1. Introduction
Breast cancer refers to a malignant tumor that grows in breast cells. In recent years, this type of cancer has been considered the main cause of cancer-related death in women, with an upward trend in the incidence rate in Iran (
Akbari et al. 2017). Although the prevalence of breast cancer in Iran is lower than that in developed countries, an important point that should be noted is the younger age of women with breast cancer in Iran, meaning that a significant number of women of a certain age are affected by this disease and its psychological and social consequences, which has made breast cancer one of the most important challenges in the field of health in Iran (
Fazeli et al. 2013). In Iran, the late diagnosis of this disease in more advanced stages due to the higher cost of treatment in more advanced stages of the disease, on the one hand, and due to disruption in patients’ jobs, on the other hand, has a high financial burden, which puts a great deal of pressure on the family and the health system (
Hakami Shalamzai et al. 2022).
There are various methods such as surgery, chemotherapy, radiotherapy, and hormone therapy to treat breast cancer, which are different based on the degree and severity of the disease. In Iran, due to the lack of screening, breast cancer is usually diagnosed in the advanced stages of the disease, and, therefore, it is logical that 81% of the surgeries performed to treat breast cancer are mastectomies (
Tahergorabi et al. 2014). Moreover, many problems in patients with breast cancer are due to the trauma caused by breast removal surgery and its effects on their quality of life. This is because after mastectomy, the patient experiences conditions similar to cutting off other parts of the body—in this case, a part that is a symbol of sex, being a woman, and being a mother—and by removing it, women suffer a great deal of stress and are likely to develop mood disorders such as depression and anxiety, in addition to a reduction in the quality of life (
Karataş et al. 2017).
Memaryan et al. (
2017) stated that after mastectomy, patients suffer from mood disorders such as depression and anxiety. In other studies, it was found that after surgery, the quality of life decreased drastically, and there is a significant relationship between mood disorders and quality of life.
Under cultural and social conditions, breast loss or breast deformity can lead to negative changes in body image and self-concept (
Renshaw 1994). Body image is defined as individuals’ mental image of their body and the attitude they have towards their body, appearance, health status, natural function, and sexual attractiveness, and it is regarded as one of the most important criteria for character development and results in high self-esteem and a positive self-concept in women (
Alinejad Mofrad et al. 2021). According to the results obtained by
Pecor (
2004), breast removal through surgery is considered the destruction of a part of the body, and in this process, young women are less satisfied with their body image after surgery than older patients. In terms of marital compatibility, the most important aspect for women is their feeling and belief about their femininity, with women often feeling worried about changing their physical and sexual status and their spouses not accepting this problem; therefore, it seems that concern about body image after mastectomy surgeries also affects sexual function (
Anagnostopoulos et al. 2010). Previous studies in various countries found that women feel that their sexual function is affected by mastectomy (
Molavi et al. 2015;
Pirnia et al. 2020). According to
Sheydaei Aghdam et al. (
2019), whenever the physical and sexual attraction of couples for each other is higher, they are more satisfied with their sexual relations.
Disease perception refers to people’s understanding and management of their illness by developing cognitive representations based on their knowledge and previous experiences (
Carnelli et al. 2017). Disease perception includes emotional evaluation. A negative perception of the disease leads to anxiety and distress (
Cook et al. 2015). It has been reported that the perception of illness plays a role in both experiencing emotional states and using coping strategies (
Krok et al. 2019). Disease perception is a major factor regarding the perception and management of cancer and other chronic diseases, which has a significant impact on the patient’s emotional response to the disease, compatibility with treatment, and functional health status (
Karataş et al. 2017). Considering the type of perception of the illness and its consequences, cancer can cause problems in a person’s perception and adaptation to it (
Saritas and Özdemir 2018). In the process of adapting to the illness, these patients react to their disease and medical care in a special way (
Vatvani et al. 2017). Patients who perceive their illness as curable show better personal control and treatment than those who consider it incurable, and their despair is also lower; this issue reminds us of the need to reduce the perceived threat of the disease and strengthen the beliefs of disease control in patients with cancer (
Park et al. 2020). Perceptions of the disease thus influence the mechanisms preferred to cope with the illness.
