TESTIMONY AND MEANING 1

Testimony and Meaning:

A Qualitative Study of Black Women with Cancer Diagnoses

M. Elizabeth Lewis Hall1, Grace E. Lee,1 Jason McMartin1, Alexis Abernethy2, Laura

Shannonhouse3, Crystal Park4, Jamie Aten5, Kelly Kapic6, and Eric Silverman7

1Rosemead School of Psychology, Biola University

2School of Psychology, Fuller Theological Seminary

3Department of Counseling and Psychological Services, Georgia State University

4Department of Psychological Sciences, University of Connecticut

5Humanitarian Disaster Institute, Wheaton College

6Biblical and Theological Studies, Covenant College

7Department of and , Christopher Newport University

Author Note

M. Elizabeth Lewis Hall https://orcid.org/0000-0002-6342-4340

Grace E. Lee https://orcid.org/0000-0001-9571-5794

Jason McMartin 0000-0003-0075-1018

Alexis Abernethy https://orcid.org/0000-0001-6380-336X

Laura Shannonhouse 0000-0001-6822-8763

Crystal Park 0000-0001-6572-7321

Jamie Aten 0000-0003-1340-2546

Kelly Kapic 0000-0001-7442-7953

Eric Silverman 0000-0001-7763-2100 TESTIMONY AND MEANING 2

This study was registered with the Open Science Framework (OSF) (https://osf.io/h3xcp).

The documentation of analyses can also be found there. We have no conflicts of interest to report. Our work was funded by grant 61467 from the John Templeton to M.

Elizabeth Lewis Hall and C. Park, co-PIs.

Correspondence concerning this article should be addressed to M. Elizabeth Lewis Hall,

Rosemead School of Psychology, Biola University, 13800 Biola Ave., La Mirada, CA 90639.

Email: [email protected]

Word count text: 5833

Word count abstract: 174

Short title: Black women’s religious coping with cancer

Key words: cancer, religion, , Black psychology,

© 2021, American Psychological Association. This paper is not the copy of record and may not exactly replicate the final, authoritative version of the article. Please do not copy or cite without authors' permission. The final article will be available, upon publication, via its DOI: 10.1037/cdp0000465

TESTIMONY AND MEANING 3

Abstract

Objectives: Research has established religion and spirituality as important resources for Black people in the US coping with adversity. Most research has been from an etic perspective, examining religious variables that are valid across multiple . In the present study, we asked what emic aspects of the Black church’s practices and theological emphases women with cancer drew on in constructing meaning-making from their cancer experience.

Methods: In this consensual qualitative research study, we interviewed 30 Black women with cancer histories with an average age of 64.5. Results: The religious practice of testimony emerged as the predominant theme. Testimony (a) provided a meaningful purpose to the cancer experience; (b) had a specific content of describing what God had done in their lives as well as some common theological emphases; (c) had dual desired outcomes of helping others and bringing glory to God; and (d) had an associated practice of giving testimony. Conclusions:

We discuss testimony as a narrative structure and highlight its importance in informing culturally-sensitive interventions aimed at supporting Black women with cancer.

Public significance statement: This study suggests that many Black women employ the religious practice of testimony in coping with cancer diagnoses. Testimony has a narrative structure in which the cancer story is intertwined with a story about God’s involvement. These findings suggest that counselors may find it productive to facilitate narratives that draw on the characteristics of testimony in supporting the coping of Black clients with cancer.

TESTIMONY AND MEANING 4

Testimony and Meaning:

A Qualitative Study of Black Women with Cancer Diagnoses

A cancer diagnosis is disruptive, causing individuals to question their assumptions about the world and sense of purpose in life (Hall et al., 2020). In meaning-making regarding their cancer, survivors draw from available cultural resources. Narratives by which we construct meaning are “psychosocial constructions that are jointly authored by the individual whose life is being told and the culture within which the individual lives, from which he or she gathers the narrative resources and frameworks that shape storytelling itself” (McAdams et al., 2001, p.

