Reflective writing about breast cancer experiences as part of an interactive poetry therapy group process

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Reflective writing about breast cancer experiences as part of an interactive poetry therapy group process © 2024 The Author(s). Published by Elsevier Ltd. Published version Holopainen, Johanna; Ihanus, Juhani Holopainen, J., & Ihanus, J. (2024). Reflective writing about breast cancer experiences as part of an interactive poetry therapy group process. Arts in Psychotherapy, 90, Article 102194. https://doi.org/10.1016/j.aip.2024.102194 2024 The Arts in Psychotherapy 90 (2024) 102194 Available online 17 July 2024 0197-4556/© 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Reflective writing about breast cancer experiences as part of an interactive poetry therapy group process Johanna Holopainen a , * , 1 , Juhani Ihanus b , 2 a Department of Music, Art and Culture Studies, University of Jyv¨ askyl¨ a, Seminaarinkatu 15, PO Box 35, 40014, Finland b Department of Psychology, Faculty of Medicine, University of Helsinki, PO Box 21 (Haartmaninkatu 3), 00014, Finland ARTICLE INFO Keywords: Breast cancer Poetry therapy Reflective writing Transformative writing Writing group ABSTRACT This study focused on texts written by breast cancer survivors who participated in an interactive poetry therapy group process. The writing group consisted of 4–6 participants who met 18 times during 2019. The group activities followed the RES poetry therapy model, and the poetry therapy intervention was implemented following the Reflective and Transformative Writing Process Model. The aim of the study was to describe the methods used in the group and to analyze the themes identified in the participants’written reflections on their experiences with their illness. Specifically, the study sought to answer the following questions: 1) What kinds of things were found meaningful by the participants in writing about their experiences with breast cancer? 2) How were these things thematized through the process of facilitated reflective and transformative writing? Participants’writings were analyzed using Interpretative Phenomenological Analysis (IPA). Three main themes, along with several subthemes, were identified. The main themes were: 1) being seen and heard as a breast cancer survivor, 2) the traces left by the disease, and 3) I live and breathe despite the disease. This study provides new insights into how breast cancer becomes integrated into a person’s selfhood and life story. Introduction Breast cancer is the most common cancer among women worldwide, with 2.3 million cases each year (World Health Organization WHO, 2023, xiv). Beyond medical treatment, breast cancer survivors need support services and interventions that address their psychosocial, spiritual, and existential needs. Common psychosocial challenges during treatment include stress, depression, anxiety, fear of complications during recovery, anger, and concerns about relationships, quality of life, body image, spirituality, coping, and intimate relationships. Social support services can help alleviate these symptoms. These services include support from family, friends, and the community, such as peer support, art and music therapies, and spiritual services (World Health Organization WHO, 2023, xiv, 69–70). Art therapy has been shown to have an alleviating effect on anxiety, depression, and fatigue in breast cancer patients (Tang et al., 2019), and on fatigue during breast cancer treatment, improving overall quality of life (Joly et al., 2022). Additionally, art therapy interventions have been reported to benefit quality of life and emotional well-being in breast cancer patients (Kievisiene et al., 2020). However, art therapy appears to have a greater impact on reducing anxiety than depression (Xu et al., 2020). An earlier systematic review and meta-analysis (Boehm et al., 2014) suggested that while arts therapies, including music therapy, various types of art therapy, and dance/movement therapies, positively affect anxiety in breast cancer patients, they do not significantly impact depression or quality of life. A later meta-analysis (Cheng et al., 2021), found that arts therapies, such as music, painting, and dance, can improve quality of life and depression in patients with breast and gynecological cancers and have positive effects on anxiety, pain, and fatigue in breast cancer patients. Dance and movement therapy can help breast cancer patients cope with the intense emotions induced by the disease (Karaferi et al., 2022) and has therapeutic effects on pain, fatigue, sleep disturbances, depression, and body image (Silva da Costa et al., 2022). Music therapy has been found to alleviate preoperative anxiety and postoperative pain related to breast cancer surgery (Tola et al., 2021) and reduce anxiety caused by chemotherapy after surgery (Kievisiene et al., 2020). It also * Corresponding author. E-mail addresses: [email protected] (J. Holopainen), [email protected] (J. Ihanus). 1 Permanent address: Lehtorannantie 14 a 5 40520 Jyv¨ askyl¨ a, Finland. 2 Permanent address: Vanha H¨ ameenlinnantie 11 B 4 06100 Porvoo Finland. Contents lists available at ScienceDirect The Arts in Psychotherapy journal homepage: www.elsevier.com/locate/artspsycho https://doi.org/10.1016/j.aip.2024.102194 Received 20 January 2024; Received in revised form 13 July 2024; Accepted 13 July 2024 The Arts in Psychotherapy 90 (2024) 102194 2 has the potential to improve the physical and mental health of breast cancer patients (Li et al., 2020). A study on a poetry therapy group for people with cancer found that participants enjoyed the group and felt it improved their quality of life. They also reported a reduction in feelings of anger toward their cancer as a result of the group process (Tegner et al., 2009.) Specifically, a study on a poetry therapy group for breast cancer patients found reductions in anxiety and improvements in emotional resilience. This group also facilitated the formation of bonds and friendships that continued after the therapy ended (Gozashti et al., 2017). Poetry therapy groups have been found to promote experiences of meaningfulness and community (Tegner et al., 2009; Gozashti et al., 2017). Using arts-based research, Reilly et al. (2018) concluded that the existential and posttraumatic growth experiences of women with breast cancer can be more deeply understood through meaningful themes evoked by found poetry (reframing excerpts from interviews as poetry). Poetry therapy also allows individuals to reevaluate and work through their illness experiences, integrating them into their life history (Heimes, 2011). Creative arts therapies, including poetry therapy, utilize cognitive, emotional, and action-oriented approaches. Puig et al. (2006) found that participation in group-oriented arts therapy interventions enhanced psychological well-being by decreasing negative emotional states and increasing positive ones. Consequently, these therapies have gained a foothold not only in the treatment of psychiatric illnesses but also in the treatment of physical illnesses (Heimes, 2011). The effectiveness and potential of creative arts therapies have been demonstrated in several