J Canc Educ (2010) 25:343348

DOI 10.1007/s13187-010-0048-3

Self-blame, Self-forgiveness, and Spirituality

in Breast Cancer Survivors in a Public Sector Setting
Lois C. Friedman & Catherine R. Barber &
Jenny Chang & Yee Lu Tham & Mamta Kalidas &
Mothaffar F. Rimawi & Mario F. Dulay & Richard Elledge

Received: 23 September 2009 / Accepted: 8 January 2010 / Published online: 26 February 2010
# Springer 2010

Abstract Cognitive appraisal affects adjustment to breast

cancer. A self-forgiving attitude and spirituality may benefit
breast cancer survivors who blame themselves for their
cancer. One hundred and eight women with early breast
cancers completed questionnaires assessing self-blame,
self-forgiveness, spirituality, mood and quality of life
(QoL) in an outpatient breast clinic. Women who blamed
themselves reported more mood disturbance (p<0.01) and
poorer QoL (p<0.01). Women who were more selfforgiving and more spiritual reported less mood disturbance
and better QoL (ps<0.01). Interventions that reduce self-

29th Annual San Antonio Breast Cancer Symposium, San Antonio,

Texas, December 2006.
L. C. Friedman (*)
Department of Psychiatry, Ireland Cancer Center,
University Hospitals Case Medical Center,
11100 Euclid Avenue,
Cleveland, OH 44106, USA
e-mail: Lois.Friedman@UHhospitals.org
C. R. Barber
Menninger Department of Psychiatry and Behavioral Sciences,
Baylor College of Medicine,
Houston, TX, USA
J. Chang : Y. L. Tham : M. F. Rimawi : R. Elledge
Dan Duncan Cancer Center and Lester and Sue Smith Breast
Center, Department of Medicine, Baylor College of Medicine,
Houston, TX, USA
M. Kalidas
Austin Diagnostic Clinic,
Austin, TX, USA
M. F. Dulay
Department of Neurosurgery,
The Methodist Hospital Neurological Institute,
Houston, TX, USA

blame and facilitate self-forgiveness and spirituality could

promote better adjustment to breast cancer.
Keywords Breast cancer survivors . Self-blame .
Self-forgiveness . Spirituality

Introduction
Cognitive appraisal or how a person views a situation is
known to play a key role in adjustment to stressful life
events [16]. For example, self-blame is associated with
poorer psychological adjustment in medically ill patients,
including women with breast cancer [1, 4, 5, 7]. Because it
has been suggested that behavioral factors such as diet and
exercise may be related to an increased risk of breast
cancer, some women with breast cancer may blame
themselves for developing this disease, resulting in mood
disturbance and decreased quality of life (QoL) [3, 6, 811].
Support for a relationship between self-blame and
psychological adjustment has been inconsistent. JanoffBulman and Wortman suggest that it may be adaptive to
attribute ones cancer to internal factors that are controllable
and capable of being changed [12]. More recent studies
have examined the relationship between behavioral and
characterological self-blame and adjustment to cancer [1, 3,
13]. Janoff-Bulman suggests that behavioral self-blame is
likely to occur when people blame themselves for past
behaviors and believe that these behaviors can be changed,
perceiving themselves as having more control over future
events and adapting better to the stressor [14]. She also
suggests that characterological self-blame, on the other
hand, is associated with negative feelings and poor
adaptation because blame is directed at personality characteristics that typically are stable and resistant to change,

