In a busy health care practice, the oncology clinician is faced with many competing demands and multiple areas of assessment, all to be conducted within a limited time frame. Body image seems like a relatively minor matter that hopefully the cancer survivor will naturally adjust to over time. Furthermore, body image dissatisfaction may not be raised by the patient during consultations due to feelings of self-consciousness and shame (Fingeret, 2010) related to the sensitivity of the topic. The inherent power inequalities within the patient-health professional relationship (Mouradian, 2001) can be a further hindrance to communication, hence the issue can be easily overlooked or left unaddressed.
Some may ask, why spend time probing this issue when there are seemingly more important topics to cover in the consultation? Furthermore, what can be offered to the individual if the answer is affirmative? Are there any effective, simple approaches that can be introduced to the patient?
Body image difficulties are not rare
Although many people do readily adjust to bodily alteration, there is also a significant subset of survivors who experience ongoing body image related disturbance. There can be impacts on body image from all types of cancers and their associated treatments. For example, up to 75% of head and neck cancer patients experience body image concerns (Fingeret,Teo, & Epner, 2014). Most research regarding body image has used breast cancer populations, and longer term body image disturbance within this group has been estimated at 15-30% (Fingeret,Teo, & Epner, 2014). Hence this article will focus on the available research and acknowledged needs of breast cancer survivors.
Why is body image important?
Given increasing levels of survivorship as treatments improve over time, the number of individuals experiencing body image disturbance are expected to increase. Body image is associated with several other psychological and social difficulties, such as depression, anxiety, relationship problems and concerns related to intimacy (Fingeret, Teo & Epner, 2014). It can contribute to difficulties in social interactions, which could include reluctance to undertake routine screening, physical examinations, follow up reviews, or to avoid these activities completely. Taken together, body image difficulties can have a significant impact on survivor quality of life (Fingeret,Teo,& Epner, 2014).
A number of programs exist for breast cancer survivors that assist with body image and bodily health. These tend to focus on physical improvement, exercise, or cosmetic enhancement. Information and guidance in these areas is certainly very useful and needed by breast cancer survivors. However, a woman’s internal psychological resources to deal with negative body image alteration may not be as readily addressed. Cognitive behavioural therapy (CBT) treatments, usually conducted in group or couples format for body image, are seen as generally efficacious (Fingeret, Teo & Epner, 2014), however, such interventions can require intense use of healthcare resources such as time, facility space and clinician availability. Moreover, such formats may not suit all cancer survivors, especially those who prefer information and intervention that does not involve face to face interaction (Ussher, Perz, & Gilbert, 2013).
What to do?
In serious and chronic health care conditions such as breast cancer, a self-management approach for the longer term is required. This optimally requires the survivor to enhance their personal resources and skills to become involved in their physical and psychological care (Schulman-Green, et al., 2011). This makes good economic sense, but more importantly works towards enhancing the confidence and self-efficacy of the individual, which in turn improves quality of life (Fingeret, Teo, & Epner, 2014).
A new approach to address body image difficulties
More recently, there has been a call for change in theoretical direction regarding body image research and intervention. In oncology, there is a growing interest in positive psychological functioning (Casellas-Grau, Vives, Font, & Ochoa, 2016), and self-compassion is a relatively new topic of investigation in this field. Self-compassion can be understood as the personal ability to direct warmth, kindness and patience towards oneself during times of difficulty, hardship or loss. To do this effectively, self-compassion is applied as a multi-dimensional concept that includes: self-kindness (the ability to treat oneself with care), common humanity (the ability to recognise that everyone has imperfection, and experiences loss, which is a normal part of human life), and mindful-awareness (the ability to hold one’s experiences in a balanced perspective without avoidance or exaggeration) (Neff, 2003). In essence, this enables the individual to actively comfort and soothe themselves once they have become aware of their distressed inner state (Moller, Sami, & Shapiro, 2019). In other words, one does not avoid, ignore or distract oneself from an uncomfortable situation, but rather directly acknowledges it, places it in the context of a wider human experience, and responds with an attitude of kindness and encouragement. A self-compassionate approach works towards decreasing shame, self-criticism, and negative self-evaluation, in order to create conditions necessary for adjustment and positive change (Sommers-Spijkerman, Trompetter, Schreurs, Bohlmeijer, 2018). Given these outcomes, self-compassion is associated with an overall improved ability to deal effectively with health problems and greater compliance with medical recommendations (Terry, et al., 2013).
A clinical question…
Reflecting on these issues while working as a psychologist in a busy cancer clinic left me wondering whether self-compassion could be accessed in a way that is private, straightforward, tailored to the person’s circumstances, and without needing the involvement of a clinician? Furthermore, would such an approach be effective in reducing body image disturbance and psychological distress in a population who had undergone multifactorial bodily changes due to cancer and related treatments? I decided to investigate these questions during my PhD research….
Applying self-compassion to cancer related bodily changes
“My Changed Body” is a therapeutic writing activity with self-compassion-based prompts, specifically designed for breast cancer survivors. The intervention draws from the expressive writing paradigm (Baikie & Wilhelm, 2005), and asks breast cancer survivors to write about their deepest thoughts and emotions related to a difficult body image experience. The individual is also guided by structured self-compassion focused writing prompts to assist them in viewing their breast cancer experience in a more kind, balanced and caring way (Przezdziecki et al., 2016). These prompts commence with a narrow focus on one’s own personal experience, and gradually widen to include taking other people’s perspectives, and then a broad overall perspective considering all possible contributing factors, with the final prompt encouraging the individual to reflect on how a self-compassionate perspective can be applied in their personal circumstances. Such an activity is brief, self-administered and performed at time which suits the individual. It can be administered in either a paper-based or online format (Przezdziecki & Sherman, 2016, Sherman et al., 2018).
