Explanation of the Spiritual Experiences of Breast Cancer Patients: A Hermeneutic Phenomenological Study

Sedigheh Momenifar , Mojtaba Habibi Asgarabad , Mohammad Abbasi 1 MSc student in clinical psychology, department of psychology ,college of human science, Saveh Branch, Islamic Azad university, Saveh, Iran. 2 Health Promotion Research Center, Iran University of Medical Sciences, Tehran, Iran. Department of Health Psychology, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran. 3 Spiritual Health Research Center, Qom University of Medical Sciences, Qom, Iran.


Introduction
reast cancer is the most common cancer in women worldwide and one of the leading causes of death (1). It is also the most common type of cancer among Iranian women (2). Diagnosis of this type of cancer can be accompanied by distinctive effects and experiences on all the physical, mental, spiritual, social, and economic aspects of the patient's life (3). In general, incurable diseases can have a dramatic effect on the attitude, way of thinking, and worldview of the patients (4).
After the diagnosis of cancer, patients undergo a variety of experiences, such as the perception of the crisis in one's whole body (5), loss of the ability to enjoy life (6), the experience of confusion, depression, despair, anger, fear, and anxiety (7,8), risk of spiritual distress (9). Moreover, they become uncertain about survival in the future, feel stressed, lack purpose, value, and meaning in life, have low self-esteem and a distorted mental image of themselves while their quality of life is reduced (10,11).
According to the results of previous studies, many cancer patients, despite undergoing negative experiences, had positive experiences as well (7,12). However, the reaction to the diagnosis of breast cancer depends on several factors, such as the individual's understanding of the nature of the disease, age of the patient, stage of the disease, type of treatment, and cultural background of the patient (13).
Zamanzadeh et al. in their study have written that "Cancer patients considered cancer as an opportunity to improve their beliefs, become close to God, and see death as a rebirth" (14). Another study referred to "the boost of spirituality after being diagnosed with the disease and sense of being selected by a higher power" as the positive effects of cancer (15).
Regarding the above-mentioned factors, cancer can lead to the growth of spirituality and the acquisition of spiritual experiences in patients. In this regard, Habibi et al. in their study titled "The Comparison of Spiritual Experience and Resilience Between Women with Breast Cancer and Healthy Women" have written that "Women with breast cancer had more spiritual experiences than healthy women" (16). In a systematic review study, Saeedi et al. examined the psychological consequences of breast cancer in Iran. They found that the psychological consequences of breast cancer were divided into eight categories, namely quality of life, anxiety, stress and tension, depression, sexual function, body image, coping strategies, fatigue, and sleep quality (8).
Most studies on breast cancer in Iran have addressed some aspects of the patients' lived experiences (12,(17)(18)(19). However, there is no comprehensive report on the spiritual experiences of breast cancer patients. In addition, language, religious teachings, and cultural attitudes can play a significant role in their lived experiences (20). Therefore, patients in a particular culture and language can have a different experience of living with breast cancer than others. Nevertheless, currently, the role of spirituality in health, illness, and patient care has become important. Therefore, the significant role of spirituality and spiritualism in the lives of the patients (21) and the requests of patients for the provision of spiritual care have led to an increase in the need to recognize and understand the lived spiritual experiences of breast cancer patients.
Recognition and perception of the lived experiences of patients lead to the acquisition of distinctive knowledge in this field (22). Moreover, the recognition of the lived spiritual experiences of the patients enables the healthcare team to understand the inner world of the individuals. In addition, it can lead to the development and progress of science and knowledge.
It is necessary to conduct qualitative studies to understand and recognize the deeply hidden layers of patients' lived spiritual experiences. Therefore, it will be possible to obtain a profound understanding of the unique lived experiences of breast cancer patients and gain knowledge in this field to take practical steps in their training and their families based on their real needs. Furthermore, awareness and recognition of the lived spiritual experiences of breast cancer patients help the healthcare team to understand the real needs of patients and their family members, and thereby be able to improve the success rate of the treatment and quality of life of patients, more efficiently.
Quantitative studies do not possess the necessary flexibility and depth required for the exploration of the patients' lived experiences of the phenomena that somehow deal with human interactions, emotions, beliefs, and attitudes. Therefore, the best way to gain a deeper understanding and recognize the depth of experience and the meaning of the phenomenon in question is the conduction of qualitative studies with a phenomenological approach (23). Therefore, the present study aimed to explain the lived spiritual experiences of breast cancer patients with a hermeneutic phenomenological approach in 2019.

