Self-perception of women after mastectomy as an ego defence mechanism. Comparison with a group of healthy women

Introduction

Breast cancer is the most frequent women’s cancer in Poland (almost 22% of all cases of malignant tumour) and the main cause (among cancers) of women’s death (13% of all death cases among oncological patients). Simultaneously, among 100 Polish women with diagnosed breast cancer, almost 40 cases finish with death [1]. In many cases, notwithstanding the cancer type or the stage of disease progress, mastectomy is necessary. This operation saves life and health in the majority of cases; however, at the same time, it is felt as a great personal tragedy upsetting body and mind balance [2–4]. Psychotherapy, as an indispensable element of patient care, requires proper recognition of changes occurring in the woman’s psyche during the illness, both before and after mastectomy, as well as identification of sources and stimuli intensifying these changes [5, 6]. Among the changes occurring in the psyche of a woman suffering from breast cancer, the primary one is the change in perceiving herself [4]. It is connected with the role of a woman in life, social expectations towards her as well as a current trend promoting the aspect of a perfect woman’s physicality. Cancer illness and treatment connected therewith leads, however, to a series of changes in the woman’s appearance. It may cause not only breast deformation but also noticeable changes in body weight, i.e. gaining weight connected with hormonal therapy or a drastic weight loss in spite of keeping a regular diet, leading to starvation of the organism (cachexia) [7]. Apart from body weight, changes also affect skin and hair, which falls out in the case of the majority of chemotherapies. The women striving to deal with the consequences of illness experience at the same time considerable stress [4, 8]. Numerous changes affecting the physical and psychological sphere constitute a great challenge for the majority of patients. Some of them, with support from the environment [9, 10] both of informational and emotional character, adjust to the new situation. Many of them, however, remain under considerable emotional pressure and use various defence mechanisms for the purpose of avoiding fear [5, 6, 11, 12].

Self-evaluation is one of the personal structures which is affected by the change the most. It is determined as defining the value of oneself. It is self-evaluation which affects the feeling of happiness and is a key factor in success in many areas of life. It is also an important element of success. Therefore, it is crucial to work on self-evaluation, especially in women after cancer illness. There is much research information about self-evaluation and self-image after mastectomy [4, 7, 13, 14]. From the point of view of self-evaluation referring to the woman’s physicality, the body damage as a result of mastectomy causes direct deformation of self-image, i.e. the image of the woman’s own person [4]. The problem increases when, as a result of mastectomy, there occurs disproportion between the patient’s real self and the image left in her psyche from the time before illness (retrospective self) and a perfect image. This situation may lead to deformation of a real self-image or to negation of existence of positive aspects of self in the past, which were lost or weakened as a result of traumatic experience. The difference between the self-image and reality (disproportion in self-perception) often constitutes the cause of inner conflicts. Self-acceptance is a condition of proper self-perception and creation of a proper self-image. Self-acceptance, in case of mastectomy, appears most frequently as late as in the final phase of rehabilitation, and often it is only apparent self-acceptance. During the first phase of illness the women strive to accept changes appearing in their life and organism. Accepting what has happened is the main condition of passing to a higher level of coping with the illness. In order to create a proper picture of this illness in the woman’s mind, adequate information on the illness is needed. Perception and processing information about herself as an ill human being, and about one’s life situation changed by the illness and treatment, create emotional reactions to the illness and the situation which the illness caused [15]. It is also connected with methods of personal adjustment to cancer illness preferred by a woman (e.g. confrontation or destruction strategies) which decidedly help or (when used improperly or during an inappropriate phase) make fighting with the illness difficult [11].

The aim of the study was to verify how women after mastectomy function in the area of their self-evaluation and if and how they differ from healthy women, for the purpose of maximising effectiveness of psychic rehabilitation.

Material and methods

The main question raised by the study was: What is the perception of changes in self-image in the course of cancer illness among women after mastectomy? A complementary question was also raised: Does the current self-image of women after mastectomy differ from the current self-image of healthy women and what are the differences?

A complementary question is to determine what the factual self-perception of Amazon women is and whether defence mechanisms appear or not.

The research was done at the end of 2008 and beginning of 2010. The target persons were women belonging to Amazons Clubs from Warsaw and Częstochowa. 25 women were assigned to the experimental group after mastectomy as the result of breast cancer. The women were at least one year after the surgery and were married. The average age in this group was M = 60.88; SD = 7.61. For the purpose of avoiding ambiguous situations in analysing perceived changes in self-image, the research was extended by a control group consisting of healthy women with no history of any chronic illness. The control group was selected purposefully in respect of their level of education for the purpose of ensuring a similar level of insight among the test participants. The average age in this group was M = 55.12; SD = 8.90.

