Choice in Unconventional Cancer Therapies
Psychological Approaches to Cancer
Our current blindness to the importance of mental hygiene in cancer is all the more astonishing because of the fast-emerging and fascinating field of psychoneuroimmunology–the academic study of the new-found body-mind connections between psychological states and the neurological, endocrine, and immune systems. Psychoneuroimmunology, or PNI, is an even younger field than psychooncology. The first major text in the field, Psychoneuroimmunology, edited by Robert Ader and his colleagues, was published in 1981 and came out in a second edition in 1991. The authors describe the evolution of their field:
The neurosciences and immunology developed and matured without seriously considering that there might be communications networks between these systems that could mutually influence their respective functions. … Although it still may not be a universally accepted conceptualization, research conducted over the past ten years has made it increasingly apparent that there are complex interrelationships among behavioral, neural, endocrine and immune processes.1
In simpler terms, it is now beginning to appear that mind-body interactions are so ubiquitous that it may no longer be possible to refer to body and mind as separate entities but only as bodymind. For psychology, this means that emotional states of mind and behavioral patterns may profoundly affect not only our symptoms but also the progress of our disease itself. Most dramatically, PNI research by and large supports–though not conclusively so–the controversial position that psychosocial factors, including psychosocial interventions, may contribute to the extension of life with cancer.
Often, people with cancer who are interested in psychological approaches to their illness fail to look at the scientific evidence offered by PNI or psycho- oncology research. They turn instead to the ever-increasing collection of inspirational books–Bernie Siegel’s Love, Medicine and Miracles,2 Larry LeShan’s Cancer as a Turning Point,3 O. Carl Simonton, Stephanie Matthews Simonton, and James Creighton’s, Getting Well Again,4 or Joan Borysenko’s Minding the Body, Mending the Mind.5 Cancer patients often wonder why the psychological approaches to cancer they read about in these books are not more a part of mainstream medicine.
In fact, psychological approaches to cancer have emerged in mainstream medicine, most decisively in the past 20 years. While these certainly have limitations from the perspective of a cancer patient who is seeking what the inspirational popular books have to offer–strong affirmations of the possibility that he can participate actively in the struggle not only for quality of life but also for recovery and life extension–nonetheless they are based on a wealth of scientific studies and firmly grounded clinical observations focused primarily on coping with cancer. Let us now look at what psychooncologists have to offer.
Coping with cancer as a goal is sometimes denigrated by advocates of psychological work with life extension as a goal. But in fact, coping with cancer is a large part of the psychological work of every cancer patient, whether he also believes it may be possible to extend his life through psychological practices or not. Psychooncology research focused on coping also provides a framework for a balanced evaluation of the sometimes unbalanced claims of some of the inspirational popular books about psychological and spiritual approaches to cancer. For these reasons, psychooncology is worthy of careful study.
Psychooncology is a young field. Jimmie C. Holland, M.D., of Memorial Sloan-Kettering Cancer Center in New York, one of the founders of psycho- oncology, has traced its evolution. In the 1950s, Holland writes, interest in psychosomatic medicine led to clinical studies that sought to link personality with a predisposition to cancer. These studies were primarily anecdotal yet led to hypotheses about the relationship of personality to cancer that remain viable to this day. This led to studies in the 1960s of psychological issues that patients and physicians confronted in responding to life-threatening illnesses including cancer. In the 1970s, the field of “consultation-liaison psychiatry” began to have a greater impact on cancer patients as psychiatrists were asked to help oncologists with the problems that cancer patients–especially children and their families–faced in the course of medical treatment. The 1970s also saw the first conferences bringing together psychosocial researchers concerned with cancer. That decade also brought the development of funding for psychosocial research in cancer by the American Cancer Society and other institutions. This led to the emergence of the subspecialty called psychosocial oncology, or psychooncology.6
Just as there is a classic text on the medical treatment of cancer (DeVita’s Principles and Practice of Oncology), there is now a classic text on psychooncology. It is the Handbook of Psychooncology edited by Holland and Julia H. Rowland, Ph.D. The most useful thing for cancer patients about the Handbook of Psychooncology is that it contains an enormous wealth of research reports and clinical recommendations across the entire spectrum of problems that patients face. None of the inspirational psychospiritual books on cancer can match the range of practical, research-based findings that the Handbook offers.
Holland and Rowland introduce the field of psychooncology by proposing that there are three overarching elements that influence the psychological adaptation of patients to cancer: the sociocultural context, the medical context, and the individual psychological context. The sociocultural context refers to individual and collective beliefs about cancer; the medical context refers to the type and stage of cancer that the patient has and the treatments being used; and the individual psychological context refers to the issues that the patient faces and the resources he brings to coping with these issues.
Focusing on the third–or psychological–context, Rowland proposes that the three core issues for a cancer patient are: (1) What stage of the life cycle are you in when you develop cancer?, (2) How do you tend to respond psychologically to major developments in your life such as cancer?, and (3) What resources–both interpersonal (such as family, friends, and other social support) and concrete (such as money and health insurance)–are available to you to deal with this crisis?7
The first question is a particularly critical one. Since the fundamental psychological tasks of each stage of life are different, cancer represents a different set of challenges in every developmental period. But, whatever stage of life we are in, Rowland suggests that there are five common disruptions to the pursuit of our life goals that are caused by cancer. She refers to these five common disruptions informally (this is where the language of psychooncology is less than inspirational in its tone!) as the “five D’s.” They are:
1. Distance, or changes in interpersonal relationships that bring about shifts in emotional distance–either closer or farther apart–between you and family members, friends, business colleagues, and others.
2. Dependence, or changes in the dependence on or independence from family, friends, and others.
3. Disability, or disruption in developmental tasks, personal goals, and meaningful activities, both now and in the future.
4. Disfigurement, or changes in body image, sexual function, and physical integrity.
5. Death, or facing the existential issues that every life-threatening illness brings.
In an invaluable chapter, Rowland traces for each stage of life the common developmental tasks, the common cancers of that age, and the common disruptions created by a cancer diagnosis.8
Rowland then addresses intrapersonal issues, or what she calls “coping resources.” Early psychological studies of cancer focused primarily on the stress of the disease and the patient’s reflexive ego defenses. More recently, she says, there has been a “shift away from a view of human beings under siege … to an adaptational view of human beings in which life’s stresses are seen as challenges or tasks to be mastered.” Rowland makes a distinction between the “reflexive” ego defenses–such as denial–and the “reflective” capacities we develop to face the “difficult and unusual” qualities of the new situation, which can be summarized as “coping style,” and success in meeting these new challenges, which can be described as “mastery.”9
Rowland then turns her attention to interpersonal resources, or what she characterizes as “social support.” Social support includes: people who can help the patient mobilize his inner resources to face the illness; people who share tasks that the patient must carry out; and people or institutions that provide tangible forms of support such as health insurance, financial support, and information.10
Social support is, as we shall see, one of the most important and interesting categories which psychooncologists address. In discussing the benefits of social support, Holland and Rowland mention for the first time studies that show that cancer patients with stronger social support systems may actually live longer than patients with weaker social support systems. You will recall that it has been highly controversial in psychooncology to suggest that psychological interventions might extend life with cancer. But it has not been controversial to point out that social support may extend life with cancer. If the psycho- oncologists suspect that social support may extend life with cancer, we might very well ask why, then, do not psychooncologists place a high priority on studies to determine whether or not psychological interventions that enhance social support might extend life with cancer?
“The degree of social support is positively associated with both better adjustment and longer survival,” says Rowland. She cites, among others, studies by A.D. Weisman and J.W. Worden in 1975 in which patients with varied cancers who had “good interpersonal relationships” lived longer than those who did not. A second important study by D.P. Funch and J. Marshall in 1983 followed 208 women with breast cancer and assessed social support based on total number of acquaintances and relatives, number of religious and nonreligious meetings attended, and marital status. The study found that for women younger than 46, those with higher social involvement lived longer.11 I return to research on social support later in this chapter when I describe David Spiegel’s dramatic findings that women with metastatic breast cancer who participated in a support group lived longer than women in a control group who did not. The crucial point is that, while research into psychological interventions that extend life with cancer has until recently been professionally risky, it was both possible and necessary for psychooncologists to report those interesting “experiments of nature” that showed that social support was positively correlated with survival. Nor was this life extension only true for people who had more physical resources such as income and health insurance (it is well known that survival with most diseases, including cancer, goes up with income and concrete support). The studies Rowland presented were studies where enhanced psychosocial support alone was the key correlate of extended survival.
Holland and Rowland describe the psychological issues that people with cancer face at every stage of cancer development. In an invaluable discussion for patients and health professionals, Holland discusses the psychological issues and useful interventions for each major phase of cancer and cancer treatment: diagnosis, prognosis, treatment, remission or recovery, recurrence, renewed treatment, and progression of the disease. This is followed by chapters about psychological dilemmas that arise for cancer survivors and the issues for patients undergoing each of the major forms of cancer treatment: surgery, radiotherapy, chemotherapy, endocrine therapy, immunotherapy, and bone marrow transplantation.
Holland and Rowland also describe the problems related to the specific type of cancer a patient may have. They devote a chapter to each of the major cancers. They also present chapters on pain, sexual problems, nausea and vomiting, and anorexia. Another section in the book discusses the wide range of psychotherapeutic interventions used with cancer patients: psychotherapy, pharmacological management of psychological problems, behavioral techniques such as progressive relaxation and hypnotherapy, and support groups. Overall, the Handbook of Psychooncology covers what mental health professionals working inside cancer treatment institutions have learned over the last several decades. Holland notes that practitioners of psychooncology have worked in settings which characteristically give “low status” to psychosocial issues. In her characteristically understated way, she says: “The need to try to `sell’ the importance of these issues to some staff members who are not interested creates a sense of devaluation of the work that can be felt personally.”12 From my own experience, I vividly recall one of the most rigorously scientific andêbest-respected researchers in psychooncology, who holds a distinguished position at a major teaching institution, telling me how a senior surgeon askedêhim about his work and, after listening briefly, had said to him: “You don’t really believe all this bullshit, do you?” “Low status” is a gentle word for theêwelcome psychooncology has been afforded in much of the biomedical community.
If there is a major shortcoming in psychooncology, it derives in large measure from the defensive position that psychooncology has occupied in relation to other specialties in mainstream cancer treatment centers. Institutional constraints have made it difficult for psychooncologists to push into the most exciting frontiers of clinical practice and research–most notably to determine whether or not psychological interventions can extend the life of cancer patients. In order to minimize conflict with the cancer treatment specialists, until very recently practitioners of psychooncology have presented themselves almost exclusively as the facilitators of patients’ better adaptation to cancer, cancer treatment, cancer progression, or cancer survival. For many years, most psychooncologists strongly disclaimed any suggestion that their methods might actually contribute to life extension or the likelihood of cure. As research findings began to support the idea that psychological methods might contribute to life extension, practitioners of psychooncology did not seize on these hints and move forward vigorously with a strong research agenda for the life extension hypothesis. They remained extremely cautious. This caution is strikingly in contrast to the aggressive research agendas of specialists in other fields of cancer treatment who were seeking life extension using techniques such as bone marrow transplantation, endocrine therapy, and immunotherapy.
But in the midst of a popular culture in which excessive claims about psychologically based cures for cancer are often made in the inspirational cancer literature, it is refreshing to read in the Handbook of Psychooncology about the modest and careful descriptions of psychological problems and useful interventions. With its sometimes excessively conservative approach, psychooncology balances the popular literature with its excessively optimistic claims. For cancer patients, the truth probably lies somewhere between these two poles.
Therapies That Reduce the Stress of Cancer
One of the most important findings by psychooncology researchers is that progressive muscle relaxation training, imagery, hypnotherapy, and other stress reduction techniques can reduce the side effects of cancer treatment and some syndromes associated with cancer, such as sleeplessness, pain, and weight loss. Rene Mastrovito, in a chapter on behavioral techniques in the Handbook of Psychooncology, reports that:
The last two decades have seen a dramatic rise in the use of behavioral therapies for control of symptoms. … Particularly in cancer, they are now extensively applied to control psychological distress and pain. … The be- havioral techniques, encompassing hypnosis, meditation, autogenic training, progressive relaxation, and biofeedback, are also called by some cognitive- behavioral, holistic, and alternative modes of therapy. All are forms of self- regulating therapies, a more comprehensive and appropriate term. Such therapeutic interventions generally are characterized by two basic stages in which the patient is first guided through a primarily cognitive activity that creates the second stage, an altered state of consciousness. … By far the most widely used technique in cancer is relaxation therapy, which promotes an altered state of awareness through reducing distressing emotions and producing a physiologically quiescent state in which there is selective awareness of specific sensory stimuli to the exclusion of others.13
Behavioral interventions to diminish anticipatory nausea and vomiting represent one of the most rigorously documented and effective uses of these approaches. William Redd, Ph.D., a leading authority in this field, notes that 25% to 65% of patients in protracted chemotherapy report nausea in anticipation of treatment. “For some patients,” says Redd, “… any event or stimulus that is repeatedly associated with post-treatment side-effects becomes an elicitor of anticipatory reactions. … Clearly the most potent stimulus for the chemotherapy patient is the smell of the rubbing alcohol used to clean the skin in preparation for an infusion. After four or five infusions, the nurse’s perfume, the handsoap the doctor uses, and the odor of coffee may elicit it.”14
After reviewing the literature, T.G. Burish and colleagues report that behavioral relaxation techniques, including hypnosis, progressive muscle relaxation training, electromyogram (EMG) biofeedback, and systematic desensitization, “alleviate some conditioned side effects of chemotherapy including nausea, vomiting, and negative emotions such as anxiety and depression. These behavioral techniques are generally inexpensive, easily learned, and have few if any negative side effects.”15
Redd reviews a series of studies by different investigators who used hypnosis with imagery, progressive relaxation with imagery, biofeedback with imagery, systematic desensitization, and cognitive or attentional distraction to relieve anticipatory nausea and vomiting:
The consistency of the positive results obtained in the group of studies just reviewed is remarkable, because clinically significant reductions in ANV [anticipatory nausea and vomiting] were achieved despite wide variations in the type of cancer, stage of disease, and chemotherapy protocol … by separate groups of investigators using different research methods. … Behavioral techniques clearly appear to have a place as an adjunctive treatment in the care of many cancer patients.
