Accepted Manuscript

Title: Changes in Self-Perception following Breast cancer as

Expressed in Self-Figure Drawings: Present-Past

Authors: Ziva Ariela Barel-Shoshani, Shulamit Kreitler

PII: S0197-4556(16)30002-8
DOI: http://dx.doi.org/doi:10.1016/j.aip.2017.05.001
Reference: AIP 1452

To appear in: The Arts in Psychotherapy

Received date: 2-1-2016

Accepted date: 7-5-2017

Please cite this article as: Barel-Shoshani, Ziva Ariela., & Kreitler, Shulamit., Changes in
Self-Perception following Breast cancer as Expressed in Self-Figure Drawings: Present-
Past.The Arts in Psychotherapy http://dx.doi.org/10.1016/j.aip.2017.05.001

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Highlights

 Three drawing indices indicated differences in self-perception pre-post breast cancer.

 Drawing indices express disillusionment, distress, and reduction in the sense of

femininity.

 Projective tool may be used as part of survivor's rehabilitation program.

1
Title: Changes in Self-Perception following Breast cancer as Expressed in Self-Figure

Drawings: Present-Past

From: Ziva, Ariela, Barel – Shoshani; Prof. Shulamit Kreitler

Author 1 Author 2

Name: Ziva Ariela Prof. Shulamit Kreitler

Family name: Barel - Shoshani,

Art Therapist (M.A.)

The Graduate school of Creative Arts The School of Psychological Science, Tel Aviv

Therapies, University of Haifa ,Israel, & University. &

Women's Health Center - Merav Institute of

Kreitler center of psico-oncologia Sheba medical
Sheba medical center, Tel HaShomer, Israel
center, Tel HaShomer, Israel

zivabarel@gmail.com krit@netvision.net.il

Postal address: 5 Hadudaim st.

Rosh-HaAyin, Israel

Telephone number: 972507912083

Corresponding author: Ziva A. Barel – Shoshani

2
 Abstract

This study examined expressions of distress and changes in self-perception in women

who had breast cancer, in self-figure drawings. The Machover Draw-A-Person test was

administered to 70 survivors twice: first they were asked to draw themselves today, then they

were asked to draw themselves as they had seen themselves pre-illness. The expressions in self-

figure drawings were compared using seven indicators: breasts, hair, body outline, lower body,

mouth, eyes, head outline. The findings indicated differences in self-perception pre-post cancer

by three drawing indices: hair (short, shaggy), body outline (double, bold) and eyes (dots, hollow,

shaded), which express disillusionment and connection to self, accompanied by signs of distress,

anxiety, and damage to self-esteem and sense of femininity. In conclusion, we will demonstrate

that the projective tool tested could be used as an aid for structuring supportive care to alleviate

the distress of such women as part of a rehabilitation program.

Keywords

Breast cancer; projective tool; self-figure drawing; Self-esteem; DAP; Draw a Person

3
 Introduction

Breast cancer is the most common form of cancer in women in western society (one out of

eight) and the number one cause of female mortality (World Cancer Research Foundation

International, 2015). However, advances in medicine and technology enabling early detection have

led to a significant reduction in the mortality rate (Siegel, Miller, & Jemal, 2016). Hence, it is

important to address the psychological consequences of the disease on breast cancer survivors

(Dizon, Suzin, & McIlvenna, 2014). Breast cancer patients have to deal with the fear of recurrence,

which is perceived as an existential threat to their survival, a threat to their self-image and a

threat to the sense of control over their lives and their futures, a constant force in their lives even

when they have been declared cancer-free (Remmers, Holtgräwe, & Pinkert, 2010). Aside from

this, there are additional pressures due to the course of available disease treatments: mastectomy-

in many cases women with breast cancer are compelled to undergo surgery, which causes

distortion or even complete removal of the breast, resulting in damage to a woman‟s body image,

sense of sexual desirability and even her self-esteem (Dizon et al., 2014). Chemotherapy - which

causes hair loss, and even after the hair grows back it is often shaggy and not similar to what

once was (Bower, 2008), a phenomenon that has been linked to a sense of loss of sexuality and

attractiveness, damage to body image, personality loss and death (Annunziata, Giovannini, &

Muzzatti, 2012). Hormone therapy - found to cause weight gain which women have trouble

losing even years after their disease diagnosis (Bower, 2008; Dizon et al., 2014), which can cause

sexual dysfunction (Dizon et al., 2014; Perz, Ussher, & Gilbert, 2014; Walsh, Manuel, & Avis, 2005)

and sometimes even damage to the womb, requiring a hysterectomy- removal of all or part of the

womb (Le BouEdec, De Latour, & Dauplat, 1998; Pérez-Medina et al., 2011). Hysterectomy can

cause even more physical suffering in women, impair their ability to have children, incontinence,

4
constipation, loss of sex life, to its exclusion entirely (Dizon et al., 2014), pain during intercourse,

difficulty reaching orgasm and decreased libido (Schover, 2005; Ussher, Perz, & Gilbert, 2012),

another source of damage to sense of self-esteem and sexuality (Hald et al., 2004). Radiation

therapy - which damages skin texture and adversely affects the cosmetic appearance of the breast,

