I Need Your Love: Self-Stigma And Classification Of Communication Patterns Required By Breast Cancer Patients

Cancer patients desperately require supports from their partners or family members for survival. Various forms of supports either explicitly or implicitly are anxiously needed by them, especially in terms of communication supports to reduce the implications of negative self-stigma faced by them. This article aims to discuss the classification of appropriate communication patterns practiced by spouses and family members of these patients. Researchers suggest that there are four classifications of communication patterns that can be implemented to communicate with breast cancer patients, such as primary communication pattern, secondary communication pattern, linear communication pattern and circular communication pattern. Researchers discovered that these four communication patterns can be practiced by spouses and families of cancer patients to help them control and cope with emotions during treatment.


Introduction
Cancer is a chronic disease that contributes to mortality rates worldwide, yet the life expectancy of a patient to survive can be extended from an appropriate period of time in line with technological advances in medicine (Albert et al., 2017). Patients with cancer will experience problems involving self, physical, cognitive, role and social functioning. Due to these problems faced by these patients, their dependency on families and spouses becomes high.
Most of the caregivers involved face problems in managing and assisting cancer patients due to lack of knowledge, skills and support resources to handle tasks in this care (Albert et al., 2017). If these are not rectified, their situations will worsen thus indirectly contribute to the burden and stress of their caregivers. The crucial part in helping cancer patients is to understand the self-stigma they have.

Self-Stigma and Community Stigma Among Breast Cancer Patients
Self-stigma plays a major role in cancer patients. Positive self-stigma encourages cancer patients to remain enthusiastic in going through their daily routines. Various studies have been conducted related to the management of self-stigma. A study conducted by Tsai & Lu (2019) found that breast cancer patients can reduce the level of self-stigma by writing down their cancer-related beliefs to help them translate their emotions personally without having to think about the views of others. In addition, this study also found that the relationship of patients with the same background also benefits them. Understanding the stigma that exists in cancer patients can also be linked to the implications that occur to them.
Self-stigma is also known as internal stigma resulting from societal stigma accepted by individuals. Societal stigma refers to societal attitudes or beliefs about mental health. Selfstigma and societal stigma will lower an individual's self-esteem where both of these types of stigmas have negative impacts on most individuals who avoid getting help or supports related to mental health (Crowe et al., 2018). However, individuals who receive societal stigma will not necessarily also accept the problem of self-stigma in which it only occurs in individuals who form negative attitudes that further worsen their health as well as themselves (Kato et al., 2017). To reduce the negative implications of self and societal stigma, stigma communication should be considered to help cancer patients.

Stigma Communication
A study conducted by Shiri et al (2018) discovered that stigma communication occurs among breast patients due to the neglect and rejection by partners, lack of family supports, formal supports, treatment differences, changes in interaction with family members, and the avoidance from attending social places where family members make a big impact in the process for the patient to recover.

Couple Communication with Breast Cancer Patients
A study conducted by Xu et al (2019) discovered that there is a tendency, either from patients or partners, to reveal negative or less positive information related to breast cancer in daily life. However, this study also found that the perceptions of positive information are a mediator between the disclosure of positive or negative information and recurrent cancer anxiety.

1) Primary Communication
Primary communication pattern is a process of conveying thoughts by a communicator to a communicant by using a symbol (symbol) as a medium or channel. This pattern is divided into two symbols, namely verbal symbols and nonverbal symbols. Verbal symbol in a language is the most important and most often used verbal symbol because a language is able to express the thoughts of communicators. Nonverbal symbols are symbols used to communicate other than languages. It is a gesture with limbs such as eyes, head, lips, and hands. In addition, images are also symbols of nonverbal communication, therefore, by combining the two, the communication process in this pattern will be more effective (Purwasito, 2020;Saputra, 2013).
In this regard, a study conducted by Shiri et al (2020) found that stigma among cancer patients at an individual or family level requires increased awareness, problem-solving education, supports including counselling. On the other hand, at a community level requires cultural change and also education to benefit the physical and psychological well-being of patients as well as change society's attitude towards cancer. This includes early screening in order to reduce more serious implications and death rates from cancer.
For example, stigma resulting from an experience or acceptance of societal stigma is likely to lower the level of chronic patient self-care where patient self-care consists of patient's knowledge, skills, confidence, and behaviors to manage their disease (Kato, et al., 2020). This situation occurs because both types of stigmas refer to factors of attitude (prejudice), belief (stereotype), and behavior (discrimination) (Hasan & Musleh, 2018).
For example, stigma about body shape is not determined based on individual feelings (prejudice) towards weight but is measured based on societal beliefs (stereotypes) towards weight and negative individual evaluations (discrimination) towards the weight of others (Sevincer et al., 2017).

2) Secondary Communication
Secondary communication pattern is the delivery of a message by a communicator to a communicant by using tools or means as a second medium after using symbols on the medium first. Communicators use this second medium because it is the target of communication that is far away, or in large numbers.
In this secondary communication process, the longer it takes the more effective and efficient it will be, as it is supported by increasingly sophisticated communication technologies. This pattern of communication is based on a simple model created by Aristotle, thus influenced Harold D. Lasswell, an American political scholar who later created a communication model known as the Lasswell formula in 1984 (Purwasito, 2020;Saputra, 2013).
A study conducted by Tsai & Lu (2019) found that breast cancer patients can reduce the level of self-stigma by writing down their cancer-related beliefs to help them translate their emotions personally without having to think about the views of others. In addition, this study also found that the relationship of patients with the same background also benefits them.
However, a study conducted by Lawlor & Kirakowski (2014) found that online support to breast cancer patients has a negative impact on self-stigma because it causes them to rely too much on online support, which in turn causes their weaknesses to be more exposed.
In comparison, a study conducted by Alvarez-Mon, et al (2019) found that the use of Twitter, one of the most popular social media globally, can reduce the problem of stigma among breast cancer patients because the analyzed 'tweets' (tweets) provide accurate information related to medicine and Twitter can be used as a communication medium for anti-stigma campaigns.

