Main Article:
A Psychoanalytic Qualitative Study of Subjective Life Experiences of Women With Breast Cancer
M. Kemal Kuscu
Department of Psychiatry, Marmara University Hospital, Istanbul, TURKEY
mkkuscu@marmara.edu.tr
This article exemplifies research on the subjective life experiences of women with breast cancer, designed from a psychoanalytic perspective. Such research aims to reveal the subjective intrapsychic processes of women suffering from breast cancer, which can provide researchers and health care professionals with useful insight. Using Biographic narrative interpretative method, the study reveals some common denominators in the subjective life experiences of women with breast cancer. The study revealed that the subjects consider the diagnosis of breast cancer as one of the four main events in their lives. Even though these events are very different from each other, in terms of type and severity, the results indicate a common process in the way these life events are experienced by the participants. These results are relevant for health care practitioners in structuring their psychosocial support programs so as to better accommodate their patients’ psychological needs.
Index Terms: research frameworks & paradigms; research method; psychodynamic research; breast cancer; subjective experience; narrative research; narrative interview; life event; coping strategy
Suggested Citation: Aydin, E., Gulluoglu, B. M., & Kuscu, K. M. (2012). A psychoanalytic qualitative study of subjective life experiences of women with breast cancer. Journal of Research Practice, 8(2), Article M13. Retrieved from http://jrp.icaap.org/index.php/jrp/article/view/300/263
The relationship between psychosocial factors and breast cancer has been investigated mostly through quantitative studies (Bleiker & Van der Ploeg, 1999; Butow et al., 2000; Price et al., 2001). Those psychological studies focusing on investigating personality and coping styles, life events, and depression in relation to breast cancer rely mostly on objective or observed features of psychic life and self-report measures. We argue that while these approaches may have produced empirically sound data, some “truth of the meaning” (Crossley, 2000, p. 104) may have gotten lost in the process. This is not to claim the objectivity of the data collected in our study, but to suggest that the validity of data can be ensured within the comprehensiveness of the narrative approaches as they are co-created by the research pair “rather than being a neutral account of pre-existing reality” (Hollway & Jefferson, pp. 31-32).
Contrary to quantitative methods, qualitative methods are concerned with opinions, experiences, and feelings of individuals, thus producing subjective data. Therefore, for the current study, a narrative interview design was employed to carry out this task, based on the postulate that there is an inherent link between a verbal response of an individual and that individual’s intrapsychic experiences (Smith, Flowers, & Osborn, 1997). Wengraf (2001, p. 17) defines discourse as the mode of talk spontaneously chosen by the subject, a linguistic performance. Narrative on the other hand, implies a story. It is argued that the embedded structure in the narratives shifts the attention of the subject to the gestalt of the story, and allows the interviewer a greater access to the subject’s unstated as well as explicit assumptions, meanings, reasoning, and patterns of action and inaction (Wengraf, 2001, p. 116). We argue that to access the participants’ undefended intrapsychic experiences, one needs a method that can bypass their psychological defences which may prevent the researchers from accessing participants’ explicit, as well as implicit intrapsychic processes. Therefore in this study we set out to understand the psychological processes of breast cancer patients with a narrative method which we argue is psychoanalytically informed and allows the interviewer greater access to the subjectivity of the participants.
In this study, we investigate whether there are common factors in the subjective life experiences of women with breast cancer. Based on the above mentioned arguments, we conducted our study by using the biographic narrative interpretative method (BNIM, Wengraf, 2001) with the aim that it will allow us an insight into the subjective realm of our participants’ life experiences.
BNIM consists of three subsessions but it is mostly characterised by the first. During this subsession the interviewee’s primary response is determined by a single question that asks for a narrative, which is not interrupted by the interviewer in any way until the participant ends the conversation. As we were interested in looking at the life stories of women with breast cancer, we chose the following statement:
I would like you to tell me your life story, all the events and experiences which were important for you. Start wherever you like. Please take the time you need. I’ll listen first, I won’t interrupt, I’ll just take some notes for afterwards. (Wengraf, 2001, p. 119)
We argue that this idea is very much in line with psychoanalytic concept of free association, in the sense that the more free the behaviour from external constraints, the more completely the internal dynamics can be expressed.
