Purpose in Life for Adolescents with Oncological Diseases

Under common circumstances, adolescent age is the period of a young person having to cope with many life problems (resolving issues if personal maturity which increases, respect decreases self‐confidence, changing quality of interests, etc.) We can claim that adolescent age itself involves existential character. If this process involves a seri‐ ous disease, the situation is really demanding. The aim of the chapter is to describe the process of seeking their own identity in the situation of coping with occurrence of an oncologic disease.


Introduction
In Slovakia, since 1930 occurrence and mortality rates for cancer are increasing. According to the National oncological register of SR, occurrence has an increasing trend since 1968-1970, when about 12,000 new cases were annually registered in 2003, the number reached 22,000 and according to other data, last year it was 24,000 cases more, one-tenth thereof made up by adolescents [1].
There are specific issues of occurrence, progression and treatment of oncologic disease in adolescents and also issues regarding their re-integration in common adolescent life. Just in this age group, an important role is played by social problems and related issues of social care [2]. Křivohlavý [5] pursues an opinion that a verbal phrase "purpose in life" belongs to the human subjective-personal and initial experiences. The feeling of a purpose in life depicts a deep motivation, which is significant for any human activity, that is, it is a superior need, which involves the rest of all needs.
Waren [9] adds that to know the purpose of our life is very important because we came in this world with a certain intention. If we have purpose and objective in our life, the life will have a certain direction, because it will help us to concentrate our efforts and energy to important issues. He also says that the purpose will provide motivation for our life, because nothing can give a person more enthusiasm than his own objective. The final declaration is that the purpose in life will prepare us for eternity. The purpose in life of different people is so different, that many specialists tried to classify it and give it some measurable form [2].
A significant person who dealt with the purpose in life was Frankl [7] who states that "To be a human means to be devoted to something, to be concentrated and set for something or someone, by which he asserts himself, develops, is himself and reaches some purpose which should be achieved." Drapela [10] presents Frank's opinion that searching for purpose in life is the principal responsibility of a human, because any situation in life makes sense, however, it just cannot be introduced in the situation. He also describes that an individual can find such purpose in three ways: (a) By performing an act, where every activity involves a hidden purpose; (b) by experiencing a value, it means experiencing any real human experience that enriches an individual. According to Frank it is love, which is (c) fulfillment of a human purpose by the form of suffering.
Bačová [11] describes, that Frankl considers searching for purpose in life to be the principal motivation and driving force of a human life. One of the alternatives of existential psychology is logo therapy and existential analysis. Frankl survived a concentration camp and his theory is also based on that, which stands on the term Wille zum Sinn, which can be translated as "the will for a purpose". Frankl depicts it as an inborn desire sleeping in a human [7].
Bačová [11] defines such desire as the deepest desire of a human, where it is necessary to respond to day-to-day challenges and questions in life. Frankl [7] adds that if such desire for the purpose is not fulfilled, existential frustration develops that leads to doubts in a human about the purpose of his existence and depression and neurosis of all kinds develop. Another significant author who faced the issue of the purpose in life and was the founder of individual psychology was Adler. He worked as a general practitioner and later he orientated at psychiatry. An important aspect of his theory of the purpose in life is the origin and the roots of the purpose which he can see in early childhood. A child creates verbal and notional conclusions from the point of his feelings and strong experiences. According to it the child creates general form of his behavior, such as roles in life, purposes in life and general life style, and then the model of an adult personality develops. The human psychic is created by setting a certain goal or an ideal at the age of 15, overcoming the actual state and shortcomings. According to that goal an individual imagines successful future. Without the particular goals the activities of an individual would not find purpose [12,13].
Analytic psychologist Jung in his concept of the purpose in life includes a personal view of the world. In his opinion a human by being born wakes up in the world, which he does not understand, tries to explain it and discovers it to understand the purpose in life. Explaining the purpose in life is dangerous, because such efforts spring out of the deepest mental misery, as the need to discover the unity of life and purpose. Life itself asks a human the question of his existence which is just being hard to understand. Just that is according to Jung the elementary super-personal life role of every human being [6,7].
