Integrating Spirituality into a Group Psychotherapy Program for Women Surviving from Breast Cancer.

BACKGROUND: In spite of a significant relation between spirituality and hope, happiness and life satisfaction, the effectiveness of spiritual interventions in the mentioned mental strengths has been less dealt with. The present study is conducted in order to determine the effectiveness of spiritual group intervention on the increase of hope, life satisfaction and happiness in women surviving from breast cancer.
METHODS: Sixty women surviving from Breast Cancer were voluntarily assigned in to case and control groups, and were assessed before and after Islamic perspective spiritual intervention by spiritual experience, hope, happiness and life satisfaction questionnaires. Statistical analysis of data was performed using descriptive and inferential statistics through covariance.
RESULTS: The spiritual intervention resulted in significant increase of hope, happiness and life satisfaction (P < 0.05).
CONCLUSION: Spiritual intervention appears to be a potentially beneficial intervention for increasing mental strengths among those suffering from breast cancer. Therefore, it seems necessary to consider it as an important element incomprehensive treatment, plans, and in palliative and supportive care.

Introduction

Modern clinical psychology tries to reduce suffering from diseases and improve quality of life by reducing depression and anxiety effects. However, it does not deal with making life happier and more meaningful [1]. Positive psychology is a new field that tries to identify what makes life more worthwhile [2]. Among different subjects in positive psychology, hope, happiness, and life satisfaction have drawn a lot of attention from the public, specialists, and researchers. Despite all the progress in different scientific aspects, there are many events that can disturb our psychological well-being especially hope, happiness and life satisfaction; one of such events is cancer.

Cancer is defined as an unlimited and uncontrollable multiplication of cells [3]. Among them, breast cancer is the most prevalent in women in Iran and other parts of the world [4]. Latest statistics from the Cancer Research Center Shahid Beheshti University of Medical Sciences show that the incidence of breast cancer among Iranian women is 27.5 per 100.000 [5] i.e., over 8,000 new cases of breast cancer are diagnosed per annum; 7778 of which occur in women. Having a mortality rate of 4 per 100,000, breast cancer keeps the record of the fifth cause of death and the third source of burden in malignant diseases for Iranian women [4] . Five-year survival rate varies from 48 percent to 84 percent in different centers [6], and is about 71 percent throughout Iran [5].

These figures show that the affected people are living more than other prevalent cancer patients and are fronting more with its short and long term adverse effects. It is confirmed that as the survival rate increases, life satisfaction decreases; and there is also a positive and consistent relationship between happiness and health [7] . Breast cancer causes fear, disappointment, hopelessness, psychological trauma, and also affects all aspects of the individual's life including physical, emotional and spiritual.

Spirituality is an important element, which is becoming increasingly popular among psychologists and mental health care professionals [8] . Studies prove it as a strong predictor for hope, happiness, life satisfaction and health [9 , 10]. It now is accepted as an integral part of comprehensive health [11]. Elkins and co-workers consider spirituality a multidimensional structure with 9 dimensions : transcendent dimension , meaning and purpose in life, responsibility and mission in life, sacredness of life, ignoring the material values, altruism, idealism, awareness of the tragic , and fruits of spirituality [8]. Some cancer patients have reached the conclusion that spirituality can help them resist physical and mental crises followed by the diagnosis and treatment of cancer. It has been shown that directing women with breast cancer toward spirituality can be an effective resource to challenge physical and mental problems of cancer [12].

Accordingly, with due attention to the effect of breast cancer on spirituality of patients and vice versa [13]several studies show the positive and significant relationship of spirituality with hope , happiness, and life satisfaction [14-17].The importance of spirituality and religion (specially in days of crisis) in Iranian culture , higher rate of survival in those with breast cancer as compared with other kinds of cancer, and lack of domestic researches in Islamic spiritual interventions in patients especially cancer cases , made us design and conduct this study.

Materials and Methods

This was a quasi-experimental study, and the subjects were selected and replaced in the case and control groups voluntarily.

