Effectiveness of Spiritual Group Therapy on Quality of Life and Spiritual Well-Being among Patients with Breast Cancer.

Cancer is deemed the century's major health problem, and its increasing growth during the last decades has made experts concerned more than ever. Of all types of cancer, breast cancer is regarded as the second most common disease among women. The aim of this study was to determine the effectiveness of spiritual group therapy on quality of life and spiritual well-being among patients suffering from breast cancer. The present research was carried out between March and June 2011. The sample consisted of 24 participants randomly assigned to 2 groups: an experimental group (n, 12) and a control group (n, 12). All the subjects completed questionnaires on quality of life and spiritual well-being in pretest and posttest. The experimental group received 12 sessions of spiritual group therapy. The results demonstrated improvement in quality of life and spiritual well-being in the experimental group. In conclusion, spiritual group therapy can be used to improve quality of life and spiritual well-being (religious health and existential health) among patients with breast cancer.

RCT Entities:   Population Interventions Outcomes

What’s Known

Spirituality is a human dimension, the consideration of which can be therapeutic.

Spiritual needs often go unaddressed on the part of health care professionals.

Many patients with cancer seek recourse to religion to cope with their disease and enrich their quality of life.

What’s New

In the present study, spiritual group therapy improved the spiritual well-being and quality of life of patients with breast cancer. We consolidated the techniques of spiritual group therapy in the form of a treatment package.

Introduction

Cancer is universally recognized as the century’s major health concern, and its mounting escalation during the past few decades and detrimental impact on all physical, emotional, spiritual, social, and economic aspects of human life have rendered experts concerned more than ever.[1] Of all types of cancer, breast cancer is viewed as the second most common disease among women. Breasts are symbols of femininity and as such the majority of women find the prospect of losing them unthinkable. A woman’s reaction to any kind of actual or suspected disease may include fear of deformity, loss of attraction, and death; consequently, breast cancer is indubitably horrifying to any woman.[2] Breast cancer treatments such as radiotherapy, chemotherapy, and surgery could cause serious physical and psychological side effects, making treatment programs and rules more difficult to follow. Patients may, therefore, find it harder to adhere to the treatment protocol and inadvertently undermine the efficacy of the treatment, which could negatively impact their own life expectancy.[3] At this stage, patients suffering from breast cancer are liable to complain of various kinds of problems such as sleeping disorders, high levels of anxiety, and reduced quality of life sometimes even 2 years after the initial diagnosis. Treatment seems to come to its desirable end once such difficulties have been overcome.[4] Since modern treatment methods have turned cancer on many occasions into an acute and often curable disease out of an incurable one, various aspects of cancer psychiatry such as reaction toward diagnosis and also treatment have become increasingly prominent.[5]

One dimension of human life is spirituality, which enables individuals to communicate and integrate with the universe. Communication and integration endow hope and meaning to human life and elevate it beyond the confines of time and place. Religious/spiritual group therapy is a form of psychotherapy drawing upon special principles and religious/spiritual techniques to empower patients to attain a nonmaterial understanding of self, universe, incidents and phenomena, and ultimately health and growth.[6] The results of a research carried out by Meraviglia[7] under the title of “Effects of Spirituality in Breast Cancer survivors” on 84 women aged between 34 and 80 years suffering from breast cancer whose disease had been diagnosed 5 years earlier, along with his another study conducted on 60 patients aged between 33 and 83 years suffering from lung cancer, showed that patients should be encouraged to seek spirituality as an effective tool in dealing with physical and psychological responses to cancer.

Given the reach and influence of religious culture in Iranian society, drawing upon religion as an important source of compatibility is anticipated. Due to the lack of research evidence in this domain in our country, the present study was conducted to investigate the efficiency of spiritual group therapy in enhancing patients’ well-being and spiritual health.

