Complementary Treatment for Women with Breast Cancer: A Psychomotor Therapy Approach

Women with breast cancer face a diversity of physical, psychological, and social changes that affect their health and well-being across the different stages of the cancer journey, including treatment and survival. Moreover, breast cancer often results in greater distress than any other neoplasm, challenging women’s body, identity, and quality of life. Given the multiplicity of mind–body related problems that may confront women with breast cancer, psychomotor therapy is a valuable therapeutic approach for these women. This chapter presents a framework based on psychological and neurobiological research to understand how a mind–body approach as psychomotor therapy improves cancer-related symptoms, readjusts body schema, body image and identity, thus contributing to women with breast cancer’s health and well-being. Two intervention programs, uniquely designed as a complementary approach of medical care for women in the treatment and survival phases, are also described. The impact of these programs on health and quality of life indicators of women with breast cancer are also presented.


Introduction
Breast cancer is the most prevalent malignancy and is also the most common cause of death in women. In 2020 around 2.3 million cases were diagnosed, there were 7.8 million women alive with a breast cancer diagnosis made in the last 5 years and 685 thousand estimated deaths [1]. The rates of curative treatment and overall survival have also been increasing, and the prognosis has been improving [2]. Nevertheless, diagnosis and multiple treatments come with short-and long-term adverse physical and psychological effects that affect the quality of life of patients and survivors [3,4].
Either present or absent, the breast is a significantly visual body part [5]. The breast is also a highly symbolic organ associated with motherhood, femininity, and self-image. These symbols evoke dimensions that range from nutrition to eroticism across multiple cultures [6]. Therefore, the diagnosis of breast cancer has a profound physical and psychosocial impact on women. That is, an attack on the integrity of the woman's breast is more than a physical attack, but also an attack to the femininity symbol, bearing a notable intimate, social and cultural significance [6] and impacting socio-emotional well-being [7].
Going through the entire post-diagnostic and therapeutic period often implies taking a transformative journey through a suspended femininity, lived in a different body. The concept of body goes beyond its physical dimension and should be replaced by the concept of corporeality, which is related to an existential perspective of the body, that encompasses multiple dimensions of the human being, such as the physical body, the mental and the spiritual dimension [8]. Merleau Ponty's model allows a perspective on the person beyond the 'biomedical' perspective or even the 'psychological' perspective. The body itself, the sick body in breast cancer, is considered a space of existence where many dynamics intersect and are experienced: internal and external, past and present, anticipated and bereaved, accompanied and lonely. Hence, breast cancer should be considered from a holistic perspective, enabling the connection of the different mind-body dimensions. Such an integrative approach will result in integrated interventions that allow women with breast cancer to rediscover and rebuild themselves in this new body throughout a transformative journey.

