Corporeal Posttraumatic Growth As a Result of Breast Cancer: An Interpretative Phenomenological Analysis

Abstract

Women’s traumatic experience of breast cancer (BC) can result in posttraumatic growth (PTG). Women’s embodied experiences of BC seem particularly pertinent to their experiences of both difficulty and growth. While PTG is usually conceptualized as having five domains, it seems that BC survivors experience a sixth domain—corporeal PTG (CPTG). CPTG was recently defined as a “reclaiming” and renewed connection to the body through increased appreciation of the physical self, a new sense of bodily responsibility, positive health changes, and a new sense of positive identification with the body. This study’s aim was to explore how women experience CPTG due to BC. In-depth interviews were conducted with female BC survivors. Interpretative phenomenological analysis extracted three themes: losing, regaining, and relinquishing ultimate control over the body, reconstructing embodied identity, and a newfound appreciation for the body. Participants spoke of a complicated journey from distress, loss, and fragmentation to a reshaping of their assumptions about their bodies. The findings suggest that the body plays a vital role in women’s traumatic and growth-related experiences of BC. Future research on the embodied experience of BC is recommended as it forms a crucial part of BC recovery.

Keywords

corporeal posttraumatic growth breast cancer the body

Much current psychological literature positions the experience of breast cancer (BC) as psychological trauma (Cordova et al., 2007; Jim & Jacobsen, 2008; Morris, Shakespeare-Finch, & Scott, 2011; Sumalla, Ochoa, & Blanco, 2009). It appears that BC is traumatic, representing a serious threat to women’s lives, bodily integrity and, ultimately, personhood (Cassel, 1982). On the one hand, BC signifies the potential for death and the end of both body and self as they are known on earth (Arman & Rehnsfeldt, 2003; Frank, 1998). On the other hand, breast loss, hair loss, and weight gain often caused by BC treatment may fundamentally threaten women’s sense of embodied identity—the corporeal aspect of a person’s self-representation (Crompvoets, 2006; Fang, Chang, & Shu, 2014).

Aligned with the notion of BC as trauma, the literature uses the term “posttraumatic growth (PTG)” to describe the positive outcomes that women may experience as a result of BC, as well as traumatic experiences more generally. Tedeschi and Calhoun (2004) define PTG as “positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (p. 1). PTG is thought to comprise five domains: new priorities and appreciation of life, improved intimate relationships, increased feelings of personal strength, identifying new life prospects, and spiritual development (Tedeschi & Calhoun, 1996). Women diagnosed with BC often experience some or all of these domains of PTG (Bellizzi, 2004; Cordova et al., 2007; Lelorain, Bonnaud-Antignac, & Florin, 2010; Sears, Stanton, & Danoff-Burg, 2003; Tomich & Helgeson, 2002; Weiss, 2002, 2004). Recent work also shows that PTG should not necessarily be conceptualized as an “outcome,” but rather as a “journey” or “growth trajectory” (Arman, Rehnsfeldt, Lindholm, & Hamrin, 2002; Coward & Kahn, 2005; Danhauer et al., 2015; Eide, 2006; Wang, Chang, Chen, Chen, & Hsu, 2014).

It is theorized that PTG occurs because trauma such as BC poses a deep-set challenge to individuals’ understandings of the world (Janoff-Bulman, 1992; Jim & Jacobsen, 2008; Joseph, 2009; Joseph & Linley, 2005; Neimeyer, 2004; Pals & McAdams, 2004; Tedeschi & Calhoun, 2004). Individuals who experience PTG adapt and rebuild their previously held assumptions about themselves, their lives, and the world around them to accommodate the trauma they have experienced. This allows individuals a newfound lease on life, as they are able to approach life with more realistic assumptions and improved psychological functioning. This growth does not exclude the concurrent experience of distress which, in fact, seems a prerequisite for the challenging circumstances required for PTG (Tedeschi & Calhoun, 2004).

Qualitative research has begun to yield evidence for a new embodied aspect of PTG due to BC. While women experience growth in all five traditional PTG domains, they also seem to experience what Hefferon et al. suggest as a sixth domain—corporeal PTG (CPTG; Hefferon, 2012; Hefferon, Grealy, & Mutrie, 2009, 2010). CPTG describes psychological growth that occurs in people’s experiences of, and attitudes toward the body and the body’s relationship to the “self.” More specifically, it refers to a newfound awareness of the body and heightened perception of its importance due to the struggle with a trauma such as physical illness (Hefferon et al., 2009).

Traditional conceptualizations of trauma and PTG have gravely neglected the role of the body. For instance, current measurement tools, such as the PTG inventory (Tedeschi & Calhoun, 1996), do not assess attitudes toward the body or indications of health behavior change (Park & Lechner, 2006). Although initially it may seem that the physical self is unconnected to psychological experience, theories of embodiment (e.g., Bunge, 1980) consider the body as an inseparable part of our overall subjective psychological worlds. Frank (1998) argues that it is only possible to know the world through the body and that, as such, people’s self-identity is necessarily intertwined with their bodily experiences. Therefore, the absence of the experience of the body in PTG research is concerning. This seems particularly problematic for the experience of a physical illness such as BC, where experiences and perceptions of the body may be fundamental elements of patients’ trauma and subsequent PTG (Hefferon, 2012; Hefferon et al., 2010; Sumalla et al., 2009).

Several authors have argued that BC should be seen as a unique trauma, notably involving women’s experiences of their physical selves (Kangas, Henry, & Bryant, 2002; Mehnert & Koch, 2007; Smith, Redd, Peyser, & Vogl, 1999; Sumalla et al., 2009). While most traumas originate from an external circumstance, BC has a physically internal cause leading women to feel a sense of loss of control over their own bodies, and even to feel that their bodies are self-sabotaging. This may be especially difficult given that the physical changes caused by BC and its treatment often provide daily physical reminders of the disease within (Brennan, 2001; Gurevich, Devins, & Rodin, 2002; Sumalla et al., 2009). Furthermore, while trauma often entails a single circumscribed stressor, BC is associated with multiple and prolonged threats to the physical self, which may bring an uncomfortable awareness of the body’s vulnerability. Thus, while acute stressors normally entail traumatic memories of past events, BC entails a future-oriented fear of illness and death, as well as a sense of uncertainty around the body’s ability to avert cancer (Bower et al., 2005; Sumalla et al., 2009). Finally, although traumas often occasion distressing physical injuries, the breast loss or hair loss associated with BC may be significantly more distressing for women’s body image and gender identity, and may actually threaten their sense of self (Crompvoets, 2006; Fang et al., 2014).

