Worry and Rumination as a Consideration When Designing Health and Risk Messages
Summary and Keywords
Rumination is typically thought of as pessimistic, repetitive thinking or mulling that is deleterious for one’s health. Rumination, however, can take several forms and is not always harmful. In fact, it could actually be helpful in certain circumstances. It is common and often helpful when something stressful happens, like a health scare or problematic health diagnosis, for people to ponder or reflect on why it happened and brainstorm potential solutions to it. This is referred to as reflective rumination. Rumination affects people’s risk perceptions related to their personal and relational health and decision-making about their health. Research on negative rumination and health and positive rumination and health focuses on the impact of these patterns of thinking on health outcomes such as mental health, physical health, and relational health and as perceptions of health messages and risk likelihood.
When people experience a health scare or worry about a diagnosis, they often have recurring thoughts about what it means for their future, how it might affect them and their loved ones, and why it happened and how to resolve it. Sometimes these thoughts are negative, but other times they can be positive reflections of one’s health, relationships, or self. For instance, after receiving a diagnosis of their child’s Type 1 diabetes, some parents are able to reflect on that diagnosis and see it as something that could make them even stronger as a family. Other times, people cannot stop thinking and talking in depressing ways about their health, and it can inadvertently affect their health and the health of those around them. What was once cognitive rumination can turn into people talking incessantly about their health in an effort to garner social support, make sense of it, and make decisions about how to manage it. Over time, it can be difficult to provide support to someone when the same topic continues to surface repeatedly, despite one’s best support attempts (Nolen-Hoeksema & Davis, 1999; Stroebe, Zech, Stoebe, & Abakoumkin, 2005). Similar to cognitive rumination, verbal rumination can have positive or negative consequences, depending upon the type of support provided and whether people are able to positively reframe the problem (Afifi, Merrill, Davis, Denes, & Coveleski, 2016; Afifi, Shahnazi, Coveleski, Davis, & Merrill, 2016).
Our purpose is to provide an overview of the literature related to rumination and health. In particular, we attend to how rumination affects people’s risk perceptions related to their personal and relational health and decision making about their health. Rumination is defined, and some of the research on (a) negative rumination and health and (b) positive rumination and health is outlined. The focus is on the impact of these types of rumination on health outcomes (e.g., mental health, physical health, relational health), as well as health messages and risk perceptions.
Definitions of Rumination
Rumination is typically thought of as pessimistic, repetitive thinking or mulling that is deleterious for one’s health. Rumination, however, can take several forms and is not always harmful. In fact, it could actually be helpful in certain circumstances. It is common and often helpful when something stressful happens, like a health scare or problematic health diagnosis, for people to ponder or reflect on why it happened and brainstorm potential solutions to it. This is referred to as reflective rumination (Haran, Mor, & Mayo, 2011; Treynor, Gonzalez, & Nolen-Hoeksema, 2003). Other scholars have similarly focused on the notion of positive rumination. Positive rumination is “the tendency to respond to a positive affective experience, and one’s favorable life circumstances” (Feldman, Joormann, & Johnson, 2008, p. 1). Positive rumination has the ability to improve confidence and boost self-esteem (Martin & Tesser, 1996). This can be seen when individuals encounter a positive emotional state, such as recognition, good news, or a pleasant conversation, and reflect pleasantly on it.
Rumination becomes harmful when people go beyond reflection to engage in depressive rumination or brooding. Cognitive brooding involves passively engrossing one’s self in depressive thoughts about one’s problems, becoming preoccupied with negative emotions, and repetitively focusing on past failures and obstacles to overcoming the current problems (Nolen-Hoeksema & Morrow, 1991). Brooding involves a vicious cycle of intrusive thoughts about past failures and an inability to move beyond pessimistic thoughts about current issues and fears about the future (Nolen-Hoeksema, 2000). Both reflective and brooding rumination involve self-attention, but they differ on the focus of that attention (Joseph, Afifi, & Denes, 2016). For instance, someone with chronic back pain who is brooding might focus on why bad things always happen to him or her and how things are going to get worse. A person with chronic back pain engaging in reflective rumination might reflect inward about the source of the pain and problem solve about what can be done to make the pain more manageable. It is not surprising, then, that brooding is predictive of the negative effects of rumination, such as a lack of problem solving, as well as anxiety and depression (Abela, Vanderbilt, & Rochon, 2004). To the contrary, reflective rumination has been associated with resilience, problem solving, and positive attitudes about a problem (see Joseph et al., 2016).
