 185–220, 194–195).
Positive appraisals of God were rarely experienced as strongly as Beth and Sophia described. Nevertheless, religious coping activities were activated; praying and a high frequency of praying were described by more than half of the participants. As the example stories reflect, the participants described praying as consoling and providing security. Following their serious health problems, the participants prayed less than they did during them. Still, they wanted to hold on to the conviction that they had formed. In addition, some of them had discussions with a hospital chaplain, and others carried figures of angels with them. The religious activation during that time made religion more central in their meaning system. These examples demonstrate how a different praxis can provide meaningful religious experiences in a time of crisis (see Ganzevoort and Roeland 2014).
Generally, two kinds of spiritual meanings were described: identity-related existential meanings and relationship-related value-based meanings. Around half of the participants’ narrated spiritual meanings for the cancer were presented in terms of a buffered identity. For many, this new kind of courage led to a change of career. When the work-related stories included these elements of contingency, such as Beth’s story, it was understood as spiritual meaning-making that includes existential joy. For many of these emerging adults, becoming a peer support person indicated the discovery of a meaning for cancer.
In Beth’s story, the identity issues were narrated in terms of the inner power she found. In Anna’s story, existential questions were seen in her expressions of suffering from cancer and the strengthening of her self-confidence in expressions of hope, love, and joy. Sophia’s story indicated existential questions in her existential anxiety and wish for death. A counternarrative to her depression was her inner strength, which helped her to complete the physical exercise that helped her to recover from the surgery and discover a hopeful future. These findings affirm Hvidt’s (2013a) notion that patients who identify themselves as spiritual also report having a belief in their own inner strength (pp. 132–137).
Participants often described relationships in terms of belonging, and these relations included the feeling of being accepted. Family was seen as the most important provider of emotional support. For example, Beth’s drawing highlights the support of her family; her family kept her standing through the cancer process. The importance of family was usually both narrated and drawn by the participants. These relationships helped the participants to focus on getting better, since in order to cope, it is important to hold on to positive thoughts of recovery (Landmark et al. 2001, p. 224). The three stories included fears of stigma, although the participants’ peers and friends helped with these issues. In addition, the occasional opportunity to live a normal life was found to be extremely helpful. The tellers often described how meaningful it was to meet with friends and forget the disease for a while.
Hobbies provided a break from cancer-associated thoughts and gave Anna hope for living a normal life. Overall, the participants described a variety of hobbies: walking in nature provided consolation for one, whereas another started yoga and wondered about her eating habits, and still others read a spiritual guidebook. Having “disease-free zones” offered relief and a sense of normality (Seibaek et al. 2012, p. 366). A sense of existential relief was strongly entwined in the stories of these emerging Finnish adults. Practices of lived religion commonly appear in “everyday life” but still “relate somehow and to some degree to notions of sacredness, transcendence and existentiality” that make them spiritual experiences (Ganzevoort and Roeland 2014, p. 95).
Anna’s story indicates how a career change provided a secular meaning for cancer. This is closely linked to finding an existential meaning in having the courage to attain her personal goals after achieving a strengthened identity. As an outcome of meaning-making, Anna’s new career does not fit with the idea of what is most important. A couple of the work-related stories contain the same elements; a buffered identity provided an opportunity to change careers. This shift from one type of work to another is important but not existentially relevant.
From the perspective of coping, practical support (such as cleaning, cooking, helping with ordinary tasks) from family, friends, and health caregivers were identified as an important source of support by all of the participants. Storytelling about these ordinary aspects was minimal. Often the participants referred to this type of support when describing (in many words) the significance of the emotional support that they received.
A few participants had the strong view that their cancer experience carried no meaning. These stories convey the view that the cancer was sheer bad luck, and they did not wonder whether there was a purpose or reason for it and did not seek the meaning of the experience. In contrast, there were a few whose treatment had recently ended and who strongly wanted to find the meaning of their cancer experience but had not yet discovered it.
The task of this paper was to identify the significance of religion and spirituality in the coping process of emerging Finnish adults and to discover what kinds of meanings the participants compose from their cancer process. Previous studies have shown that cancer evokes age-specific needs; in this study, from the point of view of religious coping, many similarities to religious coping studies were found that were not related to age. The Finnish emerging adults often described their individual worldview as stronger, their religiosity was often activated, and their appraisals of God were both a burden and a consolation. In addition, one special feature was their meaning-making, which is rarely scrutinized in qualitative cancer studies.
Most of the emerging Finnish adults with cancer were identified as religious authors of their stories, even though no religious orientation was required for participation in the study. The participants usually had a belief in God or a higher power, and they also practiced various religious and spiritual coping practices. As an outcome of their coping process, they found religious, spiritual, and secular meanings.
