1. Background
Breast cancer is the first common cancer diagnosed in women (1). It is the second most common cause of death for women worldwide (2). Breast cancer is not just a physical problem because its psychological symptoms lead to serious problems for patients and their families. About 29 to 47% of breast cancer patients suffer from different psychiatric problems such as a change in their quality of life, and fear of death, and also loss of breast, leading to induce a sense of concern about body image and sexuality for most women (3, 4). Believing and adjusting the situation and hoping to cure takes weeks, and their distress and anxiety may result in depression (5). Studies show psychiatric problems are accompanied by giving up the therapy and increasing pain and other symptoms in patients (6). Cancer can be affected by different psychosocial factors such as personality character, social stress, and lack of emotional support (7). Most of the patients explain that their family cannot support and understand their situation and need emotional support from other sites (8). However, some people feel safe in peer-support groups. They feel comfort when they know that they have some places to go with their concerns.
Poetry therapy is an international method related to literature, language, and communication for healing. It was used first in the 1960s in hospital clinics to promote the expression of emotions and any tensions. Its process uses imagination, imagery, and metaphor (9). In the last decades, it has substituted some other psychiatric therapies like drugs, especially in some patients with psychiatric symptoms and chronic diseases such as cancer (10).
All over the world are interested in reading a 13th-century poet. Today, classical Persian stories and literature can be an excellent cure for human souls and are widely used for psychotherapy and bibliotherapy. The most experienced literature in this field is Masnavi by Baha al-Din Muhammad, known as Rumi in the west and Mawlana in Iran, who is a renowned spiritual poet (11, 12).
Staying away from human nature and separation from essence cause hopelessness and depression (13). Previous studies showed that Mawlana (Rumi) believes that psychological problem is derived from negative thoughts and can be managed by managing subjective identity.
2. Objectives
In this study, we investigate an outpatient creative intervention based on Masnavi therapy for breast cancer patients.
3. Methods
This study was carried out in Cancer Research Center, Shahid Beheshti University of Medical Sciences, from 2017 to 2019. This study was conducted on 91 patients with breast cancer that was selected by convenience sampling. They were divided into poetry therapy group (n = 31) and no intervention as the control group (n = 60) by simple random allocation. The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences. Informed consent was obtained prior to the study. The inclusion criteria were as follows: (1) Non-metastatic female breast cancer patients aged 18 - 65, (2) Being able to read and write, (3) Willing to complete the questionnaire, (4) Having no severe psychological condition in self-report, (5) Being able to attend the group poetry therapy sessions, (6) Under treatment for at least two weeks baseline cancer treatment. The exclusion criteria were no tendency to participate in the study. Weekly poetry therapy was held for six weeks by an expert in literature and poetry therapy. In every session, selected awaits of Mawlana (Rumi) poems were read, and at the end of sessions, the patients were recommended to read a special book between sessions. The concepts in six sessions included epistemology, hope, praying, believing in God, testing by Allah, patience, and tolerance. The Persian translated version of Depression Anxiety Stress Scale (DASS-21) was completed by all participants before the study and at weeks one and eight after the last session. DASS-21 is a 21-item self-report questionnaire designed to measure depression, anxiety, and stress. Each item has a scale from zero to three. Sahebi et al. validated DASS-21 on Iranian samples and showed that DASS-21 was a useful inventory in Iranian psychological research and clinical settings (14).
3.1. Statistical Analysis
The DASS-21 was scored and data was analyzed with SPSS V17. The mean, median, standard deviation (SD), and range were used to describe the data. We applied the Kolmogorov-Smirnov test, parametric test (MANOVA and independent t-test), and also Friedman non-parametric test to investigate the changes in anxiety and stress scores after the intervention. Mann-Whitney U test was applied to compare stress and anxiety scores between the two groups. Independent t-test was used to compare depression between the groups. The significance level was defined as P-value < 0.05.
4. Results
Finally, 91 patients, including 31 in the intervention group and 60 in the control group, finished the study and completed DASS-21 and were finally included in the final analysis. Table 1 shows that the baseline characteristics were not significantly different between the two groups (P-value was more than 0.05 for all parameters). The mean age of the participants was 45 years. In the case group, four (12.9%) individuals had high school diplomas or less, while 18 (30%) in the control group were under diploma. The majority of patients in the case group (84%) and 57% of patients in the control group were married. The case and control groups included 20 (64.5%) and 53 (86.7%) homemakers, respectively.
Table 1.Social and Clinical Characteristics of the Study Groups a
| Intervention | Control | P-Value | |
|---|---|---|---|
| Age (y) | 0.5 | ||
| Under 45 | 12 (38.7) | 29 (48.3) | |
| Over 45 | 19 (61.3) | 31 (51.7) | |
| Marital status | 0.09 | ||
| Single | 3 (9.7) | 3 (5) | |
| Married | 26 (83.9) | 57 (95) | |
| Divorced | 2 (6.5) | 0 | |
| Education | 0.1 | ||
| University | 11 (35.5) | 11 (18.3) | |
| Diploma | 15 (48.4) | 26 (43.3) | |
| Under diploma | 4 (12.9) | 18 (30) | |
| Surgery | 0.07 | ||
| Mastectomy | 8 (222) | 5 (8.3) | |
| Lumpectomy | 23 (77.8) | 55 (91.7) |
a Values are expressed as No. (%).