(Whelan et al., 2002; Rodríguez et al., 2013; Strnad et al., 2016), also causes fatigue and a

decrease in activity, resulting in weight gain (Vance, Mourtzakis, McCargar, & Hanning, 2011)

Studies on adaptation and coping by women with breast cancer in the broader circles of

social- occupational and spousal relationships, as well as intra-personal arenas, reported

additional difficulties due to the disease and its treatment: for example, women were afraid to talk

about their cancer, as they cited humiliation, lack of empathy and disbelief among the difficulties

they encountered in society, and sometimes even pity and participation in their pain. They felt

that talking about their cancer was ignored and avoided within their familial units. They were

concerned about whether their breast amputation was detected by others. There was a fear of

repercussions at work and in their interpersonal relationships, due to the physical difficulties they

experienced. These women developed signs of mental pressure due to fear of talking about the

disease (Remmers et al., 2010). Young women, mothers of small children, experienced great

difficulty speaking with their children, because they wanted to protect them from knowing that

their mother had cancer and about the consequences of the disease and the treatments, and even

when they did choose to speak about the disease, they had to be careful and adjust the flow of

knowledge to the developmental stage of the child (Semple & McCance, 2010). They also

described communication problems with their partner, which sometimes even led to separation as

a result of their sexual dysfunction (Walsh et al., 2005). In many cases the subjects knowingly

refrained from talking about the threat, selectively denied, disconnected (especially cognitive

5
avoidance) and refused to accept the consequences of the disease, to the point of displaying a lack

of concern for their health and a basic denial of the existence of the disease. The denial and

disconnect were used as partially effective defense mechanisms to cope with cancer awareness in

the short term, as well as during the crisis, as long as it did not interfere with disease treatments .

However, when used long term, after treatment, they created distress and anxiety (Hack &

Degner, 2004).

Diagnosis via self-figure drawing

People have „two languages‟: a primary language which is based on initial

communication means: touch, voice, sight and drawing, and a verbal language based on icons:

speech and writing (Aron-Rubin, 2011). A drawing is less defensive than a language, enables

spontaneous expression of one's own inner world, and provides diverse types of information

(Jung & Kim, 2015; Silver, 2007). E.g. in a study on adolescents 'self-representations', self-figure

drawings provided information on parent–adolescent relationship (Goldner, Abir, & Sachar, 2016).

In view of the concerns and distress found in the breast cancer population in speaking about the

'disease', it is of great importance to assess their distress and coping strategies with the help of

both 'languages': the verbal level by asking questions and the projective level by drawing. But, to

our knowledge , most studies that examined the distress and emotional consequences of the

disease and the treatment of women with breast cancer, used only verbal tools (questionnaires)

which are controlled by cognition, apart from one preliminary study which used a projective tool

self-figure drawing (Barel-Shoshani, Gill, Chernikov, & Regev, 2011). The preliminary study

found differences between the present self- figure drawing and that of the perceived-self pre-

disease with the signs: bulging breasts; head outline (bold, closed); mouth (omitted, shaded or

cut); eyes (hollow, shaded, dots); body outline (dashed, disconnected, bold); lower body

6
(disconnected, unstable); and hair in women who underwent chemotherapy . Since the initial

study included a small sample of 11, the findings do not allow inclusion. The current study will

expand the initial study by increasing the sample size, and will be based on indices examined in

the initial study (bulging breast, head outline, mouth, eyes, body outline, lower body, hair). In

addition, the current study will be based on indices found in the literature regarding self-figure

drawing in different populations which may be relevant to the characteristics of breast cancer

survivors: populations such as cancer patients (Lev-Wiesel, Ziperstein, & Rabau, 2005), those with

physical and/or mental deformities (Tal, Abuktat, Blum, & Barash, 2011; Lev-Wiesel &

Yosipov-Kaziav, 2005), mental stress and anxiety (Lev-Wiesel, 2015), femininity and sexuality

((D‟Agata, Rigo, Pérez-Testor, Puigví, & Castellano-Tejedor, 2014; Mavor, 2011). The

characteristics are: a sense of instability common among cancer survivors due to the fear and

worry of recurrence- return of the cancer (Ghazali et al., 2013; Simard, Savard, & Ivers, 2010).

Standing/lower body-legs confer to the figure stability, balance and a solid foundation to stand

on. For most, there were signs of non-stable standing, distorted/omitted legs, as an expression of

the sense of instability (Abraham, 2002) in the drawings of those groups who experience the

world as unstable and uncertain, or those who experience themselves unrealistically (Guez, Lev-

Wiesel, Valetsky, Kruszewski-Sztul, & Pener, 2010; Tal et al., 2011), and who drew themselves

in a stressful situation (D‟Agata et al., 2014; Merrill, 1994). Hence, it is likely that signs of non-

stable standing indicator may characterize drawings by breast cancer survivors.