484). Religions are important components of culture (Johnson, Hill, & Cohen, 2011). People often turn to their religions as comprehensive sources of meaning as they construct their narratives (Hood, Hill, & Williamson, 2005; Newton & McIntosh, 2013), given that religions provide guidance with respect to suffering (Hall & Hill, 2019) and offer a transcendent perspective beyond death. Religious involvement supports meaning-making coping (for reviews, see Park, 2005; Shaw, Joseph, & Linley, 2005). However, we lack clinically-relevant research identifying the specific cultural resources that particular religious traditions bring to bear on cancer patients’ meaning-making.

In the current study, we focus on suffering resources within historically Black Christian denominations in the . 1 Using consensual qualitative research (CQR), we interviewed 30 women from historically Black denominations with cancer diagnoses to

1 These are widely understood to include the National Baptist , the National Baptist Convention of America, the Progressive National Baptist Convention, the African Methodist Episcopal Church, the African Methodist Episcopal Zion Church, the Christian Methodist Episcopal Church, and the Church of God in Christ (ARDA, n.d.). TESTIMONY AND MEANING 5 investigate the religious practices and theological emphases on which they drew in constructing their cancer narratives.

Black people have the highest death rate and shortest survival of any racial/ethnic group in the United States for most cancers (American Cancer Society, 2019). Racial disparities in cancer treatment may contribute to these poorer outcomes (Morris et al., 2010). Successful coping with the disease constitutes an important part of survivorship. Religion and spirituality are significant resources for many Black people in the United States. Spirituality can be understood as “the search for the sacred” with sacred referring not only to God but also to other aspects of life perceived as having sacred qualities (Pargament et al., 2013, p. 7). Religion is

“the search for significance that occurs within the context of established institutions that are designed to facilitate spirituality” (p. 15). In a large representative sample of cancer survivors,

Black participants reported the highest levels of overall spiritual well-being, including , peace, and meaning subscales, of all ethnic groups surveyed (Munoz et al., 2015; see also Best et al., 2015; Canada et al., 2013). Earlier studies found that Black breast cancer survivors relied on their religiosity as a coping mechanism (Bourjolly, 1998; Culver et al., 2004) and relied on God as a social support more than White survivors (Bourjolly & Hirschman, 2001).

Qualitative research has documented the use of specific religious and spiritual resources: attending church and drawing church social support, singing in church choirs, engaging in , testimonies, and Bible/Scripture study, and relying on a personal relationship with

God/Jesus Christ as a source of social support, guidance, and healing (Gallia & Pines, 2009;

Gregg, 2011; Hamilton et al., 2007; Henderson et al., 2003; Holt et al., 2009; Kissil et al., 2014;

Lackey et al., 2001; Roff et al., 2009; Schulz et al., 2008; Simon et al., 2007). One study found that Black survivors reported God as a source of support more frequently than family or friends TESTIMONY AND MEANING 6

(Henderson & Fogel, 2003). Another noted additional health-related religious beliefs relevant to the cancer experience: faith and in God as necessary for healing, attributing control of the cancer to God, and believing that “one could will themselves well” (Holt et al., 2009, p. 260) through thinking or speaking positively (Henderson et al., 2003). Holt and colleagues (2009) also found that meaning-making narratives often involved religious interpretations involving

God’s protection, God’s plan, God’s purposes for the cancer, as well as the role of the devil in causing the cancer.

These religious resources seem to be effective in coping with cancer. One study of cancer patients found that religious behaviors and a sense of meaning in life significantly predicted positive emotional functioning, particularly for Black participants (Holt et al., 2011).

Peace and meaning were associated with reporting fewer cancer-related problems; two cancer- related problems, emotional and physical distress, mediated the relationships between peace and meaning, and self-rated health (Holt et al., 2009). These effects were significantly stronger among Black participants than in other races/ethnicities.

Much of the research on the religious coping resources of Black people has drawn on etic concepts, such as intrinsic religiosity or religious commitment (Watson et al., 2011). In contrast, emic accounts take an insider perspective and allow for knowledge that is specific to a particular religious tradition. Research drawing on etic resources is limited in its ability to capture the nuances of religious meaning-making, which may result in overlooking the unique resources that historically-Black denominations offer those with a cancer diagnosis.