Sixty women who survived breast cancer at Cancer Research Center (CRC)were voluntarily selected and placed in two groups of the case (30 patients) and control (30 patients )with the following inclusion criteria : Age between 30 to 65 years ;being at clinical stage I , II , or III ;no metastatic lesion at least 8 months after diagnosis and termination of acute treatment period such as surgery, chemotherapy, and radiation therapy which are effective in psycho-spiritual aspect and may have caused some bias in the study ;literacy ; no history of psycho- spiritual education ;and no history of other chronic diseases. These cases were in natural living condition, and the acute phases of the disease such as shock, anxiety, deny, challenges, and acceptance had come over. The case and control groups were matched in terms of mental health by GHQ-28 and demographic characteristics, which are shown in table1 with no significant, difference (p> 0.05). After the introduction of the research and execution of pre-test, spiritual intervention, based on some of the Richards and Bergin's psycho-spiritual intervention] 18[and in Islamic perspective (Table 2) was conducted for the case group in8 sessions of1.5 hours once a week. A week after the last session, in a separate meeting, the two groups of participants praised the cooperation in the research, and took the post- test. Five persons in each group dropped out and the final number of each group was 25 cases .To measure spirituality the followings were used: hope, life satisfaction and happiness , Ghobari-e-bonab and colleagues 's spiritual experience (2005 , Iran);Snyder 's hope (Lopez et al, 2000);the Oxford Happiness (Argyle et al, 1989);Dinner 's life satisfaction (Dinner et al, 1985) questionnaires ;and General Health Questionnaire 28.

Table 1

Clinical and demographic characteristics of women surviving from Breast Cancer

Demographic Characteristics	Demographic Characteristics level	Case (%)	Control (%)	Significant Level (P-value)
Age (years)	Minimum	29	32	0.47
	Maximum	68	59
	Mean	50.16	48.07
Duration of Diagnosis (Month)	Minimum	8	8	0.07
	Maximum	120	90
	Mean	46.68	32.64
Clinical Stage of Disease (%)	I	6(20)	9(32)	0.48
	II	16(52)	12(36)
	III	8(28)	9(32)
Marital Status(%)	Single	8(24)	3(8)	0.1
	Married	22(76)	27(92)
Education (%)	Less than diploma	3(8)	4(12)	0.6
	High school Diploma	14(48)	17(56)
	University education	13(44)	9(32)
Mental Health Status	Mean	23.28	21.69	0.6
	Standard deviation	11.77	10.16

Table 2

Weekly topics covered in spiritual intervention for Women surviving from Breast Cancer

Session	Subjects	Interventional Contains
1	Contemplation and Meditation	Defining the concept of contemplation and meditation with due attention to its effectiveness in chronic diseases, Instructing Focused meditation practically. Group practicing of two volunteers.
2	Prayer	Defining prayers and connecting with God , Familiarizing participants with individual ways of connecting with God in order to boost the feeling of closeness to God , Instructing conditions of prayers.
3	Trust to GOD	Defining the true trust in God and its types based on Islamic Instructions, Applying trust in God in daily life and its effect on hope and treatment follow up.
4	Patience	Defining the importance of patience in problems solving, Defining the right concept of patience based on Islamic perspective, Applying patience in daily life.
5	Repentance and Atonement	Defining the concept of seeking forgiveness from God and people, Teaching how to prepare for seeking forgiveness, Instructing how to atone for mistakes, in Islamic perspective.
6	Forgiveness	Defining the true concept of forgiveness, Instructing the process of forgiving and its effects on worldly and otherworldly life.
7	Gratitude	Defining the concept of gratitude toward God , people, and other creatures, and its types in Islamic view, Encouraging paying more attention to positive aspects of mishaps, and giving thanks for them, instructing different ways of Gratitude.
8	Altruistic Services	Defining the concept of altruism in Islamic perspective, Increasing sensitivity and recognizing others' needs, Familiarizing participants with ways to help the needy according to individual's situation.

