Anticipatory Mourning and Narrative Meaning-Making in Breast Cancer: History
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Contributor:
Maria Luisa Martino
,
,
Ines Testoni
,
Erika Iacona
,
Maria Francesca Freda

Breast cancer (BC) in women under 50 is a potentially traumatic experience that can upset a woman’s life during a crucial phase of her lifespan. Anticipatory mourning linked to the diagnosis of BC can produce a series of inevitable losses similar to those of the bereaved. Narration can be one tool to construct meaning, to grow through the experience, and reconfigure time perspectives during and after the illness. 

Maria Luisa Martino, Daniela Lemmo, Ines Testoni, Erika Iacona, Maria Francesca Freda and Robert A. Neimeyer

  • narrative
  • meaning-making
  • anticipatory mourning
  • loss
  • breast cancer
  • traumatic expereince
  • psychic integration

1. The Psychological IMPACT of the Breast Cancer Experience in Young Women

The diagnosis and treatment of breast cancer (BC) in patients under the age of 50 are critical and potentially traumatic experiences that can upset a woman’s life during a crucial phase of her lifespan and the achievement of her goals [1,2]. The number of people diagnosed with cancer increases every year, with BC being the most common form in women. The highest incidence is in the 34- to 49-year age group [1,2], with an 87% survival rate. Despite the increasing number of women with BC under the age of 50, the psychological literature on this specific subject, although greatly required by vulnerable and at-risk women, still appears to be extremely limited [1,2]. The diagnosis, type of surgery (mastectomy or quadrantectomy), and type of treatment (radiotherapy, chemotherapy, or hormone therapy) can engender physical and psychological issues regarding body image, fertility, early menopause, sexuality, and interactions with partners and children [3,4,5,6,7,8]. Studies link the risk of major traumatic outcomes to a more difficult psychological adaptation undermined by the fear of recurrence, a construct which has been particularly extensively investigated [9,10,11,12]. In contrast, the literature also highlights the opportunities for young women to experience personal growth during illness, transforming negative emotions into strengths, and modifying life priorities [13]. Another relevant aspect connects the psychological impact of the illness to the specific characteristics of cancer as a stressor: the intangible and internal nature of the threat, the uncertainty about the disease outcome, the unpredictable trajectories, and the chronological aspects [14], which present recurrent stressors across different phases of the medical process [15,16,17,18]. These characteristics generate an accumulated burden of adversity, which may significantly affect later psychological functioning [19].

2. The Anticipatory Mourning Condition in the Breast Cancer Experience

Despite medical advances in diagnosis and high rates of survival after treatment, still today any confirmation of BC arouses associations with the idea of death and/or the anguish of death in the affected person and in the family, making BC a life-threatening illness with internal representations [20]. Death is an inevitable phenomenon in any individual’s life, but individuals with a potentially fatal disease such as cancer demonstrate a greater anxiety about mortality as compared to people with other chronic illnesses. Patients experience anxiety during screening, when receiving a diagnosis, while undergoing treatment, and, subsequently, anticipating a recurrence of the disease. Therefore, the diagnosis of BC generates a psychological condition described as “anticipatory mourning”, studied by Elisabeth Kübler-Ross [21] and then by Therese Rando [22] and Testoni et al. [23]. Anticipatory mourning, as described by Rando [22], is a phenomenon encompassing seven generic operations (grief and mourning, coping, interaction, psychosocial reorganization, planning, balancing conflicting demands, and facilitating an appropriate death), which, within a context of adaptational pressures caused by experiences of loss and trauma, is stimulated in response to the awareness of a life-threatening illness in oneself or a significant other and the recognition of associated losses in the past, present, and future. Within the perspective of clinical psychology, anticipatory mourning can be expressed by depression, a preoccupation with the loss, and, in the case of family and close associates, an anticipation of the personal adjustments necessary to live without the dying person. Due to this anxiety, those affected also report related physical problems such as pain, insomnia, and physical discomfort and a poor quality of life. If this anxiety of death is not addressed during the treatment path, it reduces the life expectancy of the individual [24] and undermines strategies of coping with and adapting to the treatment, in particular for women, who tend to exhibit a greater level of despair, anger, somatization, depression, and death anxiety than men [25].

3. Narrative Meaning-Making and Loss: The Process of Reconstruction and Growth

Within a narrative, constructivist perspective, the experience of cancer generates a crisis affecting the basic elements that regulate the relationship between the internal and external worlds [26,27,28], interrupting the sense of continuity of one’s life story over time. The crisis affects sense-making processes that support the individual’s personal life story and continuity of life [26,29,30,31,32]. This experience imposes a narrative urgency on the mind, activating the need to synthesize new meanings and promoting the organization and connection of different elements of the experience [26]. Therefore, the device responds naturally to the human being’s fundamental need [33,34] to experience a sense of continuity and coherence by constructing stories in an intersubjective space and culture [17,18,35,36,37]. Narration is an elective tool to construct a meaning-making [38] of the BC experience and to reconfigure time perspectives [32] during and after the illness [39,40]. Narration aims to support adaptation, integrate the event, construct resources, promote well-being, and activate coping strategies [31,41,42]. These processes can be considered transformative [34] in their discursive tendency toward the search for a configuration that allows the patient to make sense, even if temporarily, of the experience of illness [26]. Importantly, the creation of meaning not only alleviates pain and distress, but also facilitates growth and well-being in the aftermath of loss, in accordance with a constructivist perspective, in which one’s sense of self is established through the stories one constructs about oneself and the sharing of these stories with others. Experiences of loss can challenge the validity of a person’s core beliefs and undermine the coherence of the narrative. Individuals can, therefore, resolve the incongruity by engaging in one of two general processes of meaning-making: either assimilating the experience of loss into their pre-loss beliefs and self-narratives or adapting to it by reorganizing their beliefs and self-narratives [38]. The literature has also highlighted how traumatic experiences, such as those related to illness, can produce post-traumatic growth (PTG) in the individual. PTG refers to a positive change in personality following events perceived as tragic [43]. A study by Walsh and colleagues highlighted the central role of PTG in the experience of prostate cancer survival. The same result was also found in children with an oncological diagnosis, confirming that growth following an oncological diagnosis is also present in young children [44]. Finally, a meta-analysis of 51 studies reported an assessment of the relationship between post-traumatic stress disorder (PTSD), post-traumatic stress symptoms (PTSS), and PTG in cancer patients and survivors. It was found that the relationship between PTSD/PTSS and PTG is moderately positive and robust. There is some evidence that the threat of advanced cancer is more closely associated with growth, but none to support the hypothesis that a longer time duration from the moment of the cancer diagnosis allows survivors the opportunity to positively reinterpret or find meaning in the traumatic aspects of the disease, resulting in a greater growth experience [45]. Considering BC as a pathology that produces a series of inevitable losses with experiences similar to those of the bereaved, Neimeyer and his colleagues [46] highlighted how attributing meaning to loss can result in an important growth process. He has developed an alternative model of bereavement arguing that the reconstruction of meaning in response to loss is the central process in bereavement [46,47]. He adopts as his starting point the view of bereavement as a process of reconstructing meaning, in line with the broader constructivist approach to psychotherapy [48] from which he derives the idea that human beings are meaning makers: weavers of narratives that give thematic meaning to the salient plot structure of their lives [49]. Through the innovative exploitation of culturally available belief systems, individuals construct permeable and provisional meaning structures that help them interpret experiences, such as bereavement or illness in this case, coordinate their relationships with others, and organize their actions toward personally meaningful goals [50]. 
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This entry is adapted from the peer-reviewed paper 10.3390/bs12040093

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