The author who is ranked to the stream of the social psycho-analysis or to the existentialismorientated authors is Fromm. In relation to the purpose in life those characteristics are important for a human, which separate him from animals, for example, self-confidence, imagination or brain. A human creates an imagination of the world which is internally compact and structured. This imagination has orientation framework and it is ranked among the basic existential needs. An individual sets a goal which he should be set for and go for it. The term "subject of worship" is used by Fromm as a certain elementary value, at which a human can concentrate his vital energy. That value is elementary for other values in life and lifts a human above his existence, doubts and uncertainties and gives purpose to his life [6].
Nákonečný [14] defines the opinion on regarding purpose in life, where growing individualization of a human means growth of his loneliness, and consequently growth of his own purpose in life. Plháková [15] adds that according to Fromm, a human can become an active creator in life, for example, a woman delivers a child and a man production or culture. Humans can also create true love by living for each other. Love is divided as fraternal, maternal and erotic. This is characterized by Fromm as the basis of human existence.
One of the most influential humanist psychologists is Maslow, who is known by his concept of personal growth and hierarchic concept of the needs. Such hierarchy of needs was set according to necessity and order, how human needs demonstrate. Elementary needs are physical needs, after their satisfaction there comes the need of safety, followed by the need to belonging somewhere and to be loved. Another level involves the need for self-esteem, knowledge, followed by the need for beauty, harmony and self-assertion. Superior needs are satisfied after satisfying the inferior need [15,16]. Maslow [7] considered purpose in life "an internal property of a human which emerges like a vigorous motivational power, when inferior needs are satisfied." Křivohlavý [5] adds that everyone can choose his purpose in life either according to his own motivation, free will or natural character. However, if it is not fulfilled, a human falls into depression and disease.
According to Yalom [8] life has no final purpose or a goal. He points out four existential dynamics, that is, death, liberty, isolation and senselessness, which he deals with in the issue of purpose in life. Purpose in life is just creative response of a human to the total senselessness of the world. If a human wants to cope with this senselessness, he must with all of his heart dedicate to resolve and experience the purpose in life and actively engage in it. Yalom also pursues two opinions, how a human should find his own purpose in life. The first way is being searching for cosmic purpose, where a human responds to the questions such as "Has life a purpose in general, if yes, is my life involved in it?" This way of searching for a purpose in life mostly occurs in religious or spiritual ideologies. Another way is searching for a secular purpose, which is more defined by searching for goals and values. We know altruism (life in favor of the others, to be useful for the others), devotion (obligation to the others), creativity (creating something new), hedonism (effort for joy, comfort and happiness) and self-actualization (considering own options). According to Yalom, these values are not about contents, but intensity of engagement, which is a human tool to fulfill his purpose in life.

Adolescent age in the context of specifics of an oncological disease
Adolescent age is a temporary phase between childhood and adulthood. It involves one decade of life from 10 to 20 years. This period involves a complete personality transfer in all aspects: somatic, mental and social. Many changes are primarily biologically conditioned, however, always significantly affected by mental and social factors which involve their interaction. Initial sexual maturation involves physical changes (as a result of a complicated process of alternating stimulation and suppression of internal secretion glands, whose hormonal activity starts physical changes and controls them), their being new and intensive impacts mental experience.
Adolescent age is definitely a psycho-social phenomenon. The principal problem of an adolescent is his "social uncertainty". He does not feel as a child, however, yet not as an adult. An adolescent asks himself questions: Who am I? (real self-reflection), What do I want myself to be? (ideal self-reflection) and How other people see me? (assumed reflection by the others). The answers in this age is lability of feelings of self-value, an adolescent oscillates between extremely euphoric expectations and depressive under-estimation. This uncertainty produces conflicts incurring in puberty and adolescent age mostly between children and their parents. Adolescents separate themselves from their parents or other former authorities and get involved in a group of people of the same age, where they are perceived as "adults". A culture of youngsters develops, which is often presented as a culture of rebellion against ruling culture of adults.