The question of whether these techniques are helpful in posttreatment nausea and vomiting, Redd reports, is more complex. Most research has not focused in this area. Some patients report that relaxation tapes themselves become aversive stimuli in situations where there is severe posttreatment nausea, especially with protocols that include cisplatin. But “Burish and colleagues consistently report reductions in post-treatment reactions when their patients use self-relaxation and distraction with protocols that do not incorporate cisplatin. Although posttreatment nausea is not eliminated, significant reductions are observed.”16
Other significant uses of behavioral therapies are less well known but equally important. Campbell and colleagues reported that progressive muscle relaxation training promoted normal food consumption and weight gain for cancer patients.17 Cannici and colleagues found progressive muscle relaxation training reduced insomnia that is often found in people with cancer. Fifteen patients trained in the technique reduced the time they spent trying to get to sleep from 124 minutes to 29 minutes, while 15 participants in the control group experienced almost no reduction. The training had a lasting effect, with the differences between the two groups continuing 3 months later.18 To have an adequate appetite, to gain weight, and to go to sleep in half an hour instead of 2 hours are no small accomplishments in living with cancer. Who is to say they are not crucial building blocks in the fight for life extension as well?
Mastrovito reviewed a series of studies on hypnosis, especially with pediatric patients whose “easy suggestibility and readiness to engage in imaginative ventures” made them especially good candidates. A number of studies showed that children undergoing bone marrow aspiration experienced less pain when prepared for the procedure with hypnotherapy or imagery.19 It is shocking that these simple procedures are not universally used for children undergoing these painful procedures.
Mastrovito also states that progressive relaxation is particularly useful (for adults as well as children) in oncology units and clinics “in situations that provoke fear and apprehension, such as painful diagnostic and treatment procedures (e.g., bone marrow aspiration, lumbar puncture, and chemotherapy infusions).” The unique assets of progressive relaxation, Mastrovito says, are that it can be done in almost any quiet place, is widely accepted by patients, has very rare adverse effects, is neither time-consuming nor expensive, and can even be applied in “emergency situations.” Mastrovito correctly notes that very occasionally progressive relaxation may increase anxiety rather than diminish it and, equally rarely, it can lead to hypnotic trance states–not at all necessarily negative in themselves–that the practitioner should be prepared to respond appropriately to.20
Does Stress Make Tumors Grow?
One of the best research summaries of the effects of stress on tumor growth is contained in an important book by Daniel P. Brown and Erika Fromm, Hypnosis and Behavioral Medicine. Brown is Director of Behavioral Medicine at the Cambridge Hospital and a member of the Harvard Medical School Faculty. Fromm is Professor of Psychology at the University of Chicago. According to Brown and Fromm:
Numerous studies have shown that animals in which tumors have been induced (by means of chemicals, transplantations, or radiation) and were then exposed to acute stressors (electrical shock, bright lights, extreme temperatures, rapid rotation, immobilization, isolation, overcrowding, confrontation with other–feared–animals) suffered from immunosuppression. Rapid tumor growth was facilitated in the stressed animals. The accumulated data for humans, although not so extensively documented, are similar and suggest that acute stressors result in immunosuppression or tumor facilitation in humans [emphasis added].21
This conclusion is supported by PNI research on the effects of stress in animals, summarized in a number of chapters in the bible of this field, Psychoneuroimmunology. One of the authors in this text, Yehuda Shavit, writes:
Reviewing the literature on stress and tumors in animal studies reveals a picture similar to that relating stress and infection. Stress can alter the incidence and development of experimental tumors in animals. In general, stress appears to enhance tumor induction and development, although stress-induced retardation of tumor growth has also been reported.
PNI research has found that the relationship between stress, tumor growth, and immunity is highly complex. Shavit describes three major areas where stress, immunity, and tumor development have been explored: acute stress is generally more likely to depress immune function and enhance tumor growth than chronic stress; giving animals a capacity to control stress enhances immunity and diminishes tumor development in contrast to situations where stress is inescapable; and housing conditions affect stress, with both loneliness and overcrowding having deleterious effects.22 In humans, the most distinctive difference is that chronic psychological stress appears to continue over time to be immunosuppressive.23
A second vital area of PNI research has focused on opiates (such as morphine) and “opioid peptides,” or opiate-like peptides. Within the body, stress can induce analgesia or pain control by different biochemical mechanisms, one of which involves opioid peptides and the other a nonopioid system. This is important because, when a stressor induces pain control with an opioid peptide, the presence of that peptide more often than not may enhance tumor development, just as morphine may support tumor development. Shavit writes:
There is growing evidence implicating opiates in the regulation of the immune system. Opiate addicts are known to be highly susceptible to bacterial, viral and fungal infections and, in fact, to have deficits in immune function. Acute and chronic morphine administration in experimental animals and humans usually produces immunosuppression. … Opiate agonists and antagonists [substances which, respectively, enhance or retard the effects of opiates] have also been implicated in tumor development. For example, morphine enhances the rate of pulmonary metastases in rats. … On the other hand, opiates and opiate antagonists were shown to retard tumor growth.24
PNI animal research has also identified critical immunosurveillance mechanisms against both viral infections and cancer that are differentially affected by stress. The two primary mechanisms considered in this research to date are cytotoxic T lymphocytes and NK [natural killer] cells. Acute stress in animal research often markedly reduces NK cell activity, and research that exposed animals to the specific kinds of stress that bring opioid peptides into play also suppressed NK cell activity. Morphine has also shown a dose-related capacity to suppress NK cell activity in animals.25 Shavit writes:
Although there are obvious differences between rats and humans in response to narcotic drugs, our results nonetheless indicate that the effects of high-dose narcotic drugs on the immune system should be studied in humans. Surgical stress, including anesthesia, has been shown to increase tumor metastasis, perhaps owing to tumor embolus [tissue fragments] dissemination during the surgery. The impairment of NK cells at the time of surgery may contribute to tumor implantation, and our findings suggest that this NK suppression is attributable, at least in part, to narcotic agents.26
In human studies, PNI researchers have found specifically that bereavement, divorce, depression, chronic stress, and academic stress (exams, etc.) may all depress immune function. Janice R. Kiecolt-Glaser and Ronald Glaser are two leading researchers in this field and summarized the research in Psychoneuroimmunology. They cite a “large and relatively consistent literature” suggesting that stressful life events, specifically “major negative life changes,” put people at greater risk for a variety of diseases. Interestingly, these events only account for about 10% of the variance in most studies. But the effects are “remarkably consistent across populations and different kinds of events. In particular, events associated with the loss of important personal relationships appear to put individuals at greater risk.”27
Among the major life stressors, bereavement and divorce have been carefully studied. The Glasers cite studies showing that bereaved people have higher mortality in general and a higher incidence of cancer in particular than controls do. (Holland, in contrast, interprets the most recent studies to show higher mortality but not an elevated incidence of cancer.) Divorce, the Glasers report, has even greater health risks associated with it than bereavement.28 But in general, while there is good evidence of an increase in morbidity and mortality associated with major negative life events, there is not a large body of robust evidence that these events result in a disproportionate increase in the incidence of cancer in particular.
Personality and Social Support as “Buffers” Against Stress
Personality may have a strong influence on how we experience stress. Recent research by S.R. Maddi and S.C. Kobasa, Holland reports, “found that the `hardy’ personality (viewing stress as a challenge, attempting to control stressful situations, and exercising a strong sense of commitment), had fewer physical illnesses, complaints and psychological distress than those who lacked these qualities.”29
As we have seen, social support is another potential antidote to stress. As Rowland writes, “One of the most important `buffers’ against the harmful effects of the stress of illness is the presence or availability of persons in the patient’s environment with whom the experience can be shared. … Research indicates that the presence of positive social support not only diminishes the psychic distress of cancer, but may be important in modulating survival as well [emphasis added].”30
This passage covers a point of vital importance to people who are considering some form of psychological work on themselves in hopes of extending their lives. Holland and Rowland explicitly endorse the view that the presence in a cancer patient’s life of people “with whom the experience of cancer can be shared” not only softens the psychological impact of cancer but may `modulate’ survival as well.
Personality and social support probably interactively modulate the psychological and biological stressors that may be related to both the incidence and progression of some cancers. Evidence for this proposition now also comes from research in PNI. Sandra Levy and her colleagues (1985, 1987) examined psychological and biological variables in women with breast cancer. The studies measured their psychosocial condition and immunological status at the time of their mastectomies and 3 months later. They found that NK cell status was a significant predictor of how many positive axillary nodes the women had. (The number of positive nodes, it should be recalled, is a significant predictor of the likelihood of recurrence of the disease and of survival.) Levy et al. also found that 51% of the variance in NK cell activity was accounted for by three “distress indicators”: lack of adjustment, lack of social support, and fatigue and depressive symptoms. In other words, if you had difficulty coping with cancer, had few social supports, and felt tired and depressed, the NK cell component of your immune system would be lower and you would be likely to have more positive nodes. This is an intriguing example of personality and social support apparently affecting the biological and psychological response to the stress of cancer with specific implications (the number of positive nodes) for survival. Jimmie Holland comments:
The Levy studies are of particular interest because of the findings from studies of Kiecolt-Glaser and colleagues that NK activity is negatively perturbed in physically healthy individuals under the stresses of examinations (1984), and loneliness (1986) in medical students. … Their reports are also important in that NK-cell activity is important in response to tumors of viral origin, such as herpes virus and cervical cancer.
The affective state described as “helplessness-hopelessness” as an outcome predictor in human cancer has received considerable attention, in part because of animal studies (Sklar and Anisman, 1981). Animals that lacked control over environmental stress (such as inescapable shock) had shorter survival from tumors than animals that could control it. Cox and Mackay (1982) have used these studies to hypothesize that helplessness is associated with depletion of catecholamines; in turn adrenocorticotrophic hormone (ACTH) release stimulates the release of corticosteroids, which suppress immune function. The intense need to regain control of events in patients with cancer has led to extrapolation of these concepts to the clinical area. Regaining a sense of control has been seen as not only promoting coping but also enhancing host resistance to tumor growth. Clearly, it is an intriguing hypothesis that needs further testing.31
Another very important set of studies, similar in concept to those of Levy, have been performed by Lydia Temoshok, Ph.D., and her colleagues who conducted pioneering studies of psychosocial variables related to prognosis in malignant melanoma. Temoshok, now principal scientist with the Henry M. Jackson Foundation for the Advancement of Military Medicine in Bethesda, Maryland, found an elegant way to compare “repressive coping reactions–defined as the discrepancy between reported anxiety and that reflected in electrodermal activity –in melanoma patients, cardiovascular patients, and disease-free controls.” She found that the melanoma patients were significantly more “repressed” in terms of expressing their anxiety than the heart patients or the healthy control group.
Temoshok then studied whether two specific clinical variables significantly correlated with the progression of melanoma. (The progression of melanoma, incidentally, varies greatly from patient to patient.) These two variables were the rate of mitosis of the tumor (the speed with which it divides and grows) and the number of lymphocytes (cells attacking the tumor) at the tumor site. Temoshok found that the patients who could express sadness and anger–rated from videotaped interviews–had a higher “protective host-response” (as measured by lymphocytes) and those who had a difficult time expressing sadness and anger had a higher mitotic rate and therefore more quickly growing cancers.
Temoshok then matched patients who had died or who were experiencing disease progression with others who had no evidence of progression of the disease. In this study, in apparent contrast to the preceding one, the patients who died or had disease progression had, in earlier testing, expressed more anxiety and distress than those who had no evidence of disease progression. Temoshok argued that these two findings could be reconciled as follows:
The following logic is offered to reconcile these findings with the ones in the preceding study, in which greater emotional expressiveness was associated with enhanced host response factors and diminished mitotic rate (which are, in turn, associated with favorable outcome): a high degree of consciously perceived stress, subjectively experienced as anxiety, distress, and/or dysphoric emotion, contributes significantly to melanoma progression. … It is possible that coping with this stress by expressing the emotion will buffer these otherwise negative effects.
Temoshok then suggested that both the negative effects of experiencing stress and anxiety–and the positive effects of expressing these feelings–are mediated by cellular immune factors. “To the extent that the course of malignant melanoma is influenced by the host’s immune response, these psychosocial factors will have an indirect, but significant effect on disease progression.”32
The role of stress in enhancing some kinds of tumor growth (and therefore affecting survival) is a key concept that cancer patients should know about. Stress probably affects different types of cancer differently. It is probably modulated by personality and coping style, social support, and other factors. With all these caveats in mind, what are the implications? A diagnosis of cancer and every subsequent experience connected with cancer are for most people inherently stressful. At each stage, the stress can be consciously and skillfully diminished by an effective collaboration between the patient, his family, his health professionals, and his friends. There are four things cancer patients can do for themselves about stresses that feel unhealthy to them:
1. Find a way to reduce or remove stresses that feel genuinely unhealthy to you, either in your medical treatment or your personal or work life. This applies not only to stress you experienced after your diagnosis but also to stresses before that time.
2. Practice stress reduction techniques that feel genuinely nurturing to you (a key criterion) such as progressive muscle relaxation, meditation, hypnosis, or imagery.