Theoretically, perceptions of disease serve as a framework for the individual’s chosen coping strategies (
Aydın Sayılan and Demir Doğan 2020). Also, patients who perceive their illness as serious, chronic, and uncontrollable show worse physical and mental health. It seems that disease perceptions play an important role in perceived health by patients with breast cancer (
Nehir et al. 2019). In addition, disease perceptions have a significant correlation with psychological distress and the emotional well-being of patients with breast cancer (
Fischer et al. 2013); therefore, disease perceptions explain a significant part of the variance of psychological well-being in breast cancer (
Dempster and McCorry 2012). Based on the research, patients with breast cancer are very interested in making changes in their lives and especially in changing their health habits. The tendency to make these changes seems to be more related to people’s differences in disease perceptions. Thus, beliefs about the consequences of the disease, causal factors, and prevention of relapse are related to behavioral changes after treatment (
Costanzo et al. 2011).
Cancer can be considered an important stressor in the formation of post-traumatic stress disorder. The sense of self-worth, autonomy, and security decreases when individuals face this life-threatening condition (
Torabi et al. 2018). These patients report negative images, anger, inconsistent judgments, avoidance, preoccupation with belief in fate, despair, and feeling helpless and helplessness, which can play an important role in maintaining depression and anxiety in these patients. Moreover, patients report intrusive thoughts, negative images, inconsistent judgments, and feelings of helplessness (
Karekla and Constantinou 2010). The most prominent stress-related symptoms reported by patients with cancer are intrusive thoughts about their illness along with efforts to avoid these thoughts, which are prominent features of a stress response syndrome (
Renna et al. 2021).
Beatty and Koczwara (
2010) showed that up to 60% of women with breast cancer suffer from symptoms of post-traumatic stress disorder, such as intrusive thoughts.
In order to improve mental health and reduce psychological problems, many counselors have proposed and developed various psychotherapies such as behavioral therapy, cognitive therapy, and metacognitive therapy, as well as existential, analytical, and integrated therapies (
Haaga et al. 1991). The main challenge of the therapies above is that the treatments can sometimes lose their effectiveness, and the symptoms of the disorders return after a short time, with psychological problems and critical states intensifying (
Haddadi Kuhsar et al. 2017).
Cognitive behavioral therapy, one of these therapeutic approaches, is a psychotherapy that integrates cognitive and behavioral principles as well as behavioral, cognitive, and rational emotional therapy techniques. The central claim of cognitive behavioral therapy is that thought patterns and beliefs, emotional states, and behaviors are interconnected. Therefore, cognitive behavioral therapy involves two essential efforts to change cognitive processes and behavior accordingly. How individuals feel and behave generally determines their perceptions and comments (
Pearce et al. 2015). In other words, cognitive and behavioral therapy aims to transform the wrong beliefs and thoughts of the individual, to increase their incomplete knowledge, to change the way they perceive and interpret events, and to gain a positive attitude as a result (
Horne and Watson 2011). In the literature, there is evidence that cognitive and behavioral therapy is an effective method for coping with stressful life events (
Groarke et al. 2013;
Horne and Watson 2011). Dealing with stressful life events is a dynamic process strongly influenced by individual and cultural factors and can take different forms within the framework of cultural and religious traditions (
Coughlin 2008;
Henderson et al. 2003). Therefore, adding religious and spiritual elements to cognitive and behavioral therapy will provide significant advantages in impacting the more profound points of the individual’s spiritual life and providing a powerful and lasting transformation in perspectives. These issues were among those that brought the attention of thinkers to the spiritual dimension of man and the inclusion of spiritual components in psychological theories, and the positive effect of this orientation was confirmed in many psychological studies (
Nasution and Afiyanti 2021).