The method used in the test was the H. Gough and A. Heilbrun ACL Adjective Check List [16, 17]. The test consists of five parts:

• the modus operandi scale which functions as control keys (it consists of four sub-scales);

• the scale of needs built on the basis of Murray’s conception which studies personality correlates of particular psychic needs related to behaviour observed and responsible for human functioning (it consists of fifteen needs);

• the thematic scale covering various aspects or components of interpersonal behaviour essential for personality description (nine sub-scales);

• the transaction analysis scale construed on the basis of Byrne’s theory which defined human behaviour as the expression of three basic states of ego: parental, covering two components: control and care; an adult and a child, consisting of a “a free child” and “an adjusted child”;

• the scale of originality – intelligence defining creativity and intelligence – understood as structural personality dimensions, consisting of four sub-scales.

In the H. Gough and A. Heilbrun ACL Adjective Test, interpretation of results achieved is connected with high or low scores. T-scores metric is used in Poland. It means that raw scores are transformed into a 100-degree scale with the average of 50 and deviation of 10 [16, 17].

The women tested in the experimental group were asked to do the test twice, first answering the question What kind of a woman were you before breast cancer? and secondly What kind of a woman are you now? The order of questions was considered non-essential assuming that in each case it would be possible to observe a moderating influence of a previous question. As there is no certainty whether self-images of women after mastectomy are different from those of healthy women, for the purpose of avoiding ambiguity of results, healthy women were asked to answer the question What kind of a woman are you? in order to compare it later with actual images of both groups of women.

The SPSS 17.0 package was used for statistical analysis, with the use of descriptive statistics and Student’s t-test of differences between the mean values for dependent or non-dependent samples (depending on groups compared).

Results

Differences in the range of real and retrospective images among women after mastectomy



The analysis of changes in self-perception among women after mastectomy, in the sense of themselves as women before the illness and after amputation, indicated that these changes are very insignificant. The scores achieved together with their significance level are shown in Table 1. In the range of the needs scale the women described themselves from the period before the disease as persons with a greater need of achievement and domination. A slight tendency has been also observed in the properties measured by the scale of endurance. Among thematic scales the differences in analysed self-images appeared exclusively in the scales of self-reliability and manhood, whereas in the scale of transactional analysis – a free child (Fig. 1).

The above means that these women do not register essential changes in the quality of their “being a woman” –

a breast loss does not seem to affect the feeling of losing femininity and even certain features considered masculine such as domination, the need of reaching higher and higher aims and connected self-confidence – undergo lowering in favour of more woman-like features. On the other hand, it may also be connected with some kind of overvaluation of what is important in life and getting more humble towards the unknown – which is indicated, first of all, by the scale of self-trust.



Differences in a real image between the Amazon women and women from the control group



A question was raised – is the self-image as a woman in the current perspective of Amazon women convergent with the self-image of healthy women? The answer to this question will allow us to state whether the experience of mastectomy really does not influence self-assessment in a negative way or whether certain defence mechanisms operate as well. The results of the tests of differences between average groups of Amazons and healthy women are shown in Table 2 (Fig. 2).

What is quite noticeable is that there are many scales in which considerable differences between healthy women and women after mastectomy were indicated. The way of evaluating oneself and one’s femininity is, therefore, quite different – women after the surgery evaluate themselves in

a much less positive way. The women after the operation showed a lower need of endurance: M = 46.28; SD = 9.39 than the healthy women from the control group M = 51.88; SD = 9.92, lower need of order: M = 48.80; SD = 9.36 vs.

M = 53.84; SD = 9.27, lower need of understanding oneself and others: M = 40.92; SD = 7.54 vs. M = 46.44; SD = 8.45 and a lower need of taking care of someone: M = 43.16; SD = 7.73 in comparison to the control group M = 49.40; SD = 8.72. The results also show that Amazons have a lower need of affiliation: M = 37.16; SD = 10.9 than women who did not undergo the operation M = 45.88; SD = 10.11, and a lower need for heterosexual contacts: M = 40.16; SD = 6.17 as compared to the control group M = 44.04; SD = 8.14.

Within thematic scales, the scores show that Amazons have considerably lower leadership abilities: M = 39.88; SD = 7.11 than women from the control group M = 45.08; SD = 8.72 and a lower score in the scale of femininity: Amazons:

M = 39.92; SD = 5.01; the control group: M = 47.76; SD = 9.89.