Breast cancer: a challenge to women's body, identity and quality of life
Breast cancer treatment often involves several long-term interventions. Typically, it involves a surgery (mastectomy or lumpectomy), followed by additional therapies that may include chemotherapy alone or in combination, radiotherapy and hormone therapy. These treatments lead to several side effects such as changes or loss of one or both breasts, visible scars, hair, eyebrows and eyelashes loss, lymphedema, increased body weight and difficulty getting used to prostheses [9,10]. Therefore, the various dimensions of the body are affected in its functionality and shape (or disshape). Besides, the imminence of a terminus of that body is a constant. Henceforth, survivors tend to be hypervigilant of their bodily sensations, which is even more intense before the routine exams due to the fear of cancer recurrence [11]. All the treatments and associated effects significantly impact women with breast cancer's body schema and body image [3,12,13]. In breast cancer, all cognitive survival schemes and bodily schemes interact in a complex way throughout the process of adjustment to the disease and the survival phase [14].
Body image is considered as the mental image of the body, the subjective perception of one's physical and appearance, health status, normal bodily functioning and sexuality [15]. Body image is also related to other dynamic elements, such as the subjective perspective of one's opening or distancing to others, the dimensions of tension/relaxation, activity/passivity and to the perception of femininity/masculinity [16]. Considering the context of a potentially deadly disease and associated decreased vital energy, loss or change of body and role in family, social and professional milieus, breast cancer is, therefore, a real test to one's body image, which is itself the foundation of identity. In fact, research shows that 77% of women with breast cancer have body image disturbances that persist beyond cancer treatments and reconstructive surgeries [10]. These disturbances are even more significant in women undergoing more radical surgeries. For example, six months after a mastectomy, only 63% of the women feel comfortable when fully clothed, and 21% feel comfortable when unclothed [14].
The body image disturbances and the organic factors (e.g., decreased sexual desire) associated to breast cancer have a significant impact on intimate relationships [3] and sexuality itself [17]. It is important to note that sexuality goes beyond sexual activity but mostly to intimacy. It is related to the experience of an interiority expressed to the other in a corporeal dimension, involving the real body and the imaginary body. The surgery often brings psychological distress accompanied by a feeling of emotional rupture that extends to the intimate relationship with the partner. Moreover, the various effects of chemotherapy (e.g., fatigue, weight changes, alopecia) also impact sexual health and intimate relationships. Also, hormone therapy, which often extends throughout time (5 or 10 years), is responsible for profound changes in sexual desire. In fact, high rates of sexual disturbances have been reported in women's breast cancer: around 70% of sexual dysfunctions and 30% of other sexual complaints throughout the treatment and the survival phases [18].
Moreover, the uncertainty, fear, pain, fatigue, discomfort, sleep disturbances and cognitive impairment associated with a breast cancer diagnosis and treatment result in anxiety and depressive symptoms [19,20]. These mental health symptoms are common at diagnosis and often become more intense with treatment burden and in the survival phase [21][22][23] and may affect the treatment, especially regarding compliance with treatment protocols, follow-up exams, and social and family routines [24].
In this pathway, it is also important to consider stress. From the diagnosis to the survival phase, stress is prevalent [25,26]. Despite the low prevalence of posttraumatic stress disorder [27,28], clinically significant symptoms are relatively common, and the diagnosis and the treatment are often experienced as traumatic [28,29]. Although stress is an adaptive response of the body to internal or/and external challenges, prolonged exposure to stress conditions, such as a breast cancer diagnosis and/or associated treatment, leads to neuroendocrine dysregulations and immune dysfunctions [30]. Moreover, chronic stress can also affect behavioral processes and pathways involved in cancer progression [31] and block health-protective behaviors, such as adherence to treatments [22].
Finally, the adverse effects described above regarding physical and emotional wellbeing, along with the difficulties on social functioning [32], compromise the quality of life both in the treatment phase and in the survival phase [10,33].
Either in the diagnosis, the treatment or the survival phase, the experience of a body limited by fatigue, pain, or even of a new/different/foreign body (i.e., with a prosthesis) involves mourning the previous body and readjusting the body scheme and the body image. Besides, all the changes associated with women's breast cancer are deeply rooted in a painful corporeality that embraces an interiority threatened by its continuity, visibility, and wellbeing. Therefore, dealing with breast cancer implies an internal and external recognition and readaptation to the new body and an internal symbolic reorganization of the female, intimate, and social identity [34].

The importance of body-oriented interventions for women with breast cancer
Treating women with breast cancer requires a multidimensional and continued approach throughout the various phases. In the first phase -the announcement of the diagnosis -it is essential to understand how the woman is experiencing her own body, helping her to locate vulnerabilities, disharmonies and difficult emotions and identify their origins. Therefore, a place for self-expression (verbal or non-verbal) supported and validated by a present and non-judgmental therapist is paramount. It is also crucial to support the discovery and the exploration of a new, more fragile, and less genitalized physical intimacy, preserving sensitive physical contact at the level of caresses and words. Besides, monitoring the maintenance of an adapted physical activity and encouraging relaxation and body care is also critical at this stressful phase [34,35].

Complementary Therapies
The second phase -treatments -is highly remarkable at the corporeal dimension. As mentioned before, in this phase, significant changes are felt at the experience of the real body (internal and external sensations) and the imaginary body (representations). Regarding the real body, it is important to minimize the impact of these physical (e.g., fatigue, physical discomfort) and esthetic changes. However, it is also essential to help them observe and relate to this "new" body, especially discovering good sensations in the body under attack. As in the previous phase, it is crucial to encourage and validate women's self-expression of the suffering and frustrations of this phase.
The perspective of being therapeutically supported should continue throughout the survival phase. In this phase, it is essential to support women to experience their bodies as autonomous, active, and relational, therefore fostering their self-esteem.
In all phases, it is essential to promote a positive experience of the body, so women with breast cancer can rediscover and reinvest in their bodies as a place of safety and pleasure. In this context, body-oriented interventions play a decisive role as they allow listening and observing bodily sensations as a starting and connecting point with the inner life.
The implementation of body-oriented interventions as complementary to cancer treatment has increased significantly, reflecting the growing interest in complementing medical treatment with other non-pharmacological approaches [36]. These interventions are reported to promote a better adaptation to the disease, the body and its new characteristics [37], contributing to symptoms' control and improving health status and quality of life [38].
Based on the body-mind relationship, psychomotor therapy is a body-oriented therapy that uses the body as the primary mediator to promote health and wellbeing. In psychomotor therapy, the body in movement and in relation supports sensory and psychic integration processes. Through various bodily mediations such as relaxation, therapeutic touch, play, body and artistic expression, psychomotor therapy helps the person feel, think, use and accommodate his/her body as a central platform of his/her emotions and inner life. This chapter focus two of these approaches implemented at different stages of breast cancer: psychomotor touchmassage regarding the treatment phase and psychomotor relaxation concerning the survival phase.