During the second subsession, the interviewer asks for more information about the topics that were raised in that initial narration, following strictly the order in which they were raised and by using the subjects’ own language--the terms of discourse (Wengraf, 2001, p. 120). The interviewer is restricted to ask questions that are aimed at eliciting stories based on the topics raised by the participant during the initial narration. It is suggested that this focus on eliciting narratives in the sequence that they were raised by the interviewee keeps the gestalt of the interview intact and applies a constant gentle pressure on the person to provide more narratives which makes her subjective point of view more explicit in the process. This mode of interviewing bears resemblance with the way the adult attachment interview is conducted (George, Kaplan, & Main, 1985).
The third subsession constitutes a semi-structured interview format and is optional. In this study no emphasis was placed on this subsession. The last subsession is followed by self-debriefing. Wengraf (2001, p. 142) calls this process “free association” by the interviewer. We argue that these steps are in contrast with traditional semi-structured interviews where the interviewer sets the agenda by asking the questions and the participants can afford to indulge in non-narrative type answers which will not necessarily reflect their own subjective psychic processes.
The pilot study took place in Marmara University Hospital Breast Centre, Istanbul, Turkey, with six actual breast cancer patients at different stages of their treatments. The data collection has been carried out in the hospital. Six patients were interviewed for this study and all patients signed a written consent form. A purposive sampling method (Silverman, 2001) was used to select six participants. Purposive sampling means that the particular cases are selected because they accommodate certain features or processes that the researcher wishes to investigate (p. 250).
The sampling criteria for this study included: (a) being female, (b) aged between 30 and 60 years old, (c) diagnosed with invasive ductal carcinoma with no metastases, and (d) having no prior history of mental health problems. All participants had completed the initial treatment cycle of surgery, radiation, and chemotherapy for at least 6 months and at most 24 months prior to the interviews. Based on our pilot study we concluded that after 6 months of the treatment termination some form of normality is restored in the participants’ lives and there is some space for self-reflection. A duration longer than 24 months after the treatment termination was not preferred since in this case the women may have forgotten their initial reactions to the diagnosis with breast cancer. All interviews were carried out in the family therapy room at the Marmara University Hospital by one of the authors, in accordance with the biographic narrative interpretative method (BNIM). The interviews were recorded by a tape recorder. The length of the interviews varied from 80 to 135 minutes.
The BNIM involves a rigorously defined and sequenced method of data analysis. Before embarking on this process, it is proposed by Wengraf (2001) that in pursuing the interpretation procedures of BNIM, the implicit theory of subjectivity of the researcher needs to be explicitly stated. The theory of subjectivity taken up by this study is derived from psychoanalytic principles and arguably constitutes a parallel with the theoretical framework of BNIM.
According to the BNIM theoretical framework, the influence of communication and interaction is regarded as a constitutive element rather than a bias, which helps the researcher to reconstruct the underlying and hidden principles along which a biography is built and which goes beyond the self-understanding of the biographer (Breckner, 1998). Wengraf (2001, p. 235) suggests that the aim is to acknowledge the interaction between two anxious subjectivities to be able to make correct inferences about the inner experiencing of the subject. Thus, according to the BNIM theoretical framework, subjectivity can be accessed by generating the best possible understanding of the “experiencing, interpreting, and acting” of the biographical agent (Wengraf, 2001, p. 5). In order to achieve this, BNIM interpretation procedures address the relations between the subject’s past, present, and anticipated future in which biographically relevant experiences are linked up in a temporally and thematically consistent pattern in three stages:
3.2.1. Stage #1. Revealing the Life Story and Its Narrative Structure
All interviews were transcribed from audio to text and translated from Turkish into English. According to BNIM, the first subsession is the most significant one in terms of accessing the informants’ subjectivity. In addition, considering the depth of analytic procedures, BNIM trainers recommend the complete analysis of one interview that is seen by the researcher as reflecting the norm among other interviews and contrasting that with another interview that is seen by the researcher as being outside the norm (T. Wengraf and P. Chamberlayne, personal communication, November 5, 2005). In the current study, four out of six interviews were analysed. Two of these interviews were selected as representing the norm and the remaining two interviews were treated as contrast cases. The rest of the interviews were transcribed but not translated and not analysed.
The first stage of data analysis entails the creation of two reports based on the interviews. The first report constitutes the life story of the participant, as told by her and the data gathered by the researcher about the context and history of the participant’s life (Breckner, 1998, p. 93).