Because of the potential ill effects of brooding rumination, most research on rumination has focused on its association with poor mental health. Brooding is predictive of a host of mental health problems, such as depression, anxiety, obsessive-compulsive disorder and post-traumatic stress disorder (e.g., Abela & Hankin, 2011; Takano & Tanno, 2011; Zawadzki, Graham, & Gerin, 2012). Anxiety is often at the heart of rumination.
Although stressful situations, like health problems, often prompt people to ruminate, research also suggests that personality heavily influences ruminative tendencies. Scholars often study and write about rumination in terms of personality traits, characterizing people as having a ruminative coping style or as ranging from “brooders” to “non-brooders” (e.g., Abela et al., 2004). Brooders tend to become consumed more often with anxiety and other negative emotions than non-brooders, which subsequently paves the way to a downward spiral of intrusive thoughts about one’s stressors (Nolen-Hoeksema, 2000). Ruminators tend to feel particularly anxious when situations are out of their control (Nolen-Hoeksema, 2000).
Even though it is less frequently studied than cognitive rumination, people also verbally ruminate about their problems. Individuals might be especially likely to verbally ruminate when they have a chronic illnesses because the illness is ongoing and requires perpetual care and support. People often turn to their friends and family for support when they are stressed about something, particularly when the issue is constant and unresolved (Rime et al., 1992). In so doing, one person might be talking about his or her health to another or two or more people could be sharing their health issues together. Researchers often refer to these situations as verbal ruination and co-rumination. Co-rumination occurs when two or more people repeatedly and jointly talk about their problems together (Rose, 2002), whereas verbal rumination consists of one person repeatedly talking about his or her problems to another (Afifi, Afifi, Merrill, Denes, & Davis, 2013). Research on co-rumination has centered on adolescents and young adults and has shown that when they co-ruminate their relationship satisfaction increases, but their anxiety and depressive symptoms ironically increase as well (Hankin, Stone, & Wright, 2010; Smith & Rose, 2011; Stone, Hankin, Gibb, & Abela, 2011). Mutually disclosing problems likely fosters trust and closeness in relationships, but it can hurt people’s mental health. For example, when both people in a couple have an illness (even if it is not the same illness), it can foster empathy and understanding and build relationship satisfaction when they can talk about their illnesses together, but it can foster poorer mental, physical, and relational health due to the stress and burden of dual care-giving.
Health and Negative Rumination
Rumination is especially detrimental to health outcomes when experiencing health setbacks. Health is often dynamic, punctuated with events where one’s health improves and gets worse. Negative health events are apt to be of greater emotional and physical impact than positive events, therefore increasing the potential for health anxiety. Health anxiety describes a consuming fear and anxiousness about having or potentially developing illness or ailments (Creed & Barsky, 2004) and is experienced in about 5% of the general population and up to 9% of patients at general medical practices (Creed & Barsky, 2004; Gureje, Üstun, & Simon, 1997). Individuals who experience increased state or trait health anxiety engage in greater brooding about their health during unfavorable health situations than those who do not experience health anxiety (Castellano et al., 2013; Rachman, 2012). These individuals experience recurring and intrusive images and memories relative to their health, leading to negative self-perceptions and a heightened sense of vulnerability to morbidity and death (Muse, McManus, Hackmann, Williams, & Williams, 2010; Wells & Hackmann, 1993). Brooding about one’s health is therefore associated with negative coping strategies (Muse et al., 2010) and can potentially alter overall quality of life.