Total mastectomy was performed in eight (22.2%) patients in the case group and five (8.3%) in the control group. The income was reported to be lower than expenses in 7% of the case patients and 14% of the controls (Table 1). The poetry group did not differ significantly in terms of stress, anxiety, and depression scale from the control group at baseline (P = 0.3, P = 0.3, P = 0.6, respectively). The effect of poetry therapy on depression was evaluated by DASS-21 at the beginning and at the end of the study (Table 2). Depression degree was decreased obviously in the case group (P = 0.001) and the improvement was found to be significantly higher in the case group compared to the control group immediately and eight weeks after the last session (P = 0.003, P = 0.02, respectively).
Table 2.Changes in Depression Scores After Group Poetry Therapy, According to DASS-21
| Intervention | Control | P-Value | |
|---|---|---|---|
| At baseline | 15.3 (8.15) | 14.37 (6.78) | 0.68 |
| One week | 10.23 (7.22) | 15.50 (7.75) | 0.002 |
| Eight weeks | 9.42 (6.58) | 13.55 (8.1) | 0.01 |
The median anxiety scores on DASS-21 scale for all patients at baseline and follow-up visits are shown in Table 3. The mean anxiety score was reduced in poetry groups (P = 0.006) and also it was significantly lower in the intervention group compared to the control group at one and eight weeks after the last session (P = 0.01, P = 0.03, respectively). Table 4 shows that there was a significant reduction in the mean stress score in poetry therapy two months after the last session (P = 0.01). The rate of change in stress differed significantly during the study between patients in the case and control groups (P = 0.003, P = 0.02, respectively). Total DASS-21 score, including anxiety, depression, and stress, was improved in the case group eight weeks after the last poetry therapy session (P = 0.006, P = 0.001, P = 0.01, respectively).
Table 3.Changes in Anxiety Scores After Group Poetry Therapy, According to DASS-21
| Intervention | Control | P-Value | |
|---|---|---|---|
| At baseline | 17 (16) | 11 (11) | 0.3 |
| One week | 10 (12) | 15 (11.5) | 0.01 |
| Eight weeks | 8 (13) | 12.5 (9.75) | 0.03 |
Table 4.Changes in Stress Scores After Group Poetry Therapy, According to DASS-21
| Intervention | Control | P-Value | |
|---|---|---|---|
| At baseline | 11 (11) | 9.5 (9) | 0.3 |
| One week | 6 (7) | 13 (10.75) | 0.003 |
| Eight weeks | 6 (9) | 10 (8) | 0.02 |
5. Discussion
Breast cancer is a bad experience for one in eight women all over the world. That causes psychiatric problems such as depression and anxiety for them. Four in every ten patients with breast cancer have depression or anxiety (15). Burgess et al. similarly indicated that the frequency of anxiety and/or depression in women with breast cancer was twice more than the general female population (16). Emotional support should be considered vital care for cancer patients (15, 17). Poetry therapy has been established for 30 years and has been used in numerous fielding such as addiction centers and clinics (18). Mazza (18) created a multi-model of poetry therapy. The most common method that we used in our study is a receptive-prescriptive method. In this method, a piece of writing or poet is read by client, and reactions are a good way to develop dialogue. Poetry therapy has many benefits, such as understanding others, improving self-confidence and communication, expressing emotions, and adjustment. According to Gozashti et al., poetry therapy resulted in better outcomes when offered as group therapy (19). In a review conducted in 2011, the majority of poetry group therapy studies were done in the United States in the field of psychiatry during ten years. The rising trend in other fields such as oncology, over the past ten years is incredible (20).
Creative therapies such as painting, reading, and drawing for cancer patients have been developed for years ago. In a review of 12 studies about art therapy interventions for cancer patients, a significant reduction in anxiety and an increase in the quality of life were reported (21). In a study by Tegnér et al., 12 patients with cancer reported a significant reduction in stress and anxiety after six weekly poetry group sessions. They measured suppression of emotions by the Courtauld Emotional Control Scale (CECS) and anxiety by the Hospital Anxiety and Depression Scale (HADS) (22). A study by Daboui et al. in 2018 showed that group poetry therapy on women with breast cancer increases hope based on Miller’s Hope Scale (MHS) and decreases stress, according to DASS-21 (23). Also, in another study, eight weekly group poetry therapy led to improvements in quality of life of patients based on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) (24).
The limitations of the present study include the limited follow-up of patients to eight weeks and the exhausting nature of six sessions for cancer patients. Additionally, it seems that intellectual abilities of the participants and level of education, as an important confounding variable, might be effective in understanding the content by the participants.
In conclusion, Masnavi-based group poetry therapy greatly affected anxiety, depression, and stress during one- and eight-weeks follow-ups. Many psychiatric drugs and other methods are used to solve the psychological problems of cancer patients, and also previous studies have shown the benefits of group psychotherapy for the survival of cancer patients (25). As a simple, non-invasive and inexpensive method, group poetry therapy can be a good opportunity for breast cancer patients to decrease their psychiatric problems.