Psychomotor touch-massage
The therapeutic aims of psychomotor therapy go beyond bodily functionality and include developing the individual's bodily and psychic identity [39]. Therefore, psychomotor touch is more than a mechanical and segmented functional action, seeking to improve the body's functionality and relief physical pain. In psychomotor therapy, the physical, emotional, symbolic, and unconscious dimensions of touch are also considered. Hence, psychomotor touch also seeks to improve body schema and body image and relief emotional pain. The primary intention is, through touch, to communicate to the person that he/she is important, that his/her pain and fears are recognized and that there is a person, a therapist, who is interested in providing him/her sensations of relief and well-being. Thus, psychomotor touch offers an opportunity of feeling and integrating the pleasure of touch, the pleasure of being touched by someone who is interested (who invests) and who takes care of him/her [40].
Among a diversity of touch techniques, psychomotor touch-massage has proved to be an important complementary therapeutic approach to breast cancer treatment. The psychomotor massage-touch consists of a slow and gentle touch that conveys an embracing and structuring contact. The person is dressed, usually in DOI: http://dx.doi.org/10.5772/intechopen.100544 a prone position with eyes closed. Touch is accompanied by passive mobilizations and micro-stretching of all body segments, emphasizing the extremities (finger and toes) and joints. Except for the erogenous zones, the whole body is mobilized, starting with the upper limbs, lower limbs, and the head. Respect for each person's body and personal space is a priority, and therefore the methodology is flexible. It is the method that adapts to the person and not the other way around. As the person relaxes, breathing and or stretching movements can be added, allowing for a more profound release of tension, and redirecting the person's attention to bodily sensations. Finally, a dialog about the sensory experience, the emotions and ideas derived during the psychomotor touch-massage is established [40].
As mentioned above, the treatment phase is a moment of suffering and loneliness, where the body is attacked from the outside and the inside. The gentil embracement and support provided by the psychomotor touch-massage is therefore particularly important in the treatment phase. It gives a pleasurable sensory experience, a pleasure experienced with another, and a communication, essentially on the non-verbal level, which secures and contains. The suffering body is thus supported, relieved, validated and revalued by the other. On the other hand, the support and balance provided by the touch provide a maternalization, as an internal momentum supported by the attentive, available and supporting presence of the therapist.
A program of psychomotor touch-massage was implemented with women with breast cancer during the treatment phase. The program involved two sessions per week for 8 weeks and was implemented at the oncology department of a Portuguese public hospital. At the end of the program, there were improvements in the quality of life of the women who participated in the program, compared to those who were part of the control group and, therefore, kept their usual routines [41]. Besides, qualitative analysis of interviews conducted at the end of the intervention revealed that all participants reported that touch-massage was helpful in their healing process. On the other hand, a large majority (84.62%) felt relief from the symptoms associated with the treatment, and reported to have changed the way they face their disease [42].
Other similar therapeutic approaches have also been shown to effectively improve perceived stress, cancer-related physical symptoms and mental health symptoms, including depression and anxiety [43][44][45]. Besides, similar touch-based approaches have also been shown to positively impact the neuroendocrine and immune systems of breast cancer patients and survivors, increasing dopamine and serotonin levels, NK cells and lymphocytes, and decreasing cortisol and betaamylase concentrations [43, 44,46].