Given the above argument, it follows that BC may lead to distinctive growth outcomes which involve women’s experiences of, and attitudes toward, their physical selves (Hefferon, 2012). This argument can be well contextualized according to the theory that PTG involves the traumatic shattering, and subsequent positive rebuilding, of an individual’s assumptions. For example, being diagnosed with an illness may lead to one’s assumptions of “physical invincibility” being threatened—which may act to heighten awareness of physical vulnerability to sickness and death (Goldenberg, 2005). This may lead to increased appreciation of the physical self, gratitude for what it is to be healthy, a new sense of bodily responsibility, and positive health changes (Hefferon et al., 2009). Additionally, while hair and breast loss can damage a woman’s body image and sense of femininity (Fang et al., 2014; Rosenberg et al., 2013), women often also speak of “reclaiming” of and renewed connection to their bodies post-BC (Hefferon et al., 2009).

Recent research has demonstrated that survivors of physical illness in general, and BC specifically, experience CPTG (Dahan & Auerbach, 2006; Hefferon et al., 2009; Hefferon, Grealy, & Mutrie, 2008; Salick & Auerbach, 2006). The major finding of Hefferon et al.’s (2009) systematic review of the qualitative literature on life-threatening illness was that many studies’ participants experienced a “new awareness of the body” because of their illnesses. More than this, findings around CPTG have revealed a “reclaiming” of, and renewed connection to, the body through increased appreciation for the physical self, a new sense of bodily responsibility, positive health changes and last, a new sense of positive identification with the body (Hefferon, 2012; Hefferon et al., 2009). Research also tends to describe participants’ CPTG as a process, or journey, where women report a heightened awareness of a “new body,” to which they do not relate, even fear, and have to work at negotiating a new physical self. They then proceed to relate an increased awareness of, and appreciation for, their physical health, as well as resultant lifestyle changes involving diet, exercise, and listening to their bodies (Hefferon et al., 2009). Finally, the body may be perceived as a vessel of hope and new life when women begin to regain health (Hefferon, 2012; Hefferon et al., 2010).

While reports of embodied growth have been widely noted by qualitative research dealing particularly with BC (Hefferon et al., 2009), much work has been done in the context of larger exercise intervention studies (e.g., Hefferon et al., 2008; Milne, Guilfoyle, Gordon, Wallman, & Courneya, 2007; Mutrie et al., 2012; Sabiston, McDonough, & Crocker, 2007). As such, very few studies have been specifically directed at BC patients’ experiences of their bodies (Hefferon, 2012; Hefferon et al., 2010). Thus, although the current findings on CPTG due to BC are both interesting and promising, the area remains largely underexplored (Hefferon et al., 2010). Much work toward an in-depth understanding of how BC survivors experience PTG related to their bodies remains to be done (Hefferon et al., 2009). This study aimed to explore how women experience CPTG due to BC. It was hoped that the study’s phenomenological approach and emphasis on the experience of CPTG would supplement the literature on PTG and BC.

Method

Methodological Paradigm

Interpretative phenomenological analysis (IPA) is centrally concerned with the phenomena that manifest in people’s consciousness as they perceive and interact with the world around them (Willig, 2008). Its broad aim is thus to engage in a detailed exploration of how participants make meaning of their subjective experiences in their own unique contexts (Smith & Osborn, 2008). Because IPA stems from the hermeneutic phenomenological tradition, it sees interpretation as a necessary element of description (Giorgi & Giorgi, 2008; Smith, 2008). Throughout the process, the researchers acknowledged that it is impossible to directly access participants’ “lifeworlds,” and that the researchers’ presumptions, interpretations, and abstractions unavoidably color the produced knowledge (Smith, 2008).

This study aimed to explore how women experience CPTG due to BC. This is a departure from the majority of PTG studies, which aim to quantitatively delineate measurable aspects of the phenomenon. Rather, this study aimed to explore this new area of research in a way that allowed unexpected and undiscovered components of CPTG to be identified. Therefore, IPA is appropriate for this study, as it allowed a focus on the participants’ unique, lived experiences of BC, their bodies, and CPTG, as well as how they had subjectively understood, or made meaning of, these experiences.

Participant Sampling and Recruitment

It is only possible to achieve the detailed, highly nuanced analysis required for IPA on a “small, purposively-selected and carefully-situated” sample (Smith, Flowers, & Larkin, 2009, p. 29). Smith and Osborn (2008) suggest that a sample of three participants allows detailed, in-depth engagement with each case and facilitate useful comparison of similarity and difference across the individual transcripts.

This study’s purpose was to look very specifically at women’s experiences of CPTG as a result of their struggle with BC. As this was an IPA study, it also required a homogeneous sample (Smith & Osborn, 2008). Thus, a purposive sampling criterion was employed, with several inclusion criteria: (a) Participants needed to be female (Male BC represents a small percentage of cases); (b) Participants needed to be between the ages of 25 and 50 years. Few women below the age of 25 years are diagnosed with BC, and this relatively young age group tends to be more positively correlated with PTG (Tedeschi & Calhoun, 2004); (c) Participants needed to have been diagnosed with BC at least 6 months before the onset of the study to ensure that participants had “struggled” with BC sufficiently long to allow a rich account of their experiences; (d) It was furthermore required that the participants had been diagnosed with BC not more than 5 years before the study. Hefferon (2012) writes about the 5-year postdiagnosis period as being optimal for PTG study; and (e) The participants needed to have experienced general PTG and corporal PTG. While PTG research has been criticized for potentially prompting participants to report a higher degree of growth than actually experienced, this potential bias was countered by assessing whether the prospective participants had experienced PTG before they were informed about the study’s focus on growth. Those interested in participating were asked to write a paragraph on their experiences of BC and a paragraph on how they had experienced their bodies. If there were evidence of PTG and of CPTG, the participants were deemed eligible.