3. Join a support group where you feel free to express your feelings–especially sadness and anger–about your situation.
4. Consciously cultivate paths of personal development that may lead you to a new perspective on life in which situations that were once stressful to you are no longer as stressful. In many spiritual traditions, the work on ourselves that transforms stress in this way is sometimes called the path to inner peace. The capacity to grow toward this inner peace is based on a fundamental reevaluation of what matters to us in our lives. Many people find that this reevaluation comes to them quite naturally in the course of facing cancer.
Psychological Approaches to Extending Life with Cancer
Many individual cases and uncontrolled studies have reported life extension as a result of psychological interventions. In 1984, Alastair Cunningham, Ph.D., of the Ontario Cancer Institute, Toronto, reviewed the studies on whether or not psychological interventions could change the course of cancer. As Locke summarizes Cunningham:
Can psychological treatments ameliorate cancer? Alastair J. Cunningham, who recognizes the methodological deficiencies of the clinical studies but who is concerned that their claims may nonetheless be “both true and important,” maintains that another standard should be used to weight the findings–a standard that might be called the principle of cross-study consistency. Cunningham argues that the results of the clinical studies are consistent with each other and also with the results of prospective studies correlating personality factors with cancer and animal studies investigating the effects of stress on tumor growth. This broad consistency, he suggests, points to a possible core of validity. It indicates, at the very least, that the clinical claims should not be dismissed on methodological grounds and that the time has come to subject the claims to “properly controlled clinical trials.”33
One example of the uncontrolled studies that Cunningham reviewed can be found in the work of a remarkable Australian psychiatrist, the late Ainslie Meares. Meares worked with cancer patients using a form of meditation “characterized by extreme simplicity and stillness of the mind.” He published specific cases of regression of cancer of the rectum, remission of “massive metastasis from undifferentiated carcinoma of the lung,” regression of a recurrence of carcinoma of the breast at the mastectomy site, and regression of a metastasized osteogenic sarcoma (bone cancer). Of the last case, he wrote: “It would seem that the patient has let the effects of the intense and prolonged meditation enter into his whole experience of life. His extraordinarily low level of anxiety is obvious to the most casual observer. It is suggested that this has enhanced the activity of his immune system by reducing his level of cortisone.”34 (The patient in this extraordinary recovery was Ian Gawler, founder of the Australian Cancer Patients Foundation and author of a spellbinding account of his recovery entitled You Can Conquer Cancer.)
In summarizing his work with 73 patients who had attended at least 20 sessions of intensive meditation, Meares found that Nearly all such patients should expect significant reduction of anxiety and depression, together with much less discomfort and pain. There is reason to expect a ten per cent chance of quite remarkable slowing of the rate of growth of the tumor, and a ten per cent chance of less marked but still significant slowing. The results indicate that patients with advanced cancer have a ten per cent chance of regression of the growth. There is a fifty per cent chance of greatly improved quality of life and for those who die, a ninety per cent chance of death with dignity.35
Meares’s method calls for the systematic use of a wordless meditation closely related to progressive relaxation. His findings show how enhancement in quality of life for all patients may go hand in hand with slowing of tumor growth for some and a regression of a tumor for a few.
Similarly, O. Carl Simonton, M.D., and Stephanie Matthews Simonton, Ph.D., developers of the most popular of imagery techniques for cancer, reported with T.F. Sparks that “a preliminary study of the effects of psychological intervention in the treatment of advanced cancer [showed that] patients so treated survived up to twice as long as would have been expected based on national averages.”36 Bernauer Newton also has reported–as we shall see in a later section–a study of hypnotherapy with cancer patients that showed at least a doubling of survival for patients who received “adequate” hypnotherapy as opposed to those who were “inadequately” treated. Both studies have serious methodological problems but they exhibit the “cross-study consistency” Cunningham noted in calling for controlled clinical trials. These studies are particularly interesting as precursors of David Spiegel’s randomized prospective clinical trial which also found a doubling of average survival in women with metastatic breast cancer who participated in a support group as compared with women who did not. Cunningham summarizes a study investigating psychological interventions aimed at reversing cancer:
A randomized control study with positive results has … been published by Grossarth-Matticek et al. (1984). They tested … the effects of both chemotherapy and 20-30 individual sessions of psychotherapy based on teaching problem-solving, examination of beliefs and expectations, relaxation and positive suggestion. The life span of randomly assigned metastatic breast cancer patients was recorded as prolonged by approximately six months on average in those receiving the psychotherapy. There was an additive effect with chemotherapy: patients receiving both treatments lived about a year longer than those getting neither [emphasis added].37
This and other similar studies by Grossarth-Matticek, while intriguing, remain highly controversial. This research has been widely questioned by researchers in the field despite its apparent methodological rigor. The accuracy of the data itself has been questioned.
The Turning Point for Life Extension Research: David Spiegel’s Study of Women with Metastatic Breast Cancer
In May 1989, a watershed event took place in the field of psychooncology. A Stanford Medical School associate professor of psychiatry and behavioral sciences, David Spiegel, M.D., told the annual meeting of the American Psychiatric Association of a very unexpected finding. He and his colleagues had studied 86 women with metastatic breast cancer who had been randomized into two groups: One group received standard medical treatment alone; the other group received standard medical treatment plus weekly group therapy sessions and lessons in self-hypnosis to help control pain.
The 10-year study found that the women in the intervention group had twice the survival time of women in the control group. At the 10-year point, 83 of the 86 women in the study had died. But the women who received group therapy lived an average of 36.6 months after entering the program, while the participants in the control group lived an average of 18.9 months. And all three long-term survivors were in the group therapy program.
“I must say I was quite stunned,” said Spiegel. He told the Los Angeles Times that he “undertook the study expecting to refute often overstated notions about the power of mind over disease, which he said he had found clinically as well as theoretically irritating, as well as destructive to many of my patients.” The science writer for the Los Angeles Times reported:
The 10-year study of women with metastatic breast cancer … is believed to be the first to examine in a scientifically controlled manner the effect of psychological and social supports on cancer patients’ survival. … The women in the support group experienced fewer mood swings and less phobia and pain than their counterparts [in addition to surviving for an average of twice as long].
Previous studies suggest that social support may influence the survival of sick people and the elderly, perhaps by serving as a buffer against stress. The opportunities to express feelings, as in group therapy, can also counter the sense of social isolation in some patients and perhaps contribute to survival, other studies suggest.
Spiegel also theorized that the group therapy might have nourished a sense of hope, enabling the women to comply better with medical treatment or perhaps improve their diet. Finally, he pointed to developing theories that the emotions may influence the immune system.
The group therapy the women received lasted one-and-one-half hours a week and centered on expressing fears, anger, anxiety and depression. The women were encouraged to confront their physical problems, to be assertive with their physicians and to grieve the loss of friends in the group who died.
“They came to feel that they were experts in living,” Spiegel said. “As a result of their foreshortened lives,” he said, “the women felt they had learned lessons about living …”
Other researchers called Spiegel’s findings marvelous and provocative–but in need of replication by other teams. Cautioned Dr. Troy Thompson, a professor of psychiatry at Jefferson Medical College in Philadelphia, “When something seems too good to be true, often it is. … This is a marvelous study, a surprising study to me as well. I would have bet the mortgage of my home that it would not have come out this way.”38
Interestingly, Spiegel did not report the kinds of dramatic and systematic patterns of regression of tumors that Meares reported in 10% of his patients, although the fact that three women in the support group were alive 12 years after the study is of great interest. He reported a doubling of survival time for the women in the treatment group (36.6 months vs. 18.9 months for the control group). He also found a significant increase in time from first metastasis to death: 58 months for the intervention group vs. 43 months for the control group. And he found that there was a “dose-effect” curve: people who had been placed in the intervention group but attended rarely if at all lived a shorter time than those who attended regularly.
In terms of quality of life, Spiegel found that mood disturbances for the intervention group grew better during the intervention while mood disturbances for the control group grew worse. The intervention group was also taught pain control through a combination of self-hypnotic imagery and relaxation. During the course of the program experiences of pain increased in the control group and decreased in the intervention group. The frequency and duration of pain attacks remained the same for both groups, but the intervention group had learned to manage pain with less distress.39
Spiegel’s report was a watershed development in the field not only because of what he found but because of who he was. He had all the right markings for the study to have a powerful impact. He was a Stanford professor, and beyond that he had–ideally from the point of view of maximizing the impact of the study–undertaken the study without any belief that psychological interventions had an effect on life extension with cancer. Moreover, he never conveyed to the group that he thought participation in the intervention would extend their lives. Spiegel’s study offered the first solid scientific evidence in support of Cunningham’s observation that the cross-study consistency of uncontrolled studies which show life extension might be “both true and important.”
When the Spiegel study came out, one leading psychooncologist commented to me that perhaps it was the “social support” aspect of the intervention that was primarily responsible for the outcome. She was referring to the studies, described above, that show that people with strong social support networks live longer with cancer, and specifically to the study by J.R. Marshall and D.P. Funch (1983) that younger women with breast cancer who had higher levels of social support lived longer.40 Other studies show that unmarried people with cancer have lower survival than married people.41 And a number of important studies, most notably those of L.F. Berkman and S.L. Syme, have shown that people with more social support have lower mortality from a wide range of diseases than those with less social support.42
My colleague’s point–that social support might be a critical explanation for the outcome of the Spiegel study–was well taken and likely true. But it also underscored the tenuousness of the distinction that psychooncology has drawn between “social support” and “psychological interventions.” As I have mentioned before and want to reemphasize, in order to survive in their institutions, psychooncologists needed to minimize claims that what they did might extend the lives of cancer patients. They also needed to acknowledge the reality that strong social support often helps people live longer. Psychooncologists even took the professionally courageous position of welcoming support groups for cancer patients–on the grounds that these support groups helped improve quality of life–which many of the primary care physicians they worked with were deeply suspicious of. But they did not press the connection between enhancing social support by means of psychological intervention and extending life that the Spiegel study finally made inevitable.
As a result of the Spiegel study–but also because of trends in psychooncology and PNI that preceded its publication–it has now become professionally acceptable for top researchers to undertake studies that investigate the effects of psychological interventions on cancer survival. As I write, additional controlled randomized prospective trials by Spiegel and others examining the effect of psychological interventions on life extension are underway.
From the point of view of the cancer patient, the main problem with the new set of studies is that they often use psychological interventions that are far less intensive than the intervention some motivated cancer patients undertake for themselves. Nor do these studies address the question of whether or not there is a synergistic effect when cancer patients undertake intensive psychological interventions in combination with nutritional, physical, and other approaches to intensive health promotion. As you will remember, Spiegel found a “dose-effect” curve in his intervention group. The disturbing and important possi- bility exists that the “therapeutic dosage” of psychological and other health-promoting interventions in the prospective controlled clinical trials conducted to date is suboptimal in terms of extending survival, and that this remains true in the new generation of studies. In other words, exceptionally motivated patients who undertake integrated programs of intensive health promotion that include a strong psychological component may possibly be achieving results outside the curve that Spiegel and others reported. No current study that I am aware of tests this crucial hypothesis. On the other hand, the Spiegel study does show that an activity that is within the range of almost every patient–attending a weekly support group–was associated with a powerfully beneficial outcome.
Bernard H. Fox, Ph.D., Professor of Psychiatry at Boston University School of Medicine, one of the most respected, circumspect, and thorough of researchers in psychooncology, introduces a useful caution when he takes the view that if there is a contribution of psychological factors to survival in cancer, it is likely to be a very small one–a view that Holland cites as authoritative.43
More Support for the Life Extension Hypothesis: Fawzy I. Fawzy’s Research on Malignant Melanoma
As this book was going to press, a second very important but far less widely reported study suggesting life extension as a result of a limited psychological intervention was published by Fawzy I. Fawzy, M.D., of the University of California at Los Angeles School of Medicine.
Like Spiegel, Fawzy had initiated a study some years before to assess the effects of psychological intervention of quality of life in cancer patients. He studied “changes over time in methods of coping and affective disturbance,” and concluded in his earlier study that a brief psychiatirc intervention lowered depression, fatigue, and total mood disturbance and increased vigor in early stage melanoma patients.44
Six years later, Fawzy looked at the effects of the structured psychiatric intervention on survival and time to recurrence in his intervention group and the control group. He found that 10 of the original 34 patients in the control group with stage I disease had died, and 3 others had experienced local recurrences, while in the experimental group only 3 of the original 34 patients had died, and 4 had recurrences. The experimental group–those who participated in the psychiatric intervention–also achieved greater disease-free intervals than the control group.
Fawzy’s intervention was strikingly minimal. It consisted of only six structured group sessions over a 6-week period, with each session lasting 1<$E 1/2 > hours. The group meetings offered (1) education on melanoma and basic nutritional advice; (2) stress management techniques; (3) enhancement of coping skills; and (4) psychological support form the staff and from other group members.
Like Spiegel, Fawzy emphasizes that his study was not originally designed to assess survival as an outcome, and says simply that, because of the small sample size and other methodological issues, the results warrant further research using a large number of properly stratified subjects.
He also found “to our surprise” that high levels of distress at the beginning of the study, rather than being a negative sign, were “a critical measure of awareness and behavioral motivation,” and were associated with enhanced survival. The study also showed that “positive coping behavior can be learned or enhanced, and if implemented, improves health outcomes.”45
The reader should bear these important findings in mind when reading elsewhere in this chapter about Lydia Temoshok’s work with malignant melanoma, since the results of her research are so consistent with Fawzy’s findings.