However, adolescent age brings also positive development. There is self-reflection (an adolescent is capable to cope with his environment and take critical standpoints to it, he discovers himself as an independently thinking and acting individual, etc.) and to the social separation of adolescents, that is, separation from the family; however, even though an adolescent is emancipated from the family, still some bonds to the family last [17]. Adolescent is also a period when changes in life events occur in a different sight, which has in many aspects existential character, resulting from the character of adolescent problems. Discovering own limits as a normal part in life involves also thinking of death. Research in this area is important, directly related to the issue of oncological disease. Rationality of modern and post-modern human pushes out the ultimate reality of death from mind and it reflects it less. Death is tabooed at present and is extinct as death reflected, and its individual and personal concern is hidden behind anonymous dying in hospitals. Also adolescents realize death and many think about it. Coming across their own mortality is a strong experience. Adolescents thinking about death are more mature than adolescents, for whom this issue was absent or it was supressed [18].
For a child, an oncological disease presents a major change in his previous way of life. After discovering diagnosis he undergoes many examinations, sometimes painful ones, therapy and hospitalization. He must get used to impersonal hospital environment, exposed to unknown situations, adapt to the new regimen, be people and engage in new daily activities, all of that in isolation from the family and friends [19].
It applies also to an adolescent that disease does not affect only individual organs and their functions, but the overall human personality as well. On the top of physical stress, for an adolescent such disease presents a changed life situation which he must cope with. Certainly, an adolescent realizes his disease and his close social environment shares this experience; he reflects to the changed social situation and tries to cope with it. Uncertainty of the parents and other close people, their moods, standpoints, unusual conduct and sudden behaviors changes, all of that can affect the patient severely [20].
Adolescent age is a period of human development, his preparation for adulthood. It depends on the closes surroundings. An adolescent is trying to achieve his own place in the society, that is, the social status and his role in it. However, he needs for that satisfaction of his necessities and requirements in the real extent, time and space and his rights to be respected. From this aspect, we perceive adolescent age as a social phenomenon. And it is true that of all the cases of occurrence of cancer in European population adolescent and infant patient make up only about 1%. It seems that it is unnecessary to deal with this issue if this disease is relatively rare in infants and adolescents. However, cancer is the second most frequents cause of death in infant age. In the period of the last 30 years, we can observe permanent mild increase of its incidence. At present annually 14 of 100,000 children in the age under 15 years fall ill. Annual incidence of cancer in the Slovak republic is 13.0-13.6 per 100, 000 children under 15 years of age. That means that annually in this age group, 170-180 new cases of cancer occur. Other 70-80 involve the group of 15-18 years of age. Under conditions of SR, cancer is on the second place of death causes of children (after accidents) which corresponds to the world statistics. Oncological diseases in children present a serious medical, ethic and social problems [21]. Although the percentage of children and adolescents which get cancer, does not seem so alarming at the first sight in comparison with the percentage of adult population, it is necessary to pay attention to it. Above all because a human society perceives a child as a human youngster which must be long time cared for, it needs a lot of love and understanding and protection and its development must be directed the way to make it able to get involved in the society and which ensures its further growth.
Cancer in children is serious but curable and at present the percentage of curable cases is high. In 1960s, 97% of children with cancer died. Ever since there is growth of cured children rare. At present 75% of infant patients are cured at specialized department [22].
In treatment of cancer patients an unfavorable role has been played for centuries by lasting and still live "myth of cancer". These are false imaginations of disease accompanied by great suffering and inevitable death. Moreover, a part of this negativist attitude is supported by the natural and deeply rooted imagination that children and adolescents should not be fatally endangered; they should not be dying, but living. Such imagination is suddenly ruined, because the disease often comes like a flash of lightning, without previous warning; it affects a kid that had always been healthy before. To "wipe it out" is as much important as to recognize it early and to cure it. Only this way it will be possible to prove objectively and definitely that cancer in children and adolescent is a serious disease, but it makes no difference from other, also serious diseases, which are not surrounded by such a myth. There is a lot of work left still for the specialists in this area [23].
Life quality of children is significantly different from that one of the adults, because disease itself as well as the treatment damages normal psycho-motoric development of the child. An important role is played by his growth and development, immunologic and hormonal immaturity. The disease reduces his life quality by intellectual, emotional and physical impairment. Physical and functional deficiency leads to emotional unbalance of the child, to the feeling of depending on others, to the feelings of inferiority. As he cannot come with the environment, this often involves problems to be a part of desired children's life. All of that can lead to the feeling of fear, loneliness and isolation. Anger with all the surroundings appears with the feeling of crying. Every child must be approached individually [24].
