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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234On-line version ISSN 1980-220X

Rev. esc. enferm. USP vol.53  São Paulo  2019  Epub Oct 03, 2019

http://dx.doi.org/10.1590/s1980-220x2018024103497 

ORIGINAL ARTICLE

The meaning of integrative guided imagery relaxation therapy for women with breast cancer*

Bruna Francielle Toneti1 
http://orcid.org/0000-0002-8565-4905

Juliana Maria de Paula Avelar1 
http://orcid.org/0000-0002-4960-1558

Fernando Henrique Sousa1 
http://orcid.org/0000-0003-0599-6866

Adrielle Naiara Toneti1 
http://orcid.org/0000-0002-0340-2430

Helena Megumi Sonobe1 
http://orcid.org/0000-0003-3722-0835

Namie Okino Sawada1 
http://orcid.org/0000-0002-1874-3481

1Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brasil.


ABSTRACT

Objective

Understanding the meaning of guided imagery relaxation for women with breast cancer, also investigating how patients view cancer and their immune system during guided imagery relaxation sessions and feel after it.

Method

A qualitative study with a phenomenological approach and a Heideggerian theoretical-methodological reference based on the Creative and Sensitive Method, developed in the radiotherapy outpatient clinic of a public teaching hospital in the interior of São Paulo. The Heideggerian understanding was used for analyzing the data, which occurred in two stages: vague and medium understanding, and hermeneutics.

Results

Nine women between the ages of 45 and 67 participated in the study. The data allowed us to understand the meaning of guided imagery relaxation from the participants, since they could be classified into three units of meaning: cancer stigma, facing disease and treatment benefits.

Conclusion

The meaning of guided imagery relaxation made it possible to understand the being-in-the-world during the provided reflections, and it is possible to verify the importance of the nurse’s offer of therapy in caring for women with breast cancer.

Key words: Breast Neoplasms; Relaxation Therapy; Complementary Therapies; Oncology Nursing; Women’s Health

RESUMO

Objetivo

Compreender o significado do relaxamento com imaginação guiada para mulheres com câncer de mama, buscando investigar, também, como as pacientes visualizam o câncer e seu sistema imunológico durante as sessões de relaxamento com imaginação guiada e se sentem após sua realização.

Método

Estudo de natureza qualitativa, com abordagem fenomenológica e referencial teórico-metodológico heideggeriano, fundamentado no Método Criativo e Sensível, desenvolvido no ambulatório de radioterapia de um hospital de ensino público do interior paulista. Para a análise dos dados foi utilizada a compreensão heideggeriana, que ocorreu em duas etapas: a compreensão vaga e mediana e a hermenêutica.

Resultados

Participaram do estudo nove mulheres com idade entre 45 e 67 anos. Os dados permitiram compreender o significado do relaxamento com imaginação guiada pelas participantes, pois puderam ser classificados em três unidades de significado: o estigma do câncer, o enfrentar da doença e os benefícios do tratamento.

Conclusão

O significado do relaxamento com imaginação guiada possibilitou a compreensão do ser-no-mundo durante as reflexões proporcionadas, sendo possível verificar a importância do oferecimento da terapia pelo enfermeiro nos cuidados da mulher com câncer de mama.

Palavras-Chave: Neoplasias da Mama; Terapia de Relaxamento; Terapias Complementares; Enfermagem Oncológica; Saúde da Mulher

RESUMEN

Objetivo

Comprender el significado de la relajación con imaginación guiada para mujeres con cáncer de mama, tratando de investigar asimismo cómo las pacientes visualizan el cáncer y su sistema inmunológico durante las sesiones de relajación con imaginación guiada y se sienten después de su realización.

Método

Estudio de naturaleza cualitativa, con abordaje fenomenológico y marco de referencia teórico metodológico heideggeriano, fundado en el Método Creativo y Sensible, desarrollado en el ambulatorio de radioterapia de un hospital de enseñanza pública del interior del Estado de São Paulo. Para el análisis de los datos fue utilizada la comprensión heideggeriana, que ocurrió en dos etapas: la comprensión vaga y mediana y la hermenéutica.