344

implying that perceived control mediates the self-blame/

distress relationship. Likewise, Timko and Janoff-Bulman
observe that behavioral self-blame increases feelings of
invulnerability to breast cancer recurrence, which in turn
decreases depressive symptoms [15]. Bennett et al. [1], in a
prospective study of women newly diagnosed with breast
cancer, found that both forms of self-blame were related to
psychological distress at 4, 7, and 12 months post-diagnosis
but that perceived control did not mediate the relationship
between self-blame and level of psychological distress.
Since blaming ones self for developing breast cancer
may lead to shame, guilt and decreased QoL, a selfforgiving attitude, or the ability to accept responsibility
without excessive self-blame and guilt, may be particularly
salient for women with breast cancer. Self-forgiving people
admit their mistakes and let go of self-resentment and selfcriticism [16]. Only recently has the relationship between
self-forgiveness and adjustment to medical illness been the
focus of investigation. Romero et al. found a positive
relationship between self-forgiveness and psychological
adjustment in a predominantly African American and
Hispanic sample of low-income women with breast cancer
[17]. A similar relationship was found in a predominantly
Caucasian sample of women with breast cancer in a private
sector breast clinic [18]. It is possible that women who are
more self-forgiving are less likely to blame themselves for
developing breast cancer, and consequently experience less
mood disturbance and enhanced QoL.
Spirituality also may be important for breast cancer
patients adjustment to illness. Several studies have
established a connection between spirituality and health
(see Powell et al. [19] for a review). Advanced lung cancer
patients ranked faith in God as a significant factor in their
medical decision making [20]. Spiritual well-being has
been associated with QoL [21, 22] and perceptions of
quality of and satisfaction with medical care [23] in cancer
patients. Romero et al. found that spirituality was related to
psychological adjustment in a mostly African American and
Hispanic sample of low-income women with breast cancer
[17]. A recent study found that two components of
spirituality (meaning/peace and faith) were related to
psychological well-being [24].
The purpose of the present cross-sectional study was to
examine relationships among self-blame for having developed breast cancer, self-forgiveness, spirituality, mood and
QoL in women in a public sector outpatient breast clinic. In
the current study, we characterized self-blame as including
behaviors, cognitions and feeling states that potentially
could be thought as contributing to the development and
course of ones breast cancer. We characterized selfforgiveness as a global predisposition to avoid unwarranted
guilt and shame across various circumstances. We hypothesized the following: (a) self-forgiveness and spirituality

J Canc Educ (2010) 25:343348

would be directly related to QoL and inversely related to

mood disturbance and (b) self-blame would be inversely
related to QoL and directly related to mood disturbance. We
also examined relationships between demographic and
clinical variables (age, marital, educational and employment status, and time since diagnosis) and the dependent
measures (mood and QoL).

Materials and Methods

Participants and Procedures
The Baylor College of Medicine Institutional Review Board
and Harris County Hospital Districts Ben Taub General
Hospital approved the study and consent procedures.
Participants were 108 women attending an outpatient breast
clinic at a county general hospital that provides medical care
to the uninsured and underinsured residents of Harris
County, Texas. To be eligible for this study, women had to
have been diagnosed with Stages I to III breast cancer and be
able to read and understand either English or Spanish.
Physicians asked their patients to complete a battery of
questionnaires assessing adjustment to breast cancer. Questionnaires were either completed by the patients themselves
or read to them and completed by a research assistant.
Questionnaires were available in both English and Spanish.
A Spanish-speaking research assistant was present to assist
those patients who were more comfortable interacting in
Spanish. To protect patient confidentiality and due to the
busy nature of the clinic, physicians did not to provide data
on patients who declined to participate. Participants were
contacted only once. By completing the questionnaires,
patients consented to participate in this research.
Measures
Questionnaires measured demographic variables (age, race/
ethnicity, marital, educational and employment status), time
since diagnosis, self-blame, self-forgiveness, spirituality,
mood and QoL. Questionnaires took approximately 20 min
to complete.
Self-blame This measure was developed for the present
study and was based on items from Nosarti et al.s Beliefs
About Breast Cancer Questionnaire, Stewart et al.s 26
items and a modified version of Glinder and Compass
behavioral self-blame item [3, 25, 26]. We developed this
scale to measure the types of things to which women attribute
breast cancer as well as extent of self-blame. Participants
rated on a 4-point Likert-type scale (1=Not at All; 4=
Completely) the extent to which they considered each of 11
items responsible for the development of their cancer and/or

J Canc Educ (2010) 25:343348

could affect the course of their cancer in the future. Higher

scores indicated greater self-blame, and a score of 2 or higher
on any item was considered endorsement of that item as
having contributed to cancer. Sample items include Not
eating right, Lack of exercise and Placing high demands
on myself. The internal consistency (Cronbachs alpha) was
0.79 in the current study.
Self-forgiveness The Forgiveness of Self scale is a 15-item
scale that measures attitudes and practices related to the
global tendency to forgive ones self [27]. Participants
indicated the degree to which they agreed with each item on
a 6-point Likert-type scale (1=Strongly Disagree; 6=
Strongly Agree). The wording of most items was in the
direction of higher scores indicating less self-forgiveness
(e.g., I frequently apologize for myself, and I find it
hard to forgive myself for some things that I have done). We
reverse-scored these items for ease of interpretation so that a
higher score indicated more self-forgiveness. Cronbachs
alpha of this measure in the current study was 0.91.
Spirituality Spirituality was assessed by the Functional
Assessment of Chronic Illness Therapy-Spiritual Wellbeing Scale (FACIT-Sp) [28]. This 12-item measure is
made up of two subscales, sense of meaning and peace and
the role of faith in illness. We used the total spiritual wellbeing scale. Cronbachs alpha was .85.

