Breast cancer is the most frequent cancer among Polish women and the second most fatal. Developing cancer involves feelings of stress, fear of dying, uncertainty, unpredictability, and a sense of a constant threat to one’s life (Gurevich, Devins, Rodin, 2002). Cancer causes dramatic changes in the life of the patient and their family, and the diagnosis that confirms the existence of a tumour may affect the sense of control over one’s health (Astin et al., 1999, Mystakidou, Tsilika, Parpa, Galanos, 2015).
The loss of the sense of control may result from situations of stress and uncertainty when we are unable to make decisions or are deprived of such possibilities by factors beyond our control. The sense of lack of influence on the treatment process and on the cancer itself may be the reason for the feelings of fear, helplessness, and depression. A patient who is afraid about their chances of survival may experience the need to seek information about their condition and the chances of recovery. As a result, a sense of control is an important psychological resource that influences the ways of coping with stress effectively by oncology patients at all stages of the disease: diagnosis, treatment, and after the end of treatment.
The internal sense of control convinces the patients that they may have an influence on the emerging crises (Kay, Gaucher, McGregor, Nash, 2010). The sense of empowerment is related to the sense of safety, stability, coherence, and the belief that no situations happen by chance. A patient who has an internal sense of control believes that their experiences and illness are a result of their own behaviour or logically explained events. They believe that they understand the causes of the disease and feel that their actions may influence the treatment process (Sharif, 2017).
The internal sense of control is linked to coping and adapting to the disease, depending on the chosen time perspective. If the internal sense of control is oriented towards influencing present and future situations, those cancer patients are better adapted to the situation of illness. However, if the given individual decides to focus their internal sense of control on the sense of influence on past situations, this results in a stronger feeling of anxiety and worse ability to cope. The internal positioning may improve the adaptation to illness if the control over the problem is realistic, but it may be counter-adaptive if there are difficulties in exercising personal control (Mystakidou et al., 2015).
The internal sense of control together with community support, have a significant influence on the course of treatment of oncological patients. They give the patient the conviction that the control over the health situation depends to a major extent on their own actions, while the support of friends and relatives ensures assistance and motivation in fighting the disease (Juczyński et al., 2000).
Fatalist loss of control in a crisis (such as developing cancer) may result in delegating the internal source of control over one’s health to external sources of control such as the healthcare personnel, support groups, family, or a divine figure (Kay et al., 2010). If the source of control is external, the patient believes that their illness is a result of external factors (such as the state of the environment, other people, or act of God), which, in their opinion, cannot be foreseen or controlled (Burish, Meyerowitz, Carey et Morrow, 1987; Mystakidou et al., 2015).
Patients with an external sense of control may position the reasons for their illness beyond their personal control and responsibility, which allows them to avoid feeling guilty. Individuals, who attributed the reasons for their illness to themselves, experienced a worse mood and were less adapted to the situation. Attributing the reasons of illness to external factors allows the patient’s sense of empowerment to remain intact and prevents the patient from feeling guilty that they are unable to deal with the illness on their own because the cause of cancer was independent of them (Mystakidou et al., 2015).
In situations of a deteriorated internal sense of control, the patient may search for alternative sources of control, such as a controlling God (Kay et al., 2008, in: Kay et al. 2010, Pargament, Kennell, Hathaway, Grevengoed, and Newman, 1988). In such cases, God is understood as a figure that is capable of exercising total control over life. As religious beliefs may serve as a source of both external and internal control, they cannot involve only the role of a controlling, supervising God. Internal religious control may make the individual more self-confident and give them a stronger feeling of empowerment (Allport, Ross, 1967, in: Kay et al., 2010, Pargament, Smith, Koenig, Perez, 1998).
People who seek compensation in secular sources of control may put more trust in the actions of the government, doctors, and all secular institutions that may offer them a sense of control and stability in a situation that contributes to the feelings of stress and helplessness. What is important, the sense of belonging to a supportive community may also be an external source of control (Kay, 2008, in: Kay et al., 2010).
Psychological situation in the group of women in the course of chemotherapy
Chemotherapy is one of the main methods of cancer treatment. This kind of treatment involves side effects that are not only physical, but may also be of a psychological nature (Puchalska, Sierko, Sokół et al., 2011). One of the best-known side effects of chemotherapy is hair loss. This problem is still considered to be a traumatic experience, which is closely linked to the sense of attractiveness and aesthetics of female breast cancer patients (Zielińska-Więczkowska, Betłakowski, 2010; Terelak, Krzesicka, Małkiewicz, 2009). What is important is, hair loss does not only affect the scalp. As a result of treatment, the patients may also lose their eyebrows and eyelashes. Chemotherapy results in the deterioration of one’s own body image, self-esteem, self-confidence, and the sexual life of the patient, which is reflected in their quality of life. Other commonly reported side effects of chemotherapy include sexual disorders, problems in relationships with partners and negative perception of oneself (Charalambous et al., 2017). Apart from the problems related to hair loss, chemotherapy may also cause weight loss resulting from nausea, lack of appetite, diarrhoea, frequent vomiting, and increased sleepiness caused by exhaustion (Manterys and Błażek, 2021). What is interesting, patients who receive steroids together with chemotherapy report significant weight gain, which may also worsen the satisfaction with their body image (Lemieux, Mausell, Provencher, 2008; Kim et al., 2012; Nies, Ali, Abdullah, Islahudin, Shah, 2018; Juczyński et al., 2000).