Resultados

Participaron en el estudio nueve mujeres con edades entre 45 y 67 años. Los datos permitieron comprender el significado de la relajación con imaginación guiada por las participantes, pues pudieron clasificarse en tres unidades de significado: el estigma del cáncer, el enfrentamiento de la enfermedad y los beneficios del tratamiento.

Conclusión

El significado de la relajación con imaginación guiada posibilitó la comprensión del ser-en-el-mundo durante las reflexiones proporcionadas, siendo posible verificar la importancia del ofrecimiento de la terapia por el enfermero en los cuidados a la mujer con cáncer de mama.

Palabras-clave: Neoplasias de la Mama; Terapia por Relajación; Terapias Complementarias; Enfermería Oncológica; Salud de la Mujer

INTRODUCTION

Cancer is a disease characterized by abnormal and disordered cell proliferation, which can affect several parts of the body and consequently impair its functional capacity. Mutated and undifferentiated cells are highly capable of spreading to other tissues, which is often associated with most cancer deaths(1). With the population aging process, cancer has become a major public health problem. For the 2018-2019 biennium, there are estimates of the occurrence of 600 thousand new cases of cancer for each year in Brazil(2).

Conventional treatments for cancer can be done through surgery, radiation therapy, chemotherapy, hormone treatment, and bone marrow transplantation is also used in some types of cancer, and there may also be a combination of more than one of these treatment modalities. However, conventional treatments are often associated with side effects which significantly interfere with patients’ quality of life and lead them to seek non-pharmacological resources to help them control and prevent such symptoms(3).

Complementary therapies are defined as techniques which do not replace the prescribed conventional (pharmacological) treatments and are concomitantly used to alleviate the symptoms or side effects, such as reducing pain and fatigue, offering physical and psychological comfort to the patient(3-5). Mind-body therapies, especially relaxation and guided imagery, have been used as a way to assist cancer patients in relieving the disease and treatment symptoms, and are useful for the patient’s coping and rehabilitation processes(5-6).

Guided imagery relaxation is already recognized for its effectiveness and for the profound state of relaxation it provides, resulting in reducing some side effects and allowing, with each development of practice, the patient to become increasingly able to control their own level of relaxation(6). In addition, the association between mind-body therapy and conventional cancer treatment enables the patient to be more active in responding to disease and directs care practices which intensify the healing process.

Literature on the subject shows that the female gender especially with the diagnosis of breast cancer, uses more complementary therapies than the male gender. The use of such practice was also associated with age, since middle-aged adults were more adept at using complementary cancer treatment therapies, as well as patients with a higher education level. In addition, some cancer treatment symptoms have also been shown to be linked to the patient’s chances of being involved in therapy in studies, such as pain, insomnia, fatigue, and depression(4-5).

Studies have shown a reduction in the assessed levels of anxiety and depression of cancer patients who used the therapy, as well as in their systolic and diastolic blood pressure, respiratory and heart rates, showing that more guided imagery relaxation sessions had a greater benefit(5-7).

In Brazil, the National Policy on Integrative and Complementary Practices was established in 2006 with the purpose of meeting the needs of research, support and incorporation of complementary therapies for strengthening the Unified Health System (SUS – Sistema Único de Saúde) and ensuring comprehensiveness in health offered to the population(8). Recently, with the publication of Administrative Rule GM/MS No. 849/2017 and Administrative Rule no. 702/2018, integrative and complementary practices were expanded regarding their offer in the SUS, totaling 29 therapies available to system users, as well as an increase in health resolution in the scope of basic attention(9-10).

It is also known that nursing care for cancer patients is increasingly demanding knowledge which supports clinical practice, and alternative therapies are recognized by the Federal Nursing Council in Resolution No. 0500/2015, as a qualification and/or nurse’s specialization, upon completion and approval in courses in the area in recognized educational institutions(11-12).

Nurses are one of the professionals who can provide more information about the effects and benefits of using complementary therapies to oncological treatment, since they have direct and more prolonged contact with the patient during the treatment and rehabilitation process of the disease, which it gives them a more focused attention on the patient and their needs.

