Psychotherapeutic Applications of the SASB Cluster Analysis of Intrapsychic Behaviors in Women With Breast Cancer: A Step by Step Approach

Abstract

Background

This study describes the approach and phases of psychotherapeutic interventions in women with breast cancer on the basis of a personality cluster analysis performed using the Structural Analysis of Social Behavior (SASB) Model by Lorna S. Benjamin.

Methods

The SASB Model is a tool for diagnosing and planning the stages of psychotherapeutic intervention. Therefore, based on the cluster analysis of the intrapsychic problems of the 2 different profiles SASB-Love and Autonomy and SASB-Control and Hate Traits, it was possible to describe the phases and methods of the psychotherapeutic SASB intervention for each profile and the most suitable therapeutic approaches.

Results

The results of the analysis, based on the intrapsychic profile derived from the SASB model and distributed along a continuum, indicate the need for specific psychotherapeutic interventions. Although some common intrapsychic issues were identified, their intensity varied across individuals, suggesting that tailored therapeutic approaches are necessary for each patient. The identified intrapsychic profiles, characterized by passive adaptation, low self-affirmation, and self-criticism, highlight the importance of facilitating self-contact, enhancing self-awareness, and promoting the elaboration and integration of emotional experiences.

Conclusion

In this context, a targeted psychotherapeutic treatment aimed at fostering self-affirmation and reducing self-criticism can help women with breast cancer to transform their approach to dealing with their condition, leading to more effective adaptation and improved quality of life.

Introduction

An understanding of the complex biological, psychological, and social factors influencing patients with cancer is crucial for developing treatment plans that are tailored to each individual’s needs. Cancer not only affects the body but also has profound impacts on a person’s mental and emotional state, as well as their social environment. To this end, it is crucial to perform an accurate psychological diagnosis of the patient’s psychosocial condition and conduct a comprehensive personality screening.^1-3 In fact, the ability to adjust to the cancer experience is influenced not only by medical treatments, but also by the individual’s relational (interpersonal) and intrapsychic characteristics (behaviors). ⁴ When developing psychosocial and psychotherapeutic interventions for cancer patients, it is essential to consider the significance of intrapsychic behaviors and how they influence interpersonal behaviors.

From the study ⁵ involving 236 women recently diagnosed with early-stage breast cancer, 2 distinct personality profiles emerged. These profiles were evaluated through cluster analysis, conducted using the Structural Analysis of Social Behavior (SASB) developed by L. S. Benjamin. ⁴

The SASB observation method offers a comprehensive framework for analyzing both intrapsychic and interpersonal behaviors. It can serve as a valuable diagnostic and programming tool for designing interventions that promote psychological growth and maturation. In the context of mental illness, SASB can be employed to guide therapeutic strategies aimed at fostering the recovery and revitalization of intrapsychic structures, which are often compromised. By identifying specific behavioral patterns, SASB helps clinicians develop targeted interventions that not only address relational dynamics but also support deeper emotional and cognitive transformation, enhancing overall mental health and well-being.^5-7

In fact SASB applications extend from research to practice: evaluation (diagnosis), planning of the psychotherapeutic intervention and verification of the outcome.

The value of the SASB in describing psychological behaviors from normal to pathological is that of considering the whole person. Furthermore, it allows us to distinguish between chronic or reactive depressions, avoiding rigid classifications. Understanding which intrapsychic mechanisms underlie psychic distress is fundamental for theoretical explanation and planning and verification of the processes of change. 6

Thus, on the basis of the results that emerged from the study of Vespa et al, ⁵ we can design the most suitable psychotherapeutic intervention plan based on the profiles of the SASB Model for women with breast cancer, which is the goal of the present analysis. This can suggest a critical description of which kind of psychotherapeutic approaches are more suitable (indications and contraindications) on the basis of cluster analysis of personality.