To recruit participants meeting entry criteria, the study was advertised at BC support groups in Johannesburg. It was reasoned that women who attend support groups tend to have actively engaged with their cancer and have sought a supportive environment to aid them in this, making it more likely that they had experienced CPTG. After gaining permission, the study was verbally advertised at several support group meetings. Women who expressed interest were invited by e-mail. Attached to this invitation was a form requesting demographic details and the descriptive paragraphs. Six women indicated interest and completed the form. Three met the inclusion criteria and were interviewed.

Procedure

Each participant was briefed on confidentiality and ethical issues and completed a consent form. In line with most IPA work, this study used semistructured interviews, which utilize a flexible interview schedule that guides the interview (Smith & Osborn, 2008). The focus of the interviews was to allow the participants, as “experiential experts” to provide in-depth accounts of their subjective experiences (Smith, 2008). The interview schedule was constructed in two parts. The first section focused on the participants’ experiences of BC, diagnosis, treatment, recovery, and their experiences of general PTG. This used questions such as “What was it like for you when you were diagnosed with BC?” and “How have you made sense of your experience of BC?” The second section focused on the women’s experiences of their bodies in relation to BC and on their experiences of CPTG. This used questions such as “How did you feel about the physical changes that BC brought?” and “How do you think about your physical health?” The questions all aimed to elicit an honest account of how the participant had experienced BC without probing for positive or negative experiences. However, when participants raised experiences indicative of PTG and, specifically, CPTG, the interviewer probed further.

Analysis

Smith and Osborn’s (2008) steps for IPA were utilized to analyze the data. First, the interviews were transcribed verbatim. The first transcript was read a number of times, while summarizing what was significant, before returning to look for emerging themes. Next, the themes that had emerged were clustered into meaningful groups. This was an iterative process, where the connections were checked and reformulated until there was consistency between the participant’s words and the thematic clusters. This process was repeated for each transcript. Once the separate transcript’s analyses were complete, a final table of superordinate themes and subordinate themes was constructed. This required the data to be reduced by deciding which themes were most significant in the analysis. Each theme’s significance was determined not only by prevalence but by the richness of the passage from which the theme arose and how well the theme tied into other aspects of the analysis.

This study followed Smith et al.’s (2009) suggestion that Yardley’s (2000) criteria for research quality are suitable for IPA. Yardley (2000) outlines four criteria: sensitivity to context, commitment and rigor, transparency and coherence, and impact and importance. In line with these, the primary researcher transcribed the interviews herself, and reread the transcripts until she was immersed in the study’s data. The connections between the data and the interpretations were maintained by using verbatim extracts from the interview transcripts in the discussion of findings. The primary researcher was reflexive around how her own characteristics influenced the interview process and data analysis. Completeness of interpretation was ensured through an iterative process of hermeneutic meaning making, where the analysis cycled between interpretation and the data until an understanding that included the data’s variation, but was free of internal contradiction, was reached. Finally, the reasonableness of the primary researcher’s interpretations was assessed by the second researcher, who is an expert in IPA work and the PTG field.

Discussion of Findings

Analysis of the data revealed that CPTG was indeed experienced by the three participants. Three superordinate themes of CPTG emerged. These were as follows: losing, regaining, and relinquishing ultimate control over the body, reconstructing embodied identity, and a newfound appreciation for the body. In line with recent ideas that PTG resembles a “growth trajectory” (Arman et al., 2002; Coward & Kahn, 2005; Danhauer et al., 2015; Eide, 2006; Wang et al., 2014), the themes all evidenced some sort of progression; the women experienced a type of journey from negative to positive experience for each aspect of CPTG identified. As pointed out by Hefferon et al. (2010), this suggests that it is not having BC that directly leads to PTG, but “the subsequent physical and psychological responses and processes” (p. 232) with which they endure and respond to BC.

Losing, Regaining, and Relinquishing Ultimate Control Over the Body

The participants all spoke about the issue of bodily control as being a core part of their BC experience. The women initially felt powerless to prevent the effects of their cancer, or of their treatments, as well as a decreased ability to make decisions about their own bodies. This culminated in an experience of loss of bodily control. After first acting to try to regain bodily authority, the women waived their claims on ultimate corporeal control and accepted that their bodies were vulnerable and that they were unable to be in complete authority. They responded to this by beginning to appreciate and make the most of their lives and physical health, understanding that they could not control how long this “gift” would last for.

“You’re Sort of Not in Control of Your Body Anymore”: Losing Authority Over the Body

The participants experienced their cancer as a foreign invader of their bodies. For instance, Candice and Theresa both experienced an urgent desire to expel their BC—which they termed “thing,” and “stuff”—from their bodies. This set up their bodies as territories and implied a fear that cancer would take over if they did not immediately act to eradicate it.

But I was also like—Just get this thing out of me. (Candice)

Because I was like, okay, just get this stuff out of me. (Theresa)

Anita used a more explicit battle metaphor to describe her struggle to remain free of BC.

I think that’s keeping cancer away . . . I think it’s a fight. To be honest. Ja.

The experience of BC as a foreign invader has been found in other research. Gibbs and Franks’ (2002) research on the metaphors in BC narratives identified the idea of cancer as being an “alien to the self.” Both Gibbs and Franks (2002) and Waskul and van der Riet’s (2002) participants described a sense of being invaded by something they did not want to be part of them. As a city under attack loses control to the authority of the colonizer, the participants seemed to experience BC as threatening to “take charge” of their bodies.