The Present Study

While meaning-making in suffering has been extensively studied, and religion has been found to be largely helpful in the meaning-making process, the religion-specific details in TESTIMONY AND MEANING 7 meaning-making coping are understudied. Consequently, we focused on one particular religious tradition: historically-Black Christian denominations. Our focal research question was, “what aspects of the Black church’s practices and theological emphases do women with cancer diagnoses draw on in constructing meaning-making narratives during their cancer experience?”

Method

Participants

The sample consisted of 30 women, with an average age of 64.5 (SD = 10.86), and a range from 40 to 86. The sample was predominantly Black (28, 93.3%), with one biracial participant (Black and Native American, 3.3%) and one European American participant (3.3%; this participant had attended a historically Black congregation for over 30 years and was married to a Black man). Ten had completed some college (33.3%), four (13.3%) had completed college, and seven (23.3%) had a graduate or professional degree. Three were single (10%), 11 (36.7%) were married, 14 (46.7%) were divorced, and two (46.7%) were widowed. The average amount of time since diagnosis was 7.38 (SD = 5.77) years, with a range from zero to 18 years. Twenty- two (73.3%) had a diagnosis of breast cancer and the remainder (5, 16.7%) had other kinds of cancer (i.e., ovarian, lymphoma, lung, stomach, melanoma, uterine); three (10.0%) had two kinds of cancer. Cancer diagnoses represented the full range of staging, varying with respect to degree of severity and prognosis; 3 reported having metastasized cancer. Twelve (40%) reported attending church/other religious meetings more than once/week, 10 (33.3%) reported once a week, five (16.7%) reported a few times a month, and three (10%) reported a few times a year.

Procedure

The study was reviewed and approved by the first author’s institutional human subjects committee. Study participants were recruited from a large Baptist church and a Christian cancer TESTIMONY AND MEANING 8 support ministry on the west coast of the United States, both with primarily Black membership, and were compensated $50. Eligibility criteria included self-identification as a Christian and having received a diagnosis of cancer. The semi-structured interview began with a request to

“tell your cancer story,” followed by more specific questions relating to what they found helpful, the role of faith, change connected to the cancer experience, and tensions experienced in their faith, meaning and purpose. The full preregistered interview protocol and documentation of the

CQR analyses are available through the Open Science Framework (OSF) project page

(https://osf.io/h3xcp). The first two authors conducted all the interviews, which took place in the church office or the cancer support group building. Interviews lasted approximately 45-90 minutes, were digitally recorded, and transcribed verbatim.

Qualitative Research Analysis

CQR (Hill et al., 1997; Hill et al., 2005) is based on the assumption that multiple perspectives are more effective when trying to understand complex issues and minimize researcher bias: this study included (a) a clinical psychologist with research and clinical work in meaning-making in suffering; (b) a doctoral student in clinical psychology with research experience in transformative suffering; (c) a theologian with expertise in spirituality and meaning making from suffering (external auditor); and (d) a clinical psychologist with both personal and cancer research experience in a historically Black denomination (external auditor). Hill et al.

(2005) described three steps in analysis: (a) develop domains to cluster the data, (b) construct core ideas to summarize the main ideas, and (c) conduct a cross analysis of data to identify categories consistent across participants. Emphasis is placed on reaching consensus, and relies on equal involvement, mutual respect, and shared power (Hill et al., 1997). TESTIMONY AND MEANING 9

The two first authors read and coded two transcripts and developed language to describe the domains. Discrepancies were discussed until consensus was reached, new codes were identified, and a stable list of domains was generated and used for coding. Core ideas that made up each domain for each participant were then developed, reviewed by the other team member, and consensus achieved. Next, a spreadsheet was created to visualize the consensus domains and categories that captured the core ideas across cases (i.e., cross analysis). Throughout the process bracketing notes were reviewed to ensure that the categories emerged from the data rather than being superimposed due to bias (Fischer, 2009) and the external auditors reviewed the developed codes and the core ideas, which ensured that the codes identified were worded appropriately and captured the essence of the data. The external audit indicated no major omissions, noted some additional nuances in the transcription, and suggested ways to further simplify the domains and core ideas.

