Getting Out or Remaining in the Cage of Inauthentic Self: The Meaning of Existential Challenges in Patients' with Cancer

INTRODUCTION

The importance of cancer is obvious to everyone in light of the changes in its prevalence worldwide, and its impact on family, economy, and society.[1]

Cancer causes a person to become physically weak so that one cannot tolerate her/his disabilities. In addition, the symptoms and the side effects cause the person to think about his/her death.[2] Thus, in many cultures worldwide, cancer is still associated with the concept of death.[3] Therefore, cancer develops a range of existential challenges in a person.[4] Existential tensions in patients with advanced cancer are even greater than their psychological tensions.[5] As cancer threatens patients' life, patients encounter an existential uncertainty so that they do not know whether they will be alive in the coming moments or not.[26] This deep understanding of both being and not being at the same time, causes the patients to repeatedly encounter some existential questions such as why me?, If I am to die, why was I born?, and what is the meaning and purpose of life.[78]

In this stage, if the individual fails to find the meaning, he or she will be occupied with existential predicament.[9] The authors use various equivalents for existential tensions such as existential predicament, existential crisis, existential suffering, spiritual suffering, and spiritual pain [1011121314] Existential tensions are life experiences with low or no meaning,[9] which lead to a sense of deep separation between the person and himself, others and the world.[6]

Bruce et al.[11] and Bilderman (2005) have shown that the existential crisis refers to the circumstances in which a patient experiences problems such as frustration, feelings of frivolity, meaninglessness, regret and blame, death anxiety, disorder in personal identity and proposes the question “Why me?”[111415] also argues that being aware of mortality (the main characteristic of the existential crisis), the loss of the future and opportunities of life, lead to fear, anxiety, and panic. Disappointment, loneliness, disability, and cognitive crisis are also issues that occur in this crisis.[1416] Mount considers the existential crisis as a split between the person and the previous reality, which results in a change in the person's attitude and lifestyle.[17] However, despite the fact that there are numerous attempts to define this concept, Boston et al.,[18] Sand and Strang [19] and Strang et al.[20] state that a precise definition has not yet been provided.[181920] Bruce et al.[11] reported that during the existential crisis, patients experience concepts such as groundlessness or, in other words, breaking from within, and then, the concept longing for Ground in a Ground (less) World is proposed. In this stage, the person experiences a feeling of groundlessness, and this propels the person to attempt to achieve an existential stability that prompts him to seek a way to understand what life is.[11]

Although a great deal of research has been done over the last few years on the existential challenges in patients with cancer, there are still many deficiencies in the care of these patients.[21] For providing a better palliative care, a deep understanding of the patients' psychological pain near death is necessary.[22] (Mardani-Hamooleh and Heidari, 2016). Therefore, care providers should receive accurate and rigorous training in this reality.[1023] Based on Newman and Watson's theory, both the length of time a nurse passes alongside the patient, as well as interviewing and listening to the patient, are parts of holistic nursing care.[2425] Unfortunately, there is no clear theoretical framework for understanding the nature of existential crisis, and there are not any protocols or therapeutic interventions for relieving these people's pain.[26] According to Henoch and Danielson,[21] there are few qualitative studies in this area.[21] Studies in the field of existential challenges in cancer patients are often quantitative and in our country there is a lack of qualitative research in the field of existential challenges.[27] Phenomenology is one way of studying phenomena within a culture. The methodology seeks to focus on a person's experience, previous understanding and knowledge, which are embedded in culture and religion.[28] Thus, this phenomenological hermeneutic study was conducted to illuminate the meaning of existential challenges in patients' with cancer in Iran.

SUBJECTS AND METHODS

Participants and setting

From autumn 2016 to spring 2017, patients who had cancer were interviewed. Patients had referred to three hospitals affiliated with Kerman University of Medical Sciences for undergoing therapy. A purposive sample of participants, who had experience of cancer (leukemia, non-Hodgkin's Lymphoma, colon, pancreas, and breast cancers) participated in the research. They were selected through a chain sampling approach; a key informant recommended one person who in turn, recommended another.[31] On average, the participants had 9 months to 4-years-experience of cancer. The mean age of participants was 45.7 years [Table 1].

Table 1 Characteristic of participants

RESULTS

The results section in this study includes three stages of (1) simple and fast understanding, i.e. naïve understanding, (2) structural analysis, and (3) comprehensive understanding.