The second report is based on how the participant told her story and encompasses a technical analysis of the narrative which indicates certain shifts in the text. These are either the change of speaker and topic or both. In addition, the shifts within one topic are also to be identified.
3.2.2. Stage #2. Explaining the Subject’s Life Choices
The second stage of the BNIM data analysis is essentially executed by a panel of at least three persons for purposes of objectivity. In the current study, panel members were recruited both from mental health as well as other professions. Six panel sessions were conducted with ten persons who consisted of four men and six women from seven different countries: England, Finland, Greece, Guyana, Portugal, Scotland, and Turkey. This, we argue, provided the study a greater degree of validity.
As explained above, the two reports generated based on what has been told and how the story is told by the participants were presented to the panel members by the first author in the form of data segments on a flipchart. The panel members were asked to develop hypotheses based on the data chunks presented to them. And for each data chunk, the panel is invited to construct more than one hypothesis so that all possible hypotheses could be considered. These hypotheses are then falsified or verified in the course of analysis when more data are introduced to the panel (Breckner, 1998). Consequently, every hypothesis about each chunk is tested in a future-blind fashion. This leads to the falsification of some of the hypotheses as more data are presented. Those that are not falsified are kept as possible explanations of the choices made by the subject and form the foundation of the case story (which is the output of the final stage, see Stage #3 below). This process constitutes the basis of panel work and aims to mirror the sequential character of social action (Breckner, 1998).
3.2.3. Stage #3. Integrating “Told Life” and “Lived Life”
The third stage of data analysis constitutes combining the panel reports in a way that integrates the analyses of told life with lived life stories. The integration of the two different panel reports enables the researchers to have an integrated view of the subjects’ motivations, ways of thinking, and psychological defences. This task was carried out by the first author in a way that also incorporates a psychoanalytic view. This concluding report is called the case story.
The biggest limitation of this study lies in its limited generalisability. Despite the qualitative value of this study, its findings cannot be generalised due to several reasons. The small number of participants, the purposive sampling, and the lack of a control group make it impossible to draw conclusions from the current study that can be generalised. In addition, the findings reported in this study may not be claimed to be exclusive to breast cancer patients. It is possible that healthy individuals and patients with many other diseases may have the same subjective life experiences as described in this study. The retrospective design constitutes another significant limitation as people’s subjective experience can change quite dramatically after the event. Breast cancer is a very complex phenomenon the cause of which is still unknown. Due to the retrospective nature of this study, it is possible that subjects may have consciously or sub-consciously restructured the narrative of their life experiences in search of meaning.
Another limitation of this study is that all of the subjects belong to the same culture as the researchers (i.e., Turkish). Although this has clearly positive effects on the interview process, such as establishing easier rapport with the subjects and being more alert to certain clues which may be communicated in ways that only people from the same culture can understand, it may have confounded the findings by creating blind spots in the researchers. However, we believe that this limitation was somewhat compensated by the input of the panel members who were from seven different countries.
Therefore, we would like to emphasise that the findings of the current study cannot be generalised without probing these ideas on a large scale, with a prospective randomised controlled study.
The research was aimed at investigating the presence of common factors in the subjective life experiences of women with breast cancer (invasive ductal carcinoma). The analysis of the biographic-narrative interviews indicates that there are indeed common factors in the way certain life events are experienced by women who have breast cancer. The results indicate a string of at least four significant stressors, which are associated with common patterns of subjective experiences, in the lives of the women we studied.
These stressors were found to occur in a certain sequence which was repeated in the life stories of all the subjects whose narratives were analysed. According to this sequence, each subject had a life event between the ages of 9 and 14. This was followed by a long-term stressor which was present in all subjects’ life stories during adulthood years. The third stressor was a negative life event and was experienced by all subjects two to three years before the diagnosis of breast cancer. The diagnosis itself constitutes as the fourth significant stressor in the context of the life stories of the subjects, confirming beliefs primed by earlier stressors.
The significance of these experiences was identified through analyses of the told story (for Subjects 1, 2, 3, and 4) and the lived life (for Subjects 1 and 2), the procedures of which were discussed in the previous section. In the following, the reader can find excerpts from the case story of Subject 1 which demonstrate how each life event and the respective common subjective experiences were identified by the panels. The reader may find a heavy reliance on the analysis of the told story rather than the analysis of the lived life in the case story of Subject 1, as we found that the analysis of the lived life did not add more to the case story in this particular case.