Studies on adaptation and coping of women with breast cancer found that the women

experienced great difficulty and fears speaking about their cancer (Semple & McCance, 2010;

Remmers et al., 2010). Abraham (2002) observed that omission, distortion or highlighting of

body parts which are injured or related to their physical or functional disability were expressions

7
of conflict about self-identity and body image. Self-figure drawings by patients who experience

difficulty in expressing their feelings (Guez et al., 2010) or difficulty in communication (Lev-

Wiesel & Yosipov-Kaziav, 2005) were characterized by emphasized or omitted mouth. Hence it

is likely that omission, or highlighting of the mouth, may be an indicator characterizing drawings

by breast cancer survivors.

In addition, properties found in drawings made by specific populations, such as the deaf,

highlighted and emphasized the ears, mouth and hands (organs used for communication) (Lev-

Wiesel & Yosipov-Kaziav, 2005), and in another study, were found to have omitted or distorted

ears (D‟Agata et al., 2014). Cancer patients who underwent resection of the colon and creation of

stoma in their stomach omitted body parts and added extras in the abdominal area, which

represent the stoma or malignant growths (Lev-Wiesel et al., 2005). The breast organ in the

breast cancer population is the injured body part that may cause a woman's death. Aside from

this, due to the treatments, in many cases women with breast cancer undergo breast surgery

which causes distortion or even complete removal of the breast (Dizon, et al., 2014). In previous

drawing research, omitting breasts expressed poor female body image, (Guez et al., 2010),

whereas prominent breasts expressed a high sense of femininity (Mavor, 2011), or preoccupation

with femininity, sexual identity and conflicts (D‟Agata et al., 2014). In the preliminary research

by Barel-Shoshani et al. (2011) breast indicators were quickly noticed in the self-figure drawings

of the present and past, among women who had breast cancer (regardless of whether they

underwent surgery), in that breasts were omitted in the present drawing as compared to that of the

past. Hence it is likely that breast indicator may also be relevant in the current study.

Breast cancer patients described communication problems with their partners (Walsh et

al., 2005), children, friends and acquaintances (Remmers et al., 2010). Machover stated that eyes

8
- which represent a basic organ used to communicate with the outside world (Kahill, 1984), that

are omitted, hollow, shaded, dots, express feelings of helplessness, depression and anxiety, fears,

denial of reality, difficulties in reality testing and interpersonal relations (Abraham, 2002); such

eyes were found to characterize the drawings of people suffering from physical deformity,

physical or functional disability, as an expression of difficulty making social connections due

their disability (Lev-Wiesel, 2015; Lev-Wiesel, Shabat, & Tsur, 2005; Tadmor, Shaw, Shlomo, &

Lavie, 2011), and in drawings by colon cancer patients as an expression of sense of helplessness

(Lev-Wiesel et al., 2005). Hence, it is likely that the indicator of non-communicated eyes may

characterize drawings by breast cancer survivors.

Distress and anxiety are common among breast cancer survivors (Hack & Degner, 2004).

Body outline is a line that defines the boundary between the body and the environment (Kahill,

1984). Bold or doubled outline, which expresses a barrier between the patient/respondent and

the environment, with the goal of maintaining the unity of personality (Saneei, Bahrami, &

Haghegh, 2011), may indicate a source of external pressure that characterized drawings done

under situations of anxiety (Dans-Lopez, Caridad, & Tarroja, 2010; Merrill, 1994) and drawings

done by groups known to have a high anxiety level (Catte & Cox, 1999; D‟Agata et al., 2014;

LaRoque & Obrzut, 2006; Lev-Wiesel, 2015). Body outline which is detached, noncontiguous,

shaky or omitted (no boundaries) is an expression of anxiety stemming from an internal source

(LaRoque & Obrzut, 2006), caused by the very awareness of inability or weakness in coping with

environmental stimuli (Lev-Wiesel & Yosipov-Kaziav, 2005), characterized drawings done by

patients with colorectal cancer (Lev-Wiesel et al., 2005), and very likely may characterize

drawings made by breast cancer survivors.

9
Chemotherapy is often characterized by loss of hair (Bower, 2008). Long flowing hair represents

femininity and attractiveness across different cultures (Barkai, 2016). Women internalize these

expectations within the culture, and they represent potentially damaging images of normative

femininity to women who can‟t achieve these ideals. E.g. Barkai cited a dance/movement therapy

student who expressed her problem with her self-image through her hair: "I remember looking

longingly across at the girls in my class who had long, straight healthy hair and so wanting to

look like them. I thought that every girl in the class had hair that looked better than mine."

Another example: long flowing hair characterizes drawings of women who are connected to their

femininity and sexuality (Mavor, 2011). Whereas, the preliminary research by Barel-Shoshani et

al., (2011) found differences between the present self- figure drawing and that of the perceived-

self pre-disease in the hair drawings among women who underwent chemotherapy. Hence it is

likely that the hair indicator may be relevant also in the current study.