Maladaptive rumination about one’s health can also be rooted in anxiety about negative past or future health events. These health events could range from significant concerns about the probability of developing an illness or disease (e.g., knowing that one has a genetic predisposition to developing Alzheimer’s disease) to a serious health diagnosis or prognosis (e.g., being diagnosed with end-stage cancer). A majority of individuals experience health anxiety as recurrent, unrelenting, and distressing (Creed & Barsky, 2004). As a response to health anxiety, individuals are apt to engage in brooding as a coping mechanism. Maladaptive rumination like brooding exists as an avoidant response to intrusive health-related thoughts and memories (Muse et al., 2010) and has been identified as a cognitive process through which health-anxious concerns and thoughts are maintained and perpetuated (Fink et al., 2004; Marcus, Hughes, & Arnau, 2008; Simard, Savard, & Ivers, 2010). Thus, brooding in health contexts consists of perseverative, intrusive, and circular thoughts that are centered on triggers and outcomes of an individual’s health symptoms (Nolen-Hoeksema, Morrow, & Fredrickson, 1993). Brooding can include both visual and verbal content and often contains upsetting and obtrusive memories (Pearson, Brewin, Rhodes, & McCarron, 2008; Watkins, Moulds, & Mackintosh, 2005). Because these negative thoughts, memories, and conversations are pervasive, individuals are likely to continually retrieve and ruminate about the same negative memories (Brewin, 2006; Conway & Pleydell-Pearce, 2000). This recurrent sequence of cognitions is therefore likely to interfere with daily life and individuals’ sense of self as relevant to their health perceptions.
Maladaptive health anxiety not only exists among ill populations, but also among those that are physically well (Fulton, Marcus, & Merkey, 2011). Typically healthy individuals may engage in health anxiety and negative health cognitions due to increased salience of disease development, to perceptions of predisposition to illness, or for a variety of additional physical and psychological factors. These individuals might engage in dysfunctional cognitions pertaining to their personal health and health risk factors. Two aspects of health risk that may cause dysfunctional health assessment in healthy individuals are comparative and absolute risk perceptions. Comparative health risk perceptions occur when individuals assess their health risk compared to that of their peers, while absolute health risk perceptions refers to an assessment of one’s overall and total health risk of developing a certain ailment or disease (Zajac, Klein, & McCaul, 2006). Both of these types of perceptions may cause health anxieties and foster brooding. For example, comparative health risk perceptions might lead some people to feel anxious that they may develop breast cancer after a close and similar friend is diagnosed with the disease. Having a close other who is experiencing a certain health setback might make those risk factors more salient, resulting in increased health anxiousness and brooding about disease development. Similarly, absolute health risk perceptions may provoke people to pay increased attention to their total health risk for developing a certain ailment and to be anxious and brood about possible health risks. For example, after learning that one’s personal total risk for developing Type 2 diabetes is approximately 25%, or 1 out of every 4 individuals, anxiety and brooding might increase and fuel possible preoccupation about the possibility of personally developing the disease. This might be compounded by the presence of trait anxiety, where individuals are more likely to ruminate about their health if they tend to be more anxious overall. Research suggests that increased perceptions of comparative health risks create worry and are subsequently related to increase perceptions of absolute health risks (Lipkus, Klein, Skinner, & Rimer, 2005). Thus, comparing oneself to others can perpetuate worry and anxiety, leading to potential increases in brooding about overall perceptions of health vulnerability.
Ill populations can also experience health anxiety and brooding stemming from past fearful health events and the possibility that they might recur or increase susceptibility to other comorbidities (e.g., cancer patients with significant fear of cancer recurrence) (Simard, Savard, & Ivers, 2010). Generally, awareness of illness is very present for ill and health-anxious individuals, giving way to fears of any ambiguous health symptoms and further rumination (Fulton et al., 2011). Differential health symptoms that do not appear directly related to the cause of one’s initial anxiety may cause new health anxieties for fear that something catastrophic may inevitably happen. This constant and continual awareness and brooding is likely to reduce quality of life. Furthermore, continuous rumination about health is likely to alter one’s perceptions of what it means to be healthy. Because health is often conceptualized as a state in which one is completely symptom-free (Fulton et al., 2011), this construction of meaning proves somewhat difficult and unattainable for health-anxious and ruminative individuals who are experiencing or have experienced health setbacks. These dysfunctional beliefs are likely to lead to further health-anxious ruminations, creating a detrimental cycle.
