AGGRESSION AND CANCER IN GROUP TREATMENT
Louis R. Ormont, Ph.D.
Director, The Center for the Advancement of Group Studies, New York;
Clinical Professor, Gordon Derner Institute for Advanced Psychotherapy, Adelphi University
E-mail: ormont-mm@msn.com
This article was originally published in Psychotherapeutic Treatment of Cancer Patients, Goldberg J. (Ed.), 1981, New York: The Free Press, pp. 207-227
January, 2001
Louis R. Ormont, Ph.D.
Director, The Center for the Advancement of Group Studies, New York;
Clinical Professor, Gordon Derner Institute for Advanced Psychotherapy, Adelphi University
E-mail: ormont-mm@msn.com
This article was originally published in Psychotherapeutic Treatment of Cancer Patients, Goldberg J. (Ed.), 1981, New York: The Free Press, pp. 207-227
January, 2001
Every practitioner is familiar with examples of what J. B. Cannon called “wisdom of the body." The patient with a somatic problem knows without knowing. The unconscious holds vast stores of information which communicates hieroglyphically and indirectly. This information may remain meaningless if untranslated and yet manifest itself in bodily reactions.
The thesis that emotions and cancer are related is neither novel nor startling. For centuries, the role that grief, frustration and despair play in neoplasms has impressed many outstanding physicians. In 1870, Sir James Paget1, the great oncologist of his day, wrote that deferred hope, disappointment, and deep depression were followed by an increase in cancerous tissue. Others - Cutter2, Hughes3, Snow4 - went beyond a positive correlation; they were convinced that "mental depression" was the direct cause of a cancer.
These clinical observations lay fallow because there was little physicians could offer their patients beyond reassurance and a regimen of diet, rest, and relaxation.
The treatment challenge was taken up by the cellular specialists. With microscopes, x-ray machines, and chemicals, they attacked the malignancies. Great advances were made in the local destruction of neoplasms. The total organism within which the cell resided with its neural and hormonal systems received scant attention.
However, each time they identified a specific cause-effect relationship, specialists found they had to account for some annoying fact. For example, their research demonstrated that tobacco was directly implicated in lung cancer. Yet only a small fraction of the addicted smokers developed a malignancy.
The specialists attacked the problem anew. Every year they stumbled on additional precipitants of lung cancer. Why, with so many people exposed to so many different kinds of irritants, did so few develop lung cancer?
Early in the twentieth century, theoreticians began an energetic search for a framework that would account for the bewildering array of facts. The result was the hormonal-immunological theory.
This construct starts with the assumption that the body is always turning out defects due to faulty constitution, viruses, or pollutants. Fortunately, its defense system has a way of detecting maverick mutants and destroying them. But stress disrupts this detection and protection process; the body cannot correct the imbalanced physiology. The defective cells are free to reproduce themselves at random. This theory was supported by the observation that a cancer patient has weaker immunological defenses than the average person; his body cannot quickly and effectively destroy defective cells.
During the 1950's, Hans Selye5 and others mustered enough data to support the contention that emotional tensions may act as stressors. Such emotional states as depression and disappointment can exhaust the adrenal gland. It is no longer able to produce the hormones the body needs to prime the immunological response. If the exhausted gland does manage to send out signals, they are inadequate or misleading.
At this point, any of a number of carcinogenic precipitants can set off a toxic train of reactions. The over stressed system cannot monitor mutant ells or neutralize invading substances. Parasitic penetration, chemical and pollutant contamination, or ionizing radiation can do deadly damage to the vulnerable cellular tissues.
This finding was corroborated by experiments on healthy subjects. Cancer cells died when implanted under the skin of vital and vigorous subjects [Boyd, 1957]6. Even if these subjects did develop foci of neo plasia, they contained them and held them in check. It appeared, therefore that the nineteenth century surgeons were right. Emotions do influence the body's defenses.
However, long before the physiologists constructed their immunological theory, psychotherapists were observing and writing about the psychological implications of organic disease. Therapists had noted that the tendency to somatize develops early in life. Persistent stress during the developing years or a psychic trauma could lead to a life-long tendency toward organic expression of tension.