Although the women fought hard to prevent BC “taking control,” they did experience a period of profound loss of control over their bodies. While this was linked to their experience of BC as an invader, it was also related to the effects of their treatment. Whether their hair fell out against their will, or whether they were “forced” to have a mastectomy, they experienced a subversion of their sense of bodily authority that was highly distressing.

That [hair loss] was a huge, huge thing for me a, a constant reminder of, like, what was happening to me. That you’re sort of not in control of your body anymore. (Candice)

It [her mastectomy] was probably the biggest thing—was because there was no choice, in my opinion. And that’s odd in my life. Generally speaking . . . I could control what was going on in my life. (Anita)

And, um . . . it’s almost like you go, you go through an—I can’t believe that boob betrayed me type feeling. It sounds so ridiculous. (Candice)

It’s like—This thing [her mastectomy] that I didn’t choose has now happened. (Candice)

The experience of powerlessness resulting from the loss of control of, and betrayal by, women’s own bodies has been widely reported in the BC literature (Arman et al., 2002; Coward & Kahn, 2005; Hefferon et al., 2010; McWilliam, Brown, & Stewart, 2000; Milne et al., 2007; Sabiston et al., 2007; Waskul & van der Riet, 2002). Women’s experience of loss of bodily control appear particularly connected to their experiences of diagnosis and of the negative effects of treatment that are unwanted, yet uncontrollable (Waskul & van der Riet, 2002).

The women’s’ loss of control was also experienced within the health service domain.

I felt like a . . . like a science project. I felt like a lab rat. Ja, like! Ja. All these drips stuck into you. And you get so horribly ill. (Theresa)

Theresa’s experience of objectification—with her body seen as an object from which her illness needed to be removed—is a typical one reported by BC patients (Arman et al., 2002; Hurley, 2014). Patients’ feel “colonized” or turned into medical territory, leading to a sense of powerlessness or loss of control (Taylor, 1979; Waskul & van der Riet, 2002).

The women also described how their bodies were taken control of by their doctors.

The drain was horrid. . . . And my body, it didn’t drain a lot [after her mastectomy]. So you have to drain a certain amount, um, and only then would they actually take out the drain. . . . And it was the worst, the worst possible. (Anita)

Um, my stay was not three days. It ended up being for seven days because I wasn’t responding to the antibiotics . . . they kept on saying—No, you’re fine. You’re going to go home tomorrow . . . they, in my mind it’s like they were treating me like a child. It’s like, you know you’re not allowed to know all the information. (Theresa)

It has been found that the “depersonalization” of medical patients happens, among other things, due the routinization of treatment procedures and the provision of little information (Taylor, 1979). This results in the experience of a loss of authority over the body and health.

“Screw You, This Is My Body”: Reclaiming Control of the Body

The participants went on to describe their experiences of regaining and retaining authority over their bodies—both during treatment and after recovery. Once Candice was cancer free, but still taking Tamoxifen, she wanted to “keep [her] body [her] own.” She felt she had regained control, and fought to retain control by preventing the Tamoxifen causing weight gain against her will.

And now it’s more about, like, trying to keep my body my own. I don’t want those hormone tablets [Tamoxifen] to take over and make me balloon.

Anita and Theresa had earlier experienced a loss of control of their bodies within the medical system. They went on to describe how they reclaimed authority over their bodies—privileging their own opinions about their bodies and health over the decisions of the doctors.

They’re like—No you mustn’t have anything! No vitamins, no nothing to help your body get though all of this crap. . . . So I took my supplements. I thought—Screw you, this is my body. Theresa Um, the second reconstruction . . . I also needed a drain . . . Um, I took longer than other people. And I, I jimmied the result. I just, said that it had drained. (Anita)

By choosing to exercise their own authority over their bodies, both of the women fought to regain their sense of bodily control. Theresa’s phrase—“screw you, this is my body”—captures the essence of what both their decisions symbolize—the women’s belief that they should have the right to decide what ultimately happens to their bodies.

The participants’ experiences of trying to reclaim authority over their bodies was in line with several other findings that “in their efforts to regain control over their bodies, the women believed they were in a battle and were struggling not to give in” (Arman et al., 2002, p. 101; Coward & Kahn, 2005; Lam & Fielding, 2003).

“You Have to Let It Go and Live Your Life”: Relinquishing Ultimate Control of the Body

Finally, the participants described what seems to be a form of CPTG—a change of attitude and behavior where the women waived their claims on ultimate control over their bodies. One example of this is that the participants began to see their BC as something random and therefore uncontrollable.

And that’s the thing with cancer, it doesn’t discriminate at all. . . . It’s just one of those things that can happen to anybody. (Theresa)

I mean in my ward, I had somebody who was nearly 75, 80. And it was, like, you want to say to the world—What the flowers. . . . And then I had a lady that was younger than me. And it’s like, ja. It is random. (Anita)

Anita’s description speaks to her feeling that BC is not linked to any definite “predictive” variable. She referred to “the world” as something that “gives” women BC in a decision-making process that seems indiscernible. Because BC “can happen to anybody,” it must be “random” and uncontrollable. This is in line with Coward and Kahn’s (2005) study of BC survivors experiences of self-transcendence, where the women accepted that illness is not always preventable and that even as “young, healthy women” (p. 272), they are vulnerable.

Theresa went on to juxtapose BC against HIV/AIDS, to bring home the point that her illness was not controllable. HIV is typically brought on by specific, “choice-based” actions (i.e., unprotected sex), which is not the case for BC.

And, you know, it’s not one of those diseases, say like HIV, where you like maybe had a choice. . . . It is not something that you can prevent. It’s just what it is.

Candice spoke explicitly of her realization that she lacks full control over her body.

At that stage I was probably, like, yoh, this is—My body is actually quite vulnerable. So I guess I went from being quite, like, stable with myself and who I was in my body, I went to like a—I know the vulnerability of my body now.