345

Statistical Analyses
Descriptive statistics were computed for the independent
variables (self-blame, self-forgiveness, spirituality) and the
dependent variables (mood and QoL). Bivariate correlations
and one-way ANOVAs were computed to examine relationships among the demographic, clinical, independent and
dependent variables. Finally, multiple regression analyses
were used to examine the proportion of variance in mood
and QoL accounted for by age, education, marital and
employment status, time since diagnosis, self-blame, selfforgiveness and spirituality. The final set of independent
variables used in the regression analyses was based on the
significant between-variable correlational analyses and
between-group differences. Age, education, employment
and marital status and time since diagnosis originally were
proposed as predictor variables but were removed from the
regression analyses because they did not relate significantly
to any of the dependent variables (with the exception of
employment status when predicting QoL). Self-blame, selfforgiveness and spirituality were entered simultaneously in
the regression when predicting mood disturbance. Employment status was entered into block 1 and self-blame, selfforgiveness and spirituality were entered simultaneously
into block 2 when predicting QoL.

Results
Mood Mood disturbance was assessed by the total mood
disturbance score of the Profile of Mood States-short form
[29]. This 37-item instrument also has six subscales
measuring both positive and negative emotional states.
Participants endorsed the extent to which they had
experienced each emotion during the past week on a 5point Likert-type scale (0=Not at All; 4=Extremely).
Higher scores indicate more mood disturbance. Excellent
reliability and validity have been demonstrated for this
measure [30]. The internal consistency (Cronbachs alpha)
of this measure in the current study was 0.94.
Quality of life The Functional Assessment of Chronic
Illness TherapyBreast version scale is a 27-item scale that
measures four domains of QoL (physical, social/family,
emotional and functional well-being) and has nine additional items assessing breast-specific well-being [31]. These
items are summed to provide a global measure of QoL.
Participants indicated the extent to which each item had
been true for them during the preceding seven days, using a
5-point Likert-type scale (0=Not at all; 4=Very much). We
used the total quality of life score, with higher scores
indicating better QoL. This frequently used instrument has
excellent reliability and validity [31]. Cronbachs alpha in
the current study was 0.74.

Participant Characteristics
Patients mean age was 52 years. Forty-four per cent of the
participants were Hispanic, 41% African American, 10%
Caucasian, 4% Asian American and 1% Native American.
Thirty-six per cent were married and 24% were employed.
Mean number of years of education was 12 (SD=2.6). The
average time since diagnosis was 21 months (SD=19.9).
Descriptive Statistics
The frequency with which self-blame items were endorsed
was lack of exercise (65%), not eating right (61%),
difficulty coping with stress (52%), decision to take
hormone replacement therapy (51%), placing high demands
on self (50%), anxiety/nervousness (45%), decision to use
oral contraception (37%), not expressing feelings (37%),
delay in seeking medical consultation (31%), alcohol use
(23%) and pessimism (21%).
Bivariate Analyses
Table 1 presents the Pearson correlation coefficients among
the non-dichotomous independent and dependent variables.

346

J Canc Educ (2010) 25:343348

Table 1 Pearsons productmoment correlation coefficients

for independent and dependent
variables
1
2

Age
(1)

Education
(2)

Time
(3)

FOS
(4)

FACIT-Sp
(5)

Self-blame
(6)

POMS-SF
(7)

FACIT
(8)