Among the psychological variables known to influence patients' responses to perceived

threats such as cancer, ego defense mechanisms are considered central "automatic unconscious

psychological processes that protect the individual against anxiety and from the awareness of

internal or external dangers or stressors, mediating his or her reactions to emotional conflicts and

stressors" (Hyphantis et al., 2013). Defense mechanisms were classified into three major styles:

reality distortion- considered being the immature level of the defensive functioning which may

leads to serious problems in a person's ability to cope effectively, affective regulation- considered

being the average level of defensive functioning, and adaptive style considered being the mature

level of functioning (Maricutoiu & Crasovan 2016). Defenses are very complex affective and

cognitive styles that the brain uses to alter conflictual inner and outer realities. (Vaillant, 2012).

Clinical psychologists developed self-reported and observer-reported methods for assessing

10
defense mechanisms (Maricutoiu & Crasovan, 2016). However, relying solely on self-report

measures for this purpose is questionable, for it ignores the possibility that either intentionally or

unintentionally, the self-report is biased (Cramer, 2000). In art therapy, when opposing images

evolve in a drawing, an opportunity arises for observing the client's reaction to it. A careful

phenomenological observation of the drawing enables us to support an experience- near

discussion, which is truly bound with client's subjective and idiosyncratic language. The drawing

may serve as a representational process record, while the discussion about it may serve in therapy

as a meta-representational process. The distinction between these two level is in terms of thinking

vs. thinking about thought, or, at a deeper level, possessing a mental representation of an

experience vs. being able to reflect on it validity, nature, and source. An image might

communicate a new or even opposite, aspect of the dialogue between client and therapist, which

adds a new dimension/ perspective to the client-therapist relationship that bring about new level

of consciousness (Or, Ishai, & Levi, 2015). Head shape - head outline which is closed or bold is

an expression of intellectualization, (Machover, 1949), a defense mechanism in which the person

engages in excessive abstract thinking to avoid experiencing disturbing feelings but leave

awareness of events (Vaillant, 1992). Head line is characteristic of drawings by subjects with a

high self-awareness of the gap between their actual behavior and their desired behaviors (Catte &

Cox, 1999), and drawings of those with neurotic anxiety (an internal source of anxiety) (Catte &

Cox, 1999; LaRoque & Obrzut, 2006). In the preliminary research of Barel–Shoshani et al.

(2011) indicators of a closed or bold head outline distinguish between the present self- figure

drawing and that of the past; among women who had breast cancer, a closed heavy bold head

outline is present mainly in present self-figure drawings- after the disease. The researchers

hypothesized that this boldness represents the use of intellectualization as a way of defense

11
strategy with the disease and treatments, distinguishing between "self" today and “self” pre-

disease. Hence it is likely that the head shape indicator may also be relevant in the current study.

Current Study

The purpose of the current study was to examine the expressions of distress and changes

in self-perception in women who had breast cancer, in self-figure drawings as women perceive

themselves (present) after they became ill, in relation to the perception (present) of themselves

before becoming ill (past).

The study hypothesis is that differences will be found in self-perception expressing: an

impaired sense of femininity and body image; a sense of anxiety and instability; difficulty and

fear of speaking about it; feelings of helplessness, depression and lack of will to see and the use

of intellectualization. These differences will be expressed in the drawings by gaps in the indices

of: bulging breasts, hair; body outline, lower body; mouth; eyes and head outline.

Methodology

Participants

The participants of this study were 70 women aged 35-66 (M = 52.21, SD = 8.81), who

had had breast cancer and were now cancer-free; between one and ten years had passed since the

end of their treatments , they currently showed no evidence of disease and had never been

diagnosed with another form of cancer. Participants' age range at time of diagnosis was 32.5-62

(M = 47.28, SD = 8.14). The women had all come for routine follow-up examinations at the

Women's Health Center - Merav Institute of Sheba Medical Center, Tel HaShomer, Israel.

Participants are volunteers who agreed to participate in the study of their own volition.

12
 Most participants were married (72%), academics with B.A. degrees (75%) and working

women (68%). The percentage of those working pre-illness was higher (90%); 22% percent had

stopped working: some due to the illness (20%), and some retired due to age (2%). Among the

remaining participants who worked, 18% reduced their hours due to their illness. 36% of the

participants were assisted by independent contractors for support and relief due to the

difficulties and emotional and mental distress of their illness and treatment (of which 8% were

assisted by NGOs). Some of the participants (17%) knew they carried the breast cancer gene

BRCA1/2, while 10% did not check at all.

Sixty five percent of the participants underwent a lumpectomy and 35% underwent a

complete mastectomy. None of the women who underwent a partial mastectomy had a breast

reconstruction. Among women who underwent a complete mastectomy, 64% had breast

reconstruction, though most have not undergone a full restoration; only 31% chose to reconstruct

the nipple, with 7% reconstructing the areola. 76% of the participants received radiotherapy as

adjuvant therapy, mostly among those who had a lumpectomy (60%), 61% received

chemotherapy or biological therapy, 65% received hormonal therapy, 25% underwent

oophorectomy for prevention and 11% underwent hysterectomy (7% after the discovery of the

disease, following the damage caused as a result of taking the pill tamoxifen).