Candice described feeling “stable” with her relationship to her body initially. This likely at least partially referred to her belief that she was “in charge” of her body, and could ensure that it was protected against illness. She went on to realize that her body was actually quite vulnerable to illness and furthermore, that her relationship to her body was less stable than she assumed. Consequently, she could not fully control or overcome her body’s vulnerability.

In their meta-analysis of the qualitative literature on PTG and illness, Hefferon et al., (2009) report that Affleck, Tennen, Croog, and Levine (1987), Arman and Backman (2007), Collins, Taylor, and Skokan (1990), Coward and Lewis (1993), Gillen (2005), Kennedy, Tellegen, Kennedy, and Havernick (1976), Lam and Fielding (2003), Milne et al. (2007), O’Connor, Wicker, and Germino (1990), Parry and Chesler (2005), Schwartzberg (1994), Siegel and Schrimshaw (2000), and Taylor, Lichtman, and Wood (1984) found that their participants were able to relinquish control over their physical illness. One participant in Lam and Fielding’s (2003) study on women’s experiences of BC said—“Now I realised I shouldn’t worry too much about anything because many things in our lives are not under our control” (p. 136). In a similar manner, this study’s participants’ relinquishment of ultimate bodily control seemed linked to a subsequent change in attitude toward their lives and health. Furthermore, by acknowledging that they did not have full bodily control, the women began to externalize the source of ultimate control and went on to see their physical health as a gift given to them.

And I think, after this whole thing, you really do want to make it count every day.

Like, I don’t do things half-heartedly, it’s just not, life’s short. So you’ve gotta actually take it with both hands. (Candice)

Um, ja, cuz you just, you start seeing things in a different light. It’s like just be appreciative of what you’ve got, and the time that you have. (Theresa)

Candice and Theresa’s realization that “life’s short” speaks to their acceptance that they are not in full control of their physical health or their longevity. Although in remission, they understood that they could not ultimately predict or control whether they would have a recurrence or, indeed, encounter a new threat to their physical health. Instead of giving up, they chose to exert the partial control they had to make the most of the health given them.

The participants in 21 of the 57 studies reviewed by Hefferon et al. (2009) echoed Candice and Theresa’s experience of realizing that life is short and that, because they cannot fully control or predict their future health, they should enjoy what they have in the present. This experience seems to at least partially represent the theme of “newfound awareness of, and appreciation for, the body” that has been reported in the CPTG literature (e.g., Hefferon et al., 2009). BC heightens the fact that humans are physical beings, which are dependent on their bodies for life (Frank, 1998). This idea of “dependence” inverts typical, yet irrational beliefs about corporeal control. Thus, it has been found that many women begin to view their lives and bodies as gifts, which they appreciate and try to make the most of. Additionally, this seems linked to the general PTG theme of “newfound appreciation of life and new priorities,” where people experience a rejuvenated recognition of the value of life in general, a changed idea of what is important, and a sense of “being so lucky” (Tedeschi & Calhoun, 2004, p. 6). This connection may speak to Frank’s (1998) assertion that people experience the world via their bodies, which seems particularly relevant to the experience of physical illness. It thus seems that women’s relinquishment of bodily control (representing CPTG) may inform their more general experience of PTG.

Reconstructing Embodied Identity

The participants’ also experienced growth concerning their embodied identities. Embodied identity is the corporeal aspect of a person’s self-representation. This is linked to sense of body image, bodily appraisal against a culturally defined and—often gendered—“body ideal,” and overall sense of identity as a physical being (Crompvoets, 2006; Fang et al., 2014). The participants’ BC initially threatened their sense of self, but eventually lead to CPTG with acceptance of and reconnection to their changed bodies—positively reframing their changes and incorporating them into a revitalized sense of embodied identity.

“My Body . . . It’s Not Mine”: A Threatened Sense of Embodied Identity

The women experienced their BC as posing a challenge to the ways in which they picture their bodies and thus how they viewed themselves. Candice’s imagined future breast reconstruction and perception of her lost breast, postmastectomy, was a good example of this.

Your breast, when it’s been reconstructed it’s not beautiful anymore . . . the ones they make are never going to be as beautiful as the original.

Because I’m abnormal and lopsided and all of these things.

Candice saw her original breast as something which could not be recreated. She ascribed a type of irreplaceable “magic” to her “beautiful,” natural breast, never to be regained. It was especially significant that, while her evaluation indicated a more negative body image than previously, her statement did not refer to her body. Instead, she directed it at herself—“I’m abnormal.” Thus, her mastectomy seemed to have affected her overall image of who she was.

Lam and Fielding (2003) reported that their participants perceived the “disfiguring” changes to their bodies as making them “abnormal.” Berterӧ and Wilmoth (2007) furthermore found that it is common for BC patients to perceive themselves as “abnormal” compared with women with two, “unmutilated” breasts. They also described the studies’ participants’ altered bodies as leading to a changed identity.

The participants also experienced parts of themselves as being lost, and their new, postcancer bodies as being foreign and not “part of them.”

Then when I looked at that mastectomy scar and it was just that stripe across your chest type thing, where your own breast used to be. Um, yoh, it’s really not easy. (Candice)

It’s [her reconstructed breasts] just two things . . . Ja it’s like an added sort of thing. . . . They’re not mine. . . . They don’t, my breasts don’t feel a part of me. (Anita)

Candice claimed ownership and connectedness to her original breast—“your own breast”—highlighting how difficult it was to lose a part of herself and to be left with “just” a scar. Anita then represented her reconstructed breasts as abnormal, “things” which were “added” on to her body. She also made it clear that her representation of her embodied self no longer really included her breasts, or had had to change to include breasts which felt “foreign.”

The sense of a loss of a part of the self has been found in other work. Berterӧ and Wilmoth (2007) explained that BC patients’ pictures of their bodies are often fundamentally changed; due to their removed or altered breasts, they no longer perceive themselves as “complete.” Many studies report that women experience despair over the loss of a part of their bodies—a “personal [loss]” (Arman & Rehnsfeldt, 2003, p. 516) affecting their sense of self.