Methods
The present qualitative study was performed using the hermeneutic phenomenological approach with an emphasis on Van Manen's views and method in 2019. Phenomenology as a research method emphasizes how the studied subjects experience a phenomenon. The selected phenomenon in this study was "the spiritual lived experience of cancer patients". In order to know the lived experience of these patients, phenomenology is a suitable approach to use for entering the world of patients and discovering their real experiences. Van Manen recommends six overlapping dynamic activities to guide hermeneutic phenomenological research (22).
The first step refers to the interest of the researcher in the phenomenon. The idea of "the spiritual lived experience of cancer patients" arose from the personal concern of the researcher since someone she knew was suffering from this disease.
The second step was the selection of research participants who were actually living with breast cancer. Participants in this study were purposefully selected from breast cancer patients who were treated in the oncology department of Shahid Beheshti Hospital in Qom, Iran. In total, 20 eligible participants were included in this study. The inclusion criteria consisted of 1) definitive diagnosis of breast cancer, 2) breast cancer diagnosis for at least one year, 3) history of treatment with one of the common methods for this cancer (surgery, chemotherapy, radiation therapy, or a combination of these methods), 4) no history of mental illness, 5) willingness and satisfaction to participate in this research, 5) age range of 18 years and above, 6) passage of at least one year since the start of treatment, 7) ability to understand their experiences and transfer them to the researcher, and 8) ability to understand and speak Persian. On the other hand, people with mental health problems were not included in the study.
In-depth semi-structured interviews were used to obtain the required data. The interviews were conducted individually and face to face in Persian and lasted 50-75 min. They began with a general question about the lived experiences of patients from life with breast cancer. The researcher stayed silent to allow them to share their lived experiences. In cases where there were ambiguity and need for a question in their speeches, the researcher asked them to elaborate by the provision of an example and further explanation.
The third step is to reflect on the essential themes that describe the phenomenon. At this stage, the researcher used thematic analysis to determine the main themes of the lived spiritual experience with breast cancer. To reach a thematic analysis, Van Manen has suggested three approaches, namely holistic, selective, and detailed approaches.
It is worth noting that the researcher used the two holistic and selective approaches in this study. In the holistic approach, the researcher tried to gain an overview of the experiences of participants. For this purpose, she considered each transcribed interview as a whole and wrote his general understanding in several paragraphs and read the same text several times based on the selected approach. The researcher changed the sentences or phrases that seemed to describe the phenomenon of experienced spiritual life with breast cancer in order to make them into units of meaning. The meaning units extracted from each interview were written on a separate sheet and in a column, then were placed in a separate category based on their semantic and conceptual similarities in order to extract more general and abstract expressions.
The fourth step is describing the phenomenon through the art of writing and rewriting. In order to achieve a strong description of the selected phenomenon, the researcher wrote the text of the interviews and the found themes several times in order to obtain a rich phenomenological text.
The fifth step is to maintain a strong and directional relation to the phenomenon. The researcher tries to maintain a strong relation to the phenomenon by considering the main question of the research so that any related findings were analyzed. The sixth step is balancing the research context by considering parts and the whole. At this stage, the researcher maintains the connection between the parts and the whole by using the holistic and selective approaches and focusing on the main research question with going back and forth between the parts and the whole.
To investigate the validity of this study, an effective and trust-based relationship was established with the participants. Therefore, in order to verify the data, each interview was given to the participants in the study after analysis to obtain their opinions. Moreover, this research was investigated step by step with the participation of the research team and several observers, and their helpful opinions were used in all stages. This research was approved as the first researcher's Master's thesis in clinical psychology in the ethics committee of Qom University of Medical Sciences (registration code: IR.MUQ.REC. 1397.076). While presenting the letter of recommendation to the relevant units, the researcher obtained permission from the relevant authorities to conduct the research. Furthermore, the researcher introduced himself to the participants, obtained the oral written consent of the participants, and assured them of the confidentiality of the interviews and their anonymity in the research.