Many studies have studied the relationship between religion, spirituality, and mental health. Although conflicting findings are reported among various studies, meta-analytical studies reveal that religion and spirituality are influential factors in mental health. They note that spiritual/religious coping can increase pain management, improve surgical outcomes, and protect against depression (
Koenig and Larson 2001;
Larson and Larson 2003;
Yapıcı 2007, pp. 50–51). Studies indicate that religion and religiosity increase positive emotions such as well-being, hope, and optimism (
Cohen and Koenig 2004).
It seems that in surgeries in which an organ is removed from the body, control over the body is reduced, and this causes the person to feel incompetent concerning their own body, leading to insecurity and a negative mental image. The breasts are an important part of a woman’s self-image, and they are strongly associated with gender identity, sexuality, physical attractiveness, self-confidence, nurturing, and a sense of motherhood. Therefore, after surgery, a number of women worry about a perceived reduction in their feminine attractiveness. Breast removal changes their physical attractiveness schema in their view, which causes sexual and marital satisfaction problems. Due to these maladaptive and distorted thoughts, they lose the ability to regulate their emotions and to adopt favorable coping styles (
Tahergorabi et al. 2014). Spiritual therapy helps to identify these maladaptive thoughts and distorted thinking styles and to evaluate them, as well as use spiritual teachings for replacing the thoughts with more adaptive and realistic thoughts (
Memaryan et al. 2017). According to this therapeutic approach, connecting with a source beyond the patient’s existence, dealing with spiritual themes, and trying to find the meaning of life can lead to providing conditions for recovery after the traumatic event (
Pearce et al. 2015). It is also stated in the Quran that peace of mind is possible only by turning to God. In Rad’s Surah, “Verily in the remembrance of Allah do hearts find rest” (13:28).
Cancer diagnosis and its treatment are challenging for a woman and may threaten the meaning of their life and sometimes lead to a feeling of collapse (
Alinejad Mofrad et al. 2021). Research has shown that spirituality acts as an “inner resource or inner aspect of a person” against a wide range of stressful events that people face (
Dadfar et al. 2023;
Sharifi et al. 2023). Spiritual coping can help people deal with their problems. The mechanism behind this type of coping may reflect finding meaning, purpose, and hope, which in turn will strengthen people and aid them in dealing with their pain and suffering (
Jafari et al. 2013). In this process, spiritual coping is defined as the use of cognitive and behavioral techniques when faced with stressful life events, which arise from a person’s spirituality. Other research has shown that patients tend to increase their focus on religion and connection with God as their cancer progresses (
Ghahari et al. 2017). Religiosity is also thought to have a protective mechanism in mental health conditions, including against depression (
Koenig and Larson 2001;
Koenig 2008;
Koenig and Büssing 2010). Also,
Sajadi et al. (
2018) showed that spiritual approaches are the main coping strategy in Iranian patients with cancer, who consider spirituality the primary source of coping and hope. According to
Hajabadi et al. (
2020), when people—especially Muslims—are affected by chronic or incurable diseases such as cancer, they often report that their religious beliefs and practices are a source of comfort in reducing physical and mental discomfort.
Although much research has been carried out regarding the importance of paying attention to psychological issues in patients with breast cancer, paying attention to psychological issues as a part of treatment and complementing medical treatment has not found its place as it should have. For this reason, these patients can be found to have a low quality of life and with problems in family-related and social fields. On the other hand, despite the existence of studies on the effectiveness of different therapy methods to improve psycho-social and family-related conditions, it is still necessary to use new treatment methods due to existing shortcomings, especially in relation to paying attention to psychological issues.