Psychomotor relaxation
Psychomotor relaxation involves the regulation of the tonus and attention through several techniques, such as body awareness, muscular relaxation, or breathing techniques [47]. Through relaxation, the person can obtain neuromuscular relaxation in each part of the body, locating the tension and passivity in the different segments compared to the rest of the body and integrating what is felt in the tension and passivity phases. The therapist observes the tonic changes, facilitates the association between sensations, images and emotions and promotes reflection on the meaning of the tonic-emotional experience, thus facilitating the psychic elaboration of sensations [48]. Thus, the entire corporeality is mobilized, favoring a new experience of the body (real and imaginary). Psychomotor relaxation implies the presence of another, a therapist that recognizes, evaluates and values the person's intimate expression, as well as a relationship, a bond that stabilizes and provides the necessary security for the person's investment [49].
Unlike psychomotor touch-massage, relaxation sessions are characterized by the diversity of proposals and sensations experienced, which promote a progressive internal rediscovery of the body itself, as a source of pleasure, security, and possibility. This process is essential for the elaboration of the losses associated with breast cancer [50]. The woman discovers her body, an active and skilled body that she can use to feel better. Thus, while in the first sessions, relaxation is induced by the therapist, as the sessions progress the participants gain autonomy and actively relax their bodies and minds. This growing autonomy, supported by a continuous and secure therapeutic relationship, is fundamental in the survival phase, a phase in which treatments, consultations and social support suddenly cease, giving place to emptiness and an expected autonomy, often difficult to support.
Besides, the possibility of expressing the inner experience and incorporating such sensory and emotional experience in one's personal story and identity (past and present) is of paramount importance for women survivors of breast cancer, as it facilitates the literal and metaphorical communication of the experience and, therefore, its elaboration. When this communication and elaboration happens within a group, the therapeutic process becomes even more powerful. Indeed, the group context allows sharing experiences and the validation of one's feelings by similar others. In a group, members have an opportunity to see how others experience the same changes and emotions and cope with similar-or even worse -circumstances as themselves [51].
Participating in a therapeutic group also reduces social isolation and promotes social support. Social support can significantly impact stress management, adjustment to cancer, quality of life, and cancer-related symptoms [52,53]. Support from other group members also generates a need to be available to support others and a sense of belonging and commitment to the group, which fosters a sense of meaning and increases the motivation for the session [37]. In fact, one of the main incentives for adherence to group intervention programs is the increase of social support and the decrease of social isolation provided by therapeutic groups for breast cancer survivors [54].
With the increase of cancer survivors and the associated need of improving their quality of life, some therapeutic relaxation programs have been developed. In particular, after an oncology department of a Portuguese public hospital identified the need to provide therapeutic support to breast cancer survivors, a psychomotor relaxation program was developed and implemented. Through movement, awareness, self-regulation and body expression, an affective and positive experience of the body, in a context of individual and collective construction, was provided to a group of women with breast cancer, aiming to improve their health, well-being and bodily and affective experience. The program involved group sessions of 45 minutes, twice a week, for 8 weeks. The sessions began with an initial dialog, in which the participants prepared for the session and could share their feelings. Then followed a moment of body centering and breathing regulation, in which exercises of body (and breathing) awareness and muscle relaxation were proposed. Then, a guided imagery moment enabled rediscovering the inner body and the pleasant sensations of calm, comfort, and satisfaction. Afterwards, body and attentional activation stretches were proposed. Finally, there was a moment for the expressive representation of the experienced sensations, which led to the final dialog, encouraging sharing emotions, difficulties, and life experiences [55].
The participants were always receptive and enthusiastic about the proposed activities throughout the program, becoming progressively autonomous. As the sessions progressed, they were increasingly able to focus attention on their bodies and particularly on bodily sensations and to regulate the moments of arousal, as well as to transpose the acquired skills to their daily life (e.g., relax in moments of greater anxiety, relax on sleepless nights to fall asleep). At the end of the program, significant improvements were revealed in physical (e.g., more vitality and less fatigue) and mental health, quality of life, body appreciation and interoceptive awareness [55].
In this study [55], variations in salivary cortisol concentrations between the beginning and the end of the session were analyzed. Although there were no significant changes at the beginning of the program, in the 15th session, there was a significant decrease from the beginning to the end of the session, indicating that the participants learned to self-regulate their stress levels effectively. Interestingly, the control group, which did not participate in the program, and kept their usual routines, faced a decrease in the health and quality of life indicators and affective experience of the body. These study showed that psychomotor relaxation effectively promotes the health and quality of life of women survivors of breast cancer. Not participating in relaxation sessions implies that health and quality of life indicators deteriorate throughout the survival phase [55].

Conclusions
Breast cancer is a significant challenge to women's body, identity and quality of life. All the changes associated with breast cancer are deeply rooted in a painful corporeality, threatened by its continuity, visibility and well-being. Therefore, either in the diagnosis, the treatment or the survival phase, the real body (internal and external) and the imaginary body must be carefully considered. Minimizing the impact of cancer on physical well-being is important. But mourning the previous body, rediscovering the pleasure and possibilities of the new body, and reorganizing the intimate and social identity is of paramount importance, bringing benefits for emotional and social well-being.
Psychomotor therapy is a beneficial, complementary approach to medical care for women with breast cancer. In the field of pain and psychosomatic changes, psychomotor therapy enables a unique experience of the body and a reconstruction of women's identity, which results in improved health and quality of life.