Spiritual Experience Questionnaire:

This questionnaire was built by Ghobari-e- Bonab , Lavasani and Mohammadi , 2005 in Iran and included 75 items and 6 components including: Nineteen items in meaning of life, fifteen items relation with God's influence , spiritual actualization and spiritual activities 10 questions , transcendental diagnostic experiences 15 subjects , negative experiences 11 items , religious and social activities 5 articles . Test reliability coefficient of this questionnaire in some studies was 0.94 and 0.95 respectively [19, 20].

Snyder's Hope Scale:

This scale was constructed in 2000 by the Snyder's group (Lopez and colleagues) and includes12 items: 4 items relating to the pathway, 4 relating to the agency, and 4 are misleading. Reliability coefficient of this scale in some studies in Iran has been reported to be 0.89, 0.87, 0.82[21-23].

Satisfaction with Life Scale:

This scale is produced by Diener and colleagues (1985) to measure life satisfaction and includes 5 items. Study results have shown that this scale has good validity and reliability. The reliability coefficient of this scale in some studies in Iran has been 0.82, 0.85 and 0.83[24-26].

Oxford Happiness Questionnaire (revised):

Oxford Happiness Questionnaire revised was produced by Argyle, Martin and Cross land in 1989. They believed this questionnaire is the opposite of Beck Depression Inventory ; its final form contains 29 items ; and in each question the person ranks his feelings from being very unhappy to being very happy.Reliability coefficient in different studies in Iran has estimated to be 0.98 and 0.85[27, 28].

GHQ-28

This Questionnaire was developed by Goldberg (1972) to identify non-psychosis mental disorders. It has 28 questions and 4 sub-scales; each having seven questions. The overall validity coefficient of 0.88, and validity coefficients of 0.50 and 0.81between the sub-scales have been reported [29].

Data analysis was done by descriptive and inferential statistics with the covariance analysis.

Results

Mean and standard deviation of each variable in the pre-test and post test in both case and control groups are presented in table 3. Covariance analysis was used to observe the effectiveness of spiritual intervention and removal of pre-test effect.

Table 3

Mean and Standard deviation and Analysis of covariance to compare two groups pre-test and post-test

Variance Source	Variable	Total square	F	Significant Level	Group	Mean	Standard deviation
Covariate (pre-test)	Hope	108.002	18.27	0.001	Case	27.28	3.91
					Control	26.92	4.46
	Happiness	4720.02	107.57	0.001	Case	46.76	13.51
					Control	45.19	14.78
	Life satisfaction	456.06	25.69	0.001	Case	24.36	5.56
					Control	23.38	5.99
	Spirituality	34158.09	62.09	0.001	Case	358.36	35.3
					Control	343.07	49.63
Group (Post-test)	Hope	173.63	29.37	0.001	Case	27.92	1.99
					Control	25.80	3.56
	Happiness	2904.17	66.19	0.001	Case	55.32	12.51
					Control	39.1	11.07
	Life satisfaction	196.37	11.06	0.002	Case	23.38	4.6
					Control	22.34	5.65
	Spirituality	33620.80	61.12	0.001	Case	391.72	25.59
					Control	330.19	42.35

As demonstrated in table 3, spiritual intervention was effective in increasing hope, happiness and life satisfaction in women surviving from breast cancer (P < 0.05).

The post- test corrected mean in case and control groups after excluding the pre-test effect is shown in Table 4.

Table 4

Post- test corrected mean, after excluding the pre-test effect

Variable	Group	Mean	Standard error
Hope	Case	29.82	0.48
	Control	26.09	0.48
Happiness	Case	54.76	1.32
	Control	39.64	1.32
Life Satisfaction	Case	26.53	0.83
	Control	22.59	0.83
Spirituality	Case	387.01	4.63
	Control	334.80	4.63

The reliability of scales used in this study based on " Cronbakh a" was as follows:

Snyder's Hope scale: 0.79; Satisfaction with Life Scale: 0.81; Oxford Happiness Revised Scale: 0.93; Spiritual Experience Scale: 0.88.