The participants also linked their hair loss and breast loss to a loss of womanhood.

Breasts are also the nurturers of your body, in terms of if you have children. So there’s a whole complicated psychological aspect to boobs. (Anita)

It’s [her mastectomy] really not easy. . . . It’s a complete loss of femininity. (Candice)

And, um, I think the most traumatic thing is when the hair starts falling out. It really is.

Because it’s kind of like a loss of your femininity. (Theresa)

The BC literature widely reports on women experiencing their altered physical bodies as signifying a change, or even a loss, related to their sexual, mothering, and feminine selves (Berterӧ & Wilmoth, 2007; Fatone, Moadel, Foley, Fleming, & Jandorf, 2007; Hefferon et al., 2008, 2010; Lam & Fielding, 2003; McGaughey, 2006; Taleghani, Yekta, & Nasrabadi, 2006). For example, in describing her own experience of BC, Hurley (2014) asks the question—“Would I still be myself without hair, without a breast, with an implant, without my fertility?” (p. 312).

The final way the participants’ embodied identities were threatened and changed was by their experience of taking on the unwanted identity of a “BC patient.”

I really looked like a cancer patient. I was pale and thin and I had no hair. (Candice)

So when I come out the shower in the morning. And when I come out the shower in the afternoon. You see your scars. You can never get away from it. (Anita)

The whole mastectomy thing is a huge reminder. It’s like the thing you that you think about first thing in the morning. Because you’re about to get in the shower, and every time you walk past the mirror you’re like—Ooh, sherbet that’s really me. (Candice)

“It’s a Part of Me Now”: A Rejuvenated Sense of Embodied Identity

The participants went on to describe their experiences of accepting, reconnecting to, positively reframing, and even transcending their changed bodies. This resulted in a new and rejuvenated sense of embodied identity, which seems to represent CPTG. Candice spoke about “becoming comfortable” with her mastectomy scar, and of accepting her scar and the hot flushes caused by her Tamoxifen as parts of herself.

Um, so I feel a lot more comfortable with the mastectomy and stuff. . . . To the point where I’m like, ug, I’m excited to have a reconstruction, but it’s not an urgent thing. And um, it’s the scar is sort of a part of me.

I guess to be having hot flushes at 26 is really not ideal. Um, but, I think, somehow, ja. Somehow you just cope with it. And it’s kind of, it’s a part of me now.

Candice seemed to describe an advanced, well-integrated form of acceptance, actually reincorporating her hot flushes and mastectomy scar into a new self-concept.

The women went on to describe rediscovering their sense of beauty—part of their self-concept which had been threatened previously. Theresa described enjoying her process of healing and discovering her reconstructed breasts, which she preferred to her old breasts.

At least by then, you know, at least you could see the shape of the boobs. And I was like—Okay I’m starting to heal. And, I was like—Oh okay, at least this doesn’t look so bad. And, uh, I thought about the irony of it all. It’s like, ah, I was always complaining that they were hanging and big, and now they were lifted and reduced.

Both Dahan and Auerbach (2006) and Hefferon et al. (2010) found that some participants experienced a sense of corporeal rejuvenation as their health returned. Hefferon et al. (2010) liken this to a butterfly emerging from a cocoon. Indeed, Theresa’s “renewed breasts” seem to have given her a sense of rejuvenation as she healed from surgery.

The women also repositioned their scars as symbols of their success and bravery.

You see your scars. You can never get away from it. . . . And then that’s not necessarily bad. Because, um, it’s a reminder of your survival. Of your success. (Anita)

It’s [her scar] almost a mark of . . . We [her fellow cancer patients and her] used to call each other chemo warriors. . . . That scar is like a sign of being a warrior. (Candice)

In repositioning their scars as positive symbols, the women engaged in a process of meaning-making, which is at the core of how PTG is conceptualized. While they initially struggled with a sense of loss due to their physical changes, they eventually made meaning of these and integrated their changed bodies into a new, comprehensive sense of self, which sometimes even seemed to be improved from what they perceived before their cancer. This is in line with Hefferon et al.’s (2010) finding that women report a more positive body image and improved relationship with their bodies post BC. More than this, the women seemed to have developed what Coward and Kahn (2005) and Hefferon et al. (2009) respectively term a “stronger self” of “fighter self.” A sense of newfound personal strength is a domain of PTG. Importantly, however, this experience of growth was symbolized by their scars and thus experienced via their bodies.

Finally, Candice actually transcended her reliance on her body to inform her identity.

It’s sort of—Actually boobs are just flesh. And they don’t make you who you are.

Candice relegated her breasts to the physical domain and separated her sense of self from her body. This experience is echoed by participants in other studies (e.g., Bredin, 1999; Paterson, Thorne, Crawford, & Tarko, 1999). Paterson et al. (1999) found that diabetic patients reported a new ability to differentiate between the body and the self, and were thus able to reshape their beliefs regarding the body’s relationship to their identity.

The experiences described here directly address the definition of CPTG—a reclaiming of, and renewed connection to, the physical body, resulting in a renewed sense of positive identification with the body and a new sense of corporeal identity (Hefferon, 2012; Hefferon et al., 2009, 2010). Furthermore, the women’s rejuvenated embodied identity also seem intricately linked to their experience of the PTG domain of newfound personal strength.

Newfound Appreciation for the Body

Finally, the participants experienced a newfound appreciation for their bodies and health. The women’s assumptions about continuing health were threatened as they were confronted with the reality of their vulnerability to sickness. They then experienced a change in attitude and began to experience a newfound sense of gratitude for their bodies and health. This manifested in their engaging in new health behaviors and encouraging others to do the same.

“My Body Is Actually Quite Vulnerable”: Shattered Assumptions Around the Body’s Invincibility

The participants all described how their BC diagnosis was totally incongruent with their presumptions of continuing personal health. For example, Candice spoke about how unexpected their BC was, and their disbelief that it was happening to her.