Levitt et al. (2017) recommend that integrity, including utility and fidelity, be established as the methodological foundation of trustworthiness. Utility was established by recruiting participants representing a Christian perspective, and with a wide variety of cancer diagnoses, histories, and life experiences. Given the potential influence of the researchers on the analytic process, fidelity was sought by constructing a reflexive statement (i.e., bracketing; Fischer, 2009) that considered how their perspectives might have influenced the research and analysis. One of the primary researchers has a history of cancer. Both primary researchers identify as , with religious histories in Latinx and mainstream churches for the first author, and Asian

American churches for the second author. Ethnic differences with participants may potentially have limited what participants were willing to share, although most participants expressed feeling comfortable with the interviewers. The ethnic differences may have enabled recognizing TESTIMONY AND MEANING 10 unique aspects of the stories that might not have been easily noticed by those sharing the same cultural assumptions.

Second, after each meeting, the primary investigators utilized memo-writing to document initial thoughts and perceptions of the data. Third, to manage subjective bias, the final codes developed by the first and second authors were audited by two external auditors who each reviewed half of the coded excerpts. Fourth, consensus on all coding was achieved among this team. Fifth, all domains and core ideas were grounded in the data. Sixth, a brief summary of the major findings of the study was constructed by the researchers and e-mailed to participants to check if the summary captured their experiences. Only one participant expressed disagreement about portions of the summary.

Results

The interviews provided an abundance of themes related to our research question. Some of our findings reflect those found in more religiously diverse samples (e.g., stress-related growth, Hall et al., 2020; purpose, Hall et al., 2020, Mattis, 2002; spiritual surrender, Mattis,

2002). Consistent with other research on coping in Black cancer survivors, our participants reported relying heavily on their Christian faith. We focus here on aspects of the meaning- making narrative that reflect distinctive features of historically Black denominations. One overarching theme was an emphasis on testimony, a particular kind of story referenced spontaneously by 21 participants.

Testimony (a) provided a meaningful purpose to the cancer experience; (b) had a specific content of describing what God had done in their lives as well as some common theological emphases; (c) had dual desired outcomes of helping others and bringing glory to God; and (d) had an associated practice of giving testimony (see Table 1). Testimony served simultaneously TESTIMONY AND MEANING 11 as a component of the meaning that was made (in the form of purpose), a narrative structure (in terms of content and desired outcomes), and a religious practice.

Testimony as Purpose

Cancer is often experienced as a disruptive event that threatens the meaningfulness of life. Attributing a purpose to cancer is one means of making it meaningful. In our interviews, the purpose of cancer was often tied to God’s purpose in giving them a testimony; 11 women stated this directly. One woman eloquently noted testimony’s important role in purpose, not just for others, but for herself:

I saw what God has done [for] other people. And I said, ‘Oh, God has done this.’ But I

needed my own personal story that I can say, ‘that’s what God has done or what he did

do.’ And [the cancer experience] gave me that, I can tell you what God's done for me, not

my mom, not my dad, not my sisters, but what he's done for me.

We see this motivational facet in one woman’s testimony: “My girlfriends who were like,

‘You're the strongest person we know. …You can't quit now. What is your testimony going to end up being if you quit now?’” The thought of having a testimony to share encouraged this woman to persevere despite the challenges she faced.

The Content of Testimony

Testimony’s thematic content can be summarized as telling others what God had done in one’s life. Eight women referenced this theme directly; many others referenced God’s involvement. Several reported telling others of God’s healing: “I tell them the Lord healed me; I tell anybody”; “he healed me and let me see, ‘I want you be able to tell people it was me’.”

Another participant extensively described her call to tell what God had done in her life. She TESTIMONY AND MEANING 12 spoke of multiple difficulties she encountered, then said, “the Lord just says, ‘I want to use you.

You've made yourself available. You will speak of my glory.’”

Four theological emphases were noted that shaped the presentation of the primary content: (a) an emphasis on relational experience with God; (b) an emphasis on gratitude; (c) an emphasis on God’s promises; and (d) a dualistic .

Emphasis on Relational Experience of God

God was referenced in every interview, often expressing an intimate sense of relationality. Women spoke of God as a supportive relational presence who provided strength and guidance (28 participants). They spoke to God informally throughout their day, often in terms expressing intimacy. One woman recounted, “God helped me through it each and every day. … I love him and I really believe that he's brought me through this far.” Another said, “It was a feeling that I had constantly, that I was not alone. He had never left. You know, even going into surgery or them prepping me for surgery and all of those things. … I could just feel he was there.”