Methods

This is an analysis of the SASB profiles based on the results of a prior study, ⁵ aiming to discuss and develop suggestions for psychotherapeutic applications in women with breast cancer. The study that identified the SASB profiles using cluster analysis ⁵ was approved by the ethics committees of the INRCA-IRCCS National Institute of Science and Health on Aging and Marche Polytechnic University in Ancona, Italy (IRB approval under the number: CdB: SC/10/271/bis). The reporting of the present study conforms to COREQ guidelines. ⁸

Measures

All subjects participated in the study ⁵ were asked to complete a demographic form, including data on age, marital status and educational level and the following psychological questionnaire:

- The SASB Intrex Questionnaire ⁹ describes the personality structure on both intrapsychic (internal) and interpersonal (external) behaviors through a circumplex model (Appendix A). The SASB Intrex Questionnaire’s brevity, combined with its reliability and validity, makes it an efficient choice for assessing interpersonal and intrapsychic behaviors. Its validation against the DSM-IV and DSM-V criteria enhances its credibility, ensuring that it measures relevant psychological constructs accurately.

Interviewed subjects had to respond to 36 items in the questionnaire describing their intrapsychic and interpersonal behaviors over the last year (eg, ‘I let myself feel glad about and pleased with myself just as I am’; ‘I ignore and don’t bother to know my real self’; ‘I think up ways to hurt and destroy myself. I am my own worst enemy’). They are rated on a 10-point scale responses rating from 0 (Never) to 9 (All the time). The 36 questions of Form-A are grouped into 8 clusters (Cl) focused on intrapsychic (“Oneself”) and interpersonal (“Other”) behaviors. This structure not only facilitates understanding of individual experiences but also allows for inferences about interpersonal experience based on intrapsychic patterns. Each cluster is represented on a scale ranging from a minimum of 0 to a maximum of 10.

The 8 clusters focused on intrapsychic “Oneself” and interpersonal “Other” behaviors are both complementary and opposite (see Appendix B for details). For this study was used the Italian version of the SASB Intrex Questionnaire. ¹⁰

Results

Two distinct personality profiles emerged from the results ⁵ respectively called Profile 1: SASB Love/Autonomy Traits- Intrapsychic behaviors and Profile 2-SASB-Control and Hate Traits – Intrapsychic behaviors. The 2 profiles are distributed along a continuum, sharing some intrapsychic problems but of different intensity.

Description of the Profiles Emerged

Profile 1-SASB Love/Autonomy Traits-Intrapsychic Behaviors

The SASB Love/Autonomy personality profile (1) includes the following traits: a medium aptitude to be spontaneous and autonomous (Cl1) with a medium acceptance of their deepest feelings (Cl2). This is due to a control exercised over themselves (Cl5). There is sufficient self-acceptance and self-appreciation and an adequate capacity for self-esteem and self-care (Cl3, Cl4). Intrapsychic behaviors like self-esteem could be negatively impacted by stressful situations (Cl2, Cl8), with the consequence of ignoring the possibility of choices for personal growth (Cl8). Women with profile 1 may occasionally adopt self-neglect behaviors by not making choices deemed good for themselves and/or by not directly expressing their emotional experiences and needs, due to their medium-low autonomy and medium-high control (Cl1, Cl2, Cl3, Cl5). Furthermore, they occasionally express critical behavior toward themselves (Cl6). Considering the low scores reported in Cl7, these self-critical methods rarely lead to self-destructive behaviors, but may neglect of options and choices that are good in themselves. ⁵

Profile 1-SASB Love/Autonomy Traits-Interpersonal Behaviors

The dependence and conditioned behaviors in relationships with others can create a cycle where these women struggle to express trust and foster independence in others (Cl1). The tendency to control (Cl5) and low autonomy can further complicate interpersonal dynamics, as it may lead to a lack of mutual support and growth. On the other hand, women with breast cancer can express empathy, gratitude, and understanding, even amid their own challenges (Cl2). However, their medium-low spontaneity and autonomy may inhibit them from openly expressing these feelings (Cl1). This internal control can stem from a desire to maintain a sense of stability or protect themselves and others from emotional vulnerability. This tendency to prioritize the demands of others often leads to a neglect of personal needs, which can be especially challenging for women facing the physical and emotional stresses of breast cancer. Even if they wish to be attentive and close to the each other, in presence of stressful situations they may incur in behavior of neglecting the option of choices for the growth of others (Cl3, Cl8). They occasionally exhibit critical behaviors and blame others (Cl6). The low scores in Cl7 suggest that they generally avoid aggressive or harmful actions. This could indicate that their criticisms stem more from frustration or a sense of helplessness rather than a desire to inflict harm. ⁵