The first life event was experienced sometime around late childhood or early adolescence (around the ages of 9 to 14) by all subjects. Although most of the subjects did not give any information about their early childhood experiences, all subjects spontaneously mentioned a significant incident that happened during this period. The detailed analyses of the first life stressor by separate panels revealed that it was experienced by all subjects as a rejection, separation, or loss. Thus, although each subject’s story differs greatly, the analyses of the interviews indicate that the so called first stressor had been experienced in a similar way by the subjects.
The common factor in all these life stressors was identified by the panels as the way they were experienced by the subjects. In order to arrive at the subjective experience of these events, the panels had to analyze them in the context of each subject’s individual life story. These panel reports were then converted into respective case stories and their gist into generic formats (by the first author) to depict the common factors in the way these different life events were experienced by these subjects. The following partial report is based on Subject 1’s case story which mostly consists of the analysis of the told story where the panel analysed how she talks about her first stressor.
4.1.1. Subject 1: Case Story (First Life Stressor)--Extracts
Structure of Subject 1’s initial narrative constitutes shifts between a report like format and argumentative statements. It is likely that the thematic field of Subject 1’s initial narrative is composed by a tension which reflects two conflicting aspects of her life: Wanting to appear conventional and not showing her ambivalence by using a report like format and her need to justify her negative feelings by using an argumentative one.
After the initial question has been asked, Subject 1 presented the interviewer with a counter question, whether or not she should make a differentiation between before marriage and after marriage in telling her life story. Based on this question, the panel assumed that, there may be a problematic connection between her life before and after marriage. This hypothesis was confirmed by the following account of her life story.
Subject 1 started talking about her life in an emotionless and matter-of-fact way about where she was born and brought up. The panel viewed this as a way of steadying herself to avoid being overcome by negative feelings that might surface by telling her life story. This assumption was confirmed by the first incident Subject 1 chose to refer to in her initial narrative where she reverted to an argumentative format. Subject 1 was a good student up until the first year of high school, when she was taken away from school because of the family’s pressure:
Statement 1/19 [evaluation]: That uhhmmm, really, in my life so far unbelievable so, you know those things that leave scars, deepest points, that really was a very deep point. It is still the same, nothing has changed in that. And I found out years later that, as a consequence of me being taken from that school, the possibility of my school life has ended completely, may be that is why this got so deep in me.
* End of extract
This narration, which was classified by the first author as “evaluation” in terms of told story demonstrates the conflicting aspects of Subject 1’s life: Wanting to appear conventional versus wanting to express her negative feelings. The panel thus decided that this incident also demonstrated the underlying theme of her life: unresolved loss and anger.
The panel suggested that not only was powerlessness implied in Subject 1’s lack of control over such a fundamental area of her life which impacted her future greatly, but also her continuous feelings of insufficiency and futility as she pointed out that this is still one of the deepest points of her life. The panel has predicted by the above mentioned evaluation that she will try to recover from this unresolved loss through manic reparation by trying to live her life through her husband or children after getting married.
4.1.2. Common Subjective Experience of the First Life Event
Based on similar analyses of each of the four subjects’ life stories in terms of content and structure, we came to the following conclusions regarding the common subjective experience of the first life event.
The first life event, was experienced by each subject as the confirmation of their internal “badness” and generated a belief that they must have done something wrong to bring this incident upon themselves. This is our interpretation of the panel results, all of which pointed to the fact that subjects, as a result of the first life event, showed a high need to align themselves with others and that they were unable to show their anger in situations where appropriate. We further interpret the panel results and argue that subjects’ conviction of their inherent badness gave way to persecutory anxieties such as being abandoned by their loved ones. The fact that prior to this incident they acted on their own emotional needs and had negative feelings, reinforced their conviction about their own part in the outcome. As a result, they learned to dissociate themselves from their negative feelings, particularly anger. Instead, every time they felt negative feelings towards their loved ones, from whom they now desperately needed to obtain some form of goodness, they felt guilt and shame. They felt guilt because of an omnipotent conviction that they may harm their loved ones, were they to act on their negative feelings. They felt shame, because were they to act on their negative feelings, their badness would be visible to others, as it was after the first incident of rejection/separation. Instead, they started to take “very good care” of their loved ones, more often than not at the expense of their own needs and feelings.