Successful treatment of an adolescent with cancer (with long-term life prospective in future) assumes management of the three areas, which are mutually conditioned (a) biological treatment (a cured child will die as an adult in unlimited time period and for other reason), which is a condition for (b) mental treatment (personal coping with cancer, its treatment and eventual complications and consequences, also unlimited capability to cope with different life situations). This conditions (c) social treatment (equal involvement in society).
Cancer brings an extraordinary interference in the life of a child and an adolescent, their families and all the surroundings. Disease affects not only the patient himself, but all the members of his family. Every family has its own way of common functioning, which is seriously affected by a serious and long-term disease and it is necessary to create a new, temporary model. To keep the family functioning in this period, it is important not only to divide obligations and roles flexibly but to include the common rituals and activities (meals, play, tales before sleep) which should involve the patient as well. The patient must have a space in the family to be involved in the family in spite of his limitations caused by disease. The patient himself should control how much family activities he can stand and when he needs some rest. It is a painful feeling to be a burden.
It is important for his family to understand and know the natural needs of an adolescent considering his age and find a way to satisfy him maximally in spite of the limitations. Communication quality with an adolescent diagnosed with cancer (besides others also the one concerning providing or concealing information regarding his disease) can significantly affect experiencing of such a period by the young person. A young person can feel that something serious is going on with him anyway. He can observe it also from conduct of his environment, atmosphere in the family and non-verbal speech of others. If such conduct is in accordance with the verbal information the patient receives, this will make him feel confused and scared.
Sometimes disease cannot be stopped. If an adolescent's life cannot be saved, we do not decide on death which is coming. However, we can decide on life which is left. In spite of the painful fact that we cannot save the young person, we can do a lot for him to avoid insupportable suffering, to be able to feel joy and life to the fullest. In such case, we concentrate on treatment of the problems caused by the disease with the objective to improve life quality as much as possible. We do not treat the cause of disease, because it is not possible. We treat the problems caused by the disease to avoid his suffering. We cannot change duration of life but its quality. Adolescents, who feel their life is coming to an end, always feel that they walk to the unknown and their way cannot be changed. Uncertainty, fear from departure, loneliness, suffering of the close people cause sadness. They often detach themselves, do not wish to go out and to meet friends and lie or sit alone in the room for hours. Sometimes they reject food and pills. To accept for a human that his life is coming to an end, he must be sometime left alone to cope with the anxiety and internal pain. We should respect his wish, but should stay close to be ready to help when he needed.
To consider it, we must try to sup up the adolescent period in the context of cancer, having regard to the fact that there are significant individual differences between adolescents.
Under standard conditions an adolescent is gradually involved in the society of adults as an equal partner. He has an intensive feeling of adulthood and wants this adulthood to be recognized also by the others. However, adult people often are unable or do not want to respect the efforts of an adolescent to be independent. They often impose their superiority, care and wisdom against him. An adolescent longs for independence and freedom. To become a mature, independent and responsible person, he needs to be free from dependence of the family and parents' authority. Life in the family therefore becomes stressful and uninteresting. He looks for an appropriate position in his life, thinks about future, forms his life goals and thinks about purpose in life. In the moment when a serious oncological disease appears in his life, this process of achieving independence is interrupted. Building his own independence is reverted by the disease to the position of maximal dependence. Attitude to adolescent must be very sensitive, because that period typically involves tendencies to isolation, negativism, feeling inferior and pessimism, supported by severe disease and aggressive treatment, which is long term, cyclic, unpleasant and sometimes even painful. An adolescent becomes dependent of his environment, above all of the parents and relatives. New authorities anger his life in the form of physicians, nurses and specialists. Again he must subordinate to the requirements of adults, severe regiment and discipline. This period is characterized by emotional liability, frequent mood changes, impulsive action and instability which worsen the situation. Moreover, it involves increased fatigue, alternating and being apathetic and short phases of increased activities. This state can be accompanied by neurovegetative disorders such as sleeping disorders, impaired sleep, appetite disorders, etc. The fact of disease with eventual permanent limitation for future is processed by adolescents with more difficulties than younger children or adults. Endangered life, reality of death is understood as shocking, unjust, destructive and traumatizing fact. They react with anger, confusion, disgust, destructive conduct (externalizing) or escaping from reality and depression (internalization). Sometimes different escapades occur as substance abuse or other auto-destructive conduct as suicidal risks. These are important facts which may affect significantly treatment and rehabilitation process.