With all the qualifications that careful researchers introduce, Fawzy’s research was a dramatic second positive finding regarding genuinely significant evidence of life extension with a very modest psychological interventions. But what if people go all out in a fight for life, with intensive and continuing psychological work, often in combination with other lifestyle interventions? This remains an unexplored frontier in mainstream psychological and behavioral research. But it brings us to the pioneering work of one of the great maverick psychologists in this field, Larry LeShan.
Psychotherapy and the Fight for Life: The Work of Lawrence LeShan
Perhaps the most remarkable claim for life extension with metastatic cancer comes from Lawrence LeShan, Ph.D., one of the pioneers of psychotherapeutic treatment for cancer. His reported success rate exceeds that of almost all other psychological investigators. LeShan writes:
Ever since I learned how to use this approach some twenty years ago, approximately half of my “hopeless,” “terminal” patients have gone into long term remission and are still alive. The lives of many others seemed longer than standard medical predictions would see as likely. Nearly all found that working in this new way improved the “color” and emotional tone of their lives and made the last period of their lives far more exciting and interesting than they had been before starting the therapeutic process.46
LeShan never published data in support of these claims, and other psychological investigators, including a number who share his psychotherapeutic philosophy and admire his contribution to the field, have never been able to replicate these results in their own experience with patients. But, while few psychotherapists would claim to have witnessed the frequency or extent of life extension that LeShan claims, many agree with him that life extension can be achieved using psychotherapeutic techniques similar to his. Because of the enormous influence that LeShan has had on psychotherapy and cancer, his work, recently summarized by him in Cancer as a Turning Point, is worth reviewing in some detail.
LeShan began researching the relationship of personality to cancer in 1947. “The first thing I found was that up to 1900 the relationship between cancer and psychological factors had been commonly accepted.”47 He cites Gendron, who in 1759 stressed the importance to cancer of “disasters in life, as occasion much trouble and grief.”48 He quotes Walter Hoyle Walshe, an authority on cancer in 1846:
Much has been written on the influence of mental misery, sudden reverses in fortune, and habitual gloominess of temper on the deposition of carcinomatous matter. If systematic writers can be credited, these constitute the most powerful cause of the disease. … I have myself met with cases in which the connection appeared so clear that I have decided questioning its reality would seem a struggle against reason.49
In 1885, Willard Parker in the United States summed up his half-century experience as a surgeon treating cancer: “It is a fact that grief is especially associated with the disease. If cancer patients as a rule were cheerful before the malignant development made its appearance, the psychological theory, no matter how logical, must fail: but it is otherwise. The fact substantiates what reason points out.”50
After 1900, LeShan writes, the viewpoint that cancer had roots in the psyche disappeared from the literature as psychosomatic medicine went out of style. It lay dormant until LeShan and a few others began to revive it in the 1950s: “Since 1955 literally dozens of studies have shown conclusively that emotional life history often does play an important part in determining an individual’s resistance to getting cancer and in how cancer develops after it appears. It is certainly not the only factor and does not play a part for every person with cancer by a long shot, but every cancer patient’s emotional life should be considered.”
In 1952, when LeShan began his clinical research into the question of whether or not psychotherapy could affect life expectancy with cancer, he applied for permission to conduct his studies at 15 New York hospitals. He was turned down by all 15 institutions–a reflection of the cultural status of this kind of research in medical centers at that time. He finally found “an excellent work relationship” at Trafalgar Hospital, the unconventional New York hospital then operated by Emanuel Revici, M.D., a leading unconventional cancer clinician and researcher (see chapter 23). He worked with patients at Revici’s hospital for 12 years.
The single thing that emerged most clearly during my work was the context in which the cancer developed. In a large majority of the people I saw (certainly not all), there had been, previous to the first noted signs of the cancer, a loss of hope of ever achieving a way of life that would give real and deep satisfaction … the kind of life that makes us look forward zestfully to each day …
Often, this lack of hope had been brought into being by the loss of the person’s major way of expressing himself or herself and the inability to find a meaningful substitute.51
For years, LeShan struggled to treat these cancer patients with psychological support. For years, he reports, his cancer patients continued to die. His approach at the time was “very Freudian and psychoanalytic.” He finally concluded that the psychological methods in which he had been trained were inadequate for the treatment of cancer.
Conventional psychotherapies, LeShan believes, ask three questions: (1) What is wrong with this person?, (2) How did he or she get that way?, and (3) What can be done about it? LeShan says: “Therapy based on these questions can be wonderful and effective for help with a wide variety of emotional or cognitive problems. It is, however, not effective with cancer patients. It simply does not mobilize the person’s self-healing abilities and bring them to the aid of the medical program. We have now had enough experience in many different countries to state this as a fact.”52
The therapeutic approach developed in his research work with cancer patients is based on entirely different questions:
What is right with this person? What are his (or her) special and unique ways of being, relating, creating, that are his own and natural ways to live? What is his special music to beat out in life, his unique song to sing so that when he is singing it he is glad to get up in the morning …
How can we work together to find these ways of being, relating and creating? What has blocked their perception and/or expression in the past? How can we work together so the person moves more and more in this direction until he is living such a full and zestful life that he has no more time or energy for psychotherapy?
LeShan found that this approach, in conjunction with medical therapy, seemed to help many of his patients extend their lives. Moreover, his patients taught him that there was more to a comprehensive approach to fighting for life than psychotherapy. He found that some patients “learned to work on all three levels of human life: the physical, the psychological and the spiritual. I began to realize that those patients who had gone beyond me, who were consciously working on all three levels, tended to do better than those who were not. Over a period of time I learned about the holistic approach to illness and how to use it.”53
LeShan’s emphasis on the importance of the individuation process must be placed in the context that individuation has been the central goal of most of the humanistic and transpersonal psychologies that have developed out of the traditions of Jung, Maslow, Assagioli, and others. Jung wrote: “I have in fact seen cases where the carcinoma broke out … when a person comes to a halt at some essential point in his individuation or cannot get over an obstacle. Unhappily nobody can do it for him, and it cannot be forced. An inner process of growth must begin, and if this spontaneous activity is not performed by nature herself, the outcome can only be fatal.”54
The Simonton Approach: Imagery and Cancer
Imagery is one of the most powerful tools in use with cancer. Though its potential for bringing about physical recovery remains an open question, it is practiced extensively by cancer patients and therapists who work with them.
What is imagery? Rachel Naomi Remen, M.D., often describes imagery as the language of the unconscious. It is the way in which all those parts of us that are not presently within our consciousness are able to speak to our conscious selves. If you are in France, she says, you need to learn to speak French in order to communicate. If you are undertaking an inner voyage of healing, it is useful to become acquainted with the inner language of imagery. Imagery is the language of dreams, poetry, the arts, religion, and myth.
O. Carl Simonton, M.D., and Stephanie Matthews Simonton were the pioneers who first used imagery with the goal of physically reversing the development of cancer. Their best-selling book, written with James Creighton, Getting Well Again, was a major, though controversial, contribution to this area when it was first published in 1978. It remains one of the most useful and comprehensive psychological self-help books for people with cancer. The Simontons recommended that a person first put himself into a deeply relaxed state. Then:
Mentally picture the cancer in either realistic or symbolic terms. Think of the cancer as consisting of very weak, confused cells. Remember that our bodies destroy cancerous cells thousands of times during a normal lifetime. As you picture your cancer, realize that your recovery requires that your body’s own defenses return to a natural, healthy state.
If you are now receiving treatment, picture your treatment coming into your body in a way that you understand. If you are receiving radiation treatment, picture it as a beam of millions of bullets of energy hitting any cell in its path. The normal cells are able to repair the damage that is done, but the cancer cells cannot because they are weak. (This is one of the basic facts on which radiation therapy is built.) If you are receiving chemotherapy, picture that drug coming into your body and entering the bloodstream. Picture the drug acting like a poison. The normal cells are intelligent and strong and don’t take up the poison so readily. But the cancer cell is a weak cell so it takes very little to kill it. It absorbs the poison, dies and is flushed out of your body.
Picture your body’s own white cells coming into the area where the cancer is, recognizing the abnormal cells, and destroying them. There is a vast army of white blood cells. They are very strong and aggressive. They are also very smart. There is no contest between them and the cancer cells; they will win the battle.
Picture the cancer shrinking. See the dead cells being carried away by the white blood cells and being flushed from your body through the liver and kidneys and eliminated in the urine and stool.
Continue to see the cancer shrinking, until it is all gone.
See yourself having more energy and a better appetite and being able to feel comfortable and loved in your family as the cancer shrinks and finally disappears.
If you are experiencing pain anywhere in your body, picture the army of white blood cells flowing into that area and soothing the pain. Whatever the problem, give your body the command to heal itself. Visualize your body becoming well.
Imagine yourself well, free of disease, full of energy.
Picture yourself reaching your goals in life. See your purpose in life being fulfilled, the members of your family doing well, your relationships with people around you becoming more meaningful. Remember that having strong reasons for getting well will help you get well, so use this time to focus clearly on your priorities in life.
Give yourself a mental pat on the back for participating in your recovery. See yourself doing this mental imagery exercise three times a day, staying awake and alert as you do it.55
The Simontons stressed that it was not necessary to see the imagery if you could sense, think, or feel it. Among the benefits of relaxation and imagery that they listed were that it could: decrease fear; bring about attitudinal changes and enhance “will to live”; effect physical changes “enhancing the immune system and altering the course of a malignancy”; serve as a method for “evaluating current beliefs and altering those beliefs, if desired”; be used as a “a tool for communicating with the unconscious”; serve as a way of decreasing tension and stress; and help “to confront and alter the stance of hopelessness and helplessness. We have seen again and again how this underlying depression is a significant factor in the development of cancer.”56
In the Simontons’ and some other imagery techniques, the immune system is considered to be the mechanism by which the body actively combats cancer. While we have cited the studies by Levy and Temoshok in support of this view, some researchers believe that other host resilience factors may contribute to life extension. The immune system may or may not turn out to be the most important system by which psychological practices modulate cancer survival.
The story of how the Simontons reached their conclusions about what was important to outcomes when patients used imagery is revealing: “We first began using mental imagery to motivate patients and provide them with a tool for influencing their immune systems, but we soon discovered that the activity revealed extremely important information about patients’ belief systems.” In brief, what they discovered was that the content of the imagery appeared as critical to positive outcomes as the regular practice of imagery. People with negative imagery in which the cancer appeared more powerful than the treatment or the response of their bodies often did not do well. Together with the assistance of Dr. Jeanne Achterberg, a research psychologist, they developed a list of criteria that can be used to evaluate the content of one’s mental imagery:
Representing cancer cells as ants, for instance, we have found is generally a negative symbol. Have you ever been able to get rid of ants at a picnic? Crabs, the traditional symbol for cancer, and other crustaceans are also negative symbols. These beasts are tenacious, they hang on. …
Interpreting mental imagery is similar to interpreting dreams: It involves a highly personal, symbolic language. … The emotional meaning of a particular symbol may be very different for different individuals, so that a symbol that means strength and power to you may mean anger and hostility to someone else. Thus, you should not automatically accept anyone else’s interpretation of your symbols.57
But Achterberg and the Simontons believed there were certain qualities of successful imagery:
The cancer cells are weakened and confused.
The treatment is strong and powerful.
The healthy cells have no difficulty repairing any slight damage the treatment might do.
The army of white blood cells is vast and overwhelms the cancer cells.
The white blood cells are aggressive, eager for battle, quick to seek out the cancer cells and destroy them.
The dead cancer cells are flushed from the body normally and naturally.
By the end of the imagery, you are healthy and free of cancer.
You see yourself reaching your goals in life, fulfilling your life’s purpose.58
Of all of these imagery processes, the Simontons regarded the imagery of the white blood cells as “aggressive, eager for battle, [and] quick to seek out the cancer cells and destroy them” as “the most crucial imagery process because it represents your beliefs about the body’s natural defenses.” They felt that critical elements in this imagery included the strength and number of white blood cells relative to cancer cells and the vividness of the imagery.59
The Simontons’ and Achterberg’s position that aggressive imagery–rather than gentle imagery–works better in support of physiological reversal of cancer remains the subject of an ongoing debate among clinicians who use imagery. One group of clinicians holds, with the Simontons, that aggressive imagery works better. Another group believes that, for some people, aggressive imagery is foreign to their personalities and to their sources of inner strength.
Rachel Naomi Remen uses the example of a client who tried to use aggressive imagery for his cancer but could not sustain the image of his white blood cells as sharks seeking out and destroying cancer cells. What came to him spontaneously, instead, was the image of a catfish, always awake, moving endlessly through the water and cleansing his blood of cancer cells. He also liked this image because he felt a great fondness for the catfish who he felt protected his blood–and he felt the catfish also loved and cared about him. To my knowledge, no research has yet been done that would offer any resolution to this debate.
A second debate in the imagery field centers on whether or not imagery that is anatomically accurate is more or less powerful than imagery that uses powerful symbolic representations. Should a cancer patient try to imagine as vividly and realistically as possible how the white blood cells and cancer cells look and how the white blood cells attack the cancer cells, or is he better off imagining his white blood cells as powerful forces of some kind overcoming the cancer cells? While not specifically addressing cancer, research studies are divided on this subject. Most clinicians are inclined to believe that symbolic representations can be just as powerful or more powerful for some patients than anatomically accurate ones.60
Martin Rossman: Self-Healing Through Imagery
Martin Rossman, M.D., has written one of the most accessible books on imagery: Healing Yourself: A Step-by-Step Program for Better Health Through Imagery. He also conducts one of the most respected imagery training programs for health professionals in the United States. While Rossman has not had a primary concern with cancer, he is widely admired by his colleagues for having articulated effectively one of the most comprehensive approaches to the use of imagery:
Imagery is a flow of thoughts you can see, hear, feel, smell or taste. An image is an inner representation of your experience or your fantasies–a way your mind codes, stores and expresses information. Imagery is the currency of dreams and daydreams; memories and reminiscence; plans, projections and possibilities. It is the language of the arts, the emotions, and most important, the deep inner self.