Therefore, in order to improve the coping methods of patients with cancer, especially in women who had undergone mastectomy, it is necessary to have a more comprehensive understanding of women’s experiences and how to modify their coping methods. Therefore, this study aimed to investigate the effect of spirituality-centered cognitive therapy on body image, sexual function, disease perception, and intrusive thoughts in women after mastectomy. There is a rich body of literature on religion and spirituality (e.g.,
Hill et al. 2000;
Spilka and McIntosh 1996;
Zinnbauer et al. 1997). This research was conducted in Iran, where Islam is dominant. Religiousness and spirituality have different meanings and are intertwined in Islam, whether Sunni or Shia. According to Islam, belief in Allah is the first requisite to be a Muslim, and spirituality independent of the core teachings of Islam is not possible. In addition, the development of the spirituality of the individual, according to Islamic thought, will be revealed by the level of compliance with the beliefs and behaviors emphasized in the Quran.
Abdulkadiroğlu (
1996) asserts that religion itself is a spiritual way of life and is of significant value in the life of human beings, constituting the foremost spiritual element. Additionally, Dr. Robert Emmons suggests that spirituality should be considered a distinct type of human intelligence. Spiritual intelligence fundamentally involves an individual’s ability to navigate and discover meaning and significance in the surrounding world. In Islamic theology, this process entails reflecting on the signs (ayat) of Allah present in the world and conveying knowledge to individuals about how to act, think, and feel in accordance with these signs. For example, when a person observes the changes in trees during the autumn season, they perceive it as a sign of Allah (
Abdul-Rahman 2017). Islam derives spirituality from religion and considers it an integral and complementary part of religiosity. Therefore, it is highly incorrect to view Sufism, which we will briefly describe as the spiritual or inner life of Islam, separately from Islam. Spirituality is the “essence”, while religion is the “form” (
Albayrak 2015). In Christianity, religiosity is formally structured and defined by religious beliefs, practices, and community, whereas spirituality is more centered on the individual (who may be religious or not). While in Christianity, religiosity and spirituality are distinguishable, they are not completely independent of one another. Previous research has shown that many participants describe themselves as spiritual but not religious. Among these individuals, there is often a tendency to not be engaged in institutional forms of religion but rather to participate in group experiences related to spiritual development, to have New Age beliefs, and to have mystical experiences (
Dadfar et al. 2019).
5. Discussion
The results showed that spirituality-centered cognitive therapy had a positive effect on illness perception in women after mastectomy, which is in line with
Alinejad Mofrad et al. (
2021),
Haddadi Kuhsar et al. (
2017), and
Sheydaei Aghdam et al. (
2019).
Memaryan et al. (
2017) reported that spiritual health can be effective in improving the perception of illness in all subscales in women with breast cancer. Spirituality-centered cognitive therapy, through increasing the sense of positivity towards events, increasing hope and trust in God, and accepting everything that God has destined for a person, reduced distress in patients with breast cancer and, therefore, enabled them to tolerate the illness and pain, easing the complications caused by the mastectomy. What is important in spiritual therapy is its semantic aspect, which forms the content of therapy and is manifested in the form of worship in every religion. These techniques in spiritual therapy can have behavioral, cognitive, metacognitive, emotional, and moral aspects and are manifest in religious concepts and behaviors such as trust, patience, prayer, meditation, etc.
