Breast Cancer Treatment (Mastectomy Experiences) May Initiate Individuation Process That Redefines Identities: A Systematic Review ()
1. Introduction
The National Cancer Institute defines breast cancer as a disease in which some of the body cells grow and spread to other parts of the body; it is diagnosed by detecting a lump in the breast or armpit, swelling of the breast, pain in the breast or nipple, or nipple discharge (American Cancer Society, 2013) in [1] . Treatment options include surgery (mastectomy, tumor removal, or removal of pectoral/chest muscles), chemotherapy, radiotherapy, hormonotherapy, and immunotherapy treatment [1] . Research has shown that breast cancer surgery may result in psychosocial distress, which negatively affects women’s mental health [2] [3] . Following breast cancer treatment, disfigurement, pain, scars, and alopecia may lead to loss of femininity, impacting sexuality and intimacy [1] [2] [4] - [9] . A high prevalence of depression and anxiety disorders was reported following breast cancer diagnosis and treatment, which is associated with body image dissatisfaction among women [10] [11] [12] [13] . However, there is a growing body of literature suggesting that breast cancer treatment may lead to post-traumatic growth, resulting in a positive change [11] [14] [15] [16] [17] . This review aims to identify studies that view mastectomy experiences from a transformative standpoint and explore the possibility of the transformation of identity and the integration process (rebirth experiences) among women. The author argues that breast cancer may act as a catalyst for women’s personal growth, altering the meaning of life and happenings in their daily lives [18] .
Few published studies view mastectomy experiences from a transformative perspective [19] - [25] . There are even fewer studies that suggest that breast cancer losses may create opportunities for personal transformation [26] [27] [28] [29] [30] . Studies investigating the impact of breast cancer experiences on the patients’ spouses, partners, and families are also limited [5] [21] [31] [32] .
2. Objectives
The main objectives of the paper were two-fold: First, the review was to explore trends regarding the factors that influence the meaning of mastectomy experiences for women and their self-image. Second, the review also aimed to unpack the impact of an altered sense of self and to identify emancipatory possibilities to renegotiate identities following mastectomy.
3. Methodology
This literature review aimed to increase awareness of the impact of breast cancer treatment, specifically mastectomy, on various aspects of patients’ lives. The review utilized electronic databases such as EBSCO, PsychInfo, Medline, CancerLit, and ProQuest to search for articles related to breast cancer treatment, mastectomy, body image, self-concept, spirituality, resilience, and mental health. The SPIDER tool was used to establish inclusion criteria based on sample, phenomenon of interest, design, evaluation, and research type. The review focused on studies involving women aged 18 to 80 who underwent breast cancer treatments such as chemotherapy, tumor removal surgery, and mastectomy. Studies published between 1990 and 2022 were selected for the review, and included those that utilized narrative and constructionism designs, qualitative methods, story-telling during focus groups, open-ended interview schedules, and peer-reviewed published and unpublished case study reports. A total of 25 studies were selected and analyzed using thematic and content data analysis methods. Results showed that breast cancer treatment, especially mastectomy, had significant impacts on patients’ body image, relationships, and mental well-being.
Theoretical Framework: Jung’s Individuation theory
Jung [33] defined individuation as the process of becoming a unique individual by embracing one’s innermost and incomparable traits. According to Jung, individuation is essential for a person’s well-being as it enables the formation of an individual’s unique personality. The focus of individuation is to discover one’s meaning and purpose, in order to improve one’s life [33] . The process of individuation is influenced by unconscious messages communicated to the individual’s ego [34] , which signals an alarm when the person struggles to adapt to external or internal reality. The subjugation of the ego to the self and the defeat of the ego are important aspects of Jung’s individuation process. The individuation process involves the experiences of “death and rebirth” through struggle, suffering, and a conscious intent to broaden the scope of one’s consciousness [35] ; these stages of individuation significantly influence one’s personality development.