Although there are some studies in the literature that show the beneficial effects of guided imagery relaxation, it is emphasized that there is no research in the area that investigates the meaning of this therapy, as well as its relation with oncological patient adherence to alternative treatment. Moreover, given the biopsychosocial effects of breast cancer increasingly incident in women, understanding the significance of guided imagery relaxation for this population can provide important data on the subjective construction of this experience.

In view of the above, this study was developed with the objective of understanding the significance of guided imagery relaxation for women with breast cancer, also investigating how patients visualize the cancer and their immune system during guided imagery relaxation sessions and how they feel after performing the sessions.

METHOD

STUDY DESIGN

This is a qualitative study with a phenomenological approach implementing the Heideggerian theoretical-methodological reference based on the Creative Sensitive Method, with dynamics of creativity and sensitivity to investigate the meaning of guided imagery relaxation for women with breast cancer.

The Heideggerian theoretical-methodological framework was adopted by offering philosophical presuppositions for understanding humans through their discourse, lived experience and interpretation and elaboration of knowledge, revealing the lived phenomenon in its essence and the meanings attributed by the subject(13).

The Sensitive Creative Method has the critical-reflexive teaching method as its theoretical bases, which has the pedagogy of collective and interactive knowledge creation as its presupposition. The dynamics of creativity and sensitization of the participants aim to promote their contact with their subjectivity. “Creativity and sensitivity are valued in the production of research data, and the dynamics aim to facilitate the expression of the research participants”(14). In addition, the authors of these studies affirm that “it combines science and art by combining data collection techniques already consolidated in qualitative research”, such as the interview and group discussion carried out in the present study, in which “the fundamental purpose is to sharpen the expression of subjectivity by the research participants”(14).

SCENARIO

This study was carried out in a radiotherapy outpatient clinic of a public teaching hospital in the interior of São Paulo, from March to April 2016. Participants were invited to the waiting room at the site while waiting for their radiotherapy session, with only three refusals of participation in the study which occurred due to the time unavailability of the women approached for the group relaxation session. The researcher presented the objectives of the study for the participants, as well as their relationship with the research group of the area and the care institution.

SELECTION CRITERIA

The inclusion criteria adopted were: women over 18 years of age, diagnosed with breast cancer, initiating radiotherapy at the site and receiving guided imagery relaxation therapy. Patients who were unable to understand the issues investigated in the present study assessed by simple questions such as date of birth, day of the week, and others, were excluded.

DATA COLLECTION

The guided imagery relaxation session was conducted by the researcher once per group, conducted by a relaxation CD with guided visualization produced by the Support Center for Cancer Patients of Florianópolis – SC, which was also used and validated by a study in the area, having demonstrated its applicability and effectiveness in relieving cancer treatment symptoms(6). This relaxation technique uses visualization in a therapeutic and symbolic way, stimulating brain zones responsible for creating images and feelings of well-being in its practitioner. During the session, progressive muscle relaxation exercises are conducted in association with image visualization, all with the clinical objectives to improve the patient’s health status and quality of life(6).

Three groups were divided among the study participants to collect the data by interview and group discussion, according to the proposed Sensitive Creative Method. The guided imagery relaxation session lasted 15 minutes and was held in a reserved room at the outpatient clinic, where participants sat in comfortable chairs with reduced ambient light and the sound of the guided imagery relaxation CD, which was reproduced by a portable stereo.

After the session, the researcher who had taken previous training through study and practice activities within their research group, conducted the phenomenological interview using an unstructured form, in which the participants were asked in groups about the following guiding questions: 1 – How do you visualize your illness?; 2 – How do you visualize your immune system?; 3 – How do you feel after relaxation with guided visualization? All the reports were audiographed and later transcribed.

DATA ANALYSIS AND PROCESSING

The transcribed interviews were submitted to a preliminary reading with the purpose of organizing the ideas to return to the initial objectives of the study and to elaborate indicators which guided the interpretation of these data. A field diary was also used to record the non-verbal expressions and the various other forms of language of the study participants. Recording expressions in the field diary is part of the phenomenological interview, and in doing so within the communicational perspective they are a system of codes produced by the participant’s perception in becoming aware of the phenomenon, and can be observed and interpreted by the medium adopted to the analysis process of the meaning attributed to them by the subject in association with their discourse.