studies. However, the heterogeneity of research designs and methods, and diverse reporting practices in qualitative research make it challenging to compare findings across different studies (Zbranca et al., 2022). Efforts have been made to develop models to guide the design, implementation, and evaluation of poetry therapy interventions. These models include the interactive bibliotherapy process by McCarty-Hynes and Hynes-Berry (1986), the RES model by Mazza (2017), the EFECT model by Alfrey et al. (2021), and the Reflective and Transformative Writing Process Model (RTWPM) by Ihanus (2019, 2022a). The RTWPM allows a theoretical examination of writing practices in poetry therapy (Ihanus, 2019, 2022a), while the RES model provides a foundation for using and applying various techniques to a wide range of audiences (Mazza, 2017). The EFECT model facilitates the examination and evaluation of a group work at different stages of the process (Alfrey et al., 2021), and the interactive bibliotherapy process offers a framework for exploring the personal meanings generated through the therapy process (McCarty-Hynes &Hynes-Berry, 1986). The purpose of this study was to analyze texts written by participants in a poetry therapy group for breast cancer survivors, as well as examine the writing process itself. In this context, poetry therapy refers to an interactive group activity focused on writing, using poetry therapy methods. First, the group activities and methods that facilitate writing were structured based on the creative component of the RES model (Mazza, 2017). The poetry therapy intervention was then implemented according to the Reflective and Transformative Writing Process Model (Ihanus, 2019, 2022a; see Fig. 1). The texts produced during the group meetings were analyzed using Interpretative Phenomenological Analysis (IPA; e.g., Smith &Nizza, 2022). The results are presented as themes emerging from the participants’writings, which are consistent across all group members’texts. The themes chosen by the participants aimed to capture meaningful experiences of their illness. Thus, the results are explored through the meanings that arise from the writings and interpreted within the framework of the process model of reflective (guided) and transformative (therapeutic) writing. The study sought to answer two research questions: 1) What kinds of things were found meaningful by the participants in writing about their experiences with breast cancer? 2) How were these things thematized through the process of facilitated reflective and transformative writing? The arrows do not represent a linear causal chain but rather “epigenetically” interlacing developmental steps, where the order can change throughout the process. These steps can occur in different successions, and at times, some steps may be less important, implicit or dormant in the ongoing process. Not all steps are functional for every participant, but the development and execution of writing require the collaboration of cognitions, emotions, and motivations with the appropriate brain processes. Continuous feedback and constructive self-evaluation through writing enhance learning and transformative feeling-thinking. Feedback from others provides a supportive, containing environment for individual and group identifications, explorations, comparisons, recognitions, and transferences. The richness and vitality of the writing experience of writing are evident in the amount of playful rewriting, which helps shape and transform identity and life stories for the future. I am not just one permanent, repetitive story but a constantly evolving constellation of stories. My meanings are never complete; they materialize and change through dynamic dialogues between the self and others, as well as between the reader/writer and the text in its various contexts. (Ihanus, 2019.) Wri�ng → Cogni�ve condi�ons → Emo�onal condi�ons → Mo�va�onal condi�ons → Defenses and coping strategies → Feedback from others → Iden�fica�on, explora�on, comparison, recogni�on, transference → Crea�ve fantasy and language play → Further personal reflec�on and expressive communica�on → Dialogical meaning nego�a�ons → Understanding and insight → Internalizing, rela�vizing, and integra�ng into the past, present, self, others, and environment → Metareflec�on = metacogni�on and meta-emo�on → Rewri�ng → Holding and transforming iden�ty stories and life stories toward the future Fig. 1. The Reflective and Transformative Writing Process Model (Ihanus, 2019). J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 3 Activities of the breast cancer survivors’writing group The main purpose of the Breast Cancer Survivors’Writing Group was for participants to write about their experiences with the disease. The group met 18 times, with each meeting lasting two and a half hours, at two–week intervals throughout 2019. The meetings and activities were guided by poetry therapy methods and facilitated by a trained poetry therapist. The activities were based Mazza´s RES-model and the steps outlined in the Reflective and Transformative Writing Process Model (Ihanus, 2019, 2022a). The RES model consists of receptive, expressive and symbolic/ritual elements (Mazza, 2017), which are identifiable in the group activities. The RTWPM includes cognitive, emotional, and motivational factors and their interactions (Ihanus, 2019, 2022a). The components of each framework may not always be distinct or follow a specific order, but they are embedded in dynamic and reciprocal relationships (Mazza, 2017; Ihanus, 2019, 2022a). Mazza’s model was chosen because it suited the study’s needs and effectively described the structure and main stages of the group meetings. Other models, such as the interactive bibliotherapy process (McCarty-Hynes &Hynes-Berry, 1986) and the EFECT model (Alfrey et al., 2021), were considered but found to have different starting points and a broader focus on the entire process. In contrast, Mazza’s RES model allowed for a more detailed and structured examination of individual meetings. Ihanus’model was selected for interpretative purposes. It provides a theoretical framework for analyzing the written texts and the themes that emerged from them as part of the group process. Mazza’s RES model was used to structure the sessions in the following ways. Each session included three phases. In the first phase, perspectives and experiences related to the theme were explored using materials, discussions, or list-writing activities. In the second phase, one theme was selected for deeper examination, followed by guided writing exercises. Sometimes a second exercise was conducted, shifting the perspective to another theme. In the third and final phase, the instructor helped the participants reorient to the present by discussing positive topics. According to Mazza’s model, the first phase involved orienting elements, the second phase focused on expressive writing, and the third phase incorporated ritualistic elements. The purpose of this paper is to describe the methods used in the group and how the participants’writings and reflections were facilitated through the group process. Table 1 presents the theme, orienting element, writing method, and ritual of each meeting. Orienting writing methods in