Stage 1 of Individuation Death-Experience
According to Jung [33] , the death-experience signifies the ego disintegration stage, characterized by losses, confusion, despondency, and uncertainty. The death-experience stage is an intense crisis experience filled with the suffering of the individual and the ego [36] . In the context of the Global South, high levels of depression and anxiety disorders were reported following breast cancer diagnosis and treatment and were associated with body image dissatisfaction among women who underwent mastectomy [10] [11] [12] [13] , which negatively affected their quality of life.
Jung’s death-experience stage of the individuation theory resonates with the onset of symptoms of breast cancer illness before and following diagnosis and during treatment. Women were found to react with shock and numbness following a cancer diagnosis, which raised fear of death, and most were anxious about the experience of chemotherapy and physical mutilation related to mastectomy. A cancer diagnosis is thus associated with significant stress, fear, and anxiety, reinforcing silence among women diagnosed with breast cancer [6] . Benson et al.’s [2] study uncovered the significantly high prevalence of depression (84.2%) and anxiety (92.5%) among women who underwent mastectomy. Turner [37] referred to the treatment stage as a state of liminality during which the sick person may embark on surgical treatment, yet her future health status remained uncertain.
Jung’s [33] individuation process during the death-separation stage can be applied to the sick woman who is in isolation, and during that alone time, the woman must embark on a process of internal work. This may enable the woman to enter into an internal dialogue of the conscious and unconscious, find the opportunity to process her distinct experiences, and formulate and author her stories. At this point, the woman may become aware of her experiences and the opinions, emotions, and thoughts she holds concerning these experiences [38] .
In their qualitative study, de Souza et al. [26] sought to identify the impact of breast cancer on the family life of Brazilian women. One woman reported her experience of loneliness during treatment: “I felt alone, my husband kept on denying it. My brother never came to visit me. And my father came before the chemo. When I did the chemo, he said that he lacked the courage to come see me” (p. 6) [26] . Similarly, some women who were undergoing breast cancer treatment were highly distressed when there was a sense of abandonment and neglect from significant others [39] . Some women with mastectomies developed a sense of helplessness/hopelessness [24] , while others described cancer as an experience of woundedness [39] . For those women, the cancer experience brought feelings of helplessness and powerlessness [39] .
Studies have shown that breast cancer treatment, including surgery, radiation, and chemotherapy, can negatively impact women’s sexual capabilities [8] [20] . For many women, the loss of reproductive organs due to breast cancer also means a loss of fertility and the opportunity for future sexual and intimate relationships [27] . In some cases, women may also develop a negative body image due to weight gain and feelings of betrayal by their bodies [27] . Furthermore, marriages may face tension and divorce incidence may escalate following mastectomy [31] [40] [41] . Women may also experience a deterioration of physical strength and ability that can interfere with their capacity to perform traditional gender roles.
Despite the death-like experiences of breast cancer diagnosis and treatment, Grogan and Mechan [27] found that younger women who underwent mastectomy were able to find acceptance by separating themselves mentally from the breast that was removed and embracing the sick role. Patel et al. [42] also found that psycho-spiritual integrative therapy (PSIT) helped breast cancer survivors let go of old ways of being and embrace the sick role. Therefore, Jung’s rebirth experience stage of the individuation theory may also be a necessary component in the cancer treatment journey.
Stage 2 of Individuation Rebirth Experience
Jung [43] described the rebirth experience as a process of adopting a new perspective in one’s psychic condition, arising from the critical examination of the unconscious. According to Robins [44] , transitioning from the sick role to the survivor role requires reconfiguration of the stigma and isolation into a positive and life-affirming identity. Jung [33] argued that merging the ego and the unconscious can enhance the dimension of living with meaning. This stage is referred to as reincorporation, in which the individual begins to get physically and psychologically well [37] . The patient is emerging from being regarded as a sick person and transitioning into a life-affirming identity while attempting to move beyond the loss [45] .
Jung’s rebirth experience within the individuation process is significant in someone becoming a centered and whole individual. For instance, Park [46] found that the survivor identity was a critical identity that was linked to promoting empowerment for those in post-cancer journey experiences. The survivor identity was correlated with psychological well-being and post-traumatic growth, as well as active involvement in a personal growth orientation, a sense of life purpose, mastery, and social relationships.