Heideggerian understanding was later used for the data analysis, which occurred in two stages: vague and medium understanding, which seeks to understand what is directly shown, meaning the essential structures of the studied phenomenon which emerge from the participants’ own statements; and hermeneutics, which seeks to unveil the phenomenon through the interpretation of the senses attributed by the participants(13,15).

The vague and medium understanding, comprising the first Heideggerian analytical moment, was accomplished by listening and attentive reading of the speeches where the highlights of the meanings contained therein were found through historiography and historicity. Historiography emerged from the ontic dimension of the being under study, when their age, marital status, number of children, professional occupation, diagnosis, prior surgery and oncological treatment were investigated. In historicity, we sought to analyze the phenomenal dimension of the participants’ experiences, when the subjectivity expressed in the statements and in the group meeting was the focus of the analysis(13,15).

For the search of the units of meaning, a codification was creating to highlight the expressions of the being-there of women with cancer. The pronouns which indicated when the participants talked about themselves, their relationships, their daily activities, and other essential structures were highlighted in different forms of the testimonies. Next, hermeneutics was performed for the interpretative understanding of the senses identified in the dimension of the phenomenon(13,15). With this, the three identified units of meaning emerged from the essential structures which revealed the senses of the phenomenon studied in the participants’ statements. These units were constructed after the proposed analysis by expressing similarities and the intersection of the phenomenologically elucidated meanings.

ETHICAL ASPECTS

This study was approved by the Research Ethics Committee of the Universidade de São Paulo at Ribeirão Preto College of Nursing, under opinion number 1.411.384, and by the Ethics and Research Committee of the cooperating institution, on February 16, 2016, Resolution 466/12 of the National Health Council. The researcher presented the study objective and the clear and Informed Consent Form (ICF) to the participants, who signed the ICF in agreeing to participate in the research. We chose to use the name of flowers for the participants in order to guarantee their anonymity, as chosen by the deponents themselves, accompanied by the number of the interview and the group performed to identify their speeches.

RESULTS

Nine women with breast cancer undergoing radiotherapy treatment were invited to participate in the study for convenience and were divided into three groups to perform a guided imagery relaxation session, as well as the sensitivity and creativity dynamics to sensitize them to their perceptions about therapy.

We also looked at the sociodemographic and clinical data of the participants in order to improve the understanding of the interviews: the interviewees’ ages ranged from 45 to 67 years; five participants underwent mastectomy surgery of one breast and four underwent quadrantectomy. Three participants underwent axillary emptying and eight patients underwent chemotherapy. Most declared they were Catholic (seven), six were married, two were single, and one was a widow. Three were retired, two engaged in formal paid employment, and four were homemakers. Two participants stated that they did not have any children, four had only one child, and three had two children.

Understanding the data from the interviews allowed us to understand the meaning of the guided imagery relaxation by the participants in light of their existential movement, which could be classified into three units of meaning: cancer stigma, facing the disease and treatment benefits.

THE STIGMA OF CANCER

It is known that cancer is a disease that carries many stigmas, beliefs and fears related to treatment and life prospects in face of the disease, which significantly influences the way in which the individual faces it. The way the participants constructed their narratives about the disease showed the way they faced it and their personal experiences about it. It may be noted that some of the women in this study did not like to visualize the image of the cancer in their body when asked during the guided imagery relaxation, and even preferred not to imagine it.

I imagined it like this ... because when you find out, Holy God, it’s a horror! But then ... I imagined it like this, it’s already taken out, it’s not remaining in me anymore, I’m going to live. I don’t have anything anymore! (Tulip4 – Group 2).

At no time do I see a wound. I don’t see anything hurt! I don’t see any disease! I say that I have nothing else and then I only think of good thing, I only see good things ... like branches (Jasmine8 – Group 3).

The manifestations of the participants before visualizing the disease in their body show their modes and ways of expressing the woman-being and her relations with the world. Existence is sometimes given by the projection of a historically and culturally created world in her life, where, in the case of women, the corporeal and gender issues are very strong. Moreover, the being-with is sometimes given as an existential characteristic of the presence, since the body is seen as an intrinsic condition to it by the interviewed women.