DISCUSSION

Cancer can be considered as light radiation which reveals the inauthentic self in the person and leads to existential challenges and the disappearance of the ego. Existential philosophers have defined cancer as a borderline. As Jaspers argued, the boundary situation occurs when a person faces situations such as death, feeling guilty, suffering, misfortune, etc., and this causes a person to encounter some paradoxes in his or her life.[33] Heidegger also believes that the situations which disturb the person's life and make the values meaningless are borderline situations.[3334] According to Jaspers, the borderline situation sometimes allows people to reach the final position, and the final position, from his point of view, is the same as the failure position. The failure means you cannot escape from it because it is your fate. However, the point is that failure can be genuine. In fact, authentic failure must happen spontaneously. It is only in an authentic failure that the person finds himself again, and an authentic dialog is reached between himself and that position.[35] Kierkegaard even considers failure to be a gift from God. In other words, brightness and light are achieved only when it is “broken,” but this “broken” light does not exist unless we consider that “broken” beam as a sign.[36] Heidegger also considers memento more as an authentic value. In fact, he believes that such an authentic life, which is based on the relationship between the persona and the universe, is meaningful. This authenticity has two salient characteristics. The first one is being aware of the fears and response to the call of conscience and the second is the autonomy and concentration. However, inauthenticity refers to the fact that the person has not realized his life.[33] The two salient features of this inauthentic self from Rumi's point of view are neglecting death and sinking in daily routine.[33373839] In fact, it can be said that one's attitude toward death determines the authenticity or inauthenticity of his or her life.[37]

According to the experiences of the participants, when a person faces cancer, he or she suddenly goes into shock and this disturbs their daily mental thoughts. He or she has already been considering himself or herself as the ego and has been sunk in daily routine. However, the cancer, as an impact, has destroyed this imaginary wall. According to Comprehensive Medical Care, Ventegodt, one of the pioneers of comprehensive medicine, explains that the necessary condition to cure cancer is achieving the real self. He says that you must abandon the efforts, values, goals, and daily routines, which are considered as the inauthentic or imaginary self, in the life before cancer, to face the authentic self.[4041] About memento mori and facing death, Rumi says that the unreal self is like a shadow or illusionary ghost that has been formed in darkness and ambiguity due to lack of observation and scholarly search.[42]

According to the results of this study, people, following the collapse of this imaginary wall, start looking for the meaning of life and questions such as “Why was I born?” are formed in their minds. Boston et al.,[10] McSherry and Cash,[43] Mackinley [8] and Wise et al.[6] also argued that the existential crisis means losing the meaning and purpose of life and finding new meanings, as well as the desire to answer questions like “Why am I here?,” “What is the purpose of my life?,” and “What happens to me after death [681043] Martela and Steger [44] has defined the “meaning” as “the goal and purpose.” He states that one should look for the meaning of his or her life, something beyond the daily routine. Another meaning of the word “meaning” is “value, importance, and credibility.” In this case, the question “Does life have meaning?” means that what is considered as a value in life or the values and credits which are important in everyday life can actually make life meaningful.[44] Ventegodt et al.[45] in his Life Mission Theory states that the nature of human is his purpose of life which the concept of existence is based on. One of the goals that a person is born with is the aspect of protecting life and another one is destructive and evil goals in life.[45] Some patients, according to their own experience, compare themselves with other patients who are in the final stages of the disease and see themselves closer to death, so they become afraid of what is going to happen in the future. They also think about the past and feel guilty. They blame themselves and look for a reason for becoming ill. They see their way of living and even their sins and deeds as the causes of their disease. From Rumi's and Heidegger's views, three nonauthentic qualities are comparing the self with others, hanging on to the past, and fear of the future.[37] Rumi believes that the basic characteristics of life with the nongenuine self are escaping from death and neglecting it and sinking in daily routine, a person who has not been aware of his or her life and has always decided without awareness and thinking about death.[37] Woodward [46] and Mosaffa [42] also state that ideas, values, beliefs, and their way of thinking about themselves are only images that have been implicated in the mind. Fear of death, destroys this imaginary, and mental identity.[4246] After these values and credits disappear, the person thinks that he or she has not achieved his or her goals yet and he or she is faced with the fear of failing to meet the demands of life.[47] Bruce et al. also state in their study that when people are faced with cancer they feel futility. They also complained about disturbing thoughts such as not traveling and failing to meet the goals ahead.[11] Some of the researchers mentioned that the sense of approaching death is considered as a kind of depression and is related to human psyche.[23] Lichtenthal's study (2009) also distinguishes between the psychological suffering and the existential challenge. In psychological suffering, such as depression, the patient does not have anxiety and proximity to death, but in existential challenges, he finds himself close to death.[5] However, Boston et al.[10] states that we cannot say with certainty that such concepts are existential, psychological, or spiritual challenges because they can be found in each of these areas.[10]