Study Tools

1. Questionnaire on background variables, used to collect personal and medical details of the

individual.

2. The “draw a person test” (DAP) (Machover, 1949), in which the participant is given two

white A4 pages, a pencil and eraser. On the first page they were asked to draw themselves

13
 today, on the second page they were asked to draw themselves as they had seen

themselves pre-illness.

Study Process

Each woman was contacted individually by the researcher, who presented the objective of

the study and requested their consent to use the information they would provide for the purposes

of said study. It was emphasized to them that participation is voluntary and they could withdraw

at any time. They were guaranteed confidentiality and anonymity in both oral and written form,

and gave "informed consent to participate in research that is not a clinical trial in humans." In

order to avoid biases, the participants were first asked to draw their drawings and then to fill out

the questionnaire on background and health variables. Most of the drawings were done while

waiting at the clinic for tests at the Merav Institute at Sheba Medical Center.

Participants who asked how they should draw were told that it was entirely up to their

discretion. They were given no further instructions beyond the written provisions. This was an

important step in preventing unwanted biases. Pages were distributed and collected by the

researcher. In total, we collected 70 present self-figure drawings, and 67 past self-figure

drawings, with the past self-figure drawings serving as the control.

In order to ensure the ethical code of this study, the study was approved by the Ethics

Committee at Tel Hashomer Hospital, numbered SMC- 8712-11 on 26/7/2011. In addition, a

written request was provided to the study participants, in which they were asked to consent to the

use of the information they provided for this study. Each participant was instructed as to the

purpose of the study, and told that participation is entirely voluntary and therefore they could

withdraw at any time. They were also assured that all information would be kept confidential.

Definition of Variables

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 In line with the research, seven indicators were selected for comparison: Breasts

(omission, distortion), Hair (cut, thin, shaggy), Body Outline (broken, dashed, dual line, bold),

Lower body (detached, omission, distortion), Mouth (omitted, line, closed firmly, cut, shaded),

Eyes (dots, hollow, shaded), Head Outline (close, bold).

Drawings were analyzed according to the prominence level of the indicators based on

predetermined characteristics, by three judges: a youth counselor graduate of an Arts program

and an engineer with a M.Sc. in exact sciences, as well as the researcher herself- an art therapist,

each one separately. Each judge received judging and measurement scales for the drawings,

including properties charts for each of the selected indicators. The judge ranked the indicators

according to a subjective scale, with 5 levels (Interval scale): ranging from 5 (very obvious) to (1)

(not at all obvious). An average of the judge's scores constituted the index score. Each subject

received a number of grades, according to several indicators, which were reviewed for each of the

drawings she did. Reliability of study indices (reliability between judges -kappa) was: eyes

(k=0.56); omitted mouth (k =0.63); for the other indices in the drawings, it was found that the

scale is too sensitive and thus low reliability was obtained. In order to downgrade the sensitivity,

indices scores were combined: scores at 1 and 2 were combined to become 1 (not at all obvious);

3 changed to 2 (partially obvious); grades 4 and 5 changed into 3 (very obvious). The reliability

of the combined scores was: shaded mouth (k = 0.47), hair (k = 0.52), prominent body outline (k

= 0.53), lower body (k = 0.54), head outline (k = 0.59) and breasts (k = 0.61). For the index of

detached body outline, reliability remained low even after grade combination; therefore this

measure was removed from data analysis.

Results

Testing uniformity of group participants

15
 This study examined the general impact of the disease on the self-perception of women

who had had breast cancer. Therefore, in order to test our hypothesis, we tested the internal

consistency of the study participants who received different treatments, controlling for the

following variables: age, education, marital status, employment status (at present and before the

disease, along with changes in employment due to the disease), emotional or mental support, and

genetic carrier status. The participants were grouped into four categories according to the type of

surgery undergone: (complete mastectomy [no distinction is drawn between single mastectomy

or double] / breast conserving surgery) and according to chemotherapy treatment (received / not

received). Group number 1 (underwent breast-conserving surgery without chemotherapy)

included 23 study participants aged 42-64 (M=54.5, SD=6.26). Group 2 (underwent breast-

conserving surgery with chemotherapy) included 24 study participants aged 35-65 (M=52.35,

SD=9.75). Group 3 (total mastectomy and chemotherapy) included 20 study participants aged 35-

62 (M=49.62, SD=10.80). Group 4 (total mastectomy without chemotherapy) included only 5

participants and was therefore omitted when referring to the effects of chemotherapy.

The results of the Fisher's exact test of independence for the demographic variables (see

Table 1), and tests for analysis of variance (ANOVA) (see Table 2) indicated that there were no

internal differences in demographics which distinguish between participants who received

different treatments.

Table 1: Distribution and differences in demographic variables, when divided into groups

according to chemotherapy and surgery

Table 2: The distribution and age differences in treatment groups.