It [BC] wasn’t even on my radar. I was completely in denial before. I definitely thought this is not breast cancer . . . [The doctor] said because I was so young and I didn’t have any family history, that it wouldn’t be breast cancer. . . . Because I kind of thought—I cannot believe this is happening to me.

Theresa described a feeling of complete unreality when she was diagnosed.

Ja it’s like this. It almost felt like there was this, you were in this, um, and almost as if you were astral projecting and you can watch the movie unfolding.

BC being completely unexpected has been widely reported in the extant literature (Arman & Rehnsfeldt, 2003; Berterӧ & Wilmoth, 2007; Coward & Kahn, 2005; Eide, 2006; Gibbs & Franks, 2002; Hefferon et al., 2010; Lam & Fielding, 2003; Sabiston et al., 2007). Janoff-Bulman (1992) suggests that people believe in quite universal conceptual systems, such as the likelihood of positive outcomes and good fortune. As such, people normally believe they are invulnerable to things like cancer (Timko & Janoff-Bulman, 1985). The occurrence of a serious illness thus shatters people’s implicit, yet illusory assumptions of continuing health. This also seems linked to the experience of cancer diagnosis as being completely shocking, often resulting in feelings of unreality (Arman & Rehnsfeldt, 2003; Gibbs & Franks, 2002; Lam & Fielding, 2003; Taleghani et al., 2006; Waskul & van der Riet, 2002).

The participants were also confronted with the possibility of death due to BC.

It’s like the one thing that’s going through your mind is—Am I going to make it? . . . Am

I going to be one of those cancer people who die? You know it’s, it’s not just a broken leg that’s going to heal. It’s, and it really messes with your brain. (Theresa)

I think you hear cancer and you just think death sentence. (Candice)

Theresa’s poignant comparison between the certainty of a broken leg healing and the uncertainty of recovery from BC drives home a reminder that the body is not always able to heal. Her diagnosis “mess[ing] with [her] brain” highlights that her assumption that death was far off was probably threatened. This type of experience is sweepingly echoed by many studies (Arman et al., 2002; Arman & Rehnsfeldt, 2003; Berterӧ & Wilmoth, 2007; Chiu, 2000; Hefferon et al., 2009; 2010; Lam & Fielding, 2003; Pyszczynski, Greenberg, & Goldenberg, 2002). Moving away from assumed invincibility, BC patients seem to enter a ‘mortality salient environment’ where they become aware of the inevitable reality of their death.

In connection with having to face the threat of death posed by BC, many women report a new awareness of how susceptible their bodies actually are to illness (Arman & Rehnsfeldt, 2003; Coward & Kahn, 2005; Hefferon et al., 2010; Parry & Chesler, 2005; Waskul & van der Riet, 2002). Candice expressed this very clearly.

You kind of take that [your health] for granted. Especially as a young person.

The fact that the self is dependent on the body for life seems to lie at the core of BC patients’ realizations of the value of their health (Hefferon et al., 2010). This speaks to why the trauma of BC is so uniquely connected to women’s feelings about their bodies. While most traumas enact a threat to life and bodily integrity at the moment of the trauma’s occurrence, BC entails a significant future-oriented fear around whether the body will succumb to cancer.

A “Mind-Shift” to Gratitude

The participants went on to talk about how they increasingly began to value their bodies and their health. For them, this represented a significant attitude change. Theresa described this most explicitly.

Um, but ja, it’s like. It’s the only body you’ve got in this life, you know.

On the bad [days] because you like go into this whole, feeling sorry for yourself thing, . . . And on the good days is, that is kind of where you think differently. And, you start counting your blessings. . . . It’s all a mind-shift thing.

Theresa’s choice of the term “mind-shift” seems significant in the context of PTG theory around rebuilding shattered assumptions to better accommodate the traumatic experience. Many studies on PTG and BC refer to the experience of moving from negative to positive thinking (Berterӧ & Wilmoth, 2007; Chiu, 2000; Gibbs & Franks, 2002; Jensen, Bäck-Petterson, & Sergesten, 2000; Parry & Chesler, 2005). In their meta-analysis of studies looking at the lived experience of BC, Arman and Rehnsfeldt (2003) called this experience a “turning point” (p. 517) and described the women as turning from a “why me” attitude to one of “why not me,” where they began to feel grateful for what they did have rather than despairing about what they did not.

The participants also began to direct their gratitude toward the treatments which allowed them to get better. For example, Candice moved from distress at her hair loss, to positively reframing this to mean that her chemotherapy was working.

A reminder that the chemo is working. So like you want it to be killing. You want to welcome it in because you want it to work. . . . The fact that it was killing the fast dividing cells, and that’s why your hair falls out, then you’re like—This is awesome.

While the women initially felt that their bodies had betrayed them by becoming cancerous, they began to express gratitude toward their bodies for trying to heal.

And that’s another thing, your body is so keen to heal itself. Um, you know it wants to be better, sort of thing. (Candice)

Um, and it’s all about, thanking your body. It’s like the whole converse of, not the mindset of—Oh my body caused cancer. . . . I need to thank my body for fighting the cancer, for dealing with the chemicals. . . . Thank your heart for beating! (Theresa)

The participants’ expressions of a newfound appreciation for their lives, health, treatments, and bodies feed directly into findings around this as an aspect of CPTG. In Hefferon et al.’s (2009) meta-review of studies dealing with PTG as a result of illness, it was majorly found that many women experience a “reclaiming of” and “renewed connection to” the body through an increased appreciation of the physical self. Hefferon et al. go on to explicitly identify this as one “outcome” of CPTG (Hefferon, 2012; Hefferon et al., 2008, 2009, 2010). This is also linked to the general PTG domain of newfound appreciation of life (Tedeschi & Calhoun, 2004).

“It’s the Only Body You’ve Got in This Life”: New Health Behaviors

The participants expressed their newfound sense of appreciation of, and gratitude for, their bodies by placing an increased amount of importance and value on their health. As aforementioned, Theresa described her body as the “only body” she would ever have:

It’s the only body you’ve got in this life, you know.