Emphasis on Gratitude

Expressions of gratitude toward God were common among our participants (16 participants). One participant expressed her broad scope of gratitude:

I did a lot of thanking … that I was able to do treatment and was thanking him that I was

able to walk into treatment. And that I wasn't so sick … And, I just first thanked God it

wasn't as bad as it could've been.

One form of gratitude characteristic of this population, sometimes known as “praise testimony,” was present in eight interviews. Praise testimony acknowledges God’s role in one’s life in general terms, often using standard phrases, such as “thank you that I awoke this morning TESTIMONY AND MEANING 13 clothed and in my right mind.” One participant stated, “I praise him every morning. ‘Thank you father for waking me up this morning, clothed [and] in my right mind. Thank you for your grace and mercy.’”

Emphasis on God’s promises

Seventeen women alluded to God’s promises, primarily those having to do with God’s healing, God’s power to strengthen them, and God’s presence. With respect to healing, one participant stated, “I took [God] at his word … where he said, ‘you ask and it shall be given; speak, you shall receive.’ So that's what I did. I asked for healing health and strength and I received it.” Several women alluded to Jesus Christ’s suffering as a source of promised healing, using the phrase, “by his stripes I am healed,” referring to “being covered by the blood,” or mentioning Jesus’ healing ministry. Referencing promises of healing was not a denial of the possibility of death. Many women expressed acceptance that they might die of their cancer. For example, one woman stated that after experiencing God’s presence through various difficult times, “[God]’s already built you up to this point that even death wouldn’t surprise you because you already know that this is where he wants you to be… I know that I’m facing death, but still

I’m okay with that.”

Several women quoted Philippians 4:13 to emphasize God’s power, “‘I can do all things through Christ who strengthens me’--a lot of scriptures that talk about God's promise and strength and enduring, and God won't put more on you than you can bear.” Another referenced the strengthening power of reading her Bible, “It was important for me to read his Word, because that was my foundation. …if I didn’t have his Word, if I didn’t talk to him, then I would get weak, I would get frail. And I might would have died.” Many women also spoke of God’s promises to be with them. “He promises that He’ll never leave you, never forsake you and that TESTIMONY AND MEANING 14 you have a home with Him in the end and eternity... So I just kept thinking of that.” Another stated, “If I don't remember nothing else, I know he's always with me, always with me.”

Dualistic Worldview

Another theological aspect of the interviews was of a dualistic worldview, in which is influenced by a non-material, spiritual aspect that profoundly interacts with material reality and is divided into competing positive and negative aspects (24 participants).

God, health, life, faith, and positivity are contrasted with the devil, sickness, death, doubt, and negativity. This reality is influenced by one’s thoughts, speech, and prayer; participants expressed the need to be active in promoting positivity and avoiding negativity. One woman stated, “Your mind is strong, and if you don’t fill it with the right things it can do things to you.

It can control you.” Many women expressed the need to avoid negativity during treatment to help themselves heal. This might take the form of avoiding certain people or asking loved ones not to cry.

One participant conceptualized her cancer as a spiritual struggle with Satan. When asked whether she experienced spiritual struggle, she responded, “No. I can't let Satan have that. I can't let him win cause if I struggled or felt any type of way that means he won. Absolutely not. …

God gave us power that we don't have to listen to him.”

Attempts to influence treatment with positivity are evident in another participant’s narrative:

In order to grow and prosper and have a positive outcome, you have to have positive

energy. You have to have faith. … So if I'm going to be like Christ, and if I want the

rewards and him to bless me, then I have to be a blessing and I can't allow the negative TESTIMONY AND MEANING 15

because then the devil, if you just let a little bit in, then he makes up a mole hill out of a

mountain in your mind.

Thoughts, speech, and prayer are thought to exert power or influence toward positivity or negativity. For example, refusing to “claim” cancer surfaced in three interviews. One interviewee recounted her reaction to being diagnosed, “it was never my cancer. I never claimed it. As matter of fact, I spoke to the cancer and I told it, ‘You don't have me, I have you. And when I have something I can do what I want with it and I don't want you, so you're gone.’”