Spirituality-centered cognitive therapy has also been effective on body image and intrusive thoughts in women with breast cancer after mastectomy surgery. Since the breasts are an important part of a woman’s body image, any type of abnormality in the breasts can lead to a negative body image in a woman. Patients who undergo a mastectomy experience body image problems because the surgery makes the patient feel like they have lost an important part of their femininity. Disease perception refers to people’s understanding and management of their illness by developing cognitive representations based on their knowledge and previous experiences (
Carnelli et al. 2017). Disease perception includes an emotional evaluation. A negative perception of the disease leads to anxiety and distress (
Cook et al. 2015). It was reported that the perception of illness plays a significant role in experiencing emotional states and using coping strategies (
Krok et al. 2019). In this regard, in spirituality-centered cognitive therapy, patients are taught to re-examine their incompatible thoughts and replace them with more compatible and realistic views through communication with a source beyond their existence and addressing spiritual themes and efforts to find the meaning of life. Allah states in the Quran that He tests people with goodness and evil (Quran, Surat al-Araf, 168; Surat al-Baqara, 155). Believers are asked to be patient in the face of calamities (Quran, Hajj Surah 35). Allah says in verse 156 of Surat al-Baqara, “Those who, when afflicted by a calamity, say: Our entire existence belongs to Allah, and Him, we return.” In other words, establishing a solid bond with the Almighty Creator and showing submission are among the spiritual values of Islam. The individual who enters into the mind-set of deficiency and dysfunction after mastectomy surgery thinks that she has lost social acceptance and appreciation and has low self-esteem (
Mete and Beydağ 2021), but she can reorganize her incompatible thoughts within the framework of the perspective expressed in the Quran during the spirituality-centered therapy process.
According to the results, the role of spiritual therapy in improving sexual function was not significant. Because, in addition to correcting beliefs and cognitive errors in women after mastectomy and since this operation targets one of the most important female sexual organs, this issue can affect marital relationships. Therefore, if the husband does not play a supporting role towards the patient and does not help her in accepting this issue, spiritual therapy cannot help in this case. Also, in these women, constant mental preoccupation with the perceived defect may cause low sexual excitability or even a lack of excitability. Frederickson and Robert point out that when people are distracted by their appearance, they cannot focus on their sexual pleasure, and this factor has a negative effect on their sexual function. In line with this,
Holzner et al. (
2001) showed that patients with breast cancer often had sexual dysfunction.
Hannoun-Levi (
2005) and
Onen Sertoz et al. (
2004) found that mastectomy and chemotherapy lead to negative changes in mental image, decreases in self-esteem and sense of femininity, and sexual disorders, especially in young women.
Schoenberg (
1979) believes that patients after mastectomy consider themselves as a failed and rejected person and avoid having sex with their spouse. Such behavior causes a feeling of rejection in the husband, such that he stops contacting her. At this stage, the woman also experiences a feeling of being pushed back, and a defective cycle is created based on the lack of a proper and satisfying relationship. One of the factors that may cause women to have sex with their husbands after mastectomy is sexual consideration. In sexual consideration, a person sees the needs of the other party as a higher priority than his own needs. The consideration performed by the patient’s husband can be impaired for reasons such as the patient’s physical weakness and the perception of sexual intercourse as a health-threatening factor, while the consideration performed by the patient is due to two main reasons, including worrying about her husband’s extramarital affairs and respecting his needs. According to the experimental study conducted by
Brandberg et al. (
2008), sexual pleasure before surgery and one year after had a statistically significant difference, which was consistent with the results of this study.
The results of this research and our ability to generalize the findings to other populations are affected by several limitations. First, the research participants were all Muslims, which limits our ability to generalize the results to followers of other religions. Second, this intervention was performed in 5 weeks on women with breast cancer after mastectomy. Nevertheless, this study has a number of strengths, including that the principles of clinical trials, including random allocation, were followed in this study. The prospective nature of this research allows for the observation of cause and effect, which is often not possible in purely correlational studies. One of limitations of this study was the absence of counseling for the control group.
Another limitation of this study is that a test measuring the spirituality levels of the participants was not included in the research. This study focused on the factors of body image, sexual function, disease perception, and disturbing thoughts that could negatively affect the mental health of women who had mastectomy surgery. The effect of spirituality-centered cognitive therapy was analyzed by assuming that the current spirituality levels of the research group were equal. It is recommended that in similar studies to be conducted in the future, spirituality levels should also be determined, and the effects of spirituality-centered cognitive therapy on individuals with different spirituality levels should also be analyzed.
In this study, spirituality-centered cognitive therapy was applied to the experimental group, while no counseling was given to the control group in order to prevent any placebo effect. Other studies to be conducted after this study could shed light on finding the most effective method by comparing different therapy applications.