Imagery is a window on your inner world; a way of viewing your own ideas, feelings, and interpretations. But it is more than a mere window–it is a means of transformation and liberation from distortions in this realm that may unconsciously direct your life and shape your health.61
Rossman’s imagery script for finding your own healing imagery starts with a standard “induction” that helps you reach complete relaxation. Then:
When you are ready, focus your attention on the symptom or problem that has been bothering you … simply put your attention on it while staying completely relaxed … allow an image to emerge for this symptom or problem … accept the image that comes, whether it makes sense or not … whether it is strange or familiar … whether you like it or not … just notice and accept the image that comes for now … let it become clear and more vivid, and take some time to observe it carefully …
In your imagination, you can explore this image from any angle, and from as close or as far away as you like … carefully observe it from different perspectives … don’t try to change it … just notice what draws your attention …
What seems to be the matter in this image? … what is it that represents the problem? …
When you know this, let another image appear that represents the healing or resolution of this symptom or problem … again, simply allow it to raise spontaneously … allow it to become clearer and more vivid … carefully observe this image as well, from different perspectives … what is it about this image that represents the healing? …
Recall the first image and consider the two images together … how do they seem to relate to each other as you observe them? … Which is larger? … Which is more powerful? … If the image of the problem seems more powerful, notice whether you can change that … imagine the image of healing becoming stronger, more powerful, more vivid … imagine it to be much bigger and more powerful than the other …
Imagine the image of the problem or symptom turning into the image of healing … watch the transformation … how does it seem to happen? … Is it sudden, like changing channels on television, or is it a gradual process? … If it is a process, notice how it happens … notice if what happens seems to relate to anything in your life …
End your imagery session by focusing clearly and powerfully on this healing image … imagine it is taking place in your body at just the right place … notice whether you can feel or imagine any changing sensations as you imagine this healing taking place … let the sensations be sensations of healing … affirm to yourself that this is happening now, and that this healing continues in you whether you are waking or sleeping … imaging … or going about your daily activities …62
The session ends with instructions to return gradually to the external world.
Two other imagery strategies described by Rossman are “meeting your inner advisor” and “listening to your symptoms.” The inner advisor, for Rossman, is a symbolic representation of our deepest inner wisdom who “may offer advice in areas as diverse as nutrition, posture, exercise, environment, attitudes, emotions, and faith. Your advisor can serve as a liaison figure to that part of your mind that thinks in images and symbols; as an ambassador between the silent and verbal brains, the unconscious and conscious minds.”63
Another imagery approach that Rossman recommends, especially for those who feel uncomfortable with “inner advisor” imagery, is “listening to your symptoms.” Citing the work of Edelstein and LeCron, Rossman suggests seven common unconscious reasons for the development of symptoms. They may be: (1) a symbolic representation of unexpressed feelings; (2) the result of unconscious acceptance of an idea or image of oneself from early life; (3) the result of past traumatic experience; (4) a way to resolve a current life problem; (5) the result of an unconscious identification with an important person in one’s life; (6) a manifestation of an inner conflict; or (7) the result of an unconscious need for punishment. Using a script developed originally by Rachel Naomi Remen, Rossman takes the patient through a relaxation, suggests that the patient focus on the symptom, invites an image to appear that represents the symptom, suggests careful observation of the image, and then suggests:
When you are sure about your feelings, tell the image how you feel about it–speak directly and honestly to it. … Then, in your imagination, give theêimage a voice, and allow it to answer you … listen carefully to what it says …
Ask the image what it wants from you, and listen to its answer … ask why it wants that–what does it really need? … and let it respond … ask it also what it has to offer you, if you should meet its needs … again, allow the image to respond …64
Rossman goes on to suggest that the patient allow himself to become the image, to notice how he feels as the image and to look back at himself through the eyes of the image. Then the patient returns to himself, and may consult an “inner advisor” figure before coming to the end of the session.
Jeanne Achterberg and Frank Lawlis: Imagery for Cancer
Since Jeanne Achterberg’s original collaboration with the Simontons, she and Frank Lawlis have over many years refined a theory and practice of imagery of great richness. Achterberg’s insightful book, Imagery in Healing, traces the historical roots of modern imagery therapies. Her thesis is that imagery is a human potential deeply associated with the feminine aspect of humanity and with nature. The wisdom and consciousness of imagery has, she believes, been systematically suppressed in the modern era, just as women have been oppressed and the earth has been exploited. Drawing on two books written with Lawlis, Image of Cancer and Bridges of the Bodymind, Achterberg argues that the images that cancer patients develop of their immune systems and their cancers prove to be more predictive of outcome than any available medical tests.
They describe an imagery assessment technique that begins with a tape- recorded relaxation induction followed by a brief education on the disease process, how the treatment may be working to the patient’s advantage, and the idea of host defense. Then the patient is advised to imagine these factors in operation in a guided, but not programmed, session that allows him considerable choice in imagery. The images are first drawn by the patient and then described in an interview, and both are scored on the basis of 14 dimensions, including: “vividness; activity and strength of cancer cells; relative comparison of size and number of cancer cells and white blood cells; vividness and effectiveness of medical treatment; the integration of the whole imagery process; the regularity with which they imaged a positive outcome; and a ventured clinical opinion on the prognosis, given the previous listed thirteen factors.”
The total scores were found to predict with 100% certainty who would have either died or shown evidence of significant deterioration during the two-month period, and with 93% certainty who would be in remission [emphasis added]. Remember, the scores are just a numerical shape put on the imagination–it was the images themselves that so accurately predicted the future.
What the patients’ imagination predicted were the dramatic changes that would occur within a short period of time. These results are often confusing to people who haven’t witnessed the erratic course of cancer. Tumors can change as rapidly as nightblooming flowers, growing, shrinking, perhaps changing shape. People with Stage IV cancer can be living active lives with no pain, or they may be bedridden; and they can move from one of these conditions to the other, and back, within days.65
Achterberg and Lawlis’s findings regarding the predictive power of imagery in cancer are startling. Their findings are so provocative and important that other research teams should replicate their studies.
Hypnosis and Cancer
Hypnotherapy for cancer is closely related to the use of imagery and relaxation, as both are part of the more general field–voluntary control of internal states of consciousness–that includes hypnosis, imagery, meditation, drug- induced alterations of consciousness, biofeedback, and traditional (preallo- pathic) systems of healing. Interest in these fields began to converge in the 1970s with annual conferences on the Voluntary Control of Inner States sponsored by Elmer and Alyce Green at the Menninger Foundation.66
What is hypnosis? Brown and Fromm describe it in Hypnosis and Behavioral Medicine:
Hypnosis is a special state of consciousness in which certain normal human abilities are heightened while others fade more or less into the background. Roughly 90% of the population has the talent to go into a hypnotic state–some more talented than others. Hypnosis can be combined with any type of therapy. … Hypnosis itself is not a therapy, although the relaxation that accompanies it can be beneficial. … That hypnosis is an altered state of consciousness is now generally accepted. Ludwig (1966) coined the term “altered state of consciousness (ASC),” defining an altered state according to the subjective experience and altered psychological functioning.67
Numerous hypnotherapists have written of their experience using hypnotherapy for cancer patients. Brown and Fromm describe three basic strategies that hypnotherapists (and other psychotherapists) have used. They are stress reduction, wellness enhancement, and direct immunotherapy.
The stress reduction strategies of hypnotherapy and nonhypnotic therapies focus on identifying stressful situations in the patient’s life and desensitizing the patient to them or teaching better communication skills, coping skills, deep relaxation, self-hypnosis, or meditation.
The wellness-enhancement strategies focus on enhancing well-being and mental health through humor, loving compassion, and a general focus on improving quality of life and quality of relationships: “The hypnotized patient visualizes his ego-ideal and merging into it, that is, becoming progressively more like the person he would like to be–healthy, competent and strong. He also imagines himself at various future times effectively living the kind of life he would most like to live.
Direct immunotherapy involves stimulating the immune system by imagery:
The Simontons teach nonhypnotic relaxation combined with somatic imagery … Subsequent clinical studies suggest that routine application of such visualization is not in itself sufficient. Patricia Norris has her patients generate and experiment with a variety of images. She claims that certain spontaneous images (not always of immune functioning) have an experientially distinct “sense” about them and are highly specific, bodily felt images of one’s natural healing forces. Their appearance increases the likelihood of a positive treatment response.68
The work of Bernauer Newton, Ph.D., presents a thoughtful exercise in the clinical use of hypnosis in cancer. Writing in a special issue devoted to cancer of the American Journal of Clinical Hypnosis in 1982-1983, Newton described 8 years of hypnotherapy at his center with more than 250 patients. Over this period, Newton and his colleagues began to emphasize quality of life rather than life extension per se:
This shift does not reflect a lessening in our belief that a person can be successful in his fight against malignant disease, but rather a growing awareness that unless the quality of his life improves, he will not engage in an all-out fight. The patient frequently is in so much distress from symptoms and side- effects of medical treatment that he has lost all or most of his desire to live and the energy to go on. …
Another change we have made is in the meaning we now attach to visualizations. We no longer pressure our patients to try for clearer visualizations. Many of our patients have done very well with weak and ephemeral images while others have gone down hill rapidly while visualizing vividly. We do believe that imaging assists some patients to strengthen their belief systems and certainly the results of biofeedback research point to its value. However this must be balanced against the possibility that urging the patient in this area … may result in his feeling that he is failing, experiencing guilt and depression, and raising his level of tension. …
Another change is really basic to nearly all that we do now. When we first began to work in this program, we were impressed with the need to help the patient make important psychological changes in what we feared might be a much shorter period of time than we usually had for non-cancer patients. This led us to be more confrontive and demanding. … As time went by, we were impressed by the progress some of our patients were making without this aggressive therapeutic interaction, and at the same time we were concerned about the rise in tension levels among those patients with whom we were being most “active.” Then in 1976 we became aware of the work Ainslie Meares was doing in Australia. The patients, many of whom were in advanced stages, were having no other medical treatment. He was having most remarkable success by assisting them to achieve daily periods of the most complete inner calm induced by unique indirect and non-verbal techniques. This seemed to confirm what we were beginning to see and encouraged us to shift the emphasis we gave to various activities in our treatment program. We still have our patients engage in the visualizations and we carry out extensive and intensive hypnotically facilitated psychotherapy but we believe that the cornerstone and absolutely indispensable part of our work is the patient’s experiencing the most profound quiet on a regular daily basis [emphasis added].69
Newton further reports clinical impressions of life extension based on a thorough review of patient records similar to, but more extensive than, that reported by the Simontons. Of the 283 patients seen over 8 years for at least one session, Newton decided that 105 would be considered “adequately treated” having had ten 1-hour sessions over a 3-month period. There were 57 “inadequately treated” patients seen three to nine times and 121 “unknown” patients seen fewer than three times. Almost all adequately treated patients experienced enhanced quality of life. There was no significant difference between adequately and inadequately treated patients with respect to diagnosis, stage of disease, age, or length of illness. But of 105 adequately treated patients, 54% were still alive at the time of the analysis, while of 57 inadequately treated patients, only 18% were still alive at the time of the analysis. And when he followed the Simontons’ method of comparing length of life for his patients to national survival rates for advanced metastatic cancer of the breast, lung, and bowel, Newton reports: “The national figure for duration of life for breast cancer patients [with advanced metastatic illness] is 16 months while Simonton reported 35 months and the median for our patients was 42.5 months. The comparison for metastatic disease of the bowel and lung show equally favorable improvement in the duration of life, being twice, and in some cases, three times better than the national figures.”70
Newton then goes on, responsibly, to emphasize that the data are “clinical impressions” and that there are numerous problems involving the small sample size, the selective nature of which patients stayed for “adequate” treatment, and other factors.
Newton disagrees with the Simontons and with Achterberg and Lawlis that clarity and power of images is an important predictor of survival. He has come to agree with Ainslie Meares, the late Australian psychiatrist, whose meditation technique places the patient in a very simple state of relaxation in which neither words nor images are used.
Meares, in fact, published one study in which he reported that a patient with advanced cancer went into remission while using intensive meditation but “a relapse occurred when she accompanied the meditation with vivid visualization of healthy cells eating cancer cells. The alertness caused by the visualization interfered with the state of regression needed for the therapeutic effect (activation of the immune system) to occur.”71 Yet, by contrast, a recent study comparing the effects on mood states of relaxation training compared with relaxation training plus imagery among 139 women with early-stage breast cancer found that both systems enhanced mood but that adding imagery further improved mood.72 It is worth noting that Meares believed and expected that meditation without imagery was better for cancer patients than relaxation with imagery, while the authors of the breast cancer study believed and formally hypothesized the reverse.