Result
The results of this study were the experience of 20 participants with a mean age of 44.25±6.86 years and the mean duration of the disease of 2.51±4 years ( Table 1). The findings of this study revealed that the spiritual experiences of breast cancer patients were "return to the Holy" with the subthemes of "spiritual beliefs and attitudes", "spiritual growth and excellence", "spiritual support", and " restoration of the power of life" ( Table 2).
According to the analysis of the findings, "return to the Holy" was recognized as the main theme.

Return to the Holy
The main theme derived from the spiritual experience of the participants through the analysis was "return to the Holy." Participants declared that breast cancer increased their faith in God Almighty and caused them to return to doing things that, in addition to worldly rewards, would have a reward in the afterlife. In this regard, one of the participants stated: "I want to say that spiritually, cancer is the closest way to God." (Participant No. 7).

Spiritual beliefs and attitudes
For the participants, breast cancer was a painful event that caused fundamental changes in the biological, psychological, and religious aspects of their lives. The spiritual beliefs and attitudes of the participants in this study, considering the cultural context and religious background of the people, had an Islamic orientation which was caused by such religious beliefs.

God: infinite power
After the diagnosis of breast cancer, the participants experienced God Almighty as infinite power. All the participants considered God as the only supreme power and saw faith in the eternal divine power as the most significant sign of hope in their lives. Moreover, they believed that sickness and health are in the hands of God and whatever he deems fit will be. They were also thankful to the merciful God for His grace and mercy which was bestowed on them so that they could overcome the difficult conditions of the disease.
"When I surrender to God and rely on Him, I feel more empowered and confident so that I can continue to endure the pain and suffering that comes my way." (Participant No. 2)

Heartfelt connection with God
Heartfelt communication with God started from the beginning of the disease and when the pain was accompanied by suffering and hardship for the patients. Through this connection, the patients considered God as a healer and achieved peace by saying the daily prayers, reading Qur'an, remembering, and conversing with God. Participants believed that God heard their voices and responded to them. Based on the experiences of the participants, the first means of heartfelt communication with God was saying daily prayers. Through prayer and invocation, they were able to communicate with God and find a way to heal their suffering, which resulted in comfort and peace of mind, and they enjoyed praying in those desperate circumstances.
"Saying daily prayers comforted me more than anything during the difficult period of illness, especially chemotherapy." (Participant No. 17)

Communicate with Imams
The infallibles are close servants of God; therefore, appealing to them and asking for healing from them were some of the things mentioned by the participants. They stated that in the face of the difficult post-operative conditions and the period of chemotherapy, they saw themselves closer to God and the Infallibles at all times, and sought healing from them.
"Every day I come to the hospital with I seek help from one of the Infallibles. For example, today I started my day with the name of Imām al-Zamān. Every day I call one of the Imams and I hope that they will answer me" (Participant No. 10).
Participants also said that during their illness, they received signs of the attention of God and healing of the Imams, after which they felt better.
"It was on the night of Eid al-Ghadir that I had chemotherapy. I was not feeling very well. After praying and saying the name of Imam Ali, I fell asleep and had a dream in which I went to the house of a person who was Sayyid and there was a very beautiful tablecloth, and I went and took the corner of the tablecloth and then all my pain was over. I am sure that Imam Ali healed me." (Participant No. 9)

Spiritual growth and excellence
According to the lived experience of the participants, facing cancer was a major factor leading to the spiritual growth and excellence of most participants. Moreover, this growth was more pronounced for people who were more challenged with the disease. The participants declared that this growth led them towards a closer relationship with God, valuing and enjoying life opportunities, appreciation of their blessings, giving attention and love to others, empowerment of the body and soul by going to spiritual places, readings, and exercising. They also expressed that they had modified and controlled some of their unpleasant behaviors and paid more attention to moral virtues.