the breast cancer survivors’writing group The process of reflective and transformative writing aims to stimulate working memory and activate autobiographical memory, involving the orientation of procedural memory and focused attention on objects of observation (Ihanus, 2019, 2022a). Mazza (2017) characterizes reception as participants’awakening to the session’s theme often through textual forms like poetry. In our group of breast cancer survivors, we referred to these materials as the orienting elements, which could be written texts, images, or music. The facilitator’s deep understanding of breast cancer and personal experience in nursing patients with this illness proved advantageous in selecting these materials. Motivation for writing was nurtured through texts presented by the facilitator, poetry collages, collectively chosen songs (listened to together), picture cards, landscape images, cartoons, and emotion-exploring fill-in-the-blank charts. The aim was to evoke responses in the participants (cf. Mazza, 2017). Moreover, the orienting materials also supported personal growth, development, and transformation throughout the sessions (Papunen &Kosonen, 2022). Participants were frequently encouraged to create their own lists relevant to the meeting themes, such as their encounters with the illness, discussions about diagnoses, medications, and more. In these instances, the meanings participants attributed to the orienting texts were deeply personal, fostering a meaningful connection with the self mediated through the texts (Papunen &Kosonen, 2022). Writing exercises as a medium for writing about breast cancer experiences The breast cancer survivors’group centered its activities on writing, structured around specific writing exercises in each meeting. Themes were designed to initially explore broad emotions (e.g., emotional process, meanings of life, my landscape) before delving into more detailed issues related to breast cancer, such as medication and corporeality. The aim was to transition from general emotional and existential themes to more specific aspects of the treatment journey. Themes were developed Table 1 Group meetings depicted according to the RES model. MEETING THEME ORIENTING ELEMENT WAY OF WRITING RITUAL* Emotional process “Good mood” cards List of emotion words Free writing Agreeing on common rules Words left unsaid Text: Human longing Letters (to the self + others) Postcard written to the self Meanings of life Follow-up story (together) "Minute exercise" “Good mood”card My Landscape Landscapes Free writing, drawing “Inspiration”card Told by a poem Poetry collage Writing poems A verse of poetry as a gift to the other participants Encounters List (positive & negative) Free writing Discussion: meeting a “sister” Places Meeting place “Minute exercise” “Emotional life” card Diagnosis List (who I told) Free writing Discussion: “a gentle meeting” Identity work Discussion about changes Free writing Presentation of a photo collage Empowering song Participants’ songs Free writing “Good mood”card Outside and belonging List (moments, situations) Free writing (insights) Positive things about the day/ week Medication List (medicines) Personification +story writing Discussion: things that make you feel better Womanhood Discussion +list compiled together “Minute exercise”Haiku writing +reading Corporeality Comic strip Free writing Discussion: positive feelings Moods "Emotional tower" Free writing and dialogue with emotions Best positive feeling Death Poetry collage, list (discussions) Free writing: figure of death +discussion about death Things that bring joy in life Breast cancer, meanings Discussion: aids, support, treatments, guides Free writing about the meanings of things the facilitator said Post-disease desires and dreams Farewell to breast cancer (independent processing) List of crying places +song: “Hunger for life” Descriptions of crying, existential meanings of personal life Song: “Tears of happiness” +farewell letter to breast cancer End session “Power animal” cards Description of current feelings Written greetings to other participants * Ritual: The rituals of each meeting include a start, a writing exercise, a discussion, a coffee break and a closing. The table shows no specific ritual for closing the meetings, as the closing ritual is not the same for all meetings. The closing rituals helped to conclude each session and facilitate a smooth transition back to the present. J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 4 with a focus on critical aspects of the treatment process, informed by the instructor’s clinical expertise in breast cancer and insights from previous studies on the topic. Additionally, themes emerged from discussions among participants, with considerations given to topics like ‘outside and belonging.’. The group was recognized as a poetry therapy group due to its inherent nature. The aim was to support participants in self-expression, enhance self-awareness, and foster interaction skills through the use of texts and writing to facilitate reflective processes (see, e.g., Linnainmaa &M¨ aki, 2022;National Association for Poetry Therapy NAPT, 2024). According to the National Association for Poetry Therapy (National Association for Poetry Therapy NAPT, 2024), poetry therapy ‘relies upon the use of poems, stories, song lyrics, imagery, and metaphor to facilitate personal growth, healing, and greater self-awareness.’Various materials were employed to offer diverse perspectives on experiences and to construct meanings and narratives. For instance, poems provide rich metaphors, comics offer interpretive possibilities, song lyrics and music connect with emotions, and images depict entities and illustrate emotional states through color. Writing serves as a pathway to access feelings, create order in lived experiences, and act as a tool for concretization (Mazza, 2017). Engaging with poetic and metaphorical materials and attachments (Ihanus, 2022a, 2022b), such as writing poems, haikus, and letters, helped participants process their feelings related to breast cancer. These activities enabled them to distance themselves from their disease-related emotions and decide how intensely they wanted to confront specific situations, feelings, or moments. Furthermore, using metaphors as a means of distancing and personifying medication accompanied the participants in their writing about their cancer experiences (Holopainen, Maanmieli et al., 2021) and enabled them to immerse themselves in the fictional world of texts (Ihanus, 2022a, 2022b). Through these methods, and by externalizing discussions (cf. White, 2008), participants were able to explore the effects and side effects of breast cancer treatment medications and the broader implications for managing their lives. A“one-minute exercise,”where participants wrote for one minute based on sentences spoken by the instructor, provided a structured transition and immersion into non-fiction. This exercise was employed to explore the meanings associated with places of care and current life situations. Within a strict time limit, participants had to quickly recognize and respond to the first association triggered by the instructor’s words, then write about it before moving on. The exercise lowered