What’s been found?
Evidence gathered from this research indicates:
- Self-compassion is relevant to coping with body image changes after cancer, and evidence indicates that it has a mediating role (Przezdziecki et al., 2013; Sherman et al., 2018)
- Low levels of self-compassion can be problematic for the individual (Przezdziecki et al., 2013)
- Structured self-compassion-based writing can assist with decreasing body image disturbance and psychological distress, and in addition, can improve levels of personal body appreciation in breast cancer survivors (Sherman et al. 2018).
- Self-compassion-based writing is an intervention that is acceptable to consumers (Przezdziecki et al. 2016), and benefits can be found after a single administration of the activity (Sherman et al. 2018).
Self-compassion as an effective intervention for the oncology patient is a relatively new area, but results hold much future promise. It has already demonstrated an effective evidence-based foundation. The research on self-compassion in many areas of physical and mental health is continuing to increase (https://self-compassion.org/the-research/), and familiarity with this topic can work towards enhancing patient care.
The take home message…
Compassion can be one of the most referenced, yet poorly understood, elements of health care (Sinclair et al., 2016), and the health care worker may need to extend their knowledge of this area. Discussing body image and understanding patient experiences can be an important aspect in providing quality care. There can be reluctance to discuss body image issues due to perceived complexity, uncertainty and concerns related to providing effective solutions for our patients. The clinician may also be cautious due to possible concerns about patient sensitivity regarding the topic. Research on self-compassion indicates that assistance for body image concerns does not necessarily have to be complicated and place heavy demands on resources or clinician time. Furthermore, a self-administered intervention could possibly be incorporated into a stepped care model within the health care setting.
Consider introducing self-compassion as an approach that could assist your patient. Evidence shows that guiding the survivor’s reflection, expression and narrative in a self-compassionate way, can assist with the process of adjustment to body image changes due to cancer. However, it can do much more than that – it can also assist them to reduce distress, increase appreciation of their body and help them to adopt a more compassionate overall outlook. Asking about body image is also an ideal opportunity for the clinician to demonstrate a compassionate approach themselves, as they seek to understand and relieve their patients’ concerns in a sensitive way.
References:
Baikie, K., & Wilhelm, K., (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment; 11:338-346.
Casellas-Grau, A., Vives, J., Font, A., & Ochoa, C., (2016). Positive psychological functioning in breast cancer: An integrative review, The Breast; 27:136-168.
Fingeret, M. (2010). Body image and disfigurement. In J. Duffy, & A. Valentine, MD Andersen Manual of Psychosocial Oncology (pp. 271-288). Columbus, OH: McGraw-Hill.
Fingeret, M., Teo, I., & Epner, D., (2014). Managing body image difficulties of adult cancer patients: Lessons from available research. Cancer; 120:633-641.
Moller, S., Sami, S., & Shapiro, S., (2019). Health benefits of (mindful) self-compassion meditation and the potential complementarity to mindfulness-based interventions: A review of randomized-controlled trials. OBM Integrative and Complementary Medicine; 4(1), Doi:10.21926/obm.icm.1901002
Mouradian, W. (2001). Deficits versus strengths: Ethics and implications for clinical practice and research. Cleft Palate Craniofacial Journal, 38(3), 255-259.
Neff, K., (2003). Self-compassion: An alternate conceptualization of a healthy attitude toward oneself. Self and Identity; 2:85-101. Doi:10.1080/15298860309032
Przezdziecki, A., Sherman, K., Baillie, A., Taylor, A., Foley, E., & Stalgis-Bilinski, K., (2013). My changed body: Breast cancer, body image, distress and self-compassion. Psycho-Oncology; 22(8), 1872-1879.
Przezdziecki, A., Alcorso, J., & Sherman, K., (2016). My Changed Body: Background, development and acceptability of a self-compassion based writing activity for female survivors of breast cancer. Patient Education and Counselling; 99:870-874.
Przezdziecki, A., & Sherman, K., (2016). Modifying affective and cognitive responses regarding body image difficulties in breast cancer survivors using a self-compassion based writing intervention. Mindfulness; 7:1142-1155.
Schulman-Green, D., Bradley, E., Knobf, T., Prigerson, H., Di Giovanna, M., & McCorkle, R., (2011). Self-management and transitions in women with advanced breast cancer. Journal of Pain and Symptom Management; 42:517-525.
Sherman, K., Przezdziecki, A., Alcorso, J., Kilby, C., Elder, E., Boyages, J., Koelmeyer, L., & Mackie, H., (2018). Reducing body image-related distress in women with breast cancer using a structured online writing exercise: Results from the My Changed Body randomized controlled trial. Journal of Clinical Oncology; 36:1930-1940.
Sinclair, S., Mc Clement, S., Raffin-Bouchal, S., Hack, T., et al., (2016). Compassion in health care: An empirical model. Journal of Pain and Symptom Management; 51:193-203.
Sommers-Spijkerman, M., Trompetter, H., Schreurs, K., & Bohlmeijer, E., (2018). Compassion-focused therapy as guided self-help for enhancing public mental health: A randomized controlled trial. Journal of Consulting and Clinical Psychology; 86:101-115.
Terry, M., Leary, M., Mehta, S., & Henderson, K., (2013). Self-compassionate reactions to health threats. Personality and Social Science Bulletin; 39:911-926.
Ussher, J., Perz, J., & Gilbert, E., (2013). Information needs associated with changes to sexual wellbeing after breast cancer. Journal of Advanced Nursing; 69:327-337.