Closeness to God
Participants stated that this disease made them feel closer to God and that they felt God's presence in all the difficult stages of the disease with all their hearts. Moreover, they said that it kept them calm and gave them hope to fight for life.
"Spiritually, cancer is the closest way to God," she said, "seriously, the disease is a way to get close to God. It's really like that with any disease. Getting close to God needs great care, meaning it should be from the heart." (Participant No. 7) "When a person is seriously ill, she really feels God with all her being, that is, she needs God a lot." (Participant No. 15)

Life as a unique opportunity
Participants said before learning about their illness, they were hopeful about continuing their lives and living long lives so that they were always postponing their plans. However, after their diagnosis with the disease, they became aware of their negligence and realized that they might have less time to do what they have always wanted to do. Therefore, they realized that they should appreciate every moment more than before and make the best use of it, and think more about their lives in this and the next world.
In this regard, one of the participants said: "But it seems that now I pay more attention to praying and remembering God. Now I also try to say my prayers as soon as I can." (Participant No. 8) "In fact, cancer teaches us that our lives are temporary, that we should make good use of every moment, and use this time and each moment to make God happy, and that we should enjoy life." (Participant No. 7) "It was a gift from God to wake me up from my slumber," she said, "God has shown me another path now. This disease led me in the right direction." (Participant No. 1)

Empowerment of the body and soul
One other spiritual experience of women with breast cancer is the empowerment of the body and soul. The participants stated that having a strong body and soul, both during and after the treatment, is an important factor in the face of disease, and each of them, according to their mood, referred to some activities to strengthen the body and soul, some of which are mentioned later. The participants said that going to the shrines of the Imams and mosques, increased their energy and elevated their spirit, which calmed them down and made them feel good about life.
"Every time I went into the shrine, I would pray to Hazrat Masoumeh to heal all the sick people. Honestly, I never prayed for myself before, and maybe I never remembered myself. I always prayed for others and it calmed me down a lot." (Participant No. 10).

Spiritual support
Participants said they were spiritually supported by their family, friends, and the healthcare team. They said that due to their disease and its negative consequences, they needed more support and attention from others to maintain their morale in the treatment process and become stronger against suffering and disease. In addition, the more support they received, the more hopeful and powerful they became in the face of the disease.

Support of family and friends
The first sub-theme of spiritual support was the support provided by family and those around the patient, which was referred to by most of the participants. Most of them considered themselves dependent on their families and their support in the face of illness, stating that the support of family members and those around them helped them in different moral, emotional, and spiritual ways to maintain their morale and stay hopeful.
The spouse and children are the closest ones in a married woman's life, and their presence and support in difficult situations are very effective. Most of the participants in the study said that the help and support of their spouses and children during the disease were soothing and gave them hope. Moreover, the participants also acknowledged that in addition to giving hope and vitality, they had the utmost intimacy and empathy with them. "My children were very helpful and may God bless them, are very helpful even now. Now my son is coming here to make an appointment with the doctor because going to the doctor's office is very expensive so he comes here and makes an appointment for me in the hospital which is cheaper." (Participant No. 11) Participants said they had received more support from their family members since they became ill so that their effective support made them feel valued and at ease. "In the days of chemotherapy, my girls come to my house with their husbands who would go to the kitchen and made me juice. I didn't expect anything from them at all. I felt like they were supporting me. My husband went for my medicine, did his job, worked at home, and supported me and the kids. I felt like they were all supporting me, and that made me feel calm." (Participant No. 1).

Support of the healthcare team
Participants acknowledged that the appropriate treatment of the healthcare team was an important supportive requirement in coping with and adapting to the disease. Moreover, they declared that it provided peace of mind and helped them maintain morale. Some participants reported that the nurses had a good emotional connection with them and motivated them to recover and continue their treatment.
"Every time I came to the hospital I cried a lot, but the nurses were very comforting. They talked very kindly and gave me hope to continue my treatment." (Participant No. 3) "When I come to chemistry, the behavior of the nurses here is very good. When they want to connect my head, they do it by mentioning the name of God, the Most Merciful, the Most Compassionate. They always say that you will be healed in the hope of God, which helps us have peace of mind and keep our spirits up." (Participant No. 20) Participants declared that the presence of a faithful and energetic doctor in their difficult situation was the cause of their calmness and positive energy.
"Right there, I thanked God that the doctor who was doing my job was faithful, energetic, and positive, which was what kept me going." (Participant No. 5)