Grogan and Mechan [27] conducted a qualitative online study that revealed how women renegotiated their identities post-mastectomy. Through the process of acceptance, some women recognized the need to adjust to their changed bodies and viewed their post-mastectomy bodies as giving them a new identity. Some women found they could renegotiate how they should be treated as women; one woman stated, “body image has never worried me. I am who I am and I don’t go out to impress people” (p. 12) [27] .
Some women rejected traditional views on how women’s bodies should look and opted to develop new body identities that were different from before their illness. One woman said, “I am happy enough with how I look with clothes on. I am accepting the scars and reconstruction. I have to be to move on and get on with life” (p. 10) [27] . Another woman said, “My scars were war wounds”, and she was proud of them (p. 12) [27] . One woman who had undergone reconstructive surgery after mastectomy stated that “my breasts are different and not natural but it doesn’t change who I am” (p. 12) [27] . Grogan and Mechan [27] also reported a single woman who had undergone mastectomy less than a year previously, with no intention of reconstruction, who learned to compensate for the perceived lack of femininity associated with breast removal through wearing clothes that emphasized her legs and increasing the amount of makeup she wore.
In less physical terms, Trachtenberg [25] reported that one participant shared that the cancer experience was a wakeup call to start looking after herself and following her dreams. In Knaul et al.’s [28] study, Mexican women living with breast cancer responded to open-ended questions pertaining to their concept of cancer survivor identity and said it meant an identity that encouraged self-preservation, by learning to negotiate and establish new boundaries and learning to care for self. For example:
“Yes, I’m very grateful for cancer experience because before I had cancer, I did not have time for myself. I used to work and had little time for rest... and now every month I don’t fail to come to the support group, it’s my me time, because it’s like recharging my batteries...” (p. 5) [28] .
Knaul et al.’s [28] study results resonated with Park’s [46] study by concluding that experiences of living through cancer can lead to new identities. In particular, the cancer survivor identity can bring positive experiences of transformation that are beneficial to the long-term physical, social, psychological, spiritual, and existential impact of cancer on one’s life. According to Jung [47] , individuation necessitates self-reflective awareness, which involves questioning preconceptions and inspiring new actions. Breast cancer treatment challenges existing dominant identities that are no longer useful. For instance, Mohammedi et al. [29] studied coping strategies for altered body image among Iranian women who underwent mastectomy and found that women adopted psychological self-empowerment skills, increased spiritual practices, and intentionally demonstrated self-compassion, leading to self-acceptance and transformation. The women also practiced self-care by managing their limits, modifying their rest and sleep patterns, and following a healthy lifestyle.
In the rebirth stage of the individuation process, sharing one’s story and employing new mechanisms of expression can aid in developing patient identity [48] [49] . Fook [49] referred to such openness as a seed to harvest freedom, which is critical acceptance that promotes consciousness and autonomy for informed judgments. Jung [33] argued that the formulation of the story characterizes the rebirth stage, generating awareness and preparing for reintegration by bringing the unconscious into consciousness and understanding one’s masculine and feminine facets. Through individuation, one defines oneself as both separate from, and a part of, humanity [30] .
Parker’s [30] storytelling study identified the potential alignment between personal experience such as mastectomy and transformation, resonating with Jung’s individuation process. Shared stories in the group process revealed the unconscious content influenced by the group’s way of creating images and resolving personal dilemmas [50] . According to Boyd [15] , shared stories identified collective points based on personal experiences, creating ideas for the desired changes across the life span, expanding consciousness, and inspiring new actions.
Breast cancer treatment presents opportunities for women to embark on the reconstruction of their feminine identity [29] and create new body identities [51] . Patel et al. [42] found that psycho-spiritual integrative therapy (PSIT) helped breast cancer survivors move beyond self-criticism and denial toward a more empowered perspective, becoming aware of their self and their own needs. Women learned to care for their feelings and act in their best interest, seeking interpersonal connections, external sources of support, and transcending the separate. Sheriff’s [16] study showed that having a purpose for living can increase a sense of urgency to accept cancer treatment and motivate one to own the healing process. For example, South Asian women with breast cancer sought to take control of their own illness, according to Patel [11] .