Even under normal circumstances the adolescent age is the period when a youngster must cope with a lot of life problems. He should, for example, select and prepare himself for future profession. At the end of this period he may start a career. Disease and following treatment will often cause interruption of studies which may affect the whole process of gradual professionalization of a youngster and totally ruin his imaginations of his own future.
Own body becomes for the adolescent a subject of continual attention and physical maturity increases his self-confidence. An adolescent is often dissatisfied with his body; he would like to look different-which is the source of negative evaluation. An adolescent cares for his appearance, carefully selects clothes, hair style, etc. Self-reflection concerns also interest in his personality. A youngster creates an imagination what he should look like.
He develops self-confidence. Sock adolescents are especially worried what will they look like, if they stay alive and become adult. However, they are afraid how they will be accepted by the people of their age if they are different. Their self-confidence suffers their self. Adolescents create their spiritual orientation; spirituality plays an important role for a human. Such questions are most frequently asked in adolescent period looking for one's individuality and orientation, mainly in the situation when all of a sudden an adolescent comes across a disease facing his own mortality.
Adolescents qualitatively change their interests (regarding intensity, level, depth and diversity). Quantity of interests is reduced, but selected interests are improved and extended and become permanent. According to the researches, most interest adolescents show for sports, trips to the nature, tourism and camping in the nature. Sports are good recreation, ventilation of fight and aggression, occasion to stay in a good team. Adolescents with cancer are, however, endangered by their physical and functional deficiency. Their interest must be adjusted to the new situation. Instead of activities of sport character they may develop their cultural and artistic interests, as music, fine arts, drama, (film and theatre) and literature, although in passive form. A youngster often shows interest in social occasions involving dancing, which provide a good opportunity to meet and know other people of the same age. Disease and impaired immunity system, related different physical changes (as hair loss and emaciation) make it possible to a cancer patient to visit a cinema, theatre and library, to go to a concert or disco.
This period involves a strong interest in discussion, to which an adolescent dedicates enough time. It is necessary as it resolves the issue of purpose in life and helps the adolescents to gain experience through conversation. The experts should use this fact and via conversations let out negative feelings (as fear, anger, anxiety, etc.) of an adolescent/a patient.
They should not hide behind a mask of "a hero", which patients often do. An adolescent is able to oppress and heroically stand the pain, physical or mental. However, this does not mean, that inside he has coped with it. Work of assisting professionals can be made difficult by ambivalent attitude of adolescents to authorities. Besides a strong interest of an adolescent in conversations, one fact makes it difficult that they are demanding partners for communication. They expect partnership attitude, respecting their space, privacy and intimacy; however, on the other hand they need much support and understanding. During treatment they should have a chance to participate actively in it, make decisions and also be responsible for its course.
Social relations issues are also significant-time of first love and of their own discovered sexuality. They break ties of social contacts based on personal ties in the family, but he just cannot remain cut off. He find it with the people of the same age and they spend lots of time together. It is an important source of social experience. He takes over their ways of conduct, appearance. He needs to be accepted and recognized by the people of the same age. In case of rejection by a group of the people of the same age, he would get into a complicated life situation. He cares for good relations with people of the same sex and partners of another sex. Friendship of adolescents is more stable, deeper, more confidential and more sincere. Friendship provides support to a young person in time when he takes his life in his own hands and feels alone and hapless. Pair relations of the people of different sexes are a true need. Awakening sexuality can take over their minds and bodies; sexual issue becomes crucial. Media, conduct of adults and other facts in actual society present sex as an important part of life. Age at the end of adolescent age is suitable (although not optimal) to get married. Theoretically adolescents can take a role of a parent. Emotional unbalance of a patient leads to a feeling of dependence from others, an inferiority feeling. They often cannot cope with their environment and to get involved in desired healthy life of the people of the same age. All of that can lead to a feeling of fear, loneliness and isolation, separation from the surroundings, depressive moods, communication breakdown, eventually aggressive and rejecting conduct.