Consequently, they adopted a helpless and powerless attitude to ensure that they would not put themselves forward in situations, where making a decision might mean acting on their negative feelings, the outcome of which may give away their internal badness. The powerlessness was also linked to some of the traits the subjects presented themselves with in the interviews. These include perfectionism, being overly concerned with tidiness, and a controlling attitude towards others.
Thus, the significance of the first life event turns out to be substantiating a belief system in the subjects. This belief system may have already been in place previously, but as a result of the first life event, it became apparent to them and they have learned to think about the consequences of their actions in terms of their newly authenticated belief system.
On the other hand, what got lost could not be recognised. Each of the subjects experienced the loss of their inherent goodness which left them with an overwhelming sense of being bad. Since recognising this loss would mean that they might be seen by others as bad, they could not afford to grieve for their loss. Therefore they were left with an unresolved loss as a result.
All subjects reported the presence of a long-term stressor (over ten years or more) during their adulthood. They talked about this mostly during the second subsession where the questions probed the themes the subjects had mentioned in the first subsession. The analyses of the interviews indicate that the long-term stressor was experienced by the subjects in a way that echoed their beliefs about themselves which they developed as a consequence of the first life event and consolidated them. Thus the following partial report on the told story of Subject 1 depicts how unhappy she was in her marriage (her second life stressor) but felt obliged to normalise it in the interview.
4.2.1. Subject 1: Case Story (Second Life Stressor)--Extracts
The initial question about the problematic connection between her life before and after marriage became apparent in her next statement where she described her passage from being a non-married girl to becoming a married woman.
Statement 1/24 [global evaluation]: Other than that, I was a house girl, became a housewife.
This statement, made the panel feel that although she initially saw marriage as her way out, it only confirmed her powerlessness and led to further disappointment. The confirmation for this point of view came when Subject 1 mentioned the fact that she has been seeing a psychiatrist for the last eight years of her life and has been using anti-depressants throughout that time. This was also brought up first in a report format and then discussed in the form of argumentation which, again, was interpreted by the panel as reflecting her ambivalence about not being conventional and deciding to seek help for her negative feelings.
Getting married and having a daughter were also mentioned in a report like format and were immediately followed by an argumentative statement as predicted, which directly confirmed the panel’s previous hypotheses:
Statement 1/25 [argument/evaluation]: With my husband, I did not have any problems that can be seen as major so far. Certain small issues that are in every family. But these last years, especially uhhhmmm, my daughter’s preparations period for the . . . exams. Until then very, well how should I put it, not always at the same level but within a certain framework we had a standard life and it did not bother any of us. Then I do not know, probably I got myself overly involved. Or this is my husband’s saying, did I exert the pressure of my not being able to study to my daughter, I was very stressed during that exam time. But I tried not to reflect it to my daughter as much as possible.
* End of extract
The panel decided that Subject 1’s accepting and resigned attitude towards her marriage is apparent in the above statement, as well as her disappointment and lack of joy which are also expressed in an indirect way.
4.2.2. Common Subjective Experience of the Second Life Stressor
Other interviews were analysed in a similar fashion which led to the following conclusion in terms of the common elements in their experience of the long-term stressor. The significance of the long-term stressor is that it maintains the subjects’ conviction of their badness. Subjects are now continually reminded of their badness (which will become more evident in the following section) by the long term nature of this difficult situation which relentlessly evokes negative feelings in them. They invariably find an aspect of the situation which they attribute to their own wrong doing which enables them to hold back their negative feelings further.
Consequently, when faced with long-term stressors such as those portrayed above, the subjects’ way of coping turns out to be one of altruistic surrender and acceptance. This was achieved by further dissociating from their negative feelings and embracing the attitude of a victim or a martyr, which is rooted in their “need” to be powerless. This approach is embedded in their earlier conviction that they have to prevent making decisions in order to avoid any possible negative consequences associated with them which may give away their assumed badness.
Altruistic surrender to the long-term stressor, on the other hand, also serves as an incentive for the subjects to obtain some form of goodness. Thus, emergence of the long-term stressor is received by the subjects as an opportunity to obtain some form of repentance.