the barrier to writing, as the time limit left little room for conventional writing constraints such as grammar, self-censorship, or editing. Free-writing techniques were frequently utilized in the group as they proved effective for the participants. For instance, participants often engaged in free writing on topics selected from a list they created themselves. Writing facilitated the expression, evaluation, and regulation of thoughts and feelings (Ihanus, 2022a). Moreover, identifying strengths and positive feelings through writing promoted empowerment, integrity, and feelings of adequacy and worthiness (Maanmieli, 2022), even when addressing challenging memories and experiences related to breast cancer. Reflection and transformation in the breast cancer survivors’writing group Writing about breast cancer experiences was based on group activities, mutually agreed rules, and the opportunity to interact with others who had similar experiences. At the beginning of each meeting, participants shared how they were doing. After that, they were introduced to the theme of the meeting and began activities such as writing lists, reading comic strips, or listening to texts read by the instructor. Next, the instructor guided a writing exercise and suggested a method, such as free writing or a ‘minute exercise.’After writing, participants could read their texts aloud or comment on them. Others were allowed to provide feedback on what they heard. The texts were not evaluated, but experiences related to breast cancer or writing were shared. If there was more than one writing exercise planned, the process was repeated. Finally, the meeting concluded with a positive ritual, such as selecting a picture card and explaining the choice or discussing positive topics (see Table 1). Metareflection in a group occurs when metaemotional and metacognitive skills develop together (Ihanus, 2019). The group engaged in extensive discussions about their breast cancer experiences, primarily based on their written reflections. This facilitated identification, recognition, exploration, empathy, transference, and proximity, fostering a process of reflective and transformative writing (Ihanus, 2019). Participants listened to each other’s experiences, recognizing and identifying with them, which facilitated the expression of feelings, a sense of being understood, and peer support. The ritual-like structure of the meetings, including the exchange of news, orientation to the topic, writing exercises, discussions, a coffee break, and a closing ritual, supported the safety of the group work (see Holopainen, Maanmieli et al., 2021). Sharing personal stories promoted reflection and communication, deepening the poetry therapeutic process both personally and collectively (Ihanus, 2019). Listening to each other’s stories allowed participants to reflect on how they process and work through their own experiences. This led to new insights and deeper understanding, helping them connect their experiences to their life stages, both past and present, as well as to their sense of self and their environment (see Ihanus, 2019). The guided writing exercises enhanced the writing process and created a space for negotiating meaning between writer and text, text and reader, and among the participants (Ihanus, 2019). The group process generated a sense of belonging and provided members with an opportunity to shape their future identity and life narratives. One participant described the activity as follows: “I think this is great, terrific. Like for me and certainly for others. We can see each other and cry together and laugh and go on living.” Method Research questions As mentioned in the Introduction, this study focused on the following questions: 1) What kinds of things were found meaningful by the participants in writing about their experiences with breast cancer? 2) How were these things thematized through the process of facilitated reflective and transformative writing? Participants and recruitment Six people took part in the group, with four actively participating until the meetings concluded. Two participants dropped out midway through the meetings for personal reasons. Recruitment was conducted in cooperation with the Central Finland Cancer Association and the Breast Cancer Association-Europa Donna Finland. The study was advertised on the target group’s social media channels, the associations’ websites, and notice boards. Interested individuals were invited to contact the researcher via email. A leaflet detailing the study was sent to those interested, describing the group as a writing group utilizing poetry therapy methods. Participation required the completion of breast cancer treatments and the absence of concurrent mental health treatments during the group intervention. Data collection Texts written by the participants during the 18 meetings comprised the study data. The meetings were structured consistently, using wellknown writing exercises in poetry therapy (see Table 1), and followed a set format: orientation, working, and ending. The writing was done by J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 5 hand and addressed topics related to breast cancer, such as medication, sharing the diagnosis, being a woman, and the personal relevance of breast cancer-related issues (e.g., wigs, peer support, etc.). Participants were asked to label their texts with their pseudonyms. Copies of the texts were then made and typed out, resulting in 85 single-spaced A4 pages of data for analysis. Analysis The writings were analyzed using Interpretative Phenomenological Analysis (IPA), which aims to understand individuals’life experiences and their self-perceptions within their personal and social contexts (Smith &Nizza, 2022). Since breast cancer experiences are unique to each person, each participant’s texts were initially analyzed separately. The IPA analysis proceeded through four stages: 1. The participant’s writings were read multiple times and, the responses they evoked (descriptive, linguistic, structural) were recorded as exploratory notes. 2. Based on these notes, experiential statements reflecting the participant´s experiences, were formulated. 3. Connections and key factors were identified and clustered. 