3) Linear Communication
Linear communication pattern here refers to the journey from one point to another in a straight line, which means the delivery of a message by a communicator to a communicant as a terminal point. This communication process usually occurs in communication (face-to-face), but sometimes through media communication. In this communication process, messages conveyed will be effective if there is planning before implementing the communication. Shannon and Weaver (1949) applied the process of human communication (human communication) which is rooted in mathematical theory in mechanical communication (engineering communication). The mathematical model describes communication as a linear process (Purwasito, 2020;Saputra, 2013).
A study conducted by Warmoth et al (2017) found that counselling services provided to breast cancer patients can reduce stigma. Additionally, a patient communication with family members as well as counselling services can help disseminate information related to breast cancer diagnosis and related health insurance in order to help patients recover.
According to a study conducted by Kayser & Acquati (2019), there are communication problems that occur between breast cancer patients and partners due to lack of communication skills or there are barriers in relationships such as abuse either from physical or emotional aspects and prolonged conflict and no solution preventing patients and spouses from interacting with each other.
For this reason, a study conducted by Badr (2017) found that communication between spouses and cancer patients consists of communication components involving cancer-related sensitivities, engaging in social support, negotiating about role changes in life, and coordination to cope with illness.

4) Circular Communication Pattern
One of the patterns used to describe the communication process is the circular pattern made by Osgood and Schramm. Both of these figures focused their attention on the role of source and receivers as key actors of communication. This pattern describes communication as a dynamic process, in which messages are transmitted through a process of encoding and decoding. Encoding is the transference performed by a source of a message, and decoding is the transference performed by the recipient of the message coming from the source. The relationship between encoding and decoding is the relationship between a source and a receiver stimulating and mutually influencing each other (Purwasito, 2020;Saputra, 2013).
As a dynamic process, an interpreter in this circular pattern has two functions, namely as a sender and receiver of a message. In the early stages, the source serves as an encoder and the receiver as a decoder. But at the next stage the receiver functions as the sender (encoder) and the source as the receiver (decoder), in other words the first source will be the second receiver and the first receiver functions as the second source, and so on (Purwasito, 2020;Saputra, 2013).
Self-stigma occurs when individuals are 'aware' (prejudice) of beliefs (stereotypes) built by the surrounding society and begin to 'agree' (discriminate) with a belief (Bonfils, et al., 2018). This situation occurs because the stigma formed by individuals will cause them to feel fear of attitudes from others such as ridicule, bias or discrimination in turn influencing negative behaviors to overcome the resulting fears of others (Lillis et al., 2020).
To explain this, the concept of stigma consists of six components of a process that occur simultaneously. These components include labelling and identifying differences; giving negative credence to people who are labelled differently; distinguishing between labelled and unlabelled individuals ('we' and 'they'); emotional reactions to both labelled and labelled parties; labelled parties experience discrimination and loss of status; and influence social, political, and economic forces to make all components of the process take place (Chang et al., 2018). In short, the stigma of society will cause sufferings among individuals and their number is increasing as well as forming a minority group in society (Adam et al., 2019). To explain this situation, the Stigmatization Model describes the symptoms of stigma in the context of social, cultural, economic, and political power. Additionally, individuals or groups labelled will continue to lose rights throughout life such as access to education, income, and use of health services where "discrimination and loss of status "will reduce stigma by" everything is normal" by hiding or being careful to reveal the stigma problem experienced (Seo & Song, 2019).
In addition, Huang et al (2020) reported that stigma due to cancer had a significant relationship with self-perceptions of age, anger, self-blame, stressful living situations, carrying problems alone, and insomnia but had no relationship with communication by treatment providers and sleep quality.
In general, the group of female patients with self-stigma is higher than male patients whereas female patients who are still single have a higher self-stigma compared to female patients who are married (Komatsu, et al., 2020). In comparison, parents of individuals with self-stigma also experience the problem of self-stigma if their children are constantly discriminated against by society because self-stigma stems from the individual's internal communication towards self and subsequently form negative thoughts about self whose effects are more harmful than stigma resulting from prejudiced public perceptions (Chan & Leung, 2021). For this reason, health communication campaigns today have shifted from disseminating information and education in general to social marketing techniques by focusing on efforts to change individuals behaviors (Lefebvre, et al., 2020).

Conclusion
Communication factors play an important role as they can influence the psychology of patients, spouses, and family members. In conclusion, it is important for couples and family members of breast cancer patients to identify the appropriate types of communication patterns to avoid problems that can lead to stigma that is negative individual beliefs. Among the beliefs are insecurity, inadequacy, threatened, depressed, troubled, unhappy, weak, or disturbed because social identity is not valued in a social context, thus affecting their level of mental health.
Thus, couples with breast cancer can build relationships by building new norms, enhancing identity through religion and motherhood, focusing on positive actions when discussing negative emotions, and even using logical alternative approaches in a form of beauty as well as humor if the type of communication pattern is suitable to be used by the patient's spouse and family members.