For cancer patients and survivors, specifically, health-anxious rumination proves detrimental to well-being. Research focusing on cancer patients six months after diagnosis found that those who had engaged in increased cancer-focused and negative memories experienced greater helplessness and hopelessness about their cancer (Kangas, Henry, & Bryant, 2005). These feelings might perpetuate health anxiety and negative rumination, as they can potentially decrease one’s sense of self-efficacy in being able to cope with and manage their symptoms and cognitions surrounding a diagnosis. A great concern and source of anxiety to cancer patients and survivors is that of cancer recurrence, which is often perpetuated by negative health rumination (Lee-Jones, Humphris, Dixon, & Hatcher, 1997). Fear of recurrence (FCR) is a distressing, often life-long experience in cancer survivors who are post-treatment and involves worries that one’s cancer will return in the same form or another (Simard & Savard, 2009). FCR is linked to distress, impaired functioning, physical stress symptoms, and lower quality of life (Simard & Savard, 2009; Vickberg, 2003). Approximately 50 to 83% of cancer survivors experience fear of cancer recurrence, rendering it a primary emotional concern (Armes et al., 2009; Humphris et al., 2003; Llewellyn, Weinman, McGurk, & Humphris, 2008). Cancer patients especially experience increased fear of recurrence prior to and after follow-up examinations, appointments, and medical testing (Lee-Jones et al., 1997; Meyerowitz, Kurita, & D’Orazio, 2008; Rogers, Scott, Lowe, Ozakinci, & Humphris, 2010). Medical appointments and tests are not the sole source of recurrence fears, however, and significant anxiety may occur around anniversaries of treatment, diagnosis, and birthdays (Meyerowitz et al., 2008).
These ruminative fears have the potential to be both ongoing and detrimental, and they can also put an increased strain on the healthcare system. For example, anxiety was mentioned as the most crucial factor in patients’ refusals to be discharged from cancer centers (Glynne-Jones, Chait, & Thomas, 1997; Thomas, Glynne-Jones, Chait, & Marks, 1997). Similarly, patients may try to reduce their fears and rumination by seeking advice and reassurance from practitioners (Easterling & Leventhal, 1989), often leading to increased, unscheduled visits to providers and to greater use of support and counseling outlets (Thewes et al., 2011). These elements are likely to result in longer hospitalizations and increased time spent by health providers to reassure patients, further straining the healthcare system. Continually brooding about cancer recurrence and other possible negative cancer outcomes is therefore associated with harmful psychological outcomes (Chan, Ho, Tedeschi, & Leung, 2011), making it likely that irrational and intrusive rumination will keep recurring and eroding quality of life (Simard et al., 2010).
While brooding about health experiences can compound and exacerbate symptoms and outcomes, certain methods could help lessen these effects. Mindfulness-Based Cognitive Therapy (MBCT), in which participants are encouraged to disengage from intrusive and recurring thoughts and to focus instead on being reflective of feelings (McManus, Surawy, Muse, Vazquez-Montes, & Williams, 2012) has been shown to be one way to reduce negative health rumination. Mindfulness practices are found to help decrease ruminative thoughts that may prolong health anxieties (McManus et al., 2012; Segal, Williams, & Teasdale, 2002). These practices help an individual to reframe stressful experiences and anxieties such that these events become more positive and reflective. Reflecting upon one’s anxieties in this way may help to greatly decrease the occurrence and obstructive nature of negative health rumination, allowing individuals to more fully live their lives.
Positive Rumination and Health
When individuals experience an emotional state, they usually attempt to regulate that emotion in some way (Koole, Smeets, Knippenberg, & Dijksterhuis, 1999). Although most research focuses on this emotional regulation in the context of negative affect (Treynor, Gonzalez, & Nolen-Hoeksema, 2003), it has also been found to be present in the experience of positive affect (Gross, 1998; Larsen, 2000). In fact, more and more research is discovering that the valance of the affective state does not determine the effect on the individual, but instead it determines the individual’s response to that affective state (Nolen-Hoeksema, 1991; Teasdale, 1988). Understanding the reasons for how individuals respond to affective states is essential in that it has been shown to be tied to disorders such as depression and could dictate the severity and duration of the disorder (Nolen-Hoeksema, 1991; Johnson, Mckenzie, & McMurrich, 2010). Responses to these affective states can include both automatic (such as changes in hormone levels; Zoccola, Quas, & Yim, 2010) and conscious reactions (such as strategies requiring deliberate effort; Gross & John, 2003). Examples of positive rumination, or the ability to respond to positive emotional experiences, may show up in the form of basking in a memory or reminiscing about an affective event and can be dictated by many personal factors such as self-esteem (Wood, Heimpel, & Michela, 2003) and self-affirmation (Koole, Smeets, Knippenberg, & Dijksterhuis, 1999).