All subjects reported a life event within two to three years previous to their diagnosis with breast cancer. Below, the reader can find an excerpt from Subject 1’s case story based on the panel’s work on her told story depicting her premorbid life event. The reader might notice that, as the case builds up, the above mentioned subjective experiences also become clearer.
4.3.1. Subject 1: Case Story (Premorbid Life Event)--Extracts
The fact that the daughter failed the exam became evident during the second part of the interview, when the interviewer probed this subject with a question seeking further narrative. Even before this piece of data was disclosed to the panel, they felt that this was the case by looking at Statement 1/25 and put forward the hypothesis that this not only meant the collapse of her hopes, but also the possibility to make up for her “failed” past as well as to overcome her feelings of powerlessness and futility. The panel decided that it is also apparent from the above statement that Subject 1 feels guilty for creating an obvious cause for unhappiness in the family by pushing her daughter to study so hard in trying to make up for her own losses. They argued that she feels ashamed that her intentions have been so visible and that she could not contain her negative feelings as a result of yet another major disappointment in her life. The panel felt that all this would make her feel like a failure and depressed and would lead the way for her husband to blame her for whatever happens next, in the sense that “she brought it all onto herself.” This view was confirmed by the following argumentation where she justifies her need to continue taking anti-depressants:
Statement 1/37 [argument/evaluation]: . . . Then after this kind of an illness started and I thought that same kind of support has to continue, because I couldn’t have overcome this kind of situation by myself.
The panel suggested that her readiness to accept her husband’s accusation of “having brought it all onto herself” may be related to a much earlier conviction that she is bad unless she does what her “loved ones” dictate her to do. Any attempts to express her needs for individuation and negative feelings may result in negative consequences, such as bringing unhappiness onto the family. This may also be an indication of why she needs to justify her decisions and the presence of any negative feelings which is evident in her argumentations throughout the initial narrative. For example:
Statement 1/34 [argumentation]: Uhhhmmm, the reason why I went (to see a psychiatrist) in the first place was because of certain problems in the family, my own family’s issues. Uhhmmm, I couldn’t help to think certain things too much. In the end, I thought that this would be the most logical way, I said that I have to go and get some help.
Her need to externalise the power and the decision making process is also evident in the fact that she chose to consult a psychiatrist who can prescribe her “pills” to make her feel better. The panel found that the above mentioned hypothesis is reinforced by an argumentative statement during the second part of the interview when the interviewer probed the subject of being taken away from school by an open-ended question:
Statement 2/42 [interviewer’s question]: How does that continue to affect your relationship with your family?
Statement 2/49 [argumentation]: What disturbs me with my family, uhhmm, in the continuing relationship with my family, it is that my position towards them, uhhmmm, I don’t know why, I was raised to stay quiet and do what they want me to do. This way of being raised also continues automatically in your own home. At a certain point, like I said, no matter how much you try to manage the situation, at a certain point your needs are left unfulfilled but you start to behave according to the wants of the people around you.
In a passage where Subject 1 talked in a report/argument format, it became evident that she was diagnosed with breast cancer the year after the examination period. She described the summer previous to her diagnosis as the worst time of her life because one of her closest friends was diagnosed with bone cancer second time and eventually she herself was diagnosed with breast cancer towards the end of the year. The panel hypothesised based on the way she talked about these experiences that she felt responsible for bringing “actual” unhappiness onto the family by having an unsettling experience such as breast cancer. The panel argued that for Subject 1, this meant that her calming and balancing function in the family, which was her “thing,” was completely gone.
* End of extract
We argue that although the premorbid life event occurring during adulthood may seem to be unrelated to the subjects’ previous life experiences, the detailed analysis of the interviews indicate that the subjective experiences of the first and the premorbid stressors are closely related. A close comparison of the first and the premorbid life events in the context of each subject’s own life story reveals that the later life event generates repetition of the subjective experience of the first life event which the subjects had worked so hard to prevent from happening again throughout their lives.
Based on the panel reports of all four subjects, we propose that the premorbid life event signifies the return of the feared outcome of the first life event. As in the first life event, this one is also experienced by the subjects as confirmation of their internal badness and the consequentially generated internal belief, that they must have done something wrong to bring this incident onto themselves.