16
Statistical analysis of the findings by the research hypothesis

This study focused on the impact of breast cancer on women with the disease in general,

regardless of the type of treatment they underwent. The research hypothesis was that perceptual

change would be found. These differences would be expressed in self- figure drawings by the

gaps between the current image and the image as perceived by them before the disease, in the

indices: bulging breasts; hair; body outline; lower body; mouth; eyes; head outline. For

hypothesis testing, analyses were conducted using One-Way repeated measure within subject

ANOVA for indices of the drawings which were defined, each one individually, on their self-

figure drawings: in the present (time 1), and in the past (time 2). The hypothesis was partially

(three of seven indicators) confirmed. Statistically significant differences were found between

past and present self-figures on three indicators (see Table 3).

A gap in the indices of hair was found (F(1,66)=62.24, p<0.001; etap2=0.49), in the

present drawings (M=2.48, SD=0.77) more signs of short or shaggy hair as compared to the past

self-figure drawings (M=1.74, SD=0.74) (see Figures 1 & 4).

A gap in the indices of body outline was found (F(1,58)=10.98, p<0.01; etap2=0.16), in

the present drawings (M=1.89, SD=0.82) more signs of double / bold body outline as compared to

the past self- figure drawings (M=1.59, SD=0.76) (see Figures 2 & 1).

A gap in the indices of eyes was found (F(1,66)=4.08, p<0.05; etap2=0.06), in the present

drawings (M=3.27, SD=1.74) less signs of unseeing eyes (dots / hollow / shaded) as compared to

the past self- figure drawings (M=3.65, SD=1.75) (see Figure 4).

The gap in the indices of lower body was observed to be leaning towards significance

(F(1,66)=2.72, p<0.1), in the present drawings (M=1.80, SD=0.84) less signs of disconnected/

17
cut-of / unstable lower body were present as compared to the past self-figure drawings (M=1.89,

SD=0.81) (see Figures 3, & 4).

No distinction was found between present self-perception as compared to that of the past

in the indices of: bulging breasts (F(1,58)=0.02, p>0.05), mouth (F(1,66)=0.04, p>0.05), and

head outline (F(1,66)=0.02, p>0.05).

Figure 1: Short/chopped hair in present self-figure drawing, compared with long flowing hair in

past self-figure drawing.

Figure 2: The body outline line is heavy and bold in the present self-figure drawing as compared

to a simple/not bold line which is found in the past self-figure drawing.

Figure 3: A stable lower body is found in the present self-figure drawing as compared to the

unstable lower body found in the past self-figure drawing.

Figure 4: Eyes are wide-awake and open in the present self-figure drawing, as compared with

hollow eyes (unseeing) in the past self-figure drawing.

Table 3: One-Way analysis of variance with repeated measure within participants' ANOVA for

comparison of drawing indicators in pre-post breast cancer self- figures.

Furthermore, from the summary table it is possible to ascertain that the index "shaded

mouth" is hardly featured in present self-figure drawings (M = 1.129, SD = 0.53) or in past ones

18
(M = 1.21, SD = 0.47). This finding narrows and refines the properties of the mouth characteristic

of self-figure drawings by women who had breast cancer: omitted mouth - line, firmly closed, or

cut.

Discussion

The current study focuses on a group of women who had recovered from breast cancer.

Aspects of conceptual change to body-image were discussed as they relate to the disease and its

treatment, in relation to present vs. past self- perception of image before the onset of the disease,

using a projective tool. We hypothesized that the perceptual change would be expressed in self-

figure drawings by the gaps between the current image and the image as perceived by them

before the disease, according to the indices: bulging breasts; hair; body outline; lower body;

mouth; eyes; head outline. The findings indicate that in three of the seven indices examined, a

significant difference was found between the two drawing (present, past) indices: hair, body

outline, eyes, while the lower body index - is leaning towards significance; however, no

difference was found in the breasts, mouth, and head outline indices.

The study findings show a significant difference between the drawings in signs of hair.

Most women drew themselves after the disease (fig. present) with shaggy hair in contrast to the

self-figure drawing pre-disease. This finding suggests a change in self-perception after the

disease and may indicate a sense of damage to their femininity and/or loss of attractiveness. This

finding is supported by the literature review presented above; for example, past studies with

cancer patients who received chemotherapy showed that hair loss may be associated with loss of

sexuality and attractiveness, damage to body image, loss of personality and death (Annunziata et

al., 2012).