4. Personal experiential themes were formulated from these clusters. These four steps were repeated for all six participants. The experiential themes from each participants’writings were then considered collectively. Themes were examined for common elements and differences within those common elements, leading to the formulation of group experiential themes that unified the entire group (see Smith & Nizza, 2022). Ethical considerations The Research Ethics Committee of the University of Jyv¨ askyl¨ a conducted an ethical evaluation of the research. Interested participants were interviewed individually before the group meetings began to gather information about their attitudes toward breast cancer and its treatments. During these interviews, interested participants were informed about the study’s purpose, objectives, and the methods that would be used in the group. They were also assured of the confidentiality of their data, the voluntary nature of their participation, and their right to withdraw at any time during the data collection process. All participants provided written informed consent for their participation and the use of their data for research purposes before entering the study. Results The themes capture significant aspects of the breast cancer experience and appeared in various contexts within the participants’texts (see Table 2). Being explicitly seen and heard as a breast cancer survivor was important to the participants. Their writings frequently described the traces left by the disease, referring to the physical, social, and mental changes it induced. Additionally, the theme of survival emerged, encompassing the survivor’s feelings of coping, introspection, and desire for self-development, as well as the lingering effects of the disease even years after the end of active treatment (surgery, chemotherapy, radiation therapy). Autobiographical writing serves various functions, including facilitating self-awareness and self-expression, and achieving artistic and aesthetic goals. It can help individuals to achieve self-awareness and self-expression, as well as artistic and aesthetic goals. It can also be comforting and nurturing, helping to structure one’s perceptions of reality and life trajectory. Through autobiographical writing, individuals produce texts that revisit, reproduce, and revive memories from their own perspective. One challenge lies in the dynamic nature of the self, where memories and life truths are never static and fully capturable. However, each moment presents an opportunity to discover new facets of the self, allowing for ongoing self-recreation (Kosonen, 2019). The autobiographical elements identified through the sub-themes were discernible in each participant’s texts. Despite the fragmented nature of the texts, they prompt writers to reflect on meaningful moments and explore emotions tied to pivotal life experiences. This process does not necessarily lead to a coherent autobiographical narrative but rather directs attention to significant life phases and feelings. The themes and their sub-themes are presented in Table 2. Being seen and heard as a breast cancer survivor This theme encapsulates the necessity brought about by the disease for interaction with various groups including professionals, loved ones, peers, and others within one’s age group. Encounters with others, particularly healthcare professionals, were noted as profoundly meaningful. The data illustrated moments and situations related to the disease, often in challenging therapeutic contexts, highlighting the significance of being acknowledged and understood as a breast cancer patient. The role of family members and close friends was also emphasized as pivotal in experiencing events and moments, frequently accompanied by tangible gestures of support and expressions of gratitude and appreciation. The importance of support and presence from healthcare professionals during the illness The support of healthcare professionals was perceived as crucial, especially during periods of anxiety and when patients were first confronting their illness. Participants vividly recalled and documented the exact words of doctors and nurses, detailing their encounters in the texts. Table 3 highlights the significant role healthcare professionals play in providing support, comfort, attentive care, and guidance to patients during their illness journey, particularly during critical and uncertain moments. The participants’narratives highlight the need for information arising from their new situation and underscore their appreciation for the encouragement and verbal support provided by healthcare professionals. The writings often contextualize the treatment experiences and emphasize the significant role of healthcare professionals’presence during these critical moments. These insights from the participants’ texts illustrate how informative and supportive interactions with healthcare professionals are valued and crucial in navigating the challenges associated with breast cancer diagnosis and treatment. The emotional elements emphasized in the texts often reflect the writers’emotional states, while, among the cognitive functions, the activated memory systems reproduce verbatim expressions and specify emotional experiences. In the example provided, the exact repetition of what was said by the nurse and the recollection of her working during her own free time can be seen as a symbolic act through which participants create a psychological distance between themselves and their emotions. This interpretation suggests that by symbolizing their Table 2 Experiential themes in the Breast Cancer Survivors’Writing Group. THEMES SUBTHEMES Being seen and heard as a breast cancer survivor The importance of support and presence from healthcare professionals during the illness Involvement of significant individuals The traces left by the disease Physical/corporeal changes caused by the disease and treatments The impact of the disease on personal relationships Presence of cancer after treatments I live and breathe despite the disease Survival mentality Initiation of spiritual growth spurred by the disease Living in continuous interaction with the disease J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 6 experiences through detailed recollections, participants can gain clarity and resilience in coping with the emotional impact of their breast cancer. This process helps strengthen their sense of self and facilitates a healthy detachment, thereby fostering a new relationship and perspective on the emotional states associated with the experience that has affected their health (cf. Lindquist, 2022). Involvement of significant individuals One of the most significant themes that emerged from the writings was the involvement of loved ones and their impact on the patient’s everyday life. Participants highlighted the presence and attention of loved ones during their illness, describing moments where their actions directly supported the patient’s well-being (see Table 4). The writings show that the concrete actions of paying attention to and helping the sick person were meaningful. The above extracts illustrate the impact of cancer treatment on the patient and how it was alleviated by the presence and involvement of those close to her, including both family members and close friends. The importance of the presence of loved ones was explicitly stated in the participants’writings that illustrate their crucial role in providing emotional support, practical assistance, and companionship. Descriptions of challenging moments were accompanied by descriptions of people important to the writer. Their actions and the feelings they evoke are highlighted when the writer is in a state of vulnerability. The act of writing brings back warm memories that may help to mitigate the return to challenging moments and situations. Such writings manifest the participants’desire to act as experiencers and shapers of their own narratives, interpreting and searching for meaning in a more understandable form. This process enables them to meaningfully contextualize their experiences in their own life history. Traces left by the disease This theme refers to writings on the impact of breast cancer and its treatment on the patient. The sub-themes