Profile 2-SASB-Control and Hate Traits-Intrapsychic Behaviors

Women with “Control/Hate” traits show low autonomy, spontaneity, and self-acceptance (Cl1, Cl2). The medium low self-worth and self-care can significantly impact their overall well-being (Cl3). The average low capacity for expressing feelings, coupled with medium-high self-control (Cl5), suggests a conflict where they may prioritize goals over emotional needs, leading to neglect of their own health (Cl2, Cl3). In stressful situations, their self-critical tendencies and neglect (Cl6, Cl7) can further inhibit opportunities for growth, trapping them in a cycle that is difficult to break (Cl8). The connection to depression within the SASB circumplex underscores the importance of addressing these issues holistically, integrating both emotional and physical health interventions. These women were likely to be depressed even before the diagnosis. ⁵

Profile 2-SASB-Control and Hate Traits-Interpersonal Behavior

Women with “Control/Hate” traits often find themselves in a cycle of dependency that inhibits not only their independence but also the growth of those around them (Cl1). Their reluctance to actively promote self-growth-both for themselves and in their relationships-can stem from low energy and motivation, potentially perpetuating a sense of stagnation. Even if they can aspire to a real intimacy with others it is difficult for them to achieve it, both due to a lack of spontaneity, low expression of emotion, openness towards themselves and others (Cl4) and control exercised towards themselves and others (Cl5). So interpersonal needs are likely to be neglected (Cl4). This type of women show a low attitude of caring for others (Cl2 and Cl3).

They tend to control the other: they control what must be done and said for “the good of the person” (Cl5). The lack of spontaneity and flexibility in relationships (Cl4, Cl6) can significantly affect how women with “Control/Hate” traits interact with others. This rigidity, especially in stressful situations, can lead to a tendency to neglect the needs of those around them, which may prevent others from making free choices or pursuing their own growth (Cl1, Cl7, Cl8). They may have difficulties in taking care of others and of their physical and emotional needs (Cl7). All these dimensions are linked to depression. This profile can be classified as borderline. ⁵

SASB Model: a Step by Step Intervention

Profile 1-SASB-Love and Autonomy Traits: SASB Model Psychotherapeutic Intervention

Given the SASB -Love/Autonomy traits profile, the first step of psychotherapy (initial phase) is to promote and strengthen the listening and expression of one’s emotions and to discriminate against the contents and fears (intrapsychic conflicts) underlying this incomplete expression (Cl4, Cl3 complementary of Cl8 to promote Cl1 and Cl2 and reduce Cl5) (ie, why do you (the patient) control yourself? Cl5). Which needs of expression do you neglect (to develop Cl3 and Cl4 complementary of C7 and Cl8)? What feelings of guilt underlie these behaviors (Cl5, Cl6)? What do you need to feel, think and experience to satisfy your needs (development of Cl1, Cl2 opposite to of Cl5, Cl6)? Do you feel entitled to it (Cl3, Cl4)? What feelings of guilt and/or duty hinder you from taking care of yourself (Cl5, Cl6)?). This listening favors the emergence and awareness of neglected needs on the emotional and physical level (Cl4). This awareness is fundamental for a positive adaptation (Cl2, Cl3) and a good quality of life with respect to the disease condition and to the medical therapy with its side effects.^11,12

The symbolic work on a bodily basis (Bio-Psychosynthesis and/or Bioenergetics) ¹³ allows the emergence, and dissolution of emotional contents through the body expression. Holistic Psychotherapy (Therapeutic Psychosyntesis) ¹⁴ favors this process by completing the integration of new models of thought, expression of emotions (Cl3, Cl4 to develop Cl1 and Cl2).