In confronting the disease, the woman finds herself and confronts the other, meaning everything that is expected of her as being-in-the-world, which makes it even more difficult to deal with the disease and its symptoms. What is often valued by society and what is expected of the woman in a situation of illness provides an intimate reflection of the being with the meanings attributed to their own existence in facing their feelings, hopes, beliefs, values and experiences(13).

In the dimension of being-to-the-other according to Heidegger, we realize that we live with other people in society, which in turn has ethical rules and precepts for its construction, where everything that is expected from another is the certain reality that presents our coexistence. In facing the experience of breast cancer in her life, especially the request for imagining the disease in her body through relaxation, women are placed in front of the opportunity to break with such a utilitarian chain imposed on the being through reflection on being-with cancer as an experience(13).

Experiencing and reflecting about the disease allows the patient to contact and notice herself during this process. The image created by the participant to represent the cancer in her body during the guided imagery relaxation evidences an increase in her imagination capacity during the therapy, since it seeks to approximate the image of the disease to her reality. Thus, the patient’s image is resignified by the patient, allowing her to reflect on her own conceptions about that experience, as well as those of the other participants in the group.

I visualized it like this ... Like an avocado pit, you know? Something that is breaking ... Something more or less of that kind. (...) It started small and was growing ... That’s how I visualized it (Daisy1 – Group 1).

(...) I visualize it like, like it was a grain of rice, you know? And this rice was very small ... It was a grain of rice! But each one has the grain of the size you want, doesn’t it? ... So mine was very small! And something stopped too ... I could see one thing stopped (...) (Sunflower7 – Group 3).

The participant Hydrangea remained emotional during the group interview, expressing her feelings in the following speech:

I had imagined it before. (...) Right at the beginning, I saw the ultrasound and it was good to visualize ... Then, every time I had an ultrasound, I went to see that with the chemo ... it was, I saw that it was shrinking... it was shrinking, shrinking (...) So, I have it very clear in my head ... The image ... Because I always saw it, you know (...) (Hydrangea5 – Group 2).

COPING WITH THE DISEASE

For the second unit of meaning found from the guided imagery relaxation session, it was also possible to understand how the woman faces cancer and the treatment process of the disease. The different enunciation modes of the participants allowed us to approach the manifest and abstract of being by them.

The feeling of deep anguish which, according to Heidegger, occurs when we realize that we are losing ourselves, awakens us from an inauthentic existence, which often reveals how we dissolve into everyday impersonality. According to the author, the anguish is revealed in the emptiness itself and is able to bring us back to meeting ourselves, as a chance of rescuing the being-there for freedom. And it is to this process that we call the halfway between being and nothingness, where in the case of the present study, women are given the possibility of not fighting and fleeing to the forgetfulness of their deep dimension (being) and returning to daily life; or even to express their power of transcendence over the world and themselves, thus managing to deal with cancer and its physical, psychological and emotional consequences(13).

In their discourse, Clove and Jasmine revealed how the woman can accept the illness and welcome it as part of her being during this coping process:

(...) now it seems like things are going in the right direction ... I am also realizing that the emotional factor influences a lot, so I still need to work on this part more so that nothing will leave me stressed and this won’t happen anymore. I already accepted it! It’s mine ... done, okay! It could be worse, right? (...) I feel that this has helped me have good improvement (Clove9 – Group 3).

(...) Now that I’m more fragile. I don’t know if it’s because of the time that has passed, or because of the pains that we feel, or because of the limitations. So, from a month and a half to now, I’m a little more fragile ... Psychologically, you know ... But, I think I’m going to improve because I’ve never stopped working and I see my positive side, right? (...) (Jasmine8 – Group 3).

It is also worth noting that it is on this path between being and nothingness that a woman with breast cancer is faced with the finitude of her existence and the possibility of overcoming it, fully realizing her being. According to this author, most people understand death only in its trivial sense, and thinking of it is a sign of morbid insecurity and pathological inadequacy on the part of Dasein, a term used by Heidegger in his work Being and Time(13) , with the meaning of being-there or being-in-the-world, which indicates the presence and the way of being in its daily life.