Another woman stated that she “did not give cancer authority over [her] life,” clarifying that this meant not thinking of it as a scary thing that could kill her, but rather as something akin to a cold.

The Desired Outcomes of Testimony

Participants expressed two interrelated purposes for giving their testimonies: to help others, and to give glory to God (18 participants). One participant stated she thought she had gone through her cancer experience to prepare her to help others, “I might not be a Bible scholar, but I sure do have something to say that I've experienced to be able to share with somebody.”

Another said, “… I think that's what my testimony is, to help somebody else along the way. …

So I think that's what [God] wants me to do is share my story with somebody else. Cause you never know. Somebody could be on the verge of giving up, you know?” Other participants spoke of helping those with cancer know they could beat cancer, that it’s not a death sentence, to give others hope, or to encourage them to have faith or to develop character.

Many interviewees reported benefitting from other’s testimonies. One stated, “We have so many strong women that has gone, been had cancer for years and it came back and they still strong. So that's a testimony in itself, so that makes me strong. You know, I look at them and I say,’ they can do it, I can do it.’” This woman went on to speak of helping others with her TESTIMONY AND MEANING 16 testimony. This cyclical, communitarian nature of testimony was also evident in another participant, who stated, “That's why I'm a member of the Women of Color cancer support group because not only do I share my story, but the stories that are shared with me, they give me something to go on. Sometimes I feel is not as bad as it was or as it seems. It's always somebody in a worse off situation than you.”

Women also referred to biblical characters’ testimonies as sources of encouragement, illustrating the power of redemption stories they heard in their religious communities. One stated, “Well, I thought about the promises, of people in the Bible. And I thought about my parents and their beliefs, and what [God] had done for them … I felt that I was deserving of those same blessings. So, I asked [God] to bless me.” Another recounted,

I saw how God really uses people that have been through something. Nobody in the Bible

just had a cake walk. The people that he really used were people that had been through

something because then they had enough confidence to say, “[God] got me out the lion's

den.” So, these stories combined with my faith also gave me the confidence ...

Some women referenced a larger goal of pointing others to God, or “giving glory to

God.” One spoke of having a testimony so that “I could tell someone that the Lord can bring you through anything like this cancer.” Another stated, “after I spoke at a church, I was asked to be a spokesperson for Susan G. Komen and I get to go on [radio station] to honor Him and give Him glory. … But my testimony goes out to so many people that maybe don't know who God is.”

Giving God glory figured prominently in the narrative of another participant:

[My sisters] were asking, ‘why did [God] pick you? … But he knew that … people see

me at church and everything, you know, everywhere I go … and [he] say, ‘[participant]

would go and she would give me the glory.’ So that's why he gave it to me. TESTIMONY AND MEANING 17

The Practice of Testimony

Ten women reported sharing their stories, informally with neighbors, friends, and acquaintances, or formally in church, cancer seminars, radio, or cancer support organizations.

One participant stated, “and these five years [God] has put so many people in my pathway … because people have heard my testimony and they have said, ‘well, if God do that for you, then I know he can do it for me.’” After being asked whether it was important for her to share her testimony, another participant stated simply, “Everywhere I go. Everywhere I go.” Yet another stated that she tells her story “every chance that I can get.” Some women noted that they had volunteered to participate in the current study precisely in order to share their testimony. One said, “My purpose, the meaning in life is to do what I'm doing with you. Tell the people if I get an opportunity to … but if someone asks me, I'm going to take the time to do it.”

Discussion

When difficult life events disrupt people’s sense of purpose and meaning, coping often involves meaning-making in the form of narratives that restore a sense of purpose and meaning.