Restoration of the power of life
Restoration of the power of life was another spiritual experience of the participants in this study. Participants had accepted and agreed that breast cancer was a test from God. They were satisfied with God's decision and declared that death and life are in the hands of God.
With this in mind, the participants accepted and then fought the disease. They believed that in the face of the crises in life, we should not surrender and be overwhelmed with despair and fear since if they stay for a long time they will have destructive physical results which will harm the body's immune system against cancer. However, hope uplifted their spirit and helped them to return to their normal lives.

Confrontation with the disease
Most of the participants accepted the disease as a divine destiny and a test from God. They believed that the disease was a fate that God had determined for them and by which He wanted to test them. Therefore, they should strive to succeed in this test.
"I always say to myself that what's happened to me must be God's will and expediency that He wanted to test me in my life in this way, and I say to myself that death and survival are only in God's hand, and these diseases are just an excuse." (Participant No. 1).

Acceptance of the disease
Based on the experiences of the participants in this study, one of the most important ways to deal with this disease is to accept it. They accepted it through fighting and coping with the disease, stating that their morale had improved since it could have been even worse than this.
"I said to myself, God puts us in difficult situations that He thinks we can survive. So I must have had the strength to fight that he chose me. Then I promised myself to fight with this disease and survive it. Survive it for myself and for my family." (Participant No. 17).
"This has happened now like I've had a cold or Pharyngitis. Now I have to take medicine for a while and rest until I'm well again. That's all I was saying to myself." (Participant No. 1)

Hope, the axis of resistance
One of the methods of fighting cancer is to think positively. Hope, as one of these methods, is the axis of resistance to continue living in cancer patients.
The participants stated that they were hopeful when they were fighting the disease and fought hard to get through the difficult stages. Moreover, each participant with their own way of managing their minds mentioned some methods of the maintenance of hope.
"I saw hope in my little boy, and the sense of caring for him gave me the strength to survive and fight the disease." (Participant No. 13)