4. Results
4.1. Thematic Analysis
A thematic analysis process was employed in which studies were categorized under two main themes of death-like and rebirth experiences, as outlined in Jung’s individuation theory. The three themes under death-like experiences were: 1) breast cancer diagnosis and treatment can trigger identity disintegration; 2) breast cancer treatment can challenge taken-for-granted masculine norms around sexuality; and 3) breast cancer can potentially decenter masculine power.
4.2. Themes under Death-Like Experiences
4.2.1. Breast Cancer Diagnosis and Treatment Can Trigger Identity Disintegration
Lechner et al. [21] defined identity as resulting from our need to categorize the world. The socially constructed self, naming, and labeling oneself as a member of a social category are aspects of identity [52] . Social identity theory focuses on how individuals categorize themselves in relation to others, based on similarities and differences, and internal and external identification [53] . These definitions focus on group membership and a fixed sense of belonging in a unidimensional manner, such as gender identity and femininity.
Mangcu [54] argued that identities are something we become. Experiences such as breast cancer illness and treatment, like mastectomy, can lead to a loss of a tissue symbolizing femininity and sexuality, causing an identity crisis [4] . The impact of the appearance of the body, which can be scrutinized by others, can affect the emotional well-being of the individual [55] . Research indicates that mastectomy can create a deconstruction of a woman’s “original” body and provoke an identity crisis [25] . This is described as spoiled identity in Turner’s [37] model, due to enduring illness experiences that open up the deepest parts of women’s psyches [55] .
Following mastectomy, some women lamented the loss of their true selves, while others learned to identify with their own identities [56] . The cognitive dissonance created by mastectomy between women’s beliefs about socially expected appearance and their reality can lead to detachment from their self-identity as a defense mechanism to protect their consciousness and ego [25] . A study of 22 Mexican women with a history of breast cancer found that almost half struggled to accept themselves after undergoing mastectomy [28] . In addition, experiences of living through breast cancer can involve developing new identities by acquiring a positive outlook on life, reflecting on positive aspects of one’s life and developing resilience [46] . The distress caused by sexual and emotional experiences and changes in body image resonate with the patient identity concept [46] .
4.2.2. Breast Cancer Can Challenge Taken-for-Granted Norms around Sexuality
Trachtenberg [25] found that breast cancer can challenge traditional norms of femininity and masculinity, with patriarchal norms restricting women’s ability to construct their own identity [49] . Unequal relational dynamics can leave indigenous and African women with breast cancer feeling silenced and withholding their emotions [19] [57] .
Gender identity can also be influenced by social interactions and historical experiences [58] , with sexuality shaping gender identity [59] . Women who undergo mastectomy report changes in their sexuality, anxiety about potential loss of marital support, changes in their mothering and caregiving roles, and loss of confidence [4] [5] [40] [60] . Feminist theory highlights how breast cancer diagnosis and treatment can impact women’s heterosexual desires and sexual attractiveness [61] [62] . However, breast cancer may allow women to step away from gendered responsibilities and reflect on their experiences, potentially bringing about social change [19] .
The loss of a breast can negatively impact women’s femininity, mothering, and nurturing roles [19] [63] [64] . Mastectomy can prevent the women from breastfeeding [65] . In addition, women may feel less sexually attractive after mastectomy and experience changes in their sexual arousal and patterns of intercourse [20] [66] . Cancer treatments such as surgery, radiation, and chemotherapy can also have negative effects on sexual capability [8] [20] . Women may fear rejection from their partner due to scars and changes in their body, leading to avoidance of showing themselves naked [1] .