Numerous side effects of chemotherapy often lead to feelings of sadness, anxiety, and shame, as well as states of depression. As a result, the patients prefer to isolate themselves from the society and loved ones, thus deteriorating their mental condition even further.
How they experience the side effects of chemotherapy depends not only on the type and dosage of the drug, but also on the fear of hospitalisation, strategies of coping with stress, the knowledge about the treatment process and condition and social support received from healthcare personnel, friends, and relatives (Gibbons & Groarke, 2018; Yaelim et al., 2019). Educating the patient about the applied treatment is essential. Patients who do not have a firm grasp of their chemotherapy treatment may fear that they do not know the side effects, they may be afraid of how their bodies will react and what changes they will undergo. Due to that, some of the patients may ignore the doctor’s recommendations and decide to use alternative (often non-medical) forms of treating the cancer, out of fear that they might die because of chemotherapy rather than cancer (Kwok et al., 2015, in: Nies et al., 2018).
Psychological situation in a group of women during a rehabilitation camp
After the end of oncological treatment, the doctor may refer the patient to physical therapy. The deterioration of health caused by the whole treatment process may lead to difficulties in both physical and mental functioning. As a result, many patients decide to go to physical therapy to return to a better condition.
In theory, successful completion of the treatment process should result in a state of joy, relief, and a sense of internal peace and safety. However, patients continue to report anxiety connected with the loss, illness, and fears concerning recovery. Moreover, they report difficulties in discussing their problems and illness with their loved ones, which makes it difficult to fully recover and to accept the changes that result from the treatment process (Taylor, 1984, in: Juczyński et al., 2000).
The end of treatment, which, theoretically, should evoke a feeling of safety, does not end the continuous stress, because former patients start to worry about potential relapse, even if the prognoses given by the doctors are good. Moreover, patients feel stress caused by fear of returning to normal social and professional life. The changes in their bodies that were caused by the illness may require changing their image, to mask the effects of treatment (e.g., mastectomy, hair that does not grow back), which leads to discomfort that hinders the return to spending time with family and friends. As far as their career and economic situation are concerned, patients often worry that they will not be able to return to a similar state from before they fell ill. Problems related to returning to life without illness also include relationships with children. Patients may worry about their children, specifically, whether they have inherited the genetic mutation that significantly increases the chances of developing cancer. This may lead to increased fear in parents who have undergone oncological treatment. Although the woman’s situation apparently improves, she still has to cope with stress after the end of treatment (Juczyński et al., 2000).
Participants of rehabilitation camps may experience tiredness, weakness, and distress connected with the whole treatment process. As much attention has been paid to chronic fatigue in patients who have undergone oncological treatment, the work of a psychologist plays an important role here. The task of such a specialist is to work with the patient to improve their quality of life (Silver et al., 2015).
Psychological situation of women who have been in remission for at least 5 years and belong to the “amazon club”
The Amazon club is a secular self-help organisation whose aim is to provide support for women who have completed oncological treatment and whose bodies have changed as a result of the process (often in an irreversible way, e.g., after mastectomy) and who experience psychological problems. The Club has about 15 000 members who belong to 190 clubs throughout Poland. The name “Amazon” originated from the mythological Greek tribe of women who had their right breasts removed to improve their archery skills (Samson, Jansen, Notermans, 2015).
Membership in the Amazon Club gives its members a sense of support and belonging to a community because it directly translates into their activities and sense of empowerment. Patients who belong to the Club support each other through social campaigns, community religious practices, forms of self-help inside the group, and working with psychologists. The psychological challenges that members are confronted with include helping other members of the club in recovering their self-confidence, and the need to redefine their identity and image as a woman. Participants may experience fear of returning to social life and they need to recreate the sense of femininity that constitutes an element of their self-esteem (Samson et al., 2015). What is important, the involvement of their partners has a positive influence on returning to social life and nurturing social relationships (Nowicki, Kwasińska, Rzepka, Walentynowicz, Grabiec, 2009).
The association considers religion to be one of the important pillars that help women who are recovering. This is why it organizes pilgrimages to places of religious worship. Every year, around the 2nd -3rd of November, members visit the Black Madonna in Czestochowa. The community created by club members may offer them an internal sense of support and belonging by means of participating in events with the aim to improve the well-being and the sense of their own identity that is being restored by the internal support inside the group, which is a vital element of the life of the “Amazons” (Samson et al., 2015).
Aim of the study
The study aimed to determine the factors that contribute to the loss of the sense of control over one's life. It was predicted that the fatalistic loss of control will: (h1) be negatively correlated with the number of planned projects and the confidence in the implementation of these projects; (h2) will grow with the duration of the illness; (h3) will be linked to a weaker faith in an active God or in the effectiveness of doctors (compensatory sources of control; and (h4) will be connected to delegating control to God.
Participants
The study was conducted on 132 women who were divided into 3 groups, depending on the stage of disease or completed treatment. The first group was composed of patients who were undergoing oncological treatment in the chemotherapy ward: 42 persons aged 27 to 75 years. The second group included women who had completed treatment and were in the physical therapy ward: 39 persons aged 28 to 86. The last group consisted of 51 members of the Amazons’ Club, aged 32 to 81. The research was conducted at the Voivodeship Oncology Centre in Gdansk, at the day wards of chemotherapy and physical therapy and in the branch of the Amazons’ Club in Gdansk. The participants filled out a printed questionnaire.