Patients and Methods

The present research was a quasi-experimental project of pretest-posttest type with a control group carried out between March and June 2011, in collaboration with Shiraz University of Medical Sciences. The study population was selected from among patients referring to Amir Hospital and Omid Hospital. For the purpose of this research, among a large number of patients suffering from breast cancer and aged between 18 to 65 years, 24 individuals were selected after clinical interviews through the available sampling method. The participants were then randomly assigned to two 12-member control and test groups. All the 24 participants were tested using the research tools, comprising structured clinical interview for DSM-IV (SCID-I), quality-of-life questionnaire (WHOQOL-26), and spiritual health scale (SWB-20). The test group members thereafter received 12 sessions of group spiritual treatment (table 1),[8] whereas the control group members did not receive any kind of treatment until the test group members were fully treated and the second group of questionnaires was collected.

Table 1

Treatment sessions in brief

Treatment session	Session title
First session	Members becoming familiar with and talking to each other about the concept of spirituality and religion and the impact it has on a person’s life
Second session	Selfconsciousness and communication with oneself and listening to the inner voice
Third session	Selfconcept
Fourth session	The word of God, communication with God or with any superior power the patient believes in, prayer and conversation with God
Fifth session	Altruism (doing something spiritual collectively)
Sixth session	Relationship with holy sites
Seventh session	Resentment and lack of forgiveness, selfforgiveness, and feeling guilty
Eighth session	Forgiveness
Ninth session	Death and fear of death and toil
Tenth session	Faith and trust in god
Eleventh session	Gratitude and thanksgiving
Twelfth session	Final session

The inclusion criteria for the present research were as follows:

Having elementary education and literacy level

Being at least 18 and at most 60 years of age

Not having the diagnostic criteria for clear psychiatric disorders such as psychosis, major depression, obsessive-compulsive disorder, and personality disorders based on the SCID-I conducted by the researcher

Subsequently, all the participants under test completed the research questionnaire in 2 rounds. The test group participated in the 12 group-treatment sessions in the form of a 120-minute session in a week.

Results

From the 24 participants, 43% were 50 and 57% under 50 years old, while 21% were single and 79% were married. Apropos education, 37.5% of the study population were below the high school diploma, 50% had a high school diploma, and 12.5% had college education. Also, 65% of the participants in each group underwent chemotherapy or had recently undergone it.

As is shown in table 2, there were significant differences in quality of life and some of its dimensions (psychological and social dimensions) between the 2 groups following the spirituality group-therapy sessions among the experimental subjects. However, as regards the physical dimension, no significant difference was observed between the 2 groups after the therapy sessions.

Table 2

Comparison of the results of the statistical analysis of covariance at pretest and posttest in the experimental and control groups

Research variables	Resources changes	Etasquared	df	Mean squares	F	Sum of squares	P value
Quality of life (total)	Posttest	0.39	1	362.8	13.26	362.8	0.002
	Pretest	0.15	1	105.08	3.84	105.08	0.063
Physical dimension	Posttest	0.5	1	3.44	1.69	3.44	0.293
	Pretest	0.164	1	12.12	4.11	12.12	0.055
Psychological dimension	Posttest	0.26	1	35.27	7.5	32.27	0.012
	Pretest	0.012	1	1.17	0.25	1.17	0.62
Social dimension	Posttest	0.2	1	53.64	2.12	53.64	0.034
	Pretest	0.108	1	26.6	2.54	26.6	0.126
Spiritual health	Posttest	0.36	1	721.72	11.62	721.72	0.003
	Pretest	0.0	1	0.354	0.0006	0.354	0.94
Religious health	Posttest	0.2	1	94.46	5.12	94.46	0.034
	Pretest	0.07	1	28.72	1.56	28.72	0.225
Existential health	Posttest	0.38	1	323.31	12.99	323.31	0.002
	Pretest	0.06	1	36.26	1.45	36.27	0.241

The eta-squared in this table shows that 39%, 5%, 26%, and 2% of the changes in the scores of quality of life, physical, psychological, and social aspects were created by the implementation of our treatment method.

With respect to the spiritual health dimension, there were significant differences between the control and test groups. Additionally, 36%, 2%, and 38% of the changes in these variables were caused by the implementation of our treatment method.

As is demonstrated in table 3, there was no significant difference in the social aspect of quality of life between the 2 groups.