19
 The study findings show a significant difference between the drawings in body outline

lines. Most women strengthened and emphasized the body outline lines in the present self-figure

drawing as compared to that of the past. This finding may indicate an increased level of anxiety

and the need to protect the body in the present - after the disease- as compared to their situation

prior to the disease. This finding is supported by the literature review presented above, for

example, past studies showing that bold or doubled, body outline characterized drawings done

under situations of anxiety (Dans-Lopez, et al. 2010; Merrill, 1994)

This study found a high presence of signs of unseeing eyes in both sets of drawings;

furthermore, the technique in this study - comparison between the pictures (present vs. past - pre-

disease) - has allowed for the identification of a significantly lower presence of

unseeing/uncommunicative eyes signs in present self-figure drawings as compared to those self-

figure drawings of the pre-disease self. Therefore, this finding may indicate a sense of

disillusionment due to the disease, a finding supported by the literature. For example, past studies

found that cancer was in a sense a wake-up call not to take your health for granted, which led to

disillusionment, especially in women who were previously healthy and thought their bodies and

health were guaranteed forever. It is possible that for them, the cancer was an opportunity for

thought and introspection, helping them stop and connect to themselves and their bodies (Yoo,

Levine, Aviv, Ewing, & Au, 2010). In addition, women who had had cancer reported that they

learned to ask for help and support from others in order to help them deal with the difficult

treatments, something which previously, before their diagnosis, would have been difficult to

request and receive (Yoo et al., 2010).

In contrast to our hypothesis, the study findings show no difference in the index

concerning lower body in the drawings. Perhaps the type of treatments the participant underwent

20
neutralized the expected effect of the findings. Some of the patients underwent all possible

treatments (mastectomy, chemotherapy and radiation) and some underwent partial treatments (for

example lumpectomy and radiation). Therefore it is possible that women who underwent all

treatments feel safer than women who underwent partial treatment, which resulted in no

difference in the sign of leg stability in the self- figure drawings. Another possible explanation

strengthens the hypothesis of neutralization of the expected effect found in the literature; there

are different profiles of fear of cancer recurrence, which vary according to severity and the type

of coping strategies used (Simard et al., 2010).

In contrast to our hypothesis, the study findings show no difference between the drawings

in signs of breasts; perhaps the type of surgery undergone by the participants neutralized the

expected effect of the findings. Some of the participants underwent complete mastectomy,

therefore it is logical that these women omitted breasts in the present drawing, and some

underwent lumpectomies. It is therefore logical that these women drew breasts in their present

self-figure drawings. Another possible explanation found in the literature is the degree of

importance attributed to the body‟s image pre-disease (Lichtenthal, Cruess, Clark, & Ming,

2005), as well as the self-image before surgery (Figueiredo, Cullen, Hwag, Rowland, &

Mandelblatt, 2004), which affected the degree of damage to self-image. It is therefore possible

that personality differences resulted in no difference in the signs of breasts in the self- figure

drawings.

In contrast to our hypothesis, the study findings show no difference between the drawings

in the mouth index - no differences were found, although in both sets of drawings there was a

very high presence (relative to other indices) of a “nonspeaking” mouth. A possible explanation

found in the literature suggests the possibility that the participants who had breast cancer are

21
compatible with a Type C personality, which is found to characterize people who have had

cancer throughout their entire adult lives, and who suppress negative emotions behind a façade of

optimism (Durá et al., 2010).

In contrast to our hypothesis, the study findings show no difference between the drawings

in the head outline index, closed/ bold head outline appeared in both sets of drawings to the same

extent and we could not find clear explanations for why this is so in the literature .

Conclusion

The projective tool- self-figure drawing, combined with the technique used in this study -

a comparison between the present self-figure drawing and a representative past self-figure

drawing pre-disease, partly helped assess conceptual changes and hardships experienced by

breast cancer survivors. Some of the findings repeated findings of previous studies. However, the

projective tool also allowed for the identification of feelings that are not expressed through verbal

tools: even women who did not undergo chemotherapy chose to draw shaggy hair, which projects

a sense of impairment to their body image, femininity, and attractiveness. Moreover, one can

detect signs of distress, along with anxieties and damage to self-esteem, as well as feelings of

opening up of their eyes and stability.

This study contributes to previous research conducted among populations of women who

had had breast cancer, which neglected the use of projective tools, and examined distress and

coping after a disease with only verbal tools. This study used a projective tool- self-figure

drawing, which allows for assessment of the developments in the deeper layers of the human soul

not expressed in overt behavior and verbal language, those often dominated by cognition. In light

of the concerns and hardships found in the breast cancer population in speaking about the

'disease', it is of great importance to be able to assess distress and coping strategies, with two '

22
languages', the verbal level by asking questions, and the projective level, such as through

drawing.

From a practical viewpoint, it seems that the studied projective tool could be used to help

clinicians understand coping strategies and adaptation to illness and concurrent medical

treatment, years after diagnosis, as a foundation for constructing supportive care to alleviate the

distress of those facing this process as part of their rehabilitation.

Limitations and Future Research Directions

A limitation of this study is that most of the drawings were done a few hours before

routine screenings for breast cancer. Due to the situation, the anxiety level of all the women was

high, therefore pre- existing bias might exist in the findings. However, this claim can be refuted

on the basis of the significant difference in hair markings which reflect the reality of hair post-

chemotherapy, and based on significant differences with opposite directions in the drawings. In

the first drawing (present), body outline expresses more signs of anxiety, whereas signs of eyes

and lower body expressed fewer signs of anxiety and instability, compared with the other

drawing (past). It can also posit that in the second drawing the women were more adapted to the

challenge of drawing. But the argument can be countered based on the significant differences

that express more distress in the second drawing (eyes, lower body) as compared to the first.