Thus, in facing anguish, a woman with breast cancer needs to acknowledge that she is mortal. In other words, getting sick from breast cancer reveals to the woman the thought of being-to-death, another dimension of being studied by the author, since cancer is widely recognized for its stigmata of severe disease and it precedes the being to death. Faced with the search for the ontological understanding of finitude, therefore, being-to-death in essence becomes anguish, which ends up promoting the acceptance of existential terminality as an absolute condition of human freedom(13).

Girl, I was so shaken ... But, let’s see what God wants to give, right? There isn’t anyone who doesn’t tremble! I only thought about God in this moment. (...) (Violet3 – Group 1).

I imagined it as if it were Jesus who took everything from me ... A white cloth, you know ... It was what I imagined, as if it were Jesus (...) Very good! (Rose2 – Group 1).

It is interesting to see how the images of the immune system fighting cancer during the relaxation session followed a religious character and represented the participants’ beliefs and life experiences.

I saw a lot of angels fighting... All dressed in white, you know? Those children ... it’s related to my own profession and a lot of other things ... I’m a teacher (...) But, I saw them as angels even fighting, right. (...) children are angels! I liked it! (Hydrangea5 – Group 2).

In terms of existential analysis, existence itself is the fundamental essence of all Dasein, and thus does not fit religious explanations for reference to being, since it already takes it as being. Religion must be part of an analysis of the factual reality of the participants, meaning of the historical phenomenon to which they belong(13). However, in facing future uncertainty, as unveiled by the women of the present study, faith and hope are revealed as covenanted virtues of the impossible. The God of the impossible, present in the most diverse biblical and miraculous accounts, puts the being before the idea of the absolute future, emphasizing the hope of resoluteness over which one does not have dominion, as in the case of cancer.

Guided imagery relaxation in the present study proved to be an interesting aid in sensitizing the participants’ ability to imagine their immune system combating the disease, also being associated with a series of physiological actions that help the participant in this confrontation.

(...) When it’s to only visualize him, I see a lot of little soldiers in white ... equal to a lot of Japanese. Samurai, you know? All in white! (...) Then when they go to do things, they wear an all-gold shield, which, when they come together, I see everything golden ... In the beginning, the gold is in the head and sees everything I have ... until the end, right. (...) Then, when everything is golden, I throw it all away ... They keep the shields and they are all white again (...) (Sunflower7 – Group 3).

THE BENEFITS OF TREATMENT

Thus, the reflection about being and the increase in the imaginary capacity by the participants provoked by the therapy evidences how relaxation can be used as a direct and powerfully therapeutic strategy for confronting the disease and treatment.

In this sense, the third unit of meaning found showed that this relaxation practice improves patients’ quality of life during treatment. The participants of the present study reported the sensation of lightness, well-being and physical and mental relaxation after the guided imagery relaxation sessions.

It’s good! I was very tense ... so it helped a lot, it relaxed me. I’m pretty tense, you know? Then it helped. I liked it! (Daisy1 – Group1).

(...) I went there on my little river ... where I was born, you know? On a ranch. It seems I was even seeing the color of the water ... sitting on a rock in the river. I felt good and relieved. It seems that the body is light. (...) I loved it, right! (Lily6 – Group2).

The opportunity to come closer to being through reflection gives us the sense of overcoming anguish. The encounter with the self is a movement in search of the essence of the phenomenon, and the experiences are intertwined with positive memories of manifesting of the being, joined with the unveiling of the way-of-being/being-there in the world of the participants(13).

DISCUSSION

The sociodemographic and clinical data of the participants are in agreement with the literature, in which there was a significant association between therapy practice and the analyzed sociodemographic and clinical variables(16-17). It should be noted that other factors are also frequently associated with therapy, such as the presence of pain, fatigue, anxiety, depression and nausea and vomiting symptoms(3,16-17).

Regarding the stigma of cancer, some authors(18) showed in their study that the body image and sexuality of women with breast cancer are “part of an important process of reformulating the body image” as a consequence of treating the disease. This study evidenced that “women submitted to radical mastectomy without breast reconstruction had higher indices of dissatisfaction with their own body image”, besides showing greater concern with their physical appearance; factors attributed to “multiple physical, psychological and social aspects which are present in the re-elaboration of the female body image”(18).