Religious meanings were narrated as discovering a personal or a new kind of relationship with God or a higher power. In other words, vertical self-transcendence provided a source of meaning for the cancer experience. Although the participants themselves rarely gave cancer an actual religious meaning, appraisals of God and intensified religious coping activities were often narrated as part of the coping process. Overall, it seems that the significance of religion was high during the acute phase of being diagnosed and treatment.
In contrast, the spiritual meanings and changes were narrated in terms of a permanent change. When lived religion and existentially oriented spirituality were taken as a starting point, most of the meaning-making themes turned out to be spiritual. Existential relevance and a sense of what is most important encouraged defining these meanings as spiritual. A buffered identity and the courage to make a career change could be seen as self-actualization since the emerging adults found the power, freedom, and knowledge that provided them the opportunity to make changes. Well-being and relatedness were narrated in terms of being supported and sharing the good. Spiritual meanings included a strong sense of existential relevance. In addition, secular meanings often appeared as an outcome of the spiritual process.
The actualization of Finnish lived religion was seen as activated vertical self-transcendence. Even though the participants in this study usually identified themselves as “spiritual” rather than “religious,” their context provided them with religious elements. In addition, most of them had a relationship to God or a higher power. Most of the participants described a “normal Finnish religious upbringing,” which usually consists of being taught to pray as a child, attending church at Christmas, and regularly attending morning prayer at school. Moreover, most Finnish adolescents attend a confirmation course that extends over several months and culminates in a one-week educational event (all in all, around 80 h of Christian teaching) (Rippikoulusuunnitelma 2001, p. 41). Thus, it seems that emerging Finnish adults still have an understanding of Lutheran teaching. The Lutheran metanarrative impacted the participants’ cancer experience in such a way that lived religion was activated in both religious and spiritual meaning-making.
In Anna’s story, there were hints of horizontal self-transcendence. Her spiritual process resulted in secular meaning. Her worldview was atheistic in the sense that she did not have deistic belief at the time of the interview. Nevertheless, her story indicated a more complicated worldview, and her negative relations with God suggested understanding her conviction as unbelief. Schnell and Keenan (2013) conclude that within contemporary atheistic spirituality the experiences of self-transcendence are not relevant from the perspective of individual identity (p. 116). Nevertheless, Anna’s case points out that her process included a strong sense of contingency when her story was interpreted as a whole, and in addition, her identity changes were highly important.
The theoretical discussion and the stories of these emerging Finnish adults with cancer lead me to think that “narrative” is only an umbrella term. Within the stories of meaning-making, each person searches for coherence in their stories; some stories turn out to have a meaning and a stable storyline, some stories are unfinished, and in some stories the storyline is not affected in that there is a specific need to discover meaning. No measurements were taken in this narrative study, but the comparison demonstrates that quantitative studies have some qualitative counterparts. As la Cour and Hvidt (2010) point out, in real life, religious, spiritual, and secular elements overlap. From religious, spiritual, and secular meaning-making, a sense of the meaningfulness of the cancer experience can be grasped. Moreover, the meaning-making of emerging adults can be seen to emphasize the self and its significance in the process. In my study, I chose to follow the participants’ self-understanding of their individual worldview constructions and pursued understanding their stories as independent entities.
In summarizing the theoretical discussion, it seems that the concepts of “religion,” “spirituality,” and “secularity” with regard to experiences and worldviews are all related to each other in the process of meaning-making. The concept of “religion” includes both explicit religion and the diverse practices that people partake in when practicing their personal religiosity. “Lived religion” is situated between the traditional concepts of religion and the broad concept of “spirituality.” The concept of “spirituality” includes religious, existential, and atheistic spirituality. The sphere of the “secularity” comprises both ordinary matters and atheistic views on life. The meaning-making process occurs within these dimensions. Depending on the individual’s worldview, the meaning-making process takes place in one or more spheres.
The stories of these Finnish emerging adults were strongly focused on the side of religion and existential spirituality rather than on the side of secularism or atheism. These results challenge the view of Scandinavia as so secularized that it has no need for the term “spirituality” (see Salander 2006). Lived religion and spirituality were highlighted in the stories of these young Finns. Even the secular meanings were described as an outcome of a deeply existential-spiritual process.
When bringing these complex and partly contradictory theories together, three specific suggestions for future studies can be made. First, a deeper cooperation is called for between psychology of religion and theology. At the moment, it seems that the dialogue between the disciplines is quite thin. Second, in order to grasp individual experiences deeply, further qualitative research is needed on meaning-making during and after a crisis. Thirdly, in this study secular meanings were detected only as an outcome of a spiritual process, and from a theological point of view, it remained unclear whether meanings that are not spiritually oriented can exist. Therefore, secular meaning-making needs to be further theorized and studied from the perspective of ordinary experience and atheistic theology.
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