These kinds of disagreements among clinicians and researchers should not surprise us. Some day answers may emerge as to whether or not aggressive imagery is preferable in cancer to nonaggressive imagery; whether vivid imagery is better than less vivid imagery or a nonimaging meditative state; and whether LeShan’s individuation-oriented psychotherapy is decisively superior to other psychotherapies in cancer. But even if these answers emerge, they will almost certainly be generalizations about average responses. Most clinicians agree that there is tremendous individual variance. Brown and Fromm have noted a trend in behavioral medicine away from “uniform treatment packages” toward greater individualization, especially in the area of self- control strategies (i.e., muscle relaxation, imagery, hypnosis, biofeedback, and meditation). And with hypnosis and imagery, individuals respond differently to various types of suggestions and images.73
In reality, most clinicians in the field treat progressive muscle relaxation, hypnosis, biofeedback, imagery, and meditation as different techniques for reaching a common set of fields of altered states of consciousness in which certain forms of healing work are most effective. Here, for example, is the explanation Newton gives as to why he presents the work he does with cancer patients as hypnosis (as opposed to presenting it as meditation or relaxation):
We have found that hypnosis has been most helpful in all phases of our program. We also believe that presenting it as hypnosis rather than as deep relaxation or meditation has a clear advantage. We have already acknowledged the importance to the patient’s belief system; the probable placebo effect of what we do; the increase in the patient’s sense that he has some control over what happens to him; and the value to the patient of achieving deeply altered states of consciousness. It is our strong belief that the use of the label “hypnosis”; the use of induction techniques rather than meditation; and having the patient experience hypnotic dissociative phenomena all have added impact and facilitate the treatment process. For this reason we use specific and rather mechanical and simplistic induction techniques rather than any more indirect and subtle ones. We want the patient to immediately begin to believe that something real and significant is happening and that he can make these important things happen for himself.74
From the beginning of human history, healers have developed their own strategies of putting their patients (and often themselves) in altered states of healing consciousness. The fundamental point here is that most of the disagreements are about how best to get into these altered states of healing consciousness and which are the best specific techniques to use once you get there. And as Fromm and Brown point out, and most clinicians would agree, the key variables are what works best for the individual patient and the individual clinician.
Is There a “Cancer-Prone Personality”?
Many cancer patients ask whether or not there is such a thing as a “cancer-prone personality”–a specific personality configuration, or certain personality traits, associated with a higher risk of developing cancer. Another question often asked is whether cancer may appear at a particular site in the body for psychological reasons.
Claus Bahne Bahnson, Ph.D., a professor of psychiatry at Jefferson Medical College in Philadelphia, has studied these questions extensively: “The relationship between stress and cancer has intrigued scientists for more than 2,000 years. Certain persons do appear to be at greater risk for developing cancer because of a personality makeup dominated by sadness, depression and unmet emotional needs.”75
Bahnson reviews the historical literature and comes to the same conclusions that LeShan came to from his historical studies. Galen (c. 130-200 A.D.) saw breast cancer more often in “melancholic women”; Gendron (1759) saw more cancer in women prone to serious depression and high anxiety; Walshe (1846) found that “misery, sudden reverses of fortune, [and] habitual gloominess” cause cancer; Amussat (1854) found “the influence of grief appears to be … the most common cause of cancer.”76 Bahnson notes that between 1870 and 1890, a surge of “psychosomatic” statements concerning the influence of loss, bereavement, grief, and melancholy on the development of cancer appeared in the literature. Then, in 1926, E. Evans reported on 100 patients with cancer who had been evaluated through intensive psychotherapy. She found that her patients had lost, or had disrupted, a major emotional relationship prior to the development of the disease. Thus, Evans was, according to Bahnson, among the earliest investigators to express a dynamic formulation of cancer.
Bahnson found that psychology and psychoanalysis have developed two major theories about cancer. According to one, loss and depression are potential precursors. According to the second, “a particular personality configuration, characterized by denial and repression as well as by strong internalized control and commitment to social norms, increases the risk of cancer development.” He cites numerous scientific studies that have lent support to the loss- depression hypothesis:
Greene and associates and Schmale and Iker evaluated personality factors in patients with lymphomas and leukemias, and uterine cancer, respectively. These investigators found that severe loss or separation–with concomitant depression, helplessness, and hopelessness–is a characteristic antecedent to the development of these malignancies. With different collaborators, Greene has made carefully analyzed clinical studies and has consistently reported that separation from a significant person or the loss of a major goal, with ensuing depression, were the key psychological factors in the development of reticuloendothelial malignancies.
Bahnson also cites a study by Greene and Swisher showing that among monozygotic twins, the twin that developed leukemia was the one that suffered individual frustration or loss. Two separate investigators, Schmale and Spence, found that they could predict which women with higher-risk cervical cancer biopsies would actually develop cancer based either on a recent history of loss or on a computerized content analysis of words referring to depression and hopelessness in their speech.
LeShan and associates, after working clinically with more than 500 cancer patients, reached a similar conclusion. LeShan emphasized that serious and incapacitating depletion and depression (or, as he calls it, “despair” in the sense of the Danish philosopher Kierkegaard) earmarked these patients who were experiencing insoluble life situations prior to the clinical onset of cancer. He also emphasized that cancer patients-to-be chronically have fragile or nonexistent affective object relations and a basic bleak hopelessness about ever achieving any real feeling or finding true meaning in life.77
Bahnson reports that LeShan and Worthington studied cancer patients and controls with a personal history test and found that cancer patients: (1) “had suffered the loss of an important relationship before the diagnosis,” (2) “had no ability to express hostile feelings,” and (3) “showed tension over the death of a parent, usually an event that had occurred many years previously.”78 Bahnson’s own clinical experience led him to elaborate further a constellation of characteristics he found frequently among cancer patients:
Childhood trauma, loss of close figures, lack of a protected and loving childhood, and parental deprivation and coldness.
An encompassing underlying main affect of hopelessness that colors all experience–the certainty that everything must go wrong, coupled with simultaneous guilt feelings because of self-blame.
A repetition compulsion of self-destructive drives, attitudes and acts, often manifested on anniversaries of other similar or related events.
The development of a double life or double self within which realistic and adaptive ego operations unfold, separated from and independent of a parallel “shadow self” that feels isolated, unloved, hurt and deserted.79
Bahnson concluded that loss in adulthood is especially traumatic and crucial in the lives of cancer patients if they experienced a devastating childhood loss, particularly of parents, and above all if they had a conflicted and unsatisfying relationship with their mothers. The pattern of mistrust and hostility are transferred from the childhood experience into adult relationships, which are therefore precarious, and when the new relationships break down “the original despair and hopelessness of the deprived and longing child reemerge, throwing the individual back on his or her own resources in the face of a renewed insult from the environment. In essence, such persons are left with little hope that any warmth or solace can be obtained from others.”80
Bahnson tested this theory by administering the Roe-Siegel Parent Child Relationship questionnaire to heart patients, cancer patients, and age-matched controls. “We found that cancer patients indeed remembered their parents as more neglecting and cold than do other patients or normal controls.” As a child, according to Bahnson, the isolated cancer patient learned to inhibit the expression of feelings as a way of dealing with cold and conflicted parental relationships.81
C.B. Thomas reinforces Bahnson’s view. In a prospective study of 1,337 medical students looking for predictors of later illness, Thomas and her associates found that “closeness to parents was a powerful factor among various groups. Tumor patients rated lowest on a closeness-to-parents scale, as did mental patients. However, mental patients rated highest, and cancer patients lowest, on matriarchal dominance. Thus of all the groups in this predictive study cancer patients were among the most emotionally deprived with regard to the mother.”82
A prospective study of 2,500 participants in Sweden found that female cancer patients had a tendency toward depression that antedated their cancer. Another prospective study of 2,107 Western Electric employees found a significant correlation between their scores on the depression subscale of the Minnesota Multiphasic Personality Inventory and the later development of cancer.83 Bahnson concluded: “There can be little doubt that a subtle relationship exists between loss and depression and the clinical onset or exacerbation of cancer.”84
This hypothesis, however, does not hold up among other researchers. A recent study found no association between depression and the incidence of cancer, and led Bernard Fox to conclude that, if there was a relationship, it was only in a subset of cancer patients.85 S. Greer and Peter M. Silberfarb, writing in 1982, emphasized the need to study patients with different kinds of cancer separately. They concluded that the “cancer personality” remains elusive:
In ensuing investigations, it is essential to study separately patients with different kinds of neoplastic disease. Systematic controlled studies in this area … demonstrated that men with lung cancer differed systematically from controls with other pulmonary diseases in having restricted outlets for emotional discharge (Kissen, 1963). These results were confirmed in a replication study (Kissen et al., 1969). A subsequent investigation of men with lung cancer revealed that psychological differences between the cancer patients and the controls were most marked among younger men (Abse et al., 1974). This interesting and surprising result was also reported in a controlled study of women with breast cancer: suppression of anger was found to be correlated with the diagnosis of breast cancer, but the correlation reached statistical significance only in women aged under 50 (Greer and Morris, 1975). These authors found no significant association between breast cancer and either extraversion, depression during the preceding 5 years, or the loss of a loved person during their preceding 20 years. The hypothesis linking breast cancer with the previous loss of a major emotional relationship was also refuted in another controlled study by Muslin et al. (1966). … Is there a cancer-prone personality? The question has not been answered conclusively (Fox, 1978), and this remains a fruitful area for further inquiry. … Research workers would do well to heed the warning with which Fox (1978) concludes his comprehensive review of this whole field: “It is, truly, a most difficult type of research.”86
Lydia Temoshok, who did the important studies with malignant melanoma described above, reviewed the literature on “personality, coping style, emotion and cancer” in the search for an “integrative model” of how these factors may affect one another. Her model is important in itself and also because Holland cited her study approvingly in the final section of her chapter, in her authoritative text.87 Temoshok reviewed a large body of literature on the role of psychosocial factors in cancer initiation and progression.
Given this heterogeneity [of the studies], we found it surprising that there were any consistencies in the literature. However, evidence from studies of various designs, using different cancer sites and different measures, converges for the most part on a constellation of factors that appear to predispose some individuals to develop cancer more readily or to progress more quickly though its stages. These factors include (a) personality traits of stoicism, niceness, industriousness, perfectionism, sociability, conventionality and more rigid defense controls, (b) difficulty expressing emotions and (c) an attitude or tendency toward helplessnes<%16>s<%12>/<%0>hopelessness.88
Temoshok developed the concept of a “Type C” behavior pattern which she conceived as “the opposite of Type A behavior shown to be predictive of the development of coronary heart disease”: “Specifically, the Type C individual was hypothesized to be cooperative and appeasing, unassertive, patient, unexpressive of negative emotions (particularly anger), and compliant with external authorities, in contrast to the hostile, aggressive, tense and controlling TypeêA individual.”89 Temoshok described the hypothetical evolution of a Type C coping style through which–as a consequence of genetic dispositions orêfamily interactions–a child learned to cope with the challenges of life by placing the needs of others in front of his own, suppressing negative emotions,êand “being cooperative, unassertive, appeasing and accepting.” This wayêof coping may be socially successful, but the chronic blockage of needs and feelings may exact a high psychobiological toll. “The Type C individual may be seen as chronically hopeless and helpless, even though this is not consciously recognized, in the sense that the person basically believes that it is useless to express one’s needs: the needs cannot or will not be met by the environment.”90
Why should this lead to the development of cancer? Temoshok developed an intriguing response. She proposed that there are basically two human ways of dealing with emotions: by externalizing them or internalizing them. People who internalize emotions would tend in general to develop physical rather than psychological problems under stress. She then suggested that an organism under stress generally seeks to respond to the stress at the highest level of mental organization available to it. If the problem overwhelms mental organization at that level, the organism responds at the next most primitive level. Both Type A and Type C people are prone to internalize emotional responses to stress and thus develop physical problems. But while Type A people prone to heart disease process stressful situations at the mental level of “motivation,” which has as its biological basis the autonomic nervous system and endocrine system, Type C people process stressful situations at a lower level of organization–the mental level of “perception”–which has as its biological foundation immunomodulatory neuropeptides.91
Three things are particularly notable about Temoshok’s model. First, while Temoshok posits a way of responding to stress learned or developed through genetic predisposition in childhood, she avoids the specific hypotheses about childhood loss and subsequent depression that entangled much of the research described previously. She does, it is true, describe the Type C personality as manifesting a learned or genetically predisposed helplessness/hopelessness, but does not posit a specific childhood loss behind it. Second, she writes as a researcher who conducts her work according to norms acceptable to the mainstream of psychooncology. As a result, her views on the role of Type C personality in cancer, while admittedly speculative, are accepted as a plausible way of integrating the wide and disparate body of research in this field. Third, and as a result of the preceding observations, her work has served as a vehicle by which hypotheses relating Type C behavior pattern to cancer incidence and progression–which closely parallel theories previously unacceptable to mainstream researchers–are sanitized, as it were, and enabled to enter the mainstream.
Does Personality Make a Difference in Recovery from Cancer?
It is one thing to wonder whether personality contributes to the incidence or progression of cancer. It is an additional step to consider whether, if personality does indeed appear to affect the progression of cancer, whether a cancer patient can do anything to alter this relationship between cancer and personality, coping style, and emotional expression. I will focus here on the research on whether or not any generalizations can be made about successful psychological responses to cancer. Greer and Silberfarb summarized the research in 1982. They found:
1. A flawed prospective study of different kinds of cancer by K.M. Stavraky revealed the most favorable outcomes in a group of patients who “differed strikingly from all others in its high proportion of individuals who had strong hostile drives without loss of emotional control.” This personality profile, the authors point out, is the antithesis of the “hopeless” or “giving-up” reaction.