4.2.3. Breast Cancer Illness Showed Potential to Decenter Masculine Power
Nasser et al.’s [67] study on Middle Eastern women diagnosed with breast cancer revealed that cancer diagnosis and treatment challenge masculine power in non-Western cultures, where male family members usually share test results with the female family member instead of doctors. However, women have started participating in decisions regarding their own health, challenging restrictive cultural practices [6] [22] . This shift in power dynamics challenges traditional masculinity norms, placing women at the forefront of treatment decisions. Although some spouses disagree on treatment modes, breast cancer experiences have empowered women to challenge oppressive practices that disempower them [19] .
Mastectomy has exposed conflicts, frustration, and tension within patriarchal societies, challenging sex-typed norms. Partners of cancer patients often express disappointment, anger, and sadness over their spouse’s diminished sexual desire [20] [68] . Husbands may experience the refusal of their sexual demands as a source of conflict, resulting in divorce [41] ; indeed, some women experience broken relationships, including divorce [22] . In Nigeria, Odigie et al. [41] study results reported that 24.7% of women who had mastectomy were divorced from their husbands over three years post-treatment, while 13.6% were separated, and 19.8% reported their spouses took a second wife. The study showed that six months post-surgery, 79% of women who had mastectomies experienced a decrease in affection from their husbands which resulted in divorces [41] .
Such situations may lead to domestic violence, as well as coping through substance abuse [19] [22] . Bell and Nkomo [69] described this as internalized oppression, which manifests as anger and self-destructive behavior.
4.3. Themes under Rebirth Experiences
The following themes fall under rebirth experiences, as per Jung’s individuation theory: 1) breast cancer treatment helps men to identify a woman’s non-sexual value; 2) breast cancer facilitates the redefinition of self and adoption of alternative identities; 3) women exhibit resilience while negotiating renewed identities during breast cancer illness; 4) reconnecting with the self can facilitate wholeness in the family; and 5) spirituality enhances the sense of growth.
4.3.1. Breast Cancer Treatment Can Help Men to Identify a Woman’s Non-Sexual Value
Cancer patients undergo physical and emotional changes and benefit from relationships that enhance adaptation to new needs and stresses. Several studies [5] [21] [23] [31] [41] adapted interventions to include partners and caregivers of breast cancer patients receiving treatment. Gabriel [31] found that discussing breast cancer within marital and family relationships facilitates genuine communication. Women seek opportunities for self-clarification and care support interventions that offer co-constructive dialogues for exploring and constructing selves [19] [25] [70] .
After mastectomy, most women reported a loss of desire for sexual intimacy, but sharing illness narratives helped women gain perspective and adjust. Through examining their own stories, women recognized the power of dominant discourses and developed a renewed strength in their intimate relationships [33] [38] [48] . During interventions, women voiced and co-constructed meaning, leading to increased intimacy, trust, friendship, and personal sharing with their partners [39] . Women developed a sense of appreciation of self and ownership of their bodies, leading to increased intimacy [33] . Furthermore, loss can become a catalyst for change to help individuals reconstruct new narratives of appreciation [17] .
4.3.2. Redefinition of Self and Adoption of Alternative Identities
Women with breast cancer must prioritize their needs and advocate for themselves to manage their illness and explore new ways to adjust [25] . Serlin et al. [24] developed a community-based workbook-journal approach to support emotional care for rural women diagnosed with breast cancer, providing a safe space for them to share personal experiences. The group process empowered women to make their own decisions and use healing imagery [24] [71] , promoting self-empowerment and self-acceptance. Illness narratives allow patients to reflect on what brought about their illness, revealing material of which they were not previously aware [33] [48] .
Mezirow [18] and Charon [48] argue that storytelling and critical examination challenge cultural assumptions and allow for transformative learning and awareness. Women who have had mastectomies often experience a shift in their identity and develop a positive attitude towards their lives after cancer [22] [72] . Women challenge gendered assumptions and social practices to alter their self-views and worldview during their breast cancer experience [20] [24] [25] [29] . The process of assessing assumptions can lead to the development of the inner self among women with breast cancer.