As health professionals navigate the complicated process of delivering positive and negative health messages, these concepts become essential to understand. We will focus on what may contribute to positive rumination, the health benefits both personally and relationally that positive rumination may garner, and strategies that health professionals can follow to encourage positive rumination to take place.
Positive rumination is especially prevalent when reminiscing about a positive life experience or concentrating on strong personal assets (Larsen & Prizmic, 2004). When positive rumination is not possible at the onset of an affective event, individuals may engage in distraction, which as it sounds is the diversion of attention away from the event and onto something unrelated (Nolen-Hoeksema, 1991). Distraction as a strategy is generally not sufficient in extinguishing unwanted thoughts, as it is only a temporary relief (Koole, Smeets, Knippenberg, & Dijksterhuis, 1999). By enacting more intentional strategies, individuals may be able to influence the narrative in a more positive way through reflection or reminiscing.
Reflection is simply the deliberation of an affective event (Johnson, Mckenzie, & McMurrich, 2010), and reminiscing is generally seen as the way in which an individual views a past event, which has the ability to increase evaluation of that individual’s view of his or her past overall (Strack, Schwarz, & Gschneidinger, 1985). Both of these concepts are different from brooding or negatively dwelling on an event (Johnson, Mckenzie, & McMurrich, 2010) in that they allow for the individual to feel good about the memory. Although reflection and reminiscing have been found to have the ability to increase depression initially, sustained reflection and reminiscing can lessen depressive symptoms over an extended period of time (Pennebaker & Seagal, 1999; Treynor, Gonzalez, & Nolen-Hoeksema, 2003). Often, however, many individuals struggle to reflect on an event and instead brood about it. There is evidence that this connected to people’s self-esteem.
Self-Esteem and Affirmation
Positive rumination is helpful because it offers a strategy to regulate emotion. Some individuals, however, might be better at this self-regulation than others. One potential explanation for why some people might be better than others at self-regulation is higher self-esteem (Martin & Tesser, 1996). For example, Wood, Heimpel, and Michela (2003) asked participants to describe positive life events and then measured the participants’ levels of self-esteem. The authors found that individuals with high self-esteem tended to display strategies that improved their mood when reminiscing on a life event, whereas those with low self-esteem suppressed positive memories, lowering their mood. Wood et al. (2003) refer to these strategies as “savoring” and “dampening.” Interestingly, the authors posited that individuals with low self-esteem may be dampening their mood because they believe that they do not deserve the positive emotion associated with the memory.
Another strategy to cope with threats introduced by affective events is self-affirmation. Self-affirmation is individuals’ ability to consciously choose to maintain a positive self-image (Koole et al., 1999). Therefore, even when negatively valenced thoughts or events occur, people actively choose whether to devote time and energy to it or simply focus on a more concrete verification of self-worth. This concept has been tested in the context of cognitive dissonance, and research has found that when people are able to enact self-affirmation, they do not feel the need to reduce the dissonance (Koole et al., 1999). This has been referred to as a person’s “psychological immune system” (Sherman & Cohen, 2006) and has been shown to make individuals more open to threatening health information (Das, 2012). For example, instead of engaging in self-hatred over the fact that one’s obesity might have created Type 2 diabetes, individuals with a strong psychological immune system might remind themselves of their self-worth and get help to lead a healthier lifestyle to lose weight.
It seems clear that having the ability to restore self-worth either through self-esteem or self-affirmation may be intrinsically tied to one’s ability to negate negative affect and instead enact positive ruminative strategies. In short, the ability to maintain positive affective thoughts protects an individual’s mood and self-concept. Intriguingly, there is convincing data that this ability also provides substantial health benefits as well.