In the scales of transactional analysis, Amazons have

a lower score in the scale of educative parent: M = 45.32;

SD = 6.96 than women who did not undergo the operation M = 50.40; SD = 7.87 and a lower score in the scale of an adult: M = 44.28; SD = 6.09 as compared to the reference group M = 49; SD = 8.04.

In the scales of intelligence and originality, women after mastectomy have a lower score in the scale of high originality, low intelligence (A-1): M = 45.72; SD = 7.93 than the control group of women M = 51.24; SD = 11.45 and a lower score in the scale of low originality, high intelligence (A-4): M = 45.72; SD = 7.93 vs. M = 51.24; SD = 11.45.

Discussion of results

The scores indicate that women after mastectomy have a lower need of concentrating on insignificant things which usually fill a woman’s life. A great majority of women think that they should show such characteristics as endurance, understanding for others, protectiveness, care for home and family. Similar results were obtained in the research of other authors [18] – the women said that daily housework did not cause any problems for them; however, in the same test it appeared that physical functioning after the operation is truly weaker. In reference to the results described, this may suggest that everyday care of the household requires great effort including emotional effort.

The news about the illness and intensive treatment causes an increase in self-attention. In this time, women can experience penetration of images from the time before the illness and subordinating all the activities and thoughts to the new situation. A woman after mastectomy requires care herself, her endurance is weakened and she is tired with fighting with her illness. Concentration on the illness, the feeling of mutilation and harm, may cause that the woman has no need and is not able to understand herself. She may notice her reactions or the difference in them in comparison to former ones but she may not be interested in recognising the sources or in elimination of negative emotions as she subconsciously fears psychic pain which could accompany this process. It seems that this corresponds to the results obtained by Margolis and Partners [4], who noticed that mastectomy causes considerable deepening of depressive moods or even suicidal tendencies. It is well known, however, that the most frequent strategy of coping with unwanted thoughts is avoiding them, among others, by performing small everyday household activities.

The second – more positive – aspect of lowered level of endurance among Amazons as compared to healthy women is overvaluation of pursuit of aims for any price. The Amazon women were convinced that in some situations it was more valuable to concentrate on themselves; therefore, their need for achievement has become weaker. All the more so that, according to other research [18,19], performing a professional job may be connected with other difficulties of, for example, cognitive nature – the authors indicate difficulties in concentrating and memorising.

In the tests, moreover, the women showed a limited need for belonging to a group or searching for closer relations with other people.

Such considerable body mutilation in the form of breast amputation, causing the loss of what allows the woman to identify herself in the society and family, may cause the attitude of withdrawal from the group, isolation, and so-called self-closing. It is probably also connected with the belief (reasonable enough) of the incapability of healthy women of understanding their physical and psychic state, which makes it difficult or sometimes impossible to reach satisfactory agreement. Other scholars obtained similar results [18, 19], indicating a subjective sense of difficulties in relations with family and friends experienced after the operation.

The woman may feel the need for connecting with other women in a similar situation; however, the opposite phenomenon may appear as well. The view of other women suffering from the illness will remind her of her own fate and may cause the desire of isolation.

Mastectomy is perceived as a kind of attack on femininity. Femininity is a set of features identifying a woman. One of the strongest feeling of most people is their connection to their sex. In the case of interference with those elements which identify a woman most strongly with her sex, one may experience a loss in self-confidence of a woman as a representative of the female sex. The fact that even among Amazons whose support system is developed the most there appear considerably lower scores in the femininity scale proves how difficult and complicated the problem is. Other authors, however, state that, despite the loss of the femininity symbol, the women tested felt fully valuable as a person and as a woman [19]. It appears, however, in the light of our research, that this result may be the effect of suppressing the attempt of adapting to the new situation in such a short time after the surgery – the tests in question were conducted half a year after the surgery and the questions were asked straightforwardly, which could provoke the denial mechanism.

Physical and psychological exhaustion related to the illness may also cause that even the women who used to show leadership abilities will show lowering of their level. The necessity of devoting more attention to herself than before, the great number of fears and anxieties rising, often cause that women after mastectomy have a problem not only with organisation of their family life but also of that of their own. It is indicated at the same time that the assistance of the closest family and friends is a very important factor in the process of recovery – patients with positive assistance recover quicker and live longer [19]; therefore, partial resignation from achievements and from deciding about everything as well as acceptance of the assistance of other people serve well the purpose of recovery.

A lower score in the scale of “an educative parent” or “an adult” means that women after mastectomy feel less able to play the role of “an educative parent” than healthy women. In the face of the illness and mutilation they feel like children themselves and they require care themselves. It is more difficult for those women to take actions or decisions than for healthy women. A woman tired of fighting for her life feels that what is the most important is life as existence and close relation with the other person. At the same time, they are more dissatisfied with their situation and they have changing moods. Other people may perceive them as unpredictable and difficult in relations. It should be remembered, however, that is a method of coping with concentrated, very strong and often contradictory emotions.