Table 3

Results of ttests on the differential scores of the social dimension

Groups	Mean±SD	F	Level of significance	t	df	P value
Control	2.08±3.62	1.94	0.17	1.42	22	0.169
Experimental	4.5±4.64

Discussion

In parallel with the findings of the present research, it has been previously observed that religiosity and spirituality can play a significant role in enhancing quality of life among patients with cancer.[9] Abedi et al.[10] suggested that prayers and religious practices could affect not only emotional moods but also physical quality and that such practices could sometimes improve a patient with physical disease in a few moments or in a few days. Quing, McCola, and Larson[11] also reported that many of their patients acknowledged the positive effects of religion on their mental and physical health.

Rahmati et al.[12] concluded that spiritual/religious group therapy could generally be effective in mental improvement in patients with schizophrenia. Rocha and Falek[13] concluded that spirituality and religion could have no impact on the social dimensions of quality of life.

Prayer reduces anxiety, promotes spirituality, and is an appropriate method for coping with diseases. In a research conducted by Hojjati et al.,[10] a direct relationship was reported between prayer and well-being: More prayer was correlated with better health.One study probed into well-being, religious adaptation, and quality of life among African-American women who had undergone treatment for breast cancer and reported that the women who probed into well-being and religious adaptation had more positive adaptation and that there was a meaningful relationship between spiritual well-being, physical and emotional aspects of quality of life, and performance health.[14] Askari et al.[15] posited that religious beliefs and optimism were predictors of spiritual health.

Spiritual and religious beliefs and practices are effective in promoting adaption to cancer by affecting existential concerns such as the search for the meaning of life and hope.

Today, faith and spirituality are regarded as some of the most significant sources of physical health and quality of life. Evidence shows that spiritual interventions could be helpful in preventing or improving an extensive range of physical problems and coping with acute pains, diseases, and death.[6] Various studies have confirmed a meaningful relationship between spirituality and religion and quality of life, spiritual well-being, and meaning of life.[16] Our results revealed that spiritual group therapy enhanced quality of life and its psychological and social dimensions as well as spiritual well-being and its religious and existential aspects. Furthermore, there is a great deal of evidence indicating that religion is a protective factor against depression and that it facilitates recovery.[17]

Prominent among the salient points of spiritual group therapy is that it can improve the patient’s attitude toward life or disease. The importance of stressors is determined through cognitive evaluations under the influence of beliefs and personal values such as self-control and existential and spiritual beliefs. Individuals make use of available resources and various coping strategies in order to manage their stress. Based on this standpoint, it can be argued that values affect significant cognitive evaluations in the process of dealing with a problem; thus, spirituality can help individuals assess negative events in different ways. Hence, spirituality offers a stronger sense of control and herewith leads to more psychological compatibility.[18]

The second factor that should be taken into account is the coordination of therapy sessions in groups. Groups help improve patients’ communicative skills and provide them with an effective supportive system. In addition, when surrounded by others afflicted with the same problem, the individual does not consider the problem as something exclusive and tends to become more hopeful.[19]

The third factor of note is the particular characteristics of patients suffering from cancer and some national and cultural features of our society. Conflicts, diseases, and severe traumas usually drive individuals away from their routine course of life and make them aware of temporary values and goals. Individuals in such situations need some tool to seek more long-lasting goals and values. Holding such group therapies probably confers such required opportunities. Experts believe that spirituality is described and formed by acceptable actions and beliefs in a certain culture.[20]

The fourth noteworthy factor in regard to spiritual group therapy is related to some procedures and techniques and also the impact of prayer, benediction, and communication with God. Essa Zadegan[21] reported that therapeutic metaphor could be an innovative method whereby patients utilize their power of imagination to achieve better insight.

There are some limitations in the current study. The therapist had inadequate experience in treating patients suffering from cancer via group therapy and spiritual therapy. Moreover, the small sample size of this study precludes generalization of the results. Furthermore, the number of group therapy sessions was limited (12 sessions). It seems that more time is needed for the treatment to become complete.

Conclusion

According to our patients’ statements as well as the results of our statistical analyses, spiritual group therapy could be deemed a suitable method for treating disorders such as depression and promoting the quality of life as well as the religious and existential dimensions of spiritual health in patients suffering from breast cancer.