Discussion

In the past two decades, spiritual and religious interventions have been applied by many psychological and clinical researchers in cancer patient management [18, 30, 31]. There are evidences that spiritual interventions are effective in preventing or healing of a variety of physical diseases and coping with chronic pain, illness , death and dying [ 18,32] . This role has been appreciated in chronic diseases such as HIV/AIDS, cancer, and even non-psychotic psychological problems [20, 33-39]. Some researchers have given an important role to spirituality to cope with breast cancer and have studied its effects on increasing hope, happiness, and life satisfaction [11, 40-47].

The findings of this research are in agreement with the mentioned studies, which emphasize the role of Islamic perspective spiritual intervention in increasing hope, happiness, and life satisfaction (P≤0.002).

Spirituality can be defined as a vital agency or pathway for breast cancer patients. In a study, 226 middle-age and old patients who were supposed to undergo a major heart surgery were studied to evaluate the effect of religious and non-religious pathways. It was revealed that faith has a major role in agency component [44]. The authors believe that spirituality can affect agency in two ways: directly, it provides the main source of objective oriented energy; and indirectly, it has a positive effect on events interpretation and equips the individual with mental strengths such as happiness, and optimism, which motivate the individual to reach goals. It can also facilitate reaching these goals by prayer, meditation and etc. That is how, a stronger agency, and more pathways to reach goals can create hope in the person according to Hope Snyder's theory.

Pargament says that when spirituality is integrated in a person's life, it can benefit him in different ways like making him happier]45[. Educating spirituality empowers the person to solidify his belief in his behavior, and such solidarity and harmony cause happiness. Spirituality and belief in God can support the person in different fields. It not only provides emotional support, but also improves the person's relation with himself, others and the world, which is called healing connection. It also creates adaptive and efficient thoughts and behaviors that help the person have a better interpretation of the events. This in turn, facilitates achieving goals and succeeding in problem solving and affects happiness [46].

Spirituality can reduce negative emotions like anxiety, depression, and anger while it increases positive emotions. Based on the Barbara Fredrickson's broaden-and-build theory, positive emotions broad an individual’s momentary thought-action repertoire, and cause personal growth and happiness[47]. In addition, happiness has a lot of favorable consequences such as life satisfaction [48]. In other words, happy people are more satisfied with their life, which is not just because of having a better feeling, but because of expansion of life resources [47].

Spirituality will fill up the gap between what the person has and what he demands to achieve, and could facilitate accepting the new real situation and increases life satisfaction by decreasing the gap between reality and ideal, and giving a new definition for them. It seems that strengthening qualities like altruism, gratitude, and other spiritual elements compensates impairments in an individual's abilities and functions, and makes the person more capable and powerful. Likewise, spirituality gives breast cancer patients the opportunity to feel they are in control of the mental trauma of the cancer. Based on Dinner theory, such feeling strengthens the person to cope with life difficulties and hence he/ she feel more satisfied with life [49-51].

Conclusion

In spite of recommendation in considering caution for generalizing this finding , because of its non randomize sampling method , we believe that spirituality is an essential component of the experience of those facing serious illnesses , and it greatly shape how individuals view themselves , their illness and their future , as Breitbart said [42]. On the other hand, a growing number of health professionals , also suppose that spiritual beliefs would be included of a variety of psychological , medical and economic benefits , that it has been significantly proven or can be [52].Spiritual and religious beliefs provide hope and a feeling of dominance on the predestination for the person and , if the believer has full trust in GOD , can any state leading to a good result , and it is not surprising that such a belief may have powerful psychological results [53].

It is recommended that comprehensive cancer control programs, spiritual intervention and its integration in psychotherapy, be more considered by experts, specialists, relevant authorities, policy makers and managers. Also, considering the apparent effects of spirituality and psycho-educational spiritual interventions in patients surviving from breast cancer, cellular and molecular changes in this process therapy should be studied is recommended in collaboration with experts in different fields of molecular and cellular biology and clinical specialists and psychologists, cellular and molecular changes in this process therapy should be studied . The effect of spirituality based on different religious beliefs for different cancer patients based on their beliefs, should be studied, too.