People’s meaning-making narratives occur at the intersection of the individual and their environment with resources available at hand. The religious context of the women in our study provided a powerful narrative resource in the form of testimony. Testimony, one of the four

“pillars” of the historically Black religious tradition, emerged as an overarching theme in the meaning-making of our participants. While several qualitative studies have investigated the experiences of Black people with cancer (Gregg, 2011; Henderson & Fogel, 2003; Holt et al.,

2009; Kissil et al., 2014; Schulz et al., 2008; Simon et al., 2007), and have often noted the importance of religion and spirituality to their coping, the theme of testimony has been relatively ignored. Holt and colleagues (2009) noted testimony briefly as a purpose for the cancer in their TESTIMONY AND MEANING 18 cancer survivor sample. In our interviews, it emerged as a prominent and complex theme, where it served as (a) a component of the meaning that was made (in the form of purpose), (b) a narrative structure (in terms of content and desired outcomes), and (c) a potentially healing religious practice (in that telling one’s story can provide personal benefits to oneself as well as others). Testimony constituted a particular kind of meaning-making framework within which to make sense of their cancer experiences, derived from the historically Black Christian tradition.

In framing their stories around God’s redemptive action in their lives, participants were able to place their individual narratives within the larger, more robust story of God’s actions in the world.

With respect to meaning, testimony was conceptualized as a purpose—one of our primary themes. Testimony was described both as a possible reason why God had allowed cancer in their lives, and as a purpose that some women gained from their cancer experience: to share their testimony with others. When accomplished, having a testimony felt like an achievement, a specific purpose in life that had been gained through the cancer experience.

Notably, theories of life meaning typically rate purpose as an essential component (e.g., George

& Park, 2016). Narratives help us connect our past, present, and future; which is why purpose is an important part of narratives, as it provides the implications of our story for our futures.

The narrative structure of testimony provides guidance in terms of the shape one’s meaning-making should take, derived from the historically Black Christian tradition. With respect to content, testimony was characterized primarily by articulating what God had done in their lives. This stepping into the narrative of God’s action in the world constitutes a kind of psychological sanctification of their cancer narrative as a process by which they appraised it as having divine character and significance and which may have yielded the corresponding benefits TESTIMONY AND MEANING 19

(Mahoney et al., 2013; Pargament & Mahoney, 2005). Further research is needed in order to confirm these potential outcomes.

The content of testimony was also characterized by four theological emphases that further shaped the way the primary content was communicated: (a) an emphasis on trust in God’s promises; (b) an emphasis on relational experience with God; (c) an emphasis on gratitude; and

(d) a dualistic worldview. Emphases (a) and (b) are consistent with past research that shows that relationship in general, and a sense of belonging in particular, predict a sense of life as meaningful (e.g., Lambert et al., 2013) and relationship with God as a relational support

(Henderson & Fogel, 2003; Mattis, 2002).

The dualistic worldview (d) acknowledges the reality of a non-material dimension, sees the world in terms of a duality of the positive and the negative, and sees thought, speech, and prayer as ways of influencing this duality (Floyd-Thomas et al., 2007). This unique cosmology has surfaced in other qualitative studies with Black participants (Mattis, 2002), including findings by Holt and colleagues (2009) that many of their participants believed in the power of the will to influence their health outcomes and sometimes refused to “claim” their cancer as a way of denying it power. While this could be seen as a way of denying the reality of the cancer

(and may constitute a form of fatalism in some people), this did not seem to be true of our participants, who were proactive in their treatments. This is consistent with previous findings

(Henderson et al., 2003; Hotz, 2015). The belief in God’s power to direct, guide, and change outcomes need not be linked with fatalism (Abernethy et al., 2005; Cooper-Lewter & Mitchell,

1986; Peek et al., 2008; Powe, 1997). Often, expressions of trust in God’s will, control, or providence were closely followed by expressions of active participation in treatment plans. TESTIMONY AND MEANING 20

The narrative structure of testimony also included two desired outcomes: helping others and giving glory to God. The desire to draw on one’s own experiences to help others is not a unique outcome in this population (e.g., Hall et al., 2020). However, the help that was offered to others in the present study was weighted heavily in terms of telling others their story as a form of encouragement. This emphasis illustrates the centrality of story in the religious life of the Black community and the felt responsibility to contribute to the well-being of others through stories of

God’s faithfulness.