Results in the scale of intraception, i.e. insight into oneself and propensity to auto-analysis, are very characteristic and at the same time distressing from the point of view of psychic rehabilitation. Women after mastectomy evaluate themselves as women of considerably lower need of insight which may impede the therapeutic process. However, it is an understandable result if we assume that the therapy and analysing own feelings can often be connected with feelings of pain and loss; it becomes, therefore, a fear building factor which women try to avoid.

The other crucial issue is the lack of differences between ill and healthy women in the range of the need for changes, getting support and following advice of others as well as autonomy. The scores indicate that women after mastectomy are strong, determined, independent and organised to the same degree as healthy women. They can also cope with stress independently in a similar way without searching for help from others. Therefore, they seem to be adjusted persons, coping well in difficult situations.

Other authors, who notice the lack of changes and good adaptation of women after mastectomy, obtain similar results [18–20]. However, in relation to a low result in typicality suggesting the possibility of assuming a defensive attitude in everyday situations and generally negative method of self perception (more negative adjectives than positive ones) it should be said that this outer seemingly positive functioning of women after mastectomy is just the result of defence mechanisms. It is worth indicating here that most tests on patients after mastectomy are not referred to a group of healthy women. This test in the range of perception of changes before the disease proves adaptation and lack of negative influence of the disease on self perception also after the disease. However, when compared with a group of healthy people, it shows that the changes exist; moreover, they strongly affect the structure of oneself. This shows the results’ similarity to the ones obtained by other scholars but not confirmed yet [19].

In other words, the fact of positive and fast adaptation of women after mastectomy and acceptance of the disease proved in numerous tests may turn out only to be the symptoms of ego defence mechanisms. A long period of maintaining those mechanisms is connected with the continuous presence of disease stressors, i.e. the fear of disease regression and health impairment.

In conclusion: the above-mentioned discrepancies between particular scores achieved by the women after mastectomy in the current and retrospective image, and also between the healthy and ill women, may lead to somewhat distressing conclusions. On the one hand, there are no differences between the self images of oneself being ill or healthy, and, at the same time, there is a great discrepancy in the current self image among healthy and ill women; at the same time, the self-image of the Amazons is not self-coherent.

It may, therefore, be concluded that the self-perception among the Amazon women – in both aspects – plays a defensive role. On the one hand, the retrospective image was adjusted to the current way of self-evaluation. It creates the feeling of losing various sources and traits desired by women and the operation made it difficult or impossible to use them as, for example, the number and quality of social contacts, a tendency to disclose and talk about themselves – even if these traits used to be intensive, currently, their role in the past was minimised.

On the other hand, the current self-image was highly adjusted to social expectations and self-expectations of the Amazons. They perceive themselves as adjusted, coping, strong and controlling what is happening around them. These are substantially social expectations, including sometimes those of members of the close family, that, after the medical treatment, everything will be well. Each woman, however, will be always accompanied by fear and anxiety of illness recurrence or metastases to other organs, which is

a sufficient reason for not gaining full psychic recovery as before diagnosis. This pressure, however, causes that the woman tries to meet these expectations and perceives or tries to perceive herself in the same way. The process of adjusting the self-image and self-assessment to external expectations is not simple, which is indicated by inner discrepancies between features presented, as for example, simultaneous occurrence of the need of disclosure (M = 47.04) and the lack of affiliation need which makes disclosure possible (M = 37.16).

Reluctance of deepened insight and attempts of self-understanding, lack of the need for changes and submission to the environmental pressure, and simultaneously, possibly strong defence mechanisms, cause difficulty in real adjustment to life in the new health situation. It seems, therefore, that, in many cases where women have such a difficulty, it is reasonable to concentrate on explanation that the situation of a woman after mastectomy is changed and she has a right to the feelings she experiences. Moreover, the closest environment of the patient should also be informed about the nature of feelings and emotions experienced by a woman after the operation, so that they could show their deepest empathy. Accepting “her new self” of a mutilated woman by the closest family will also allow her to accept herself as she is now, in a new situation, not the one it seems she should be, as this type of self-assessment is not adjustable.

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Address for correspondence



Dorota Mącik

Wyższa Szkoła Finansów i Zarządzania

Wydział Psychologii

Pawia 55

01-030 Warszawa, Poland

tel. +48 22 536 54 21, +48 22 536 54 11

e-mail: dorota_macik@tlen.pl



Submitted: 13.02.2011

Accepted: 2.12.2011