Scholars have found overwhelming evidence for the health benefits of positive rumination and emotional disclosure. When an individual is positively ruminating and chooses to disclose those thoughts or memories, the results can improve health outcomes (Afifi, Afifi, Merrill, Denes, & Davis, 2013). This can be in the form of a reduction in anxiety (Stiles, 1987; Stiles, Shuster, & Harrigan, 1992), improvements in health-efficacy (Shim, Cappella, & Yeob Han, 2011), and improvements in mood (Burton & King, 2004). Of particular importance is Pennebaker’s work examining the mental and physical health benefits of writing. For instance, Pennebaker and Seagal (1999) found that when individuals wrote about an emotional event for 15 minutes a day for three consecutive days, their mental and physical health improved. The authors argued that creating stories help humans understand and deconstruct experiences that may have been unclear. Talking about positive memories and stories has been shown to produce similar effects (Donnelly & Murray, 1991; Murray, Lamnin, & Carver, 1989; Pennebaker, 2000; Pennebaker & Seagal, 1999). This form of verbal rumination may aid in the mental organization of events and the processing and development of positive feelings and emotions. Although the focus of Pennebaker’s work often uses storytelling to lessen dwelling or brooding, similar strategies could be employed to encourage individuals to ruminate on the positive aspects of a situation as well.
The health benefits of positive rumination have been found across highly diverse populations, from prisoners to students (Pennebaker & Seagal, 1999). Similar to the act of writing an emotional story, positive rumination has the potential to improve immune function by improving t-helper cells, lessening pain (and thus the need for medication), and alleviating depressive symptoms. Reframing the emotional language used in mental processing of an event could restructure the response an individual gives and consequently change the ways in which an individual is influenced (Pennebaker, 2000). Using LIWC (Linguistic Inquiry and Word Count), Pennebaker and colleagues have discovered that people are able to demonstrate more reflection through the use of positive-emotion words in their writing, experiencing greater health benefits than those who use fewer positive emotion words. Along with personal improvements to health, positive rumination also offers highly beneficial outcomes relationally.
At the same time, it should be noted that simply disclosing or writing about a stressor or health problem does not always yield better health. In fact, there is an enormous amount of research that shows that disclosure of information can yield worse personal and relational health when the response from a person being disclosed to is taken into account (see Afifi, Shahnazi, Coveleski, Davis, & Merrill, 2016). Whether the disclosure of stressful information is beneficial or not depends upon the supportiveness of the recipient of that information (and whether a recipient was involved). Some research suggests that it is important for support providers to help those who are verbally and cognitively ruminating positively reframe the stressor or think about the stressor in a positive manner (Afifi, Merrill, Davis, Denes, & Coveleski, 2016). Positively reframing the stressor is one way for people to stop brooding. Talking continuously about one’s stress without finding a sense of closure or positively reframing a stressor can actually increase brooding and be detrimental to one’s relationship quality (Afifi et al., 2016).
There is evidence to show that the ways individuals verbally ruminate to their partner or how couples co-ruminate may be directly tied to relational health (see Afifi, Shahnazi, Coveleski, Davis, & Merrill, 2016). For instance, rumination has been linked to the ability to forgive (McCullough, Rachal, et al., 1998; Paleari, Regalia, & Fincham, 2005), which has been shown to increase relational satisfaction. Sharing ruminative thoughts has also been found to strengthen bonds within relationships because disclosure often promotes reciprocal disclosure (Altman & Taylor, 1973), especially when that response is positive and validating (Afifi, Olson, & Armstrong, 2005; Afifi & Steuber, 2009; Greene, 2009; Petronio, 2002). In healthcare contexts, relational partners often collaboratively deconstruct mixed feelings and emotions in order to successfully navigate a complex new narrative of health (Beck, 2001, 2005). Positive rumination such as reminiscing with a relational partner may serve to confirm or reject both personal and relational identities that may be threatened due to a new stressful situation like a health problem (Beck, 2005).