The integration of this step (middle phase) of psychotherapeutic intervention with Mindfulness based interventions (MBIs)^15,16 allows the patient to observe the psychic contents without being involved through effortless attention to the present moment and to become aware of psychological contents and needs. This listening (observation) leads to the emergence and experimentation of the right detachment from psychic contents and intrapsychic conflicts. Through the awareness ¹⁷ of the psychic contents and of the underlying intrapsychic conflicts, the patient has the opportunity to experiment and re-elaborate them. ¹⁸ The result is a new integration of emotions, thoughts and behaviors related to a better development of the ability to take care of oneself (Cl2, Cl3, Cl4). This process favors listening to oneself in the present moment and includes the discrimination and unveiling of what are deep physical and emotional needs, reducing negative self-criticism and promoting autonomy in the patient’s choices (Cl2, Cl1). ¹⁹ Furthermore, it promotes self-confidence and is essential for managing one’s psycho-physical health (termination phase).

Psychotherapeutic Approach Recommended

The recommended psychotherapies are an integration of Psychodynamic Psychotherapy, ²⁰ Holistic Psychotherapy (Therapeutic Psychosynthesis) ¹⁴ and/or Cognitive Behavioral Therapy, ²¹ with Mindfulness Based Interventions (MBIs). ¹⁵ In addition, techniques of expression with bodily involvement can be employed (eg, Bio-Psychosynthesis and/or Bioenergetics), for emotional rebalancing. Furthermore, Psychodrama is recommended. Through guided role-play, participants can gain insights into their interpersonal dynamics and the impact of their control tendencies on themselves and others. This experiential approach can enhance self-awareness, promote spontaneity, and foster empathy by encouraging individuals to step into different perspectives. ²²

Profile 2 - SASB-Control and Hate Traits: SASB Model Psychotherapeutic Intervention

The first step with patients with Profile 2 SASB-“Control and Hate Traits” is the support and strengthening of the ego (initial phase). This strengthening is achieved through the discrimination of neglected and/or denied needs and the underlying intrapsychic conflicts (ie, feelings of guilt). Thus, woman learns to listen to the psychic contents (thoughts and emotions) (Cl3, Cl4 complementary of Cl7, Cl8).

The goal is to strengthen the ego through gradual and careful contact with intrapsychic conflicts (ie,: sense of guilt; too much control; self critical behavior) (Cl5, Cl6, Cl7).^6,11,12 Through the discrimination of intrapsychic behaviors that are not functional to her psycho-physical health (ie, medium high self-criticism (Cl6), ¹⁸ high control (Cl5), neglect and failure to listen to one’s own needs (Cl7, Cl8), medium low autonomy in choices (Cl1) and the awareness of underlying fears and conflicts, the patient can come into contact with denied needs (Cl3, Cl4) and learn to understand and listen to the contents psychic (thoughts and emotions, needs) (SASB Cl4 complementary to Cl8; Cl3 complementary to Cl7).^10,11

In synthesis, this step (middle phase), based on the therapist’s work of support and strengthening of the ego, is aimed at enabling the patient to recognize: (1) the negative intrapsychic behaviors and the suffering linked to them (depression) (Cl5, Cl6, Cl7); (2) learning to listen to and understand their deepest feelings and needs, until then denied; (3) learning to express them (SASB: Cl4, Cl3, Cl2, Cl1). The discrimination of one’s own denied needs passes through the process to recognize the models of control and criticism as negative for the person (Cl4 as opposed to Cl 8, through the process of awareness of behaviors of criticism and self-control (Cl5, Cl6). ⁹

At the end of this process, (termination phase) woman can find within herself the levers to overcome the depressive state and understand and experience the need for self-care.