Discussion
The findings of this study revealed that the spiritual experience of breast cancer patients was " Return to the Holy " with the secondary themes of "spiritual beliefs and attitudes", "spiritual growth and excellence", "spiritual support", and "restoration of the power of life".
The participants experienced a new spiritual life after breast cancer since it had many positive effects on them. They chose the path of spirituality and decided to have a spiritual life. In this regard, in a study about the psychological characteristics and hope for the future in women with breast cancer, Soroush et al. have written that some patients after breast cancer experienced extroversion, socialization, intimacy, altruism, flexibility, spiritualism, and positivism (7).
Nikmanesh in a study titled "Prediction of Post-Traumatic Growth According to Spirituality, Social Support, and Positive Affection in Patients with Breast Cancer" has stated that spirituality and social support affect posttraumatic growth in breast cancer patients (24). In this regard, Mohammad Karimi and Shariatnia have also written that religiosity and spirituality help breast cancer patients answer their questions about life and its meaning (25).
About the adaptability of patients with breast cancer before and after the treatment, Sajjadian et al. have stated that patients with breast cancer use a spiritual strategy to adapt to the disease (26). Mehrabi et al. in their study titled "Religion, Spirituality and Coping with Breast Cancer: A Phenomenological Study" refer to the experience of patients by saying that Patients experienced "transcendental endeavor" after breast cancer (27). From the results of the present study and other related studies, it can be concluded that most patients after experiencing breast cancer tend to become spiritual and experience spiritual lives.
The participants in this study talked about their spiritual beliefs and attitudes after breast cancer. They referred to their further focus on the eternal power of God in life after breast cancer and the heartfelt connection with God and the Infallibles. Their experiences reflect the outstanding role of spirituality in overcoming this stressful event. They mostly used the strategies that were rooted in Islamic culture to adapt to their illness.
Therefore, the healthcare team should pay attention to the cultural background and opinions of breast cancer patients. Religion is intertwined with the culture and life of the Muslims, and religious beliefs play an important role in their lives, especially in the face of crises (14). According to Mehrabi et al., the participants had a spiritual attitude towards cancer and believed that God wanted them to have this disease and that they will gain their health by relying on God's eternal power and trust in Him (27). A heartfelt connection with God and the Imams was one of the experiences of the participants in this study. The results of other studies conducted in the Islamic cultural context have revealed that patients sought help from the Infallibles and communicated with God by praying, calling his name, vowing, and asking for help (20).
The participants experienced spiritual growth and excellence in their lives after being diagnosed with breast cancer. Each of the participants had experienced a kind of personal development and spiritual growth, stating that they felt closer to God and considered the continuation of life as an opportunity that God provided for them. Furthermore, despite the difficulties of this disease, they had taken advantage of this opportunity to grow.
In a study, cancer patients referred to spiritual excellence as one of the experiences of living with cancer. Moreover, the participants of the aforementioned study mentioned cancer as an opportunity for the improvement of spiritual beliefs and closeness to God almighty (14). Furthermore, in another study, breast cancer had led patients towards self-improvement and spiritual growth and change of their attitudes towards the values of life (28).
The spiritual growth and excellence of the participants of the present study were the result of the empowerment of their bodies and souls by attending spiritual places, studying, exercising, walking, and having fun. They said that by engaging in these activities, they felt better so that their pain and psychological stress were reduced and they became more hopeful for recovery.
They also argued that strengthening the body and soul in the light of spiritualism has helped them to prepare themselves for the various stages of healing and return to their routines. They attributed the health of the body to the health of the soul and considered the health of the soul to be dependent on spirituality. Presence in spiritual and religious places made them feel secure, increased their self-confidence, and prevented them from drowning in despair and encouraged them to work harder. Religious rituals had led to an increase in their heartfelt confidence and assured them that they will never be alone since there is a superpower that is always alive and present and can meet all human needs.
The participants also spoke about the experience of the perception of the support provided by family, friends, and the healthcare team. They expressed the support of family and friends as their main need in the face of cancer. They believed that having the spiritual support of those around them gave them a sense of security, empathy, and intimacy, and helped them have a better sense of hope and well-being.
Regarding the importance of social support in breast cancer patients, Dina Abadi and Dolatian have written that social support has a significant impact on the progress, treatment, and improvement of breast cancer (28). The results of a study by Taghavi et al. revealed that "the effective role of social support and religious adaptation in reducing the symptoms of depression in women with breast cancer" (29). Moreover, the participants of another study noted the role of family support in improving the patients (20). Family support is one of the key points for women with breast cancer which is very effective in managing their stress (30). One of the tools that cancer patients can use to improve their quality of life and overcome their disease is social support (31).
Participants of the present study stated that their illness was a test from God, by which He wants to test His servant. Therefore, they accepted it as a divine destiny and were satisfied with it. They also considered illness and health to come from God and believed in God's will as a superior force. These beliefs reflect the attitude of Iranian women with breast cancer in dealing with this disease which is rooted in their Islamic culture and religious beliefs.
The belief in divine destinies led to easier and better acceptance of the disease and adaptation to its dire consequences. Moreover, the patients also decided to defeat the disease by fighting and coping with it for the love of their children and family. In this way, they were able to endure the hardships and sufferings of the disease more easily and continue their normal lives like other people. When people accept that they have cancer, they often find hope. Hope is what cancer patients need to challenge the disease. Hope plays an important role in all the stages of growth and development of human life. The patients acknowledged that the prospect of living and returning to a normal life had given them a great deal of motivation to recover and deal effectively with the disease.
One of the limitations of this study was the interview with Shiite Muslim patients, which limits the generalizability of the findings of this study. Therefore, it is recommended that another study be conducted with the participation of individuals from different religions and sects.

Conclusion
Based on the findings, the spiritual experience of patients with breast cancer was a return to the Holy. Living with breast cancer had changed the path of their lives, beliefs, and spiritual attitudes. Besides, it had caused their spiritual growth and excellence. With the perception of the support of family members and the healthcare team and with hope for the future, they began to live again. The healthcare team can use the findings of this study to develop educational plans and spiritualitycentered services for breast cancer patients.