The present study focused on the impact of breast cancer on women in general, regardless

of the type of treatment they underwent. Based on the results of the study, we suggest that

perhaps the type of treatments the participant underwent affected some of the findings. We

therefore propose that a future research study considering the effects of different types of

treatment may greatly improve the present study finding.

23
24
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Table 1: Distribution and differences in demographic variables, when divided into groups
according to chemotherapy and surgery
Group No.1 Group No.2 Group No.3
Breast Breast Mastectomy &
conserving conserving chemotherapy
surgery surgery & (n=20)
(n=23) chemotherapy
(n=24) Fisher's Exact
Variable Value N % N % N % test Value
Education 12 9 31.93 93 71.95 6 33.33 6.73a
15 10 13.14 7 33.43 4 13.33 (p=0.30)
18 3 93.31 6 37.33 7 37.33
22 0 3.33 3 3.33 9 7.33
Not reported 1 1.37 - - - -

Family status unmarried 3 3.33 3 93.73 3 93.33 6.37a

married 96 61.75 95 53.43 97 57.33 (p=0.37)
divorced 3 4.61 1 96.65 3 93.33
widow 3 93.31 3 3.33 9 7.33
Not reported 3 4.61 - - - -

Employment unemployed 4 31.54 4 33.33 1 33.33 3.38a

status Part time job 6 39.31 6 37.33 4 13.33 (p=0.74)
Full time job 4 31.54 93 19.65 4 13.33
Not reported 9 1.37 - - - -

Changes in Increased 3 3.33 3 3.33 3 3.33 7.53a

Employment hours (p=0.22)
status No changes 94 54.36 99 17.43 93 67.33
Reduced 3 4.61 5 31.95 3 97.33
hours
Stopped 3 93.31 6 37.33 1 33.33
working

Employment unemployed 3 93.31 9 1.95 9 7.33 3.62a

status pre- Part time job 6 39.31 3 93.73 1 33.33 (p=0.47)
illness Full time job 93 76.73 33 43.33 91 53.33
Not reported 9 1.37 - - 9 7.33

Assisted by No 94 54.36 97 63.73 93 73.33 4.28a

emotional or other 9 1.37 3 93.73 3 93.33 (p=0.37)
mental support Yes 1 95.31 6 37.33 4 13.33

Breast cancer No 91 43.69 94 57.33 99 77.33 7.09a

gene BRCA1 / Yes 9 1.37 7 33.43 6 33.33 (p=0.11)
2 carrier unaware 3 93.31 9 1.95 3 97.33
a. p value above (>) .05, no internal differences.

30
Table 2: The distribution and age differences in treatment groups.
Group No.1 Group No.2 Group No.3
Breast conserving Breast conserving Mastectomy &
surgery surgery & chemotherapy
(n=23) chemotherapy (n=20)
(n=24)
Age F
range N % N % N % df=2/64
30-39 0 0.00 3 12.50 5 25.00 1.60a
40-49 5 21.74 7 29.17 6 30.00
50-59 12 52.17 6 25.00 7 35.00
69-69 6 26.09 8 33.33 2 10.00
M 54.50 52.35 49.62
SD 6.26 9.75 10.6
a. p value above (>) .05, no internal differences.

Figure 1: Short/chopped hair in present self-figure drawing, compared with long flowing hair in

past self-figure drawing.

31
Figure 2: The body outline line is heavy and bold in the present self-figure drawing as compared

to a simple/not bold line which is found in the past self-figure drawing.

32
Figure 3: A stable lower body is found in the present self-figure drawing as compared to the

unstable lower body found in the past self-figure drawing.

33
Figure 4: Eyes are wide-awake and open in the present self-figure drawing, as compared with

hollow eyes (unseeing) in the past self-figure drawing.

Table 3: One-Way analysis of variance with repeated measure within participants ANOVA for
comparison of drawing indicators in pre-post breast cancer self- figures.
present self- past self-figure
figure Drawing drawing
Indicator Scale N M SD M SD df F
Breast 1-3 59 2.40 0.77 2.41 0.80 (1,58) 0.02
Hair 1-3 67 2.48 0.77 1.74 0.74 (1,66) 62.24***
Body outline- bold 1-3 59 1.89 0.82 1.59 0.76 (1,58) 10.98**
Lower body 1-3 67 1.80 0.84 1.89 0.81 (1,66) 2.72^
Mouth- omitted 1-5 67 3.53 1.72 3.56 1.77 (1,66) 0.04
Mouth- shaded 1-3 67 1.19 0.53 1.21 0.47 (1,66) 0.06
eyes 1-5 67 3.27 1.74 3.56 1.75 (1,66) 4.08*
Head outline 1-3 67 2.20 0.87 2.22 0.84 (1,66) 0.07
*p<0.05; **p<0.01; ***p<0.001

34