The woman becomes, through this process, aware of excessive self-criticism and fear of criticism and rejection from others (SASB: Cl2 complementary of Cl6). This discrimination makes it possible to understand what prevents the expression of one’s needs (Cl3 and Cl4). Through this process the ego is strengthened and the patient is enabled to become aware of patterns of abandonment and denial (Cl6, Cl7; Cl8). The themes can be the right to one’s own spaces and the awareness that by denying them one harms oneself (SASB: Cl4; Cl3, Cl2 complementary of Cl 6, Cl7, Cl 8). Treatment strategies through the awareness that the depressive state is determined by certain underlying maladaptive intrapsychic behaviors. Awareness of needs in interpersonal relationships. Only by recognizing their own needs can these women take care of themselves and face and overcome the depressive state. Furthermore, women with breast cancer can have a constructive adaptation and adherence to the conditions of treatment with the side effects of medical therapy.^9-11

Psychotherapeutic Approach Recommended

Main psychotherapeutic approach suitable eg, Interpersonal Reconstructive Psychotherapy, ²³ Cognitive Behavioral Therapy ²⁴ and/or Therapeutic Psychosynthesis, ¹³ Psychodynamic Psychotherapy. ²⁵

Psychodynamic therapy is indeed centered on exploring unconscious processes and how they shape present behaviors and relationships. By bringing awareness to these underlying motivations and past experiences, women can gain valuable insights into their current challenges. This approach emphasizes the importance of self-reflection and understanding how past relationships and experiences influence current thoughts and behaviors. ¹⁷

Discussion

Critical Analysis of the Most Suitable Psychotherapies (Indications and Contraindications)

Tailoring psychotherapeutic interventions based on the 2 intrapsychic profiles identified through the SASB model is essential for effective treatment. By addressing issues such as passive adaptation, low self-affirmation, and self-criticism, psychotherapists can help these women with breast cancer to enhance their self-awareness and emotional integration.

Facilitating contact with their emotional experiences allows them to explore and process feelings that may be hindering their adaptation to their disease condition. Encouraging a shift in their life style can empower them to develop healthier coping mechanisms and resilience. So, SASB psychotherapeutic treatment could contribute in decreasing depression and stress and in improving quality of life in women with breast cancer changing maladaptive intrapsychic behaviors. Emotional memories also need to be activated in order to be modified, therefore, we propose to integrate techniques into that stimulate emotional experience. ⁶

Intervention such as cognitive behavioral therapy and/or holistic psychotherapy (Therapeutic Psychosynthesis, Bio Psychosynthesis, Bioenergetics) with Mindfulness (MBSR) could be desirable for patients with profile 1 at certain conditions for patients with profile 2. ²⁶

Observational studies from Transpersonal Psychology show that 2 important functions derive from practice of awareness (Mindfulness-spiritual practice): the first is centering in on a dimension of oneself, achieving a state of concentration, relaxation and silence (observer- Transpersonal Psychology). The second one, linked to the first, is the ability to observe one’s own psychic contents without judgment. This position makes it possible to take action on one’s experiences (including psychic contents and conflict–intrapsychic processes). In becoming aware of one’s own psychic content, a person may become able to re-elaborate and integrate them towards the capacity of detachment. Mindfulness practice indeed fosters a non-judgmental awareness of thoughts and feelings, allowing underlying emotional experiences to surface. This process can be transformative, as it helps individuals observe their emotions without the interference of self-criticism or avoidance.^27,28

Given the effectiveness of more or less short interventions with MBSR (Mindfulness Based Stress Reduction) and MBIs (Mindfulness-Based Interventions) we propose an integrated Holistic Psychotherapy (Therapeutic Psychosynthesis, Bio-Psychosynthesis, Symbolic Jungian work with body involvement, Transpersonal Psychology) with Mindfulness, and/or Brief Psychotherapies (relaxation techniques) hypothesizing that such psychotherapeutic treatment can be effective in addressing the complex needs of patients with cancer with a profile 1. Combining MBSR and MBIs with various therapeutic modalities can create a comprehensive treatment plan that supports emotional, psychological, and spiritual well-being. ²⁸ This multifaceted approach not only aims to reduce stress and anxiety but also facilitates deeper self-exploration and healing.^29,30

Some studies highlight how self-criticism is correlated with depression and anxiety and is therefore considered as a serious indicator of vulnerability to psychopathology - it predicted high levels, as well as pre-treatment-follow-up changes, in both depression and anxiety.^31,32

A further consideration: given the intrapsychic problems related to excessive self-control and criticism, depression, that emerged from our study and their influence on the quality of life in cancer patients, we hypothesize that an intervention with Holistic Psychotherapy and Mindfulness cannot be short (3 months), above all to be effective on long times in durable way.