An important fact which is also reflected in the life of an adolescent with cancer even in case of successful treatment are eventual later effects of anti-cancer treatment. As a result of increasing number of cured children and adolescents these later consequences of anti-cancer treatment come forward to the attention and also related quality of survival. For example, it involves damage of lungs, disorders of growth and development, damaged bones, thyroid, breasts, liver, muscles, senses, immunity system, skin, fertility disorders and also psychosocial problems. At present the members of multidisciplinary team caring for an infant or adolescent patient must concentrate not only on the treatment of the patient but also how to minimize treatment consequences.
Life brings many changes, some are small and expected (e.g. changes of life periods, including adolescent age) and those can take place without even noticing them, not being a burden. However, others are more demanding; we can see them as a burden and look for the ways to cope with them. These ways are called coping strategies. Although adolescent period is considered expecting change; in spite of that it is a sort of burden. As described above, it involves looking for social and personal identity. Disturbing the process of looking for own identity with cancer is very serious. An adolescent getting affected in the phase of looking for an identity, being confronted with a serious life problem, has huge impacts on his whole identity.

Results of study
The objective of research performed in January 2014-2015 was to find out which statistically important differences exist in perception of the purpose in life and its components between healthy and sick adolescents studying at grammar schools and apprentice schools according to individual social-demographic aspects. The research was realized in quantitative study by means of a standardized questionnaire PIL [25,26]. After the evaluation of results by means of t-tests for two independent selections in determining the level of significance p ≤ 0.05 statistically important results were proven, of which we choose the most significant ones. From the aspect of school type in the component of affirmation of living sick students of grammar schools achieved significantly higher score in comparison with healthy students of apprentice schools (015). Similarly in the components of perception of objectives healthy grammar students achieved significantly higher score in comparison to sick grammar school students (012). Regarding gender, in the component self-accepting, healthy adolescents reached significantly higher score in comparison to healthy female adolescents (024). Also in the component of perceiving future, healthy male adolescents achieved significantly higher score than healthy adolescents (039).
In qualitative research, we have found from no standardized interviews that adolescents deal with issues related to the topics of purpose in life even more frequently than healthy ones of the same age. They look for the answers of the kind: "Why do I live?", "What have I achieved?", "What else I am to achieve in my life?", etc. They are trying in maximum extent to fulfill the rest of their life that they are left with. Here we can see the positive aspect of the suffering brought by the disease. In spite of the well-known fact that just adolescent age is the period of the first experiences with addictive substances, the respondents have negative attitude to their use; they do not wish to make easier the solution of difficult situation in life by substance abuse and appreciate the rest of their life they are left with. They do not think about suicide and they appreciate life they are left with. They feel responsible to their families and environment and religious adolescents. Moreover, they do not want to act against laws of God, prefer to pray, ask God for help, redeeming and salvation.

Application of results
Assisting workers should provide help in searching for the purpose in life and awaken desire for its fulfillment, use disease for personal development and maturing, to create the correct attitude to the disease and eventually suffering that accompanies the client. Accepting disease is related to experiencing high meaningfulness of life.
In social practice and consulting, it is possible to utilize in favor of sick male and female adolescents above all the results of research targeted above all to reasons to live and experiencing depression related to difficult treatment of oncologic diseases.
• The higher the overall score in perception of their meaningfulness of life is, the lower is the overall score in the scale of experienced depression [27].
• In social work and consulting in favor of adolescents, we recommend to apply purposeorientated attitude in building resilience according to P.T.P. Wonga [28,29], above all module PURE and module ABCDE.
• In the interest of resilience of youth, we emphasize above all the need for integrated attitude.

Conclusion
The potential contribution of this chapter arises from the findings about the facts of diagnosis of oncological disease in adolescence in the Slovak adolescents. These adolescents try to find some purpose in this difficult life situation.
These findings provide the basis for the possible future studies in this field and for the all people which work with adolescents in the situation of oncological diseases (teachers, medical staff, parent, family members, etc.). The attention is given to help to find some solution in the field of study and in the real life situation.