are grouped according to their impact on physicality and the body, relationships, and thoughts. Physical and bodily changes caused by the disease and treatments The writings described visible signs of the illness and its treatment, such as scarring, changes in hairstyle and weight gain. Another important aspect was the impact of the disease on functional and physical capacity, such as experiences of fatigue and reduced physical performance (see Table 5). The participant’s extract (P2) shows the importance of thought and judgment, resulting in the author coming to terms with the impact of the issue on her activities and seemingly accepting her new status quo, even if this is not easy. In another participant’s extract (P3), the description of standing in front of a mirror and seeing the marks on her body left by her breast cancer testifies that the disease is real for her. The image reflected in the mirror and her evaluation of the external aspects of herself trigger an emotional reaction as her bodily situation becomes real. Descriptions of physical and bodily effects were quite common, often accompanied by stories of how external changes had been noticed by others. In the above example, the observer in the mirror is positioned as an objective observer of herself. In the previous example, the physical changes seemed to be experienced from within, with the writer noting their impact on her ability to function, such as shifting from running to walking and, finally, to just trudging along. Ihanus states that insights can emerge through reflection on personal experiences and the dialogical communication between writer and text. This makes it possible to relate such experiences to one’s personality and life course. (Ihanus, 2019.). The impact of the disease on personal relationships The writings also reflect on how disease can either drive people away or bring them closer to the sufferer (see Table 6). In one participant’s excerpt (P2), the author approaches the issue by contemplating its causes. Through a series of questions, the writer seeks to rationalize what happened rather than express personal emotions. The excerpt also indicates that the issue has reached a stage where it can be approached and examined rationally through writing. The participant reflects on the side effects of her treatments for the illness as the reason for the end of her relationship. The text suggests that the event is now consigned to the past. With time, mental health can recover, and psychological balance can be restored by confronting emotionally disturbing issues. The process of writing can be psychologically painful. However, through writing, one can come to realize that nothing bad is actually happening, which helps in tolerating exposure to traumatic events and gradually acquiring desensitization to the trauma (Lindquist, 2022). In contrast, the disease can forge a closer bond between the sufferer and their loved ones in a new way. As illustrated in the participant’s excerpt (P4), the patient perceives herself as a valuable source of information and interest, which puts her own feelings into perspective. This excerpt reveals a novel approach to viewing the patient, one that acknowledges her perspective while establishing a different foundation for interaction compared to what she was accustomed to. The participant reflects on learning at two levels: her own insight into the dynamics from a cognitive standpoint, and the other person’s interest in learning something new, with the writer herself assuming a role akin to a Table 3 The importance of support and presence from healthcare professionals during the illness. When I was in the ward at the beginning of the illness, I felt very unsafe. I tried calling the cancer nurse even though my work hours were over. He came to me and listened to me all night. (P1) Control visit: feeling at ease. The doctor will take care of it. You can ask anything. (P2) After this, needle biopsies were taken from both breasts, and she told me when they would give me the answers, and I remember at this point she said words that I carried with me, especially when I was waiting for treatments. ‘This is not a death sentence; this can be treated.’(P3) This woman had time for me and she could say exactly what was supposed to be said in that moment to a scared, feverish cancer patient: ‘This gets better, life goes on, everything will be fine.’(P4) Then he says that magical phrase that will support me more than he ever imagined: ‘We have the idea here that we will get you well, and it is good if you feel the same way too.’(P6) Table 4 Involvement of significant individuals. There is a close bond in my family. The children already live elsewhere, but we have a lot to do together. (P1) I wanted to protect my father, but it turned out that he was my most important resource during the treatments, and he continues to be. (P2) Whenever I could, I would sit at least an hour and a half in the cooling sauna. Sometimes, my husband would come to check on me to ensure I hadn’t fainted there. (P3) Care, warmth, love. I wish we could all be as fortunate to have a friend like this by our side when we run out of strength. And I hope we could be this kind of friend to our loved one when s/he needs it most. (P4) My husband’s actions warmed my heart during my cancer treatments. Every day, he brought me something good to eat that I might enjoy. He was a spiritual support and took care of many things. He also kindly cut my hair when it began to fall out. He patiently endured my “cortisone hype”and brought paint, etc. to get the door painted, and to change the door handles, etc. whatever came to my mind. Children and friends frequently called to check on me and see how I was doing. (P5) My partner´s presence, his genuine care, and his love were invaluable. A few of my friends also came when they heard about it. They all tried to instill in me a belief in healing and good treatment. (P6) J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 7 “teacher”in the situation. Other writings also explored the effects of changes in one’s agency (such as seeking help, losing control, and increasing social activity) on relationships. These writings can be interpreted as showing that the writers actively engage with their personal traumatic experiences, portraying themselves as creators and active participants in their own narratives rather than passive victims of events unfolding. Presence of cancer after treatments The participants’writings revealed that due to their illness and cancer treatments, the limitations of their lives became more tangible, and the fear of recurrence persisted (e.g., during follow-up visits). However, the experience of the disease and its treatments, along with their side effects, was also seen as just one part of life (see Table 7). The excerpt (P6) indicates that the writer’s personal experience with cancer has altered her perception and attitude not only toward cancer itself but also toward others facing the disease. The author mentions an increased understanding, seeing cancer now as something external, "part of someone’s life," while also acknowledging its personal nature through her own journey. In writing about cancer, maintaining a sense of distance is