By highlighting the fact that she only has “one body,” Theresa justified why it is important to look after the body. The women all went on to describe health changes they have made.

You know, so it’s a conscious effort the whole time to, like, try and keep my weight down . . . Um, ja, because also, like, fat produces oestrogen. And you don’t want that in your body. . . . So that’s the motivating factor. . . . More for health than anything. (Candice)

A balanced, a balanced, as healthy a life, is the best thing you can do. (Anita)

I go for Pilates twice a week. So. And that is making a difference. And there’s dietary changes that I’m going to do and all of that. (Theresa)

The women’s newfound awareness of the importance of a healthy body has been widely reported on in the BC literature (Arman, Rehnsfeldt, Carlsson, & Hamrin, 2001; Coward & Kahn, 2005; Eide, 2006; Hefferon et al., 2008; Jensen et al., 2000; Johansson et al., 2003; Kangas et al., 2002; Manuel et al., 2007; Milne et al., 2007; Pakenham, 2007; Salick & Auerbach, 2006). This represents an attitude shift that is not only cognitive but is also expressed through changed health behaviors (Hobfoll, Canetti-Nism, Galea, Johnson, & Palmieri, 2007; Sumalla et al., 2009). The women spoke about health changes that have been found in other studies—achieving balance (Coward & Kahn, 2005; Gibbs & Franks, 2002; Hefferon et al., 2009; Sodregen & Hyland, 2000), and better diet and exercise (Hefferon et al., 2009; Heiland et al., 2002; Power, Tate, McGill, & Taylor, 2003; Sabiston et al., 2007).

Beyond simply taking on new health behaviors for themselves, the women also experienced a profound need to encourage others to do the same. Particularly, they encouraged women to engage in preventative measures and to go for breast check-ups.

I’m starting to preach to people—Stay away from the pill, it’s bad news. (Theresa)

And even here [work], I called all the ladies together and I shared. . . . If five of the thirty ladies here have now gone for any kind of check up . . . I might have planted a seed for somebody . . . I felt that it was, critical. And, and it wasn’t about me. (Anita)

Both women found meaning and purpose in their experience of BC and saw it as providing them with the opportunity to help others prevent it. This is frequently reported (Dunn et al., 2005; Eide, 2006; Gotay, Holup, & Muraoka, 2002; Hefferon et al., 2010). Many women also say that they find meaning and purpose in being able to share their stories to spread BC awareness (Arman et al., 2001; Arman & Rehnsfeldt, 2003; Berterӧ & Wilmoth, 2007; Eide, 2006; Lam & Fielding, 2003; Manuel et al., 2007; Pakenham, 2007). This links to how they can experience CPTG through meaning making—if their experience of BC helps other women engage in health behaviors, there is meaning and purpose to an otherwise seemingly unfair illness. It may also link to the more general PTG domain of improved personal relationships, as the women experienced an increased care for others’ well-being, and actively engaged with helping them prevent the same difficult experience with BC that they had had.

Conclusion

The participants experienced quite widespread CPTG as a result of their BC, which emerged as three separate aspects of growth concerning the body. In each case, their growth seemed to center on their having fundamentally reshaped their assumptions about their bodies as well as their “self’s” relationship to their bodies. They experienced CPTG as a complicated transition from negative to positive in their thoughts, feelings, and behaviors. As such, their experiences of distress, loss, and fragmentation—which were not “replaced” by the positive changes—were important aspects of their experiences. It was vital to bear witness to this difficult aspect of the women’s experience of BC, and to explore how this was necessary for their subsequent growth. Ultimately, the outcome of this process was an improved level of psychological functioning where the women’s assumptions were more realistic and helpfully incorporated their interconnected physical and psychological experiences of BC. This allowed them to experience a relinquishment of ultimate control over their bodies, a rejuvenated sense of embodied identity, and a revitalized sense of connection to, and appreciation for, their bodies.

This study’s findings suggest that the body plays a vital role in women’s traumatic and growth-related experiences of BC. The data spoke to the existent knowledge of BC and PTG in two related ways. First, it seems that the body may play a more fundamental role in various well-documented aspects of the BC and PTG experience than has thus far been acknowledged. Second, women’s embodied experiences of BC seem to link to, and even feed into, their general PTG. It thus seems that, while the body may not wholly inform women’s experiences of growth, it may form a core aspect of their PTG as a result of BC. While CPTG may be conceptualized as a sixth domain of PTG, it is important to note that it may feed into, or even sometimes precede, the other domains. This makes sense in light of Frank’s (1998) assertion that people experience the world via their bodies, which is especially significant for a physical illness where women’s experiences of trauma and growth seem intrinsically connected to their experience as embodied beings.

The findings also have several implications for future research. This could focus on exploring each of the three aspects of CPTG identified in this study. To broaden the “gestalt” of CPTG, research on participants with different demographics to the women in this study would be valuable. It is also recommended that more work is done to explore the process of CPTG to provide more in-depth understanding how women move from distress to growth. This understanding could be particularly important to assist women to move through the various stages of CPTG. Finally, future research could investigate how therapeutic interventions could best support women’s struggle with BC, specifically to encourage and facilitate the experience of CPTG.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Larise du Plessis

Author Biographies

Amy Gorven is a clinical psychologist currently working in community service. After attaining her masters degree at the University of Johannesburg, she completed her training at Sterkfontein Psychiatric Hospital. She currently practices in the psychiatry department at Chris Hani Baragwanath Hospital. Her research interests include posttraumatic growth, the psychological implications of physical illness, and psychodynamic theory’s usefulness in the South African context.

Larise du Plessis is a clinical psychologist. Currently, she is a lecturer at the department of psychology, University of Johannesburg. For more than 10 years, she has been involved in the undergraduate and postgraduate training of psychologists. As a practitioner in South Africa over the past 15 years, she has developed a keen interest in trauma work especially from a posttraumatic growth perspective. Her current research interests include posttraumatic growth and the training of psychotherapists.

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