The denial of the disease constitutes a temporary phase for the woman, being later replaced by partial acceptance of the cancer and its treatment. One study has also shown that the discovery direction of a breast nodule for younger women is different from the meaning of the disease for older women, since young women are slower to become aware of the condition of being-with cancer, because they are not at the age considered to be at risk for the disease(19).

Regarding the religious involvement of the disease, this same study (above) is in line with the results of this research, showing that women with breast cancer used religion as a resource for managing experienced stressful situations, as well as the action of giving God the responsibility of solutions(19). Another study on the use of complementary and spiritual therapies by cancer patients has shown that many of them use them in seeking therapeutic spaces to share the experience and feelings about the disease(20).

A systematic review of the literature on religious/spiritual coping and breast cancer revealed the great relevance of spirituality and religiosity in facing the crisis by women(21). Confronting cancer with respect to religiosity and spirituality was also investigated in an integrative review, which evidenced how much nurses were recognized for being involved among the health professionals, with the theme being involved in research and comprehensive care to health, and its care and assistance plan is more integral to patients(22).

The search for care to treat the disease is also a problem encountered by women when coping with cancer, since a study showed that there are difficulties (as reported by them) of access to available resources in the public health services due to the great demand for care(19). Integrative and complementary practices are offered by the SUS, but there are still adversities to be overcome regarding access, structuring, professional training, acceptance by users, registration of information and expansion of scientific knowledge on it(23-24).

In this search for scientific knowledge regarding the benefits of treatment, literature on the area shows that guided images produce psychological responses which reach the hypothalamic axis, which results in a decrease in stress, a sense of well-being and an immune adaptation(6,25). Thus, the woman’s ability to imagine her immune system fighting cancer is critical during guided relaxation, as it causes a series of physiological actions which help her to cope with the disease(20).

A study in the area also showed that participants were more willing and communicative after the relaxation sessions, with feelings of well-being and more positive thoughts about life(25). However, there is a certain limitation in the literature on such findings, since there are no studies with a strong level of scientific evidence to prove and describe how these physiological processes occur, which also shows the great need and importance of developing randomized clinical research for constructing scientific knowledge in the area, with higher levels of evidence.

Moreover, although the present sample was able to answer the questions investigated in the study, the broad generalization of the presented results is considered as a limitation, a factor which is related to existentialist optics itself, in which the meaning cannot be given as something finished for the study. The existential dimension is therefore very complex and challenging for research, and the phenomena are modified at every look and never exhausted in a single perspective. However, it can be affirmed that the guided imagery relaxation therapy allowed to reveal the meaning of Dasein with breast cancer of the investigated women, with this being a reflexive and beneficial therapy with adhesion potential as a complementary treatment during this experience.

CONCLUSION

The reports unveiled the significance of guided imagery relaxation therapy for women with breast cancer undergoing radiotherapy. The analysis and interpretation of the experiences manifested by the participants’ discourses enabled understanding the phenomenon, as well as their ways-of-being/being-there in the world. Thus, the emergence of a new perspective for nursing care was offered in view of the factual situation of experiencing cancer and the process of coping with and treating the disease. The study showed that offering relaxation therapy in the care of women with breast cancer enables encountering the being-in-the-world during the reflections provided by the therapy through understanding the phenomenon.

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Financial Support. Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP). Process no. 2015/18103-6, Scientific Initiation Scholarship.

Errata

In the article “The meaning of integrative guided imagery relaxation therapy for women with breast cancer”, DOI: http://dx.doi.org/10.1590/S1980-220X2018024103497, published by the journal “Revista da Escola de Enfermagem da USP”, Volume 53 of 2019, elocation e03497, on page 1 and subsequent footers:

Where was written:

Rev Esc Enferm USP. 2019;53:e03947

Now read:

Rev Esc Enferm USP. 2019;53:e03497

Received: June 12, 2018; Accepted: January 17, 2019

Corresponding author:Bruna Francielle Toneti. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Avenida dos Bandeirantes, 3900, Monte Alegre. CEP 14040-902 – Ribeirão Preto, SP, Brazil. bruna.toneti@usp.br

*

Extracted from the Scientific Initiation work: “O significado do relaxamento com imaginação guiada para mulheres com câncer de mama”, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, 2016.

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