crucial for the experience of being in control. What becomes meaningful is the preservation of a coherent, structured self and the experience of being an agent of rational thought and an active subject of emotions, without being overwhelmed by them (Lindquist, 2022). The emphasis on cognitive factors, particularly metacognition, enables individuals to conceptualize and articulate the subject on a broader, more abstract level, fostering introspection and facilitating a reconsideration of one’s outlook on life with empathetic mentalization (see Ihanus, 2019, 2022a). I live and breathe despite the disease From several descriptions of the experience of the disease, a theme of survival emerged, either through discussing the disease or coping with its treatment. There were also notable references to the need for personal growth and development as a consequence of the illness, as well as managing its post-treatment effects. Coping mentality The survival or coping mentality was expressed in the texts as being achieved through the influence of external factors, such as support from close relatives and others who learned about the illness, as well as through functional factors like undergoing treatments (see Table 8). Telling an outsider about one’s disease seems to make the situation more conceivable and enables one to feel that it is possible to cope with it. The desire to communicate about one’s internal or external reality was perceived as meaningful. In the participants’excerpt (P3), the writer reflects on the moment she dared to tell a stranger about her situation. This moment was significant, and the writer clearly wanted to capture how outward communication (talking about the illness) led to a sense of coping. She felt that sharing her inner reality (the sense of survival) was important. In another excerpt (P6), the writer describes an inner reality in which feelings arising from actions are rationally explained. The treatments were perceived as a continuum, with survival being a step-by-step process. The excerpt indicates that the writer is making efforts to prepare for the consequences of her treatment thus far. Her desire to rehabilitate herself for the next stage of treatment shows a commitment to undergoing it and taking advantage of the opportunity to get better. In these short excerpts, one can discern attributions, perspectives, and meanings aimed at processing past experiences and structuring what will be experienced in the future (Lindquist, 2022). Initiation of spiritual growth spurred by the disease References to the desire for personal development, self-exploration, trying new things, and reflecting on one’s values as a result of the illness were evident in some form in each participant’s writings (see Table 9). Mental changes induced by reflections on facing and experiencing the illness are followed by a need to reflect on and write about changes Table 5 Physical/corporeal changes caused by the disease and treatments. My femininity is made up of small pieces. A breast, another breast. The repair of my body over time. A wig settles on my head. This restrained movement brings back memories of infatuation, of falling in love, of feeling cared for. My sexuality has been lost due to the huge weight gain. My mind thinks otherwise, but the shell of the body is a more monstrous sight. (P1) During my breast cancer treatments, the pace slowed down. Running turned into walking, walking into trudging. It felt bad at first, sad, but soon I thought I needed to slow down and give myself time to fight the cancer cells. (P2) I looked at myself in the mirror for a moment and thought, ‘I’m so hideous.’I think I said it out loud. My first feeling was confusion—had all that really happened to me? Bald head, long red scar on the left breast, slightly smaller scar on the right. The skin on the left breast next to the scar was blue-red. It made me cry. (P3) I cut my hair very short and with a new hairstyle, it came up with a lot of acquaintances. If I didn’t want to tell someone wondering about my hair, I joked about the heat and sweating of the summer (it had been shockingly cold!), and for people closer to me, I could tell them I was expecting a much rougher hairstyle. (P4) When I think about my illness, I remember a lot of bad things from the time of the treatments. Feeling unwell, difficulty falling asleep, swelling, dehydration, etc. (P5) Table 6 The impact of the disease on personal relationships. I feel at the moment that I have lost friends in my life, and somehow a nice confidential, relaxed way of life. (P1) At first, he slept next to me, and once I fell asleep, he would leave. In retrospect, he was already pulling away. Why? Because I was bald? Because I was sick, and my skin was sore? Because I didn’t want him inside me, I wanted him next to me? (P2) The people around me were important, they could listen and help without complaining. (P3) He was extremely interested in everything about cancer cells, cytostatic agents and the body’s reactions. It was a relief to meet someone who was curious and inquisitive about everything. Not so much about feelings and symptoms, but facts. For him, my breast cancer was an opportunity to learn something new. (P4) They can be as strong as you and may want to share your burden and be there for you. Trust others to persevere. It may feel comforting for them and certainly for you. (P5) Important relationships have been concentrated and refined. (P6) Table 7 Presence of cancer after treatments. Life is indeed limited and short, even if you live to be over 70 −80 years old (when you are healthy). Now, with the illness, it has become more tangible. (P1) Mammography always scares in advance for about a week. In mammography, cool on the outside, but inside fear and panic. (P2) Recurrence could cause quite a collapse. Sometimes I wonder if I survived the treatments again. (P3) My cancer carries a high risk of recurrence. No oncologist will directly quote percentages, but I know that it’s close to 50 %. So, when you get a headache, back pain, or go to bed at night with an uneasy hand searching for a new lump, terror immediately sets in. (P4) I become sad when I think about the possibility of the disease recurring. How could I go through the same thing again? (P5) A whole new world has opened up. It used to be terrifying to know that someone had cancer. Now, I understand it is just a part of someone’s life. I realize that it doesn’t stigmatize a person or define every moment of their life. (P6) J. Holopainen and J. Ihanus The Arts in Psychotherapy 90 (2024) 102194 8 in one’s inner world and attitude toward the external world. One of the participants (P2) observes how the illness and treatments stopped her in her tracks, leading her to reflect on what is important in life. This observation is significant because it reflects on how her illness affected others and their ability to respond to her needs. It also refers to letting go of her old life values and understanding the value of being able to function, even in small ways. Another excerpt (P5) reflects on pausing to appreciate and pay attention to ordinary things that ultimately matter most and make life fulfilling. The realization that things happen and are not necessarily under one’s