2. A study by A.D. Weisman and J.W. Worden that followed a series of patients at Massachusetts General Hospital with malignant melanoma, Hodgkin’s disease, and lung, breast, and colon cancer: “They found that long survivors had closer personal relationships, were less emotionally distressed, regarded their physicians as more helpful, complained less and coped better with illness-related problems than was the case among short survivors.”92
3. A contrasting study of metastatic breast cancer patients at Johns Hopkins Hospital, in which L.R. Derogatis found that long-term breast cancer survivors showed “more emotional distress (anxiety, depression, guilt, hostility), poorer adjustment to their illness and more negative attitudes toward their physicians.”93
Greer conducted his own, now famous, study which prospectively followed women with early breast cancer treated by simple mastectomy with or without postoperative radiotherapy for 5 years. Their psychological response to breast cancer was analyzed 3 months after surgery by a structured interview:
From an analysis of the patients’ verbatim statements, it proved possible to group their psychological responses in 4 broad categories: denial, fighting spirit, stoic acceptance, and helplessnes/hopelessness. Patients’ psychological responses at 3 months were found to be related to outcome 5 years after operation: a favorable outcome (recurrence-free survival) was significantly more common among patients whose initial responses had been fighting spirit or denial than in patients who showed either stoic acceptance or a helples/hopeless response.94
The finding that women showing “fighting spirit” or “denial” had better outcomes than “stoic” or “helpless” women was confirmed again at the 10-year follow-up. Using the same measurement tools, DiClemente and Temoshok found stoic acceptance in women and helplessness/hopelessness in men to be predictors of progression in melanoma 18 to 29 months after diagnosis. A half-dozen other studies cited by Temoshok found similar patterns in patients with cervical cancer, uterine or ovarian cancer, breast cancer, and (for men) the incidence of cancer in general.95
A public furor in this usually erudite research broke out in 1985 when Barrie R. Cassileth, Ph.D., of the University of Pennsylvania Cancer Center, pub- lished an article in the New England Journal of Medicine reporting that personality factors–and, indeed, all psychosocial factors–found to predict longevity in the general population did not affect survival in two groups of high-risk cancer patients. One group of 204 patients with advanced malignant disease was followed to determine length of survival. A second group of 155 patients with stage I or II melanoma or stage II breast cancer were followed to determine time to relapse. Cassileth measured psychosocial factors that included social ties, job satisfaction, drug use, life satisfaction, subjective view of adult health, hopelessness/helplessness, and perception of the adjustment needed to cope with the cancer diagnosis. She did not find that any of these factors affected length of survival or time to recurrence of the disease. “Our study of patients with advanced, high-risk malignant diseases,” reports Cassileth, “suggests that the inherent biology of the disease alone determines the prognosis, overriding the potentially mitigating influence of psychosocial factors.” Cassileth’s study, by her own admission, did not “address the possibility that psychosocial factors or events might influence either the cause of disease or the outcomes for patients with more favorable cancer prognoses.”96
The editor of the New England Journal of Medicine used Cassileth’s article as a springboard to launch a broad attack against those who claimed that psychological factors might influence outcomes with cancer. This attack, in turn, was picked up by the press and widely disseminated as the Journal’s swipe against all supporters of mind-body approaches to cancer and other life-threatening illnesses. Supporters of mind-body research responded with a barrage of letters to the Journal, most of them not published, criticizing the methodology of the Cassileth study or the inferences drawn in the editorial, for drawing, in Temoshok’s words, “conclusions that were not based on evidence from a burgeoning literature in psychosocial oncology and psychoneuroimmunology.”97 Temoshok also pointed out that with the exception of some hotly debated studies by Grossarth-Matticek, there were not yet “[any] published studies … that have attempted to change emotional expression experimentally, and thereby beneficially alter the course of cancer (although a few such studies are underway).”98
The new classic resource in this field is Spontaneous Remission: An Annotated Bibliography, by Brendan O’Regan and Caryle Hirshberg of the Institute of Noetic Sciences. At the start, the authors quote the renowned cancer researcher Lewis Thomas:
The rare but spectacular phenomenon of spontaneous remission of cancer persists in the annals of medicine, totally inexplicable but real. … No one has the ghost of an idea how it happens. Some have suggested the sudden mobilization of immunological defense, others propose that an intervening infection by bacteria or viruses has done something to destroy the cancer cell, but no one knows. It is a fascinating mystery, but at the same time a solid basis for hope in the future: If several hundred cancer patients have succeeded in doing this sort of thing, eliminating vast numbers of malignant cells on their own, the possibility that medicine can learn to accomplish the same thing at will is surely within the reach of imagining.99
Thomas spoke of “several hundred” cancer patients who had achieved spontaneous remissions, but in fact O’Regan and Hirshberg found more than 1000 articles in the world medical literature describing spontaneous remissions of cancer–often with reference to multiple cases. And, of course, these are only the published reports: conservatively, one would have to surmise that the people whose cases of spontaneous remission are not reported outnumber those reported by at least 10 to 1.
This master work by O’Regan and Hirshberg summarizes all the studies of spontaneous remission, categorizes the types of cancer for which remissions were reported, and describes the possible explanations for these remissions. Possible explanations on the list include fevers, infections, psychospiritual techniques, meditation, diet, Chinese herbs, and numerous other factors.
My inclination is to see spontaneous remissions of cancer not as an isolated phenomenon, but as the most dramatic endpoint of a continuum in many types of cancer in which a wide variety of mechanisms of self-repair may operate even as the malignancy works to turn the tide of battle the other way. I believe that the differential efficacy of these mechanisms of self-repair may help explain why, in so many cancers, there is such a wide variation in life expectancy. So I read the literature on spontaneous remissions not only with an interest in what may cause complete and lasting remissions but also for hints on what may cause partial remissions and life extension.
One article by Yujiro Ikemi and his associates at Kyushu University in Fukuoka, Japan, describes SRC (spontaneous regressions in advanced cancer). During a research trip to Japan, I visited Ikemi and spoke with him and his associates. They have published reports on five well-documented cases of SRC “among many possible SRC cases in the Fukuoka area.” They have since collected numerous additional cases. Their cases make fascinating reading.
A 64-year-old man with a histologically confirmed cancer of the upper right jaw refused all medical treatment. A Shinto preacher, he felt that “this is God’s will and I have no complaint about it. Whatever should happen will just happen.” Ikemi reports:
Ten days after the “sentence of cancer,” he visited the president of the religious organization who said to him: “Remember that you are an invaluable asset for our church.” This made him feel very happy and he shed tears of joy all the way back home. Since this moving experience, his hoarseness began to improve. … Today Dr. F. says: “The cancer of this patient seems to be practically cured. When I looked into the vocal cord through the laryngoscope, the tumor was gone.”
An 81-year-old church worker was diagnosed with a histologically confirmed tubular adenocarcinoma. Surgery was recommended but he declined:
When he was told that he had cancer at the age of sixty-six and gastrectomy was suggested, he summoned a family council. He told his relatives that he wished to serve God as long as he lived, and that he would be satisfied if his life was taken away when God so wished, and that he did not want to undergo surgery but wanted to continue his usual life with his daily work and sake (a Japanese alcoholic beverage made from rice.) All the relatives approved of him. Since this time on, he complained less of symptoms of the stomach and worked as usual.
A 39-year-old housewife with extensive metastatic stomach cancer underwent a gastrectomy as a palliative operation but the metastases remained and the surgeon estimated her survival at 1 to 3 months. Nine years later, the woman was well at the time of Ikemi’s report. The woman said:
Frankly speaking, I was not afraid of cancer. That was because I had my religious faith. But without it, I would have given in to the fear of cancer. Now I am very grateful to my friend’s mother who persuaded me to have this faith. … I suffered from cancer … before reaching what is called “the cancer age.” Because of this, I was forced to an early mental awakening. I had been a stubborn person and I felt I had my corners rounded off by having cancer. Faith is to me not the attachment to life, just wishing to be saved, but it is theêgratitude to God who saved my spirit. I have begun to live a real life since that time.
A 77-year-old man was diagnosed when he was 47 with a rectal cancer perforating the wall of the rectum. He declined surgery for economic reasons, and for 30 years has had no symptoms of rectal cancer: “When he was diagnosed,” reports Ikemi, “he was not shocked, he says. … He learned that he had to pay 100,000 for surgery from his own pocket. He had no one to turn to to borrow that amount of money, so he decided that he would work hard as long as he could live even if it meant a year or two. He says that his Buddhist father served as a big support during those trying years. He has been unconcerned about worldly ambitions.”
A 63-year-old farm wife was diagnosed at 58 with histologically confirmed extensive metastatic adenocarcinoma of the stomach. Palliative surgery was performed and she was given 1 to 3 months to live. The patient had worked extremely hard all her life on the farm. Reports Ikemi, “A drastic change took place in her pattern of life since she became ill. Before surgery she led a life of sacrifice for the family as mentioned above, while after surgery the attitude of the whole family has been very considerate and kind toward her. She was set free from many years of a self-sacrificing way of life, and was now protected by the love of the family.”
The authors conclude that what their cases have in common is that these patients “suffered cancer under more or less severe existential crisis and seem to have overcome cancer by accepting the responsibility for resolving such a crisis for themselves.” Second, “their psychological state at the time of `a sentence of death’ is the absence of anxious and depressive reactions. … All five of our patients completely committed themselves to the fate or the will of God.” Third, “in all five cases, the dramatic change of an outlook on life has been observed, which resulted in the reconstruction of the patient’s relationship with his human environment.”100
One other study of spontaneous remissions was reported by Daan C. van Baalen and Marco J. de Vries of Erasmus University, Rotterdam. The authors identified seven SRC cases over a period of 19 months. Their success in finding these cases led them to believe “that SRC is a more common phenomenon than currently accepted.” They then compared the behavioral characteristics of six of these patients with six patients suffering from advanced progressive cancer by comparing transcripts of in-depth interviews. Having identified what they regarded as key differences between the SRC cases and the progressive cancer cases, they gave the transcripts to six raters and asked them to score the transcripts independently for the eight characteristics that the authors believed differentiated the SRC cases from the progressive cancer cases.
Of all the patients, two (both SRC cases) had a tendency to deny that they had cancer. Said one: “I am a practical woman and I never want to know what I am suffering from.” [You will recall that denial, along with a fighting attitude, was one of the predictors of longer survival among Greer’s breast cancer patients.] In the behavioral sphere, the SRC patients were much more likely to make changes as a result of the cancer diagnosis, and the most common shift was in diet: five of the six SRC cases changed their diet by increasing food intake, paying more attention to the quality of food, or starting a specific diet, including diets prescribed by alternative medicine practitioners. By contrast, the progressive cancer patients were more likely to resist change.
In the sensory sphere, four patients reported altered perceptions of the world, and all four were part of the SRC group. Said one: “I could see the people around me so incredibly vividly … I heard what they said so much more clearly than in the past. Faces, expressions, everything was magnified in much more detail … like, gosh, how beautiful life can be.”
One of the most significant differences was in the area of hopelessness and depression: “All SRC patients had profound fluctuations of mood around the time of tumor regression. They experienced periods of depression and hopelessness alternating with shifts toward an attitude of hope. The PRC [pro- gressive cancer patients] showed less changes in mood.”
In the sphere of autonomy, “all six SRC patients demonstrated a shift from dependence and helplessness towards autonomy or increased autonomy. … PRC patients had in general a greater tendency to comply with their doctors, partners and/or family than SRC patients.”
In their cognitive lives, SRC patients had greater shifts in their concepts about cancer than PRC patients. Said one SRC patient: “Everybody knows that one dies of cancer, but I was not sure whether to apply this to myself. I considered this (common belief) as nonsense.”
In the area of changes in existential perspectives on life, “all SRC patients indicated that they had experienced a more or less radical existential shift.” One, who had feared sharing a home with a man, and had thus experienced many broken relationships, dropped her studies and went to live with a man. Another previously well-behaved housewife began to curse her husband and swear obscenely at him. Said a third: “From the moment I got cancer I really began to live. I became much more gentle with other people. I did not judge people too soon. I enjoyed the time I had been given to turn into myself, attend to what I am essentially doing, what I am going to make of my life.” Two of the six PRC patients also experienced important existential shifts.
In the area of social support, five of the six SRC patients experienced transformations in their support systems, while only two of the PRC patients did. In four of the five cases the relationships with spouses and family became more caring, and in three the SRC patients also became more demanding in a way that was ultimately accepted by the family. Only two of the six PRC cases experienced similar shifts.
The study has been criticized methodologically for obvious reasons, but I believe the criticism ignores the ingenuity of the approach and the potentialêsignificance of the findings. Acknowledging the limitations of this small retrospective study, the authors conclude that the results of their study suggest that there may be significant differences between the psychological history ofêpatients who have a spontaneous regression of cancer and other cancer patients:
The most significant correlates of SRC seem to be behavioral and sensory changes and shifts along the depression and autonomy axes. However, also belief and trust in medical procedures, among them alternative medicine, shifts in mental constructs about cancer and its treatment, existential shifts and improvement of social support and the quality of interpersonal relationships are significant. …
The generally high scores of SRC patients [on depression] seem to suggest that allowing oneself to experience depression temporarily, rather than repressing such a state or staying in a depression, is associated with SRC. …
Existential shifts may not be in a direction commonly regarded as “positive,” such as an increased experience of meaning in life and so-called spiritual or religious conversions. This is demonstrated by two of our patients. Their existential shifts could easily be misinterpreted as “negative” in the sense of aggressiveness and being obnoxious.101
So after reviewing all this research and clinical work–much of it conflicting–what are the basic clues we are left with for cancer patients considering psychological work at present?
If I were to advise a friend, I would do so this way: “First and foremost,” I would say, “because human healing systems are both complex and varied, each individual has his or her own unique personality and unique developmental history. As a result, the `optimal’ therapeutic strategy will vary from patient to patient and from therapist to therapist. Therefore, choose the therapies that seem to fit you best but do consider finding some way to enhance your psychobiological healing potential.” With that fundamental thought in mind, I would make the following suggestions:
Acute stress is known to enhance tumor growth in many animal experiments and probably does the same thing in some human cancers although we have evidence to the contrary as well. Nevertheless, I would recommend reviewing the major negative stress factors in your life and eliminating as many as you can. Look into stress reduction techniques–such as progressive muscle relaxation, meditation, hypnosis, and imagery–and see if they are helpful to you. Work psychologically to reach an inner state where you can carry the stresses of illness and life less heavily. These relaxation techniques are used both to enhance the quality of life and the possibility of life extension. Meares and Newton, for instance, believe the best outcomes are often associated with the capacity to enter into and practice a deep and simple meditative state. This is a teachable capacity.