In addition to being beneficial for romantic relational partners, positive rumination can influence the health of families as well. As children learn to cope with stressful life circumstances, participating in such ruminative activities as reliving family memories teaches coping and resilience (Laible & Panfile, 2009). Verbally reciting memories may increase a child’s ability to relate to others (Fivush & Vasudeva, 2002), feel empathy (Laible, Panfile Murphy, & Augustine, 2013), create social bonds (Nelson, 1996), and engage in perspective taking (Reese & Cleveland, 2006). Parent-child reminiscing about past emotional experiences develops children’s mental organization of a stressful event, as well as providing an emotional script to navigate future stressors (Laible & Panfile, 2009). Reminiscing has also been found to create more securely attached individuals by fostering open and honest communication about emotion (Fivush & Vasudeva, 2002). Through reminiscing with a parent, “children are learning to narrate their past experiences” (p. 74). On the opposite end of the spectrum, mothers who do not regularly openly talk about such issues with their children or do it in a manner lacking detail, produce children who struggle to construct a whole personal narrative as adults (Farrant & Reese, 2000). These positive outcomes provide an exceptional opportunity for healthcare providers when constructing health messages and teaching individuals reframing techniques that could aid in successful coping with stressful health experiences.
Health Messages and Narrative
Health communication scholars have struggled to design effective messages that create a change in behavior. A contributing factor to this change is psychological reactance. Reactance stems from the need to feel in control. When that control or free will is threatened, individuals generally initiate defense mechanisms, such as viewing the message negatively and countering it by performing the opposite action (Brehm, 1966; Brehm & Brehm, 1981; Das, 2012; Gardner & Leshner, 2016). Although positive reminiscing is relatively underexplored, health professionals are slowly beginning to craft messages to encourage positive rumination. Positive rumination research on both patient-provider communication and larger scale health campaigns could be crucial to mitigate the role that reactance might play to threatened populations. Even though it remains speculative, positive rumination might help patients reflect on their health issues or other problems in a new manner and replace negative emotions with positive ones. This could help break the harmful cycle of negative emotions that people often find themselves in when they brood.
One way of constructing messages that could encourage positive rumination is through narratives. Using narrative health messages can promote engagement, increase the ability to relate, and improve the clarity of the message (Kreuter et al., 2007). Narrative delivery styles can include a story with a chronological order, usually highlighting a cause and effect (Braverman, 2008; Chang, 2008; Escalas, 2004; Green & Brock, 2000). Traditionally, narrative health messages have been used in the form of testimonials and anecdotes, but they could also serve as a training tool to aid patients in traversing their health.
The use of narrative training to encourage positive rumination could benefit patients in a number of ways. Das (2012) argues that instead of using fear to convince at-risk groups to change their behavior, helping them to feel good using positive affect could be more effective. When healthcare professionals help individuals feel good about themselves, reactive behavior decreases and self-efficacy increases (Das, 2012; Harris & Epton, 2009). Aiding in the development of self-affirmation and self-esteem might lessen the threat of health messages requiring behavior change and boost “intuitive, self-relevant knowledge” (Das, 2012, p. 30).
Currently, a few techniques exist to incite positive rumination. For instance, Reminiscent Therapy (RT) was introduced as a way to treat patients with dementia and aids in remembering important life events (Norris, 1986). Through techniques like this it has been found that encouraging reflection in the delivery of a health message, especially about one’s family and friends, has the potential to reduce anger and encourage empathy. This reduction in reactance and anger is thought to happen because reflection requires so much of a person’s cognitive resources (Gardner & Leshner, 2016; Shen, 2010). This research is driving innovations in health technology, and health interventions are surfacing in the form of mobile health (mhealth) applications. For example, Good, Ancient, Postolache, Socianu, and Afghan (2013) conducted a study to test whether reminiscing about positive memories via a mobile phone application improved well-being overall. The authors posited that this technology could help populations suffering from dementia and depression as a way of self-soothing. The application prompts users to remember personal memories through the use of pictures, videos, personal stories, and a personal soundtrack of music from the user’s past. Such mhealth applications have become unanimously popular because of their ease and accessibility.
There is little doubt that positive rumination in the form of reminiscing or basking in a memory can provide benefits to individuals struggling from stress or mental health problems. It also appears that young children who learn the ability to mentally construct their personal narratives through positive rumination are more well-adjusted adults. Health messages constructed to urge reflection and reminiscing are an emerging and potentially important part of public health communication. Through new technology such as mobile health applications, these health messages could become even more influential in the care of populations struggling with stress, anxiety, and depression related to their health. Future research should focus on how to further the creation and dissemination of health technology that informs of the benefits of positive rumination and offers an accessible platform to use these positive rumination techniques.
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