According to what was mentioned, another issue that hurts patients mentally is considering the self as the physical body. In addition, challenges such as hair loss, breast removal, and sexual dysfunction are among these challenges, and a study by Pakseresht et al.[48] and Ussher et al.[41] confirms this [4849] In this regard, Mako et al.[50] based on the experiences of cancer patients stated that understanding the self and relationship with the body can be seen as a crisis or spiritual suffering.[50] However, Blondeau et al.[51] states that in some studies, the concept of mental image damage has been separated from the existential challenges and is considered as physical suffering.[51] In this regard, we can refer to Goffman's theory called Symbolic Interactionism. According to this theory, in everyday life, the first impression is very important. Appearance, which is visible and appealing to both one's own person and to others, can serve as a mark for interpreting the action.[52] Veblen also states that in the society, the value of objects is measured according to their beauty and this is considered as a credit for people.[53] Therefore, beauty is considered to be a value or credit in societies, which, according to those who became aware of this beauty and its loaned nature, are the greatest devils, and when they are admired, they grow up and become greater so that it would be quite difficult to overcome them. When that magnitude breaks down, these values and credits lose their meaning. According to the theory of panic management, facing death is a threat not only to “the physical self “but also to the” the symbolic self.” Death disturbs the credits and values that have been formed through life and made “the self” and “my being.”[54]

In this study, people suffer from uncontrollable emotions that could be considered to be the side effects of considering the ego as the self. Responses such as denial, anger, depression, and a sense of loneliness after this mental disintegration have occurred to these people according to their experiences. Bruce et al.[11] also, according to the participants' experiences in their study, state that fear, unanswered mental questions, concerns, mental disorientations, and pain are the main problems of cancer patients.[11] They mention that this experience is not similar to any previous experience and none of the compatibility mechanisms that they previously used are effective for accepting this issue.[11] Pynn [55] also states that cancer is followed by fear and anxiety,[55] and Zebrack et al.,[56] Henoch and Danielson,[21] and Yang et al.[14] state that cancer can lead to serious mental issues, including awareness of finitude and fear of facing death, dissolution of the future, loss of meaning, fear, anxiety, stress, phobia, panic, despair, disappointment, loneliness, and powerlessness [1421555657]

According to the results of this study, most people after receiving their diagnosis, show reactions such as sadness, crying, anger, aggression, and even suicide. They also ask themselves “Why me?” “Why should I get cancer?” and they think that this is not fair. Bruce et al.[11] and Mackinley [8] also state that frustration, anger and aggression, breaking the beliefs, forming questions such as “Why me?” Why did I become ill, I have always tried to be a good person? Are among the challenges of cancer patients.[811] However, in Bilderman's study, patients have stated that they have never asked “why did I become ill?” They believed that there is not something called “me,” and they felt free because they believed that they had reached “no self.”[15]

Having formed these questions in the mind of the patients and not getting the answer, they will suffer from depression and a sense of loneliness, and they welcome grief and sadness. According the profound interviews conducted by Sand and Strang [19] with cancer patients, it has also been shown that following existential loneliness, both the patient and his or her family need to be in touch with others and talk to them.[19]

CONCLUSIONS

The results of this study showed that one of the most important existential challenges in patients with cancer was being exposed to the light of awareness that revealed the cage of inauthentic self and the tension between getting out of the cage or remaining. Seeking answers to mental questions and anxiety are among the side-effects of staying in the cage of inauthentic self. In addition to the issues mentioned, it is important to note that the results of the present study are in line with the majority of studies in this field. Therefore, it can be concluded that these are not culture bound, and the existential challenges in different countries are experienced in a similar way, and the only difference is the language of expression. According to the results of this study and what the participants say in their experiences, it is important to pay attention to such needs in the patients with cancer and to provide appropriate care for them. However, the main problem is that there is no institute in Kerman providing palliative care to cancer patients to present these results and provide psychological counseling in the field of existential challenges that are fundamental issues for patients with cancer who suffer from them. In addition, according to the results of this qualitative study, it is possible to form discussion groups with peers or have self-reflective practice learning groups to reflect on the questions or existential challenges. In this way, participants can express themselves and share their experiences and challenges and learn and find the answers. In addition, there is a need for emphasis and further studies on the ego and its manifestation before death.