.13

.06
.08

.10
.07

.12
.18

.03
.08

.14
.05

.02
.06

.08

.03
.29*

.11
.39*
.27*

.11
.58*
.55*
.49*

.08
.37*
.63*
.41*
.72*

3
4
5
6
7

*p<0.01

Age, education and time since diagnosis were not related to

mood or QoL (p>0.05). Participants who reported more
spirituality and a more self-forgiving attitude reported less
mood disturbance (p<0.01) and a better QoL (p<0.01).
Participants who reported more self-blame reported more
mood disturbance (p<0.01) and poorer QoL (p<0.01).
These relationships are consistent with our hypotheses.
Between-Group Comparisons
Table 2 provides means and standard deviations from the
one-way analysis of variance conducted to evaluate betweengroup differences (married/not married and employed/not
employed) in level of mood disturbance and QoL. Women
who were employed reported better QoL then those who
were not employed, F(1/104)=6.23, p=0.01. The two groups
did not differ in mood disturbance, F(1/104)=0.79, p=0.38.
There were no between-group differences for marital
status, F(1/104)=0.14, p=0.71 and F(1/104)=0.43, p=0.52,
respectively.
Multivariate Analyses
The results from the multiple regression analyses show selfblame, self-forgiveness and spirituality were significant
predictors of mood disturbance, accounting for 50% of the
variance (p<0.001). Self-blame, spirituality and employment status were significant predictors of QoL, accounting
for 47% of the variance (p<0.001).

Discussion
The intent of our study was to examine relationships among
self-blame, self-forgiveness, spirituality, mood and QoL in
women with breast cancer. We found that a more selfforgiving attitude was related to less mood disturbance and
a better QoL which is consistent with what was found by
Romero et al. and Friedman et al. [17, 18]. We also found
that a greater level of spirituality was associated with a
reduced likelihood of mood disturbance and better QoL.
More self-blame was associated with an increased level of
mood disturbance and poorer QoL, consistent with the
results of other investigators [1, 4, 5, 13]. This suggests,
contrary to what Timko and Janoff-Bulman [15] have
suggested, that self-blame is not protective against stressful
events.
A considerable number of women in our sample felt
responsible for the development and/or future course of their
cancers, with more than fifty per cent blaming lack of
exercise, anxiety, difficulty coping with stress and poor
dietary habits as reasons for having developed breast cancer.
Investigating the effects of educational interventions that take
these results into account might be important for future
research. For example, studies could explore whether having
oncologists and nurses discuss the lack of evidence for any
specific personal cause of breast cancer with their patients
decreases self-blame and improves their adjustment to
cancer. Since recent studies suggest that increased caloric
expenditure and decreased fat and caloric intake may have an

Table 2 Psychological functioning and marital and employment status

Married
(n=39)

Total mood disturbance

Quality of life

Not married
(n=67)

Employed
(n=26)

Not employed
(n=80)

SD

SD

SD

SD

43.8
98.6

25.9
17.6

40.4
97.0

25.1
22.6

.52
.71

37.8
106.2

19.0
18.7

42.9
94.8

27.1
20.8

.38
.01

J Canc Educ (2010) 25:343348

effect on breast cancer outcome (see Chlebowski [32] for a

review), it would be interesting to assess the effects of selfblame and self-forgiveness on adherence to lifestyle recommendations such as exercise and fat and caloric reduction.
Several limitations of this study need to be noted. Since
it was cross-sectional, we were not able to determine causal
relationships between our independent (spirituality, selfforgiveness, and self-blame) and dependent (mood disturbance and QoL) variables or to assess whether the
relationships we found change over time. Another limitation was our reliance on a measure of self-blame that has
limited psychometric testing. Although we have limited
clinical data, Bardwell et al. found that symptoms of
depression in a large sample of women with early stage
breast cancer were not related to cancer-related variables
[33]. In our study, we also found that length of time since
diagnosis was not associated with mood disturbance or
QoL. Also, it should be noted that the patients in the current
study had greater mood disturbance than those in Cella et
al.s study [34] of recently diagnosed cancer patients. There
are data suggesting that what we found applies equally to a
less psychologically distressed sample of breast cancer
patients in a private-sector breast clinic [18]. These
limitations notwithstanding, our study has important implications for the psychological management of women with
breast cancer in public sector oncology clinics. Research
suggests that psychological distress is common among lowincome, ethnic minority women with breast cancer [35]. It
is important to identify factors related to psychological
adjustment, such as spirituality and self-forgiveness, when
developing interventions for this group of women.
This study offers a starting point for clinical interventions for decreasing these womens mood disturbance and
increasing their QoL. When appropriate, patients could be
offered a referral for pastoral care to meet their spiritual
needs. Interventions that reduce self-blame and facilitate
self-forgiveness need to be developed to facilitate better
adjustment to this disease. Until such interventions are
developed, oncologists should routinely reassure their
patients that they are not responsible for developing breast
cancer. Oncologists and other healthcare providers should,
when appropriate, inquire about what or who their patients
believe is responsible for having developed cancer. This
may facilitate a discussion about self-blame and may assist
healthcare providers in identifying who might benefit from
a psychosocial referral for counseling.

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