Finally, testimony constituted a potentially healing religious practice of “giving testimony.” When people construct narratives they do not only make meaning for themselves, but also create vehicles for communicating that meaning to others. Testimony serves both an internal and an external purpose. Internally, giving testimony serves to transform the women’s own experiences and connect them more deeply with their religious communities. Constructing a coherent narrative has been found to provide individuals with a sense of control and emotional acceptance, leading to improved overall health (Pennebaker & Chung, 2007; Pennebaker &

Evans, 2014; Sharf & Vanderford, 2003). Testimony helps forge deep human connections, through shared meaning and values (Anderson & Foley, 1998; Townsend Gilkes, 2001).

The practice of testimony is consistent with research showing that in a church context,

Black women’s religiosity emphasizes the well-being of the community (Floyd-Thomas et al.,

2007) and often results in community and civic engagement (Butler, 2007). Hernández et al.

(2007) proposed the concept of vicarious resilience, suggesting resilience is a social process that can be transmitted across relationships. Vicarious resilience has not yet been studied in the context of cancer survivorship. TESTIMONY AND MEANING 21

The potential negative side of testimony may be that when women have cancer experiences that do not meet the ideal criteria for testimony, they may keep silent, consequently failing to benefit from important sources of social support and meaning-making. This may explain our difficulty in recruiting participants and a minor theme in our findings regarding others who kept silent about their cancer diagnoses. This theme is consistent with findings from other studies that have found evidence that Black participants were hesitant to share a cancer diagnosis (Ashing-Giwa & Ganz, 1997; Hamilton et al., 2010; Zhang et al., 2015). This non- disclosure has negative consequences for social support. A high likelihood of dying from the cancer may be perceived as a barrier to testimony in some cases, preventing women from benefiting from the meaning-making involved in testimony. However, it should be noted that several women felt that the possibility of death was consistent with positive meaning-making, as death is not the end of the story from a Christian perspective and consequently can be accounted for within the narrative structure of testimony.

The qualitative and descriptive nature of the present study limits its ability to answer important research questions, such as the relationship between the practice of testimony and well-being. Second, future research with more geographic diversity is necessary to establish the generalizability of results. Third, given the self-selection of our participants, it is possible that women who are not able to construct a successful testimony may experience shame and feel the need to hide their experiences.

In spite of these limitations, our study reveals some insights regarding the central role that religiousness may play for Black women dealing with cancer, and these results have clinical and healthcare implications. First, our research confirms that successful strategies for encouraging health-promoting practices should be drawn from the cultural norms of a TESTIMONY AND MEANING 22 community (Abernethy et al., 2005; Airhihenbuwa et al., 2000; Resnicow et al., 1999). Our study suggests that testimony is a significant, religiously-based, and culturally salient meaning-making practice, reflecting a deep structure that perceives God as being involved throughout the cancer health narrative. A recent meta-analysis found that narratives had a significant effect in improving health outcomes in Black women, including cancer outcomes (Ballard et al., 2020).

Narrative messages drawn from a population that is targeted for health promotion can positively impact the promotions of positive attitudes, beliefs, and health behaviors (Fiddian-Green et al.,

2019). These findings support the potential efficacy of testimony as a counseling and healthcare intervention. It should be noted that the pervasive influence of religion on the Black community has resulted in lingering influences even when individuals are not personally religious (Cooper-

Lewter & Mitchell, 1986). This suggests that many aspects of testimony (except the most explicitly theistic ones) may be helpful for individuals who are not religious or who are not

Christian.

Awareness of the implicit structures of testimony can lead to more fine-tuned efforts to facilitate meaning-making coping by directing clients to the beliefs, practices, and meaning- making strategies that fit the individual’s concern. Black women may benefit from hearing the testimonies of others through participation in support groups and other such communities.

Although more research is needed to illuminate the multiple ways that faith can influence the course of cancer patients and survivors from historically Black churches, it is clear that acknowledging and these issues of faith is essential to understand their experiences.

Furthermore, the importance of testimony in our sample further affirms a growing body of suggesting that successful meaning-making that draws from cultural resources and is shared with significant others can play an important role in coping with adversity in many forms. TESTIMONY AND MEANING 23

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TESTIMONY AND MEANING 32

Table 1. Summary of Themes

Testimony as Purpose

The Content of Testimony

Emphasis on relational experience with God

Emphasis on gratitude

Emphasis on God’s promises

Dualistic worldview

The Desired Outcomes of Testimony

The Practice of Testimony