In her case study, Stromsted’s [71] movement intervention with women who have had mastectomies showed that the initial response was that of betrayal by their bodies, and therefore, they were resistant to participate in the authentic movement intervention [71] . However, once the women participated, some reported seeing images of lying on the surgery table under anesthesia and encountering out-of-body experiences. In the process, they identified with their illness while reconnecting to their bodies, and their painful experience is consciously felt; they “re-inhabit” their body. The women discovered repressed emotions, exploring their healing, experienced renewal, and became transformed. The women gained a more accepting post-surgery body image, as they were recovering a sense of pleasure in life. Breast cancer patients expressed grief over the loss of their breasts but joy at reconnecting with their bodies, resulting in increased strength and appreciation for life [71] . A woman in her thirties reported:
“During my movement, however, I experienced my right as my ‘masculine side’ and my left breast as my ‘feminine side’, and realized that both have served me well, and now I am integrated” (p. 9) [71] .
Through psycho-spiritual integrative therapy (PSIT), patients learned to go inward, relax, and identify missing spiritual elements to aid in psychological and spiritual growth and coping with cancer survivorship [15] [42] . PSIT helped clarify patients’ life purpose and built skills for overcoming life obstacles. Patients also learned deep breathing techniques [39] .
Incorporating dance, movement, and the arts through kinesthetic imagining facilitated women’s healing process, empowering them to develop their healing imagery and discover spontaneity [73] [74] . Healing practice including physical activities can lead to heightened experiences of group connectedness and comfort in stressful moments [37] [55] . Body-centered interventions, such as Bosnak’s embodied imagination approach, helped breast cancer patients connect with their bodies, acknowledge their symptoms, and gain new perspectives to break dysfunctional patterns [75] [76] [77] . Contemplation and meditative exercises also brought calmness and stability.
4.3.3. Resilience to Negotiate Renewed Identities during Breast Cancer Illness
Women affected by breast cancer started with themselves to improve their lives and develop new relationships [39] . After experiencing the unfortunate event of cancer diagnosis and treatments, they made decisions to regain composure and rebuild their femininity as their bodies changed. Women began soul-searching to get the true meaning of their lives and make changes, such as adopting a healthier lifestyle, exercising, practicing creative writing, and exploring new careers [39] . For some, cancer was seen as a gift, bringing them to a place of growth [39] .
Trachtenberg [25] reported that some women rejected traditional female roles during their cancer experience, realizing that they caused them stress and depression due to a lack of support from partners. They realized that they lost themselves by trying to please everyone, which helped them make new choices. Some women questioned beliefs about womanhood, wondering if the absence or presence of body parts defines gender. They also rejected their mothers’ or older women’s viewpoints, which imposed societal views of femininity on them. Women embarked on redefining and reconstructing their notion of beauty and deepening their appreciation for it [25] .
Women adopted an attitude of acceptance that brought them peace [39] . They accepted what was going on from day to day and remained conscious of their desires without attaching themselves to any outcome. However, they found it challenging to balance the cancer patient role and caregiver role for their families; for many, cancer was a message telling them that something was not working right in their lives [39] .
Women who were treated for breast cancer experienced enhanced connections in their relationships and developed an appreciation for their bodies [22] [25] . They appreciated the inner strength that enabled them to conquer death and expressed gratitude for a second chance in life [22] [25] [39] .
4.3.4. Reconnecting to Self Can Facilitate Wholeness in the Family
Breast cancer treatment, such as mastectomy, may trigger the spouse’s and family unit’s individuation process by exploring unconscious personal and collective processes. Participation in a support group may encourage the spouse to question and disclose negative feelings, facilitating emotional connection with oneself and the world [18] . Cancer can expose hidden views and feelings within the couple’s sub-system, requiring the spouse to learn to embrace change and new ways of relating. Studies have shown that partners of sick women benefit from care support interventions [5] [6] [31] [41] , promoting a partnership based on realistic grounds and finding new ways that fit the present and future [78] . In addition, social support from families helped women regain self-belief and developed self-acceptance [22] . Brook’s study showed that women in the study were happy with the support received from loved ones, spouses, extended families, relatives, and friends [19] [22] . They found satisfaction in supporting and sharing information with other family members [39] .