4.3.2. Common Subjective Experience of the Premorbid Life Event
The detailed analyses of the interviews indicate that the link between the first and the premorbid life events as depicted above exacerbates the impact of the later life event on the subjects, with the difference being the actualisation, either in imagination or in reality, of the persecutory fantasies evoked by the first life event. The outcome of this later experience on the subjects is one of depression and guilt, which in this context implies an expectation of persecution from others as a consequence of their actions, which they feel that they brought onto themselves but perhaps more importantly onto others. As a result, they now perceive themselves as undeniably bad, in contrast to childhood memories which they managed to keep away from their consciousness by mobilising the defences discussed above.
As a result of the premorbid life event, a persecutory expectation became prominent in the subjects’ internal worlds. This was in line with their thinking that others were harmed as a result of their actions which made them believe that they were now undeniably bad.
All subjects were diagnosed with breast cancer within two to three years after the premorbid life event. Once again, analyses of the interviews indicate that there are common factors in the way the subjects experienced this very traumatic incident in the context of their life stories. The analyses of the interviews indicate that subjects either tried to hide the situation or attempted to “fix” it on their own, denying the seriousness of it and not informing their loved ones or avoiding it as much as they could by delaying the actual diagnosis and consequent treatment. The following section of Subject 1’s case story depicts this clearly.
4.4.1. Subject 1: Case Story (Ultimate Life Event)--Extracts
As a result of being diagnosed with breast cancer Subject 1 felt that she is not worthy of being loved since her conditional goodness was not available anymore. This is also evident in her Statement 1/37 (above) regarding her need to take the pills to deal with her breast cancer since she did not feel that she could do this alone. In addition, the role of breast cancer can also be seen as a punishment she was expecting after the examination period of her daughter, since she felt and her husband accused her of bringing unhappiness onto the family. These assumptions were confirmed later on, during the third subsession which was like a semi-structured interview. The interviewer asked Subject 1 the following question:
[Interviewer’s question]: How do you think breast cancer affected your relationship with your husband?
[Subject 1’s answer]: . . . uhhmm, actually in the beginning, when I was about to be diagnosed, before I went to the doctor, he told me, he said, you are trying to make yourself get cancer.
4.4.2. Common Subjective Experience of the Ultimate Life Event
The detailed analyses of the interviews indicate that the diagnosis with breast cancer was perceived as the expected punishment by all subjects. In addition, the fact that their bodies would be mutilated--through mastectomy or lumpectomy--and put through tremendous amounts of suffering, through radio, chemo-, and hormone therapies to prevent the cancer from recurring, meant that from now on they would have to carry the physical manifestations of their inherent badness for others to see as well.
We suggest that they did not want to have much contact with others since this meant more exposure of their badness. This reluctance also manifested itself in the form of a dislike for people whom they saw as pitying them and led to degrees of isolation.
The subjects’ omnipotent attitude about the destructiveness of their negative feelings was indicated before. Additionally, we propose that in the context of being diagnosed with breast cancer, their omnipotent attitude became more evident as none of the subjects acknowledged the life threatening nature of their condition and their feelings related to having been diagnosed with breast cancer throughout the interviews.
By conducting a narrative-based qualitative study into the subjective life experiences of our participants who are breast cancer patients, we found that they constructed their life stories in a common way. The stories indicated a sequence of life stressors leading up to the diagnosis of breast cancer, which is perceived as a punishment by them. The detailed analysis of the interviews revealed that it is not the life events themselves that constitute the common elements in the subjects’ life stories, but it is the way these life events are interpreted, accommodated, and assimilated by each subject’s psyche. Therefore, we postulate that the results of the study emphasise the individual’s existing internal resources which come into question when faced with life stressors. We believe that these findings do not indicate a causal explanation for breast cancer in any form, but indeed, emphasise the need of the human psyche to attribute meaning to its experiences in the face of trauma.
While these findings cannot be generalised due to the reasons discussed above, we submit that the current study still demonstrates the importance of taking into consideration the subjective experiences of participants when interpreting the data acquired by large scale, objective, quantitative psychological studies on breast cancer, as they may provide a different perspective. In addition, we argue that the current study’s findings may also be useful for health care practitioners in caring for breast cancer patients and in structuring their psychosocial support programs to be able to better accommodate their patients’ psychological needs.
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Received 29 February 2012 | Accepted 4 November 2012 | Published 26 November 2012
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