In fact, Mindfulness can be contraindicated in a preliminary phase of therapy for patients with Profile 2 since, as one of the main exponent of Transpersonal Psychology, Ken Wilber states: “The meditative practice can be carried out when there is good integration of the ego.” ³³ In fact, without this integration of the ego, mindfulness opens the door to the emergence of emotional contents and intrapsychic conflicts that the patient with this structure will not be able to manage. In fact the Mindfulness practice can disclose unconscious contents, intrapsychic conflicts and problematic emotions and moods linked to wounds that the patient is not able to bear and face. ³⁴ So we suggest to introduce mindfulness practice only after this first step of therapy (reinforcement of ego) with Profile 2 Patients. In fact Patients with profile 2 can take advantage of these techniques only after a basic work of integration of contents and intrapsychic conflicts, certainly not of short duration that is, a work of support and reinforcement of the ego. ³⁵

At last, we need to make some considerations on interventions times. Effective psychotherapeutic interventions for cancer patients should focus on long-term results that empower individuals to navigate their emotional processes. This process requires time to address intrapsychic contents, metabolize them and integrate them.

A long intervention of at least 6 months is therefore recommended (ie, 6, 9 months or more). Short interventions could bring out contents and conflicts and leave the patient without tools and support to deal with them adequately. The long intervention is especially recommended for patients with Profile 2 (9-12 months or more). As far as profile 1 is concerned, interventions lasting about 6 months (or more) may be adequate. Short interventions (2 months) are not recommended, even for Mindfulness as it is difficult to create an emotional rebalancing in a short time. Mindfulness has the function of bringing out the intrapsychic contents and conflicts underlying the problems of profile 1 such contents (low self-assertion, self-control) and this requires integration work. ³⁶ Short interventions and brief intervention (at least 4 weeks) could even be contraindicated as it could open channels by releasing problematic emotional contents and leave the patient unable to deal with them alone (negative effects of the therapy as documented in certain steps of the psychotherapeutic processes).

Conclusions

This critical analysis of the psychotherapeutic interventions with women suffering from breast cancer does not intend to be exhaustive of the psychotherapeutic interventions used in the oncological field, but wants to give a general indication on the phases and aims of psychotherapeutic interventions scientifically based on profiles described using the SASB model. Our analysis suggests that there is no single treatment but a choice must be made between the various psychotherapeutic approach based on the intrapsychic problems of each patient. In our opinion, an integration of various therapeutic approaches is recommended. It is suggested that the personality diagnosis using SASB model can be a tool for understanding the problems of the individual patient and for avoiding unsuitable if not harmful interventions. This requires specific training and more detailed knowledge of the described model.

Supplemental Material

Supplemental Material - Psychotherapeutic Applications of the SASB Cluster Analysis of Intrapsychic Behaviors in Women With Breast Cancer: A Step by Step Approach

Supplemental Material for Psychotherapeutic Applications of the SASB Cluster Analysis of Intrapsychic Behaviors in Women With Breast Cancer: A Step by Step Approach by Anna Vespa, Roberta Spatuzzi, Paolo Fabbietti, and Maria Velia Giulietti in Journal of Cancer Control.

Supplemental Material

Supplemental Material - Psychotherapeutic Applications of the SASB Cluster Analysis of Intrapsychic Behaviors in Women With Breast Cancer: A Step by Step Approach

Supplemental Material for Psychotherapeutic Applications of the SASB Cluster Analysis of Intrapsychic Behaviors in Women With Breast Cancer: A Step by Step Approach by Anna Vespa, Roberta Spatuzzi, Paolo Fabbietti, and Maria Velia Giulietti in Journal of Cancer Control.