Breast cancer illness may facilitate genuine communication between spouses and encourage critical examination of one’s construction of reality during interactions [79] . Emancipatory learning can develop awareness and meaning of what significant others communicate concerning their emotions [18] . A new experience through breast cancer may transform meaning perspectives and develop a new meaning structure [18] , building an understanding, trusting relationship through assuming a supportive role as a significant other [80] . Communication can be enhanced by identifying opportunities to communicate, resonating with Asante’s [81] intercultural communication process.
Cipolletta et al. [82] attempted to adapt their intervention to incorporate partners and caregivers, with women satisfied with the cooperation, respect, and harmony in their relationships. The inclusion of the spouse in treatment and interventions is crucial to strengthening family dynamics. Genuine communication may reposition spouses as vehicles for addressing social injustice [80] , promoting empathy, connections, learning, expansion, and a sense of meaning in relationships [83] . For instance, Segelov and Garvey [84] employed yarning to gather information related to the impact of cancer diagnosis and treatment on self, family, and community in Australia, aiming to increase support from loved ones, spouses, extended families, and relatives.
The spouse may develop an internal “interpreter” system, promoting democracy and unity in the family system. Through cancer experience, the spouse’s sense of self may grow through learning new tasks in the caring role to assist the sick woman and unite the family as an integrated whole. However, Iranian women who went through mastectomies maintained maternal and household-related roles, as well as sexual role commitment to fulfilling their husband’s needs [29] .
4.3.5. The Sense of Growth Enhanced through Spirituality
Reconnecting with oneself can help individuals view their present condition from within a larger life perspective, live beyond the present, and remain hopeful [55] . Communal interconnectedness and collaboration provide groundedness [85] . A centered and whole individual emerges when the conscious ego and the unconscious are in a synergistic relationship. Indigenous native women patients have described their participation in traditional healing practices, such as sweat lodges, shake tents, singing songs, praying, and the Sun Dance, as centering [19] . The indigenous perspective wisdom relates to “feminine” qualities such as intuition, emotionality, and relationality [86] , emphasizing connection and relationship networks including the body, nature, earth, sky, spirit, mind, emotion, humans, and non-humans joining together.
Struthers and Eschiti [34] focused on indigenous native breast cancer patients’ case study reports of their lived experiences of traditional healing practices. Participants reported that participation in spiritual healing practices brought body-mind-spirit to a deeper level of inner knowing that leads toward integration [34] . The mystical aspects brought a connection with the spirit world through singing songs and praying. Participants who participated in the Yuwipi healing ceremony reported the experience of journeying out of the body, constant communication with the spirit world, and knowledge of mysteries of life. Participants experienced expanded awareness of a transcendent function that embraces unity and integrated wholeness.
Permeable boundaries characterize indigenous healing practices regarding time and space, self, other, and context [87] ; they transcend the limits of space and time to enable the person to reintegrate and become whole [19] and are considered healthy [88] . In indigenous healing practice, the shaman transcends personal interests to include others, both living and non-living resources, to nurture, guide, and strengthen individuals and the community [89] . For example, in the cancer group process, the group leader adopts a non-dual stance and does not stand apart from the group [77] [90] . The leadership style embraces unity and does not separate the self in the moment [91] . The leader’s sense of otherness or oneness transcends opposites beyond resistance and transference in the process. The leader’s style resonates with Vaughan’s [92] view of consciousness as the context of experience.
From an indigenous perspective, being human is to be mindful of human dignity, collective consciousness, interdependence, and wholeness [93] . Indigenous women expressed appreciation for their culture as a source of strength, power, and identity shaping [34] . Nzuza [22] explored the lived experiences of women who were to have mastectomies and who consulted traditional healers before resuming the treatment phase while waiting for surgery. Women shared their stories of how participation in spiritual interventions, such as drinking holy water and praying, brought comfort and grounded them [22] , alleviating anxiety during their cancer journeys [19] , and enhancing positive cancer outcomes.