Social support also seems to be an enormously beneficial factor both for quality of life and perhaps for increasing longevity, as well. Consider strengthening your social support system, which may or may not include an organized cancer group. Be sure you choose supports that are personally meaningful to you.
There are a wide range of behavioral or psychological techniques for reducing the side effects of cancer treatment and the discomfort of the disease itself, such as pain, weight loss, and sleeplessness. Make contact with a psychooncologist or other psychothera- pist and see what he has to offer.
Whether there is a “cancer personality” or behavior pattern–a personality that makes a person more likely to develop cancer or more likely to have it progress rapidly–remains debatable, but there is some consensus among researchers and clinicians that has led to credible hypothetical models. The implications from Temoshok’s study are that learning to increase the capacity for emotional expression–especially anger–may mitigate the progress of cancer. Studies by Greer and Silberfarb and others suggest that interventions that reduce the sense of “helplessness/hopelessness” may also extend life. Individual or group psychotherapy can be of help here. If you feel you fall into some part of the hypothetical “cancer personality” or behavior pattern, look into what psychotherapeutic help may be available.
The literature on spontaneous remissions from cancer offers an intriguing window on psychological attributes that may play a role in some recoveries from cancer.
LeShan would say that a person with a personality that enables him to engage in the fight for life, to seek out and vigorously begin to engage with “finding your own song,” would in general have a better prognosis than a person who could not fight for life or find a real reason to do so. Psychotherapy–either individual or group–is certainly a reasonable approach to the critical process of individuation.
Achterberg and the Simontons have both associated better outcomes with a capacity for vivid visualization of a strong immune system overcoming a weaker cancer. This is usually a teachable capacity.
Research and clinical experience on psychological approaches to cancer make it clear that simplistic positions in this field are not tenable. We know that psychological practices can greatly enhance quality of life with cancer. We do not know whether, or to what degree, or in what cancers, or with what kinds of people, psychological practices extend life with cancer.
Skeptical scientists can still legitimately say that the evidence in support of the position that psychological interventions extend life with cancer is still not at all conclusive. But if you review the existing scientific, clinical, and popular literature, you can find ample support for a personal decision to fight for life using every psychological resource you have.
1 Robert Ader, David L. Felten, and Nicholas Cohen, eds., Psychoneuroimmunology, second edition (San Diego: Academic Press, 1991), xxv.
2 Bernie S. Siegel, M.D., Love, Medicine, and Miracles: Lessons Learned About Self-Healing from a Surgeon’s Experience with Exceptional Cancer Patients (New York: Harper & Row, Publishers, 1988).
3 Lawrence LeShan, Cancer as a Turning Point: A Handbook for People with Cancer, Their Families, and Health Professionals (New York: E.P. Dutton, 1989). Copyright © 1989 by Lawrence LeShan, Ph.D. Used by permission of Dutton Signet, a division of Penguin Books USA Inc.
4 O. Carl Simonton, Stephanie Matthews-Simonton, and James Creighton, Getting Well Again: A Step-by-Step Guide to Overcoming Cancer for Patients and Their Families (New York: Bantam Books, 1978). Copyright © 1978 by O. Carl Simonton and Stephanie Matthews-Simonton. Used by permission of Bantam Books, a division of Bantam Doubleday Dell Publishing Group, Inc.
5 Joan Borysenko, Ph.D., Minding the Body, Mending the Mind (Reading, MA: Addison-Wesley Publishing Company, Inc., 1987).
6 Jimmie C. Holland, “Historical Overview” In Jimmie C. Holland and Julia H. Rowland, Handbook of Psychooncology (New York: Oxford, 1989), 11.
7 Julia H. Rowland, “Developmental Stage and Adaptation: Adult Model.” In ibid., 25.
8 Ibid., 25-42.
9 Julia H. Rowland, “Intrapersonal Coping.” In ibid., 44-5.
10 Julia H. Rowland, “Intrapersonal Resources: Social Support.” In ibid., 59.
11 Ibid., 65.
12 Jimmie C. Holland, “Stresses on Mental Health Practitioners.” In ibid., 680.
13 Rene Mastrovito, “Behavioral Techniques: Progressive Relaxation and Self-Regulatory Therapies.” In ibid., 492.
14 William H. Redd, “Management of Anticipatory Nausea and Vomiting.” In ibid., 423.
15 T.G. Burish, et al., “Behavioral Relaxation Techniques in Reducing Distress of Cancer Chemotherapy Patients,” Oncology Nursing Forum 10:32-5 (1983). Abstract cited in Steven E. Locke, Psychological and Behavioral Treatments Associated with the Immune System: An Annotated Bibliography (New York: Institute for the Advancement of Health, 1986), 234.
16 Redd, in Holland and Rowland, Handbook of Psychooncology, 429-430.
17 D.F. Campbell et al., “Relaxation: Its Effect on the Nutritional Status and Performance of Clients with Cancer,” Journal of the American Dieticians Association 4:201-4 (1984). Abstracted in Locke, Psychological and Behavioral Treatments, 235.
18 J. Cannici et al., “Treatment of Insomnia in Cancer Patients Using Muscle Relaxation,” Journal of Behavioral Therapy and Experimental Psychiatry 14:251-6 (1983). Abstracted in Locke, Psychological and Behavioral Treatments, 235.
19 Mastrovito, in Holland and Rowland, Handbook of Psychooncology, 496-7.
20 Ibid., 498.
21 Daniel P. Brown and Erika Fromm, Hypnosis and Behavioral Medicine (New Jersey: Lawrence Erlbaum Associates Publishers, 1987), 135.
22 Yehuda Shavit, “Stress-Induced Immune Modulation in Animals: Opiates and Endogenous Opioid Peptides.” In Ader, Felton, and Cohen, Psychoneuroimmunology, 789-90.
23 Janice K. Kiecolt-Glaser and Ronald Glaser, “Stress and Immune Function in Humans.” In ibid., 854.
24 Shavit. In ibid., 791.
25 Ibid., 793.
26 Ibid., 795-6.
27 Kiecolt-Glaser and Glaser. In ibid., 850.
28 Ibid., 851.
29 Jimmie C. Holland, “Behavioral and Psychological Risk Factors in Cancer: Human Studies.” In Holland and Rowland, Handbook of Psychooncology, 717.
30 Rowland, “Developmental Stage and Adaption: Adult Model.” In ibid., 69.
31 Holland,”Behavioral and Psychological Risk Factors in Cancer: Human Studies.” In ibid., 720-1.
32 Lydia Temoshok, “Biopsychosocial Studies on Cutaneous Malignant Melanoma: Psychosocial Factors Associated with Prognostic Indicators, Progression, Psychophysiology, and Tumor-Host Response,” Social Science and Medicine 20(8):833-40 (1985).
33 A.J. Cunningham, “Psychotherapy for Cancer,” Advances 1(4):8-14 (1984). Abstracted in Locke, Psychological and Behavioral Treatments, 223.
34 A. Meares, “What Can the Cancer Patient Expect from Intensive Meditation?” Australian Family Physician 9:322-5 (1980). Abstracted in Locke, Psychological and Behavioral Treatments, 228-9.
35 Ibid., 230.
36 O.C. Simonton, S. Matthews-Simonton, and T.F. Sparks, “Psychological Intervention in the Treatment of Cancer,” Psychosomatics 21:226-33 (1980). Abstracted in Locke, Psychological and Behavioral Treatments, 232.
37 A.J. Cunningham, “From Neglect to Support to Coping.” In C.L. Cooper, ed., Stress and Breast Cancer (New York: John Wiley & Sons, 1988), 148.
38 Janny Scott, “Study Says Cancer Survival Rises with Group Therapy,” Los Angeles Times, 11 May 1989.
39 David Spiegel, “A Psychosocial Intervention and Survival Time of Patients with Metastatic Breast Cancer,” Advances 7(3):10-19 (Summer 1991).
40 J.R. Marshall and D.P. Funch, “Social Environment and Breast Cancer: A Cohort Analysis of Breast Cancer,” Cancer 52:1546-50 (1983). Cited in Holland and Rowland, Psychooncology, 713-4.
41 Ibid., 713.
42 L.F. Berkman and S.L. Syme. “Social Networks, Host Resistance, and Mortality: A Nine-year Follow-up Study of Alameda County Residents,” American Journal of Epidemiology 109:186-204 (1979). Cited in ibid., 714.
43 Holland, “Behavioral and Psychological Risk Factors in Cancer: Human Studies.” In Holland and Rowland, Handbook of Psychooncology, 723.
44 Fawzy I. Fawzy et al., “A Structured Psychiatric Intervention for Cancer Patients,” Archives of General Psychiatry 47:720-35 (1990).
45 Fawzy I. Fawzy et al., “Malignant Melanoma: Effects of an Early Structured Psychiatric Intervention, Coping, and Affective State on Recurrence and Survival 6 Years Later,” Archives of General Psychiatry 50:681-9 (1993).
46 LeShan, Cancer as a Turning Point, 21.
47 Ibid., 6-7.
48 Gendron (1759). Cited in ibid., 7-8.
49 Walter Hoyle Walshe (1846), The Nature and Treatment of Cancer. Cited in ibid., 8.
50 Willard Parker (1885). Cited in ibid., 9.
51 LeShan, ibid., 11-3.
52 Ibid., 22.
53 Ibid., 22-3.
54 C.J. Jung, quoted in Russell A. Lockhart, “Cancer in Myth and Dream.” In James Hillman, ed., An Annual of Archetypal Psychology and Jungian Thought (Spring 1977), 2.
55 Matthews-Simonton, Simonton, and Creighton, Getting Well Again, 144-5.
56 Ibid., 148-9.
57 Ibid., 154.
58 Ibid., 155-6.
59 Ibid., 158-9.
60 Martin L. Rossman, Healing Yourself: A Step-by-Step Program for Better Health Through Imagery (New York: Walker and Co., 1987), 71.
61 Ibid., 14.
62 Ibid., 81-2.
63 Ibid., 88.
64 Ibid., 137-41.
65 Jeanne Achterberg, Imagery in Healing: Shamanism and Modern Medicine (Boston: New Science Library, Shambala, 1985), 188-9.
66 Brown and Fromm, Hypnosis and Behavioral Medicine, 2.
67 Ibid., 34.
68 Ibid., 140-3.
69 Bernauer W. Newton, “The Use of Hypnosis in the Treatment of Cancer Patients,” American Journal of Clinical Hypnosis 25(2-3):105-7 (1982-3).
70 Ibid., 110-1.
71 Ainslie Meares, “A Vivid Visualization and Dim Visual Awareness in the Regression of Cancer in Meditation,” Journal of the American Society of Psychosomatic Dental Medicine 25:85-8 (1978). Abstracted in Locke, Psychological and Behavioral Treatments, 227.
72 Linda R. Bridge et al., “Relaxation and Imagery for Breast Cancer Patients,” Advances 6(2):28-30 (1989).
73 Brown and Fromm, Hypnosis and Behavioral Medicine, 32-3.
74 Newton, “The Use of Hypnosis,” 108-9.
75 Claus Bahne Bahnson, “Stress and Cancer: The State of the Art,” Psychosomatics 21(12):975 (1980).
77 Ibid., 976.
79 Ibid., 977-8.
80 Ibid., 978.
81 Ibid., 979.
82 C.B. Thomas, K.R. Duszynski, and J.W. Shaffer, “Closeness to Parents and the Family Constellation in a Prospective Study of Five Disease States: Suicide, Mental Illness, Malignant Tumor, Hypertension, and Coronary Heart Disease,” Johns Hopkins Medical Journal 134:251-270 (1974). Cited in ibid., 979.
83 Ibid., 979-80.
84 Ibid., 980.
85 Bernard H. Fox, “Depressive Risk and Symptoms of Cancer,” Journal of the American Medical Association 262(9):1231 (1989).
86 S. Greer and Peter M. Silberfarb, “Psychological Concommitants of Cancer: Current State of Research,” Psychological Medicine 12:567-8 (1982).
87 Holland, “Behavioral and Psychological Risk Factors in Cancer: Human Studies.” In Holland and Rowland, Handbook of Psychooncology, 722-3.
88 Lydia Temoshok, “Personality, Coping Style, Emotion and Cancer: Towards an Integrative Model,” Cancer Surveys 6(3):545-67 (1987).
89 Ibid., 548.
90 Ibid., 559-60.
91 Ibid., 560.
92 Greer and Silberfarb, “Psychological Concommitants of Cancer,” 568.
94 Ibid., 569.
95 Temoshok, “Personality, Coping Style, Emotion and Cancer,” 547.
96 Barrie R. Cassileth et al., “Psychosocial Correlates of Survival in Advanced Malignant Disease,” New England Journal of Medicine 312(24):1551-5 (1985).
97 Temoshok, “Personality, Coping Style, Emotion and Cancer,” 546.
98 Ibid., 552.
99 Lewis F. Thomas, The Youngest Science: Notes of a Medicine Watcher (Viking Press, 1982, 205) cited in Brendan O’Regan and Caryle Hirschberg, Spontaneous Remission: An Annotated Bibliography (Sausalito, Calif.: Institute of Noetic Sciences, 1993), 1.
100 Yujiro Ikemi et al., “Psychosomatic Consideration on Cancer Patients Who Have Made a Narrow Escape from Death,” Dynamische Psychiatrie 8:77-93 (1975).
101 Daan C. van Baalen, Marco J. de Vries, and Marjolein T. Gondrie, “Psych-Social Correlates of `Spontaneous’ Regression in Cancer.” Monograph, Department of General Pathology, Medical Faculty, Erasmus University, Rotterdam, The Netherlands, April, 1987.