control provides an opportunity to understand and appreciate the mundane and often unnoticed aspects of life. These two participants’writings demonstrate something essential about the process of transformative writing. Both excerpts embody insights that emerge through inferred ‘causal’explanations, transforming the lives and worldviews of those who experience them. In both cases, there is a strong sense of the writer’s desire and to reshape their lives in new directions after the stagnation imposed by their illness. Living in continuous interaction with the disease Being diagnosed with breast cancer affects one’s ability to function, both physically and mentally. Participants wrote about their hope of maintaining their functional capacity after recovery, despite becoming accustomed to their existing and residual symptoms. Even after receiving a “clean bill of health,”the presence of cancer persists in the mind, repeatedly causing fear and necessitating vigilance. Excerpts illustrating these sentiments can be found below (see Table 10). A person with the disease has no choice but to accept it as part of life. How actively one thinks about it or how present it is in one’s life, such as when acting as a peer support person, can at least in part be selfdetermined. However, there is always the possibility of relapse; there are residual physical limitations and a mind that continues to work through the experience. The writer engages with her experience of the illness and creates meanings from it. The shared group process of thinking, feeling, writing, memorizing, and desiring restructures the participants´ongoing explorative and reflective discourses and meaningmaking attached to their illness and survival (Ihanus, 2019). Discussion This study analyzed a group writing process on the experience of breast cancer. The structure of the meetings and the writing methods used with the group followed The RES poetry therapy model. Participants’writings were analyzed using Interpretative Phenomenological Analysis (IPA). Three main themes and sub-themes were identified. There were “Being seen and heard as a breast cancer survivor”;“The traces left by the disease”; and “I live and breathe despite the disease”. Participants’writings were interpreted using The Reflective and Transformative Writing Process Model. The results of the study provide insights from an informational perspective, highlighting the writing process as driven by a communicative motive. Understanding breast cancer from the patient’s viewpoint is crucial. The effects of the disease and its treatment profoundly impact patients’lives, affecting both appearance and physical functioning. The illness also prompts a shift in perspective for the patient, requiring reassessment of pre-diagnosis values, routines, and cognitive capacities. Therefore, enhancing understanding of personal experiences of the illness is valuable, particularly among healthcare professionals, the patient’s close circles, and others affected by the patient’s situation. Previous research interventions with breast cancer patients have utilized the expressive writing method developed by Pennebaker (1997). This method involves writing about feelings associated with a traumatic experience for 15–20 min daily over several consecutive days. Table 8 Survival mentality. Someone once said that the forest heals. And there’s a healing agent taken from the trees in the cytostat. If the forest had just been cut down, I usually stayed and smelled it. In the early stages of my illness, I walked a lot. (P1) When I looked at my child and saw the way he looked at me with confidence, I knew I wasn’t going to die from this. It gave me strength, and that power has only grown within me. (P2) So, she was the first person outside my family who knew about my cancer. I was really glad that I told her, and that’s when it occurred to me that I’m going to get through this. (P3) One of the main thoughts when I heard about cancer was that I was thankful it hit me. Fortunately, it didn’t affect my mother, my daughter, or anyone near and dear to me, because enduring a loved one’s illness would have been much harder than enduring my own. (P4) I don’t really remember how I told the kids about cancer and how they reacted. I immediately explained the good healing rates of breast cancer. (P5) When I leave the cancer ward, I feel relieved in a way. Another step forward. Now I just have to deal with the consequences and get fit for the next time. (P6) Table 9 Initiation of spiritual growth spurred by the disease. New doors opened: studies, new fields in volunteering. (P1) I changed during the treatments. Time stopped. The here and now became important. Being with people for real became important. I realized who cared about me and who was important to me. During treatment I learned a lot about friendship and trust. When you’re afraid of dying, you understand who wants to be present in your life. My life values were redefined. Health became the most important thing—being well, not being in pain, and being able to do something. (P2) I am a worthy old lady who has begun to find herself at such a ripe age. My new hobbies have been accepted by my family because my family has noticed that I am feeling better. (P3) I need a lot of time to cope with all this. I wonder if I can become a whole person from my shrapnel. But there is so much to be happy and lively about, or at least to try to appear that way. I feel that my loved ones are suffering more from my illness than I am. (P4) I like to notice the little good things in everyday life, to stop and think about them, and to enjoy the feeling that now is good! The most important thing is that everyday life is good. A lot of things happen that you can’t do anything about, but it’s those little ‘micro-moments’that set things right. (P5) This gives me the ability to see more clearly what is important. The need to please decreases and there is healthy selfishness, strength, and the courage to say no. (P6) Table 10 Living in continuous interaction with the disease. Now, I can better think about funeral arrangements, but my loved ones still don’t want to talk. (P1) Written stories about breast cancer. I read everything that comes up. I want to hear other people’s stories of survival, struggle, and growth. Very important and fascinating. Maybe someday I’ll write and publish something myself. (P2) At the moment I don’t think much about cancer, probably because I’m feeling pretty good and have much nicer things to think about. I’m so used to the side effects of the drugs that they don’t bother me much anymore. (P3) It has become clear over the last few years that cancer is not something you just ‘get over’(the word makes me angry!), but that it accompanies you in one way or another for the rest of your life. For some, it is a constant fear, a daily reminder of years of prolonged medication; for others, it is new symptoms, new lumps, new treatment cycles. (P4) The illness brought about a tremendous mental process in me that continues to this day. One has had to look for a balance of mind control to be able to continue living with confidence, or at least in some way with peace of mind. I wish I could live my life to the end. (P6) J. Holopainen and J. Ihanus