5. Conclusions
When examining cancer treatment experiences through the lens of the individuation process, it became evident that women reported experiences that made them re-examine their self, enabling reconnection and integrating their sense of self. Studies showed that breast cancer treatment also influenced male partners to reconnect to their true self, identifying the non-sexual value of women and developing the relatedness value required to protect partnership during the process of transition, shaping the process of wholeness. The death-experiences outlined in Jung’s individuation theory were signified by deficit-based research [1] [2] [4] - [9] [20] . The negative outcomes of surgery, and mastectomy are attributed to changes in sexual capability [8] [20] , with mastectomy associated with depression and anxiety disorders, disfigurement, scars, and pain, all leading to a deep sense of loss of self-image, femininity, sexuality, and intimacy among women, as well as a loss of true self and dis-identification of their identity [56] .
On the other hand, cancer experiences that resonated with Jung’s rebirth experience within the individuation process were associated with the restoration of wholeness. The rebirth stage can be described as reincorporation, when the individual starts to become physically and psychologically well [37] . The few reviewed studies were compelling [19] - [25] [39] [57] . Rebirth was attributed to changes that transformed women’s identities through cancer experiences. Such experiences contributed to personal transformation and a renewed sense of self [15] [26] [27] [28] [29] [42] [46] , with related losses viewed as opportunities for women to transform and attain individuation.
Cancer experiences enabled women to embark on emancipatory learning that shaped the redefinition of their self through self-advocacy and improved self-care management [22] . Some women showed resilience to negotiate renewed identities through breast cancer illness [24] [25] . Women had to start with their self, make their own lives better, and develop new relationships with themselves [39] . Women questioned their caregiver role, learned to prioritize their own needs to promote agency, and made alterations regarding their boundaries [94] .
Women challenge socially constructed assumptions regarding gender roles [25] and alter their views in response to breast cancer experiences [20] . Limited research has investigated the impact of breast cancer on partners as caregivers [5] [21] [23] [31] [32] [41] . The rebirth stage includes spouses’ transformation through emancipatory learning, resulting in increased awareness of their partner’s emotions [18] . Positive relationships with others lead to post-traumatic growth for cancer patients [14] , while support from family, spouses, friends, and church members is linked to positive coping and improved quality of life [23] [28] [29] . Women’s mastectomy experiences have the potential to balance relational dynamics with spouses, but research on the transformative potential of spouses is scarce [5] [21] [23] [31] [41] . Discussion of breast cancer illness may facilitate genuine communication and reposition spouses as advocates for social justice [31] [80] .
Spirituality plays a major role in cancer diagnosis and treatment [15] [34] [39] [85] [95] , with women adopting an attitude of acceptance and non-attachment to maintain peace [39] . Indigenous native cultures value spirituality throughout the breast cancer journey, with spiritual practices leading to deeper levels of inner knowing and integration [34] . Cancer can be seen as a gift, leading to personal growth [39] , and women must rebuild and reconstruct their femininity after undergoing body changes [25] .
6. Future Research
The literature lacks knowledge on an asset-based approach to cancer experiences (such as individuation), resulting in a gap in understanding. The current review highlights that changes to women’s identities (as nurturers, caregivers, intimate partners, or spouses) were transformative and contributed to personal growth and a renewed sense of self after mastectomy. Emancipatory learning occurs when one faces new experiences and seeks to formulate a new perspective on its meaning [18] . Additional research is necessary to empirically establish the emancipatory possibilities of cancer treatment for women’s identities.
Furthermore, the review revealed that breast cancer experiences, including mastectomy, catalyzed changes in spouses [5] [21] [23] [31] [41] . Gabriel’s [31] study indicated that discussing breast cancer within marital and family relationships can encourage genuine communication. Additional research is needed to investigate the transformative potential of spouses when their partner is diagnosed with breast cancer and how cancer alters the spouse’s meaning of life. Moreover, further research is needed to examine how children experience changes in their mother’s health resulting from breast cancer.
Acknowledgement and Source of Funding
This work is based on research supported by the National Institute for the Humanities and Social Sciences.