But psychoanalysts had hit-and-miss results with their efforts to reverse the tendency to channel tensions into the body. Investigating and analyzing the emotional states of despair, hopelessness, and their noxious cousins did not guarantee desirable results.
It emerged that an underlying drive was being neglected: aggression. But knowing this fact and doing something about it were two different things. Psychoanalysts had a method of treating the effects of disordered love but not the effects of primal rage. Even uncovering this hatred was often a formidable task. Patients tenaciously held on to their acceptable social feelings.
Should the rage well up, many therapists found it difficult and frightening to confront the patient, and with good reason. First of all, an angryspeaking patient could turn into an angry-acting one. Secondly, the patient's hatred induced unacceptable counter-hatred in his therapist. The prevailing opinion was that psychotherapy could do little with irrational anger. Psychiatrists resorted to palliative drugs to keep the obstreperous patient calm. Failing that, the patient was committed to an asylum.
A new set of constructs with new attitudes was needed. Sparked by the insights of Winnicott (1958)7, Searles (1967) 8, Alexander (1948) 9, Rado (1956)10, and Spotnitz (1976)11, investigators began to use their own feelings to investigate what patients were experiencing. They used these feelings to reconstruct the past, which their patients could not recall. With these feelings they penetrated deeply into the embalmed years from birth to age two. The early psychological stimulus and physiological responses were directly related to each other. Psychosomatic patterns could be pinpointed and studied. They illustrated that people's fantasy life, distorted self and body images, primitive defenses, and unmet maturational needs played a critical role in the development of schizophrenia and organic illness.
The developmental pieces began to fall into place. Either through inherited predisposition or defective mothering, certain children are especially vulnerable during their earliest years. They cannot convert drives and tensions into identifiable feelings. Their psyches can only express these tensions along the most primitive paths of communication - through body language, symbolic gesture, frozen attitudes, and the like.
The thwarting and frustration that these people experience eventually culminate in all shades of aggression. But it is a rage that cannot be expressed. In their minds, this aggression is capable of destroying the people they need for survival.
Finding no outlet for this aggression, they turn it against themselves. Such a redirection of energy raises further havoc with the way the body functions. Our physical being becomes the target of every unexpressed and unacknowledged negative feeling. Our denied drives become expressed as physical symptoms, which can range from a canker to cancer.
Research Evidence of the Somatic Effects of Aggression
The ravaging effects of unexpressed aggression have been observed by many researchers. Cobbs (1954)12 found that conflicts around the discharge of activity were high among those with cancer-susceptible personalities. Passivity inhibits the release of anger, even under dire conditions.
Bacon et al. (1952)13 found a facade of pleasantness in many women with carcinoma. This masked an inability to deal effectively with their aggressive impulses, as well as those of others. The victims felt resigned to an inverted expression of rage in the form of "passive suicide."
Kissen and Eysenck (1962)14 found that certain people who tended to "bottle-up" emotional difficulties also tended to contract cancer.
LeShan and Worthington (1955)15 observed that cancer-prone personalities tend to push down feelings of hostility rather than bring them to the surface and work them through. They suggested that this tendency lowers resistance to a malignancy.
LeShan (1966)16 noted again that one condition predisposing to cancer was the inability to use aggression as a self-protective tool. Envy, jealousy, competition, and resentment are squelched. The person, unable to find an interpersonal outlet for these emotions, comes to feel lonely and unloved.
Goldfarb et al. (1967)17 connected this inability to express hostility with the "hopeless-helpless syndrome." Because the victims think their condition unsalvageable, they allow themselves to sink into a bottomless despair. Electroshock therapy, aimed at clearing up the depression, often led to a remission of the neoplasm. They concluded that depression affects the immunological system. Depression is classically defined as aggression directed at oneself.
Simonton and Simonton (1975)18 confirmed that a predisposing condition for cancer was a marked tendency to hold back resentment. They also noted such correlates of stunted aggression as self-pity and a poor selfimage.
Mode of Attack
Such findings lead us to ask: How can psychosomatically entrenched aggression be approached, released, and resolved?
Modern psychoanalysts, especially Spotnitz (1969)19 offer an approach to the problem. First they deal with the way the person defends himself against the awareness and release of aggression. Then they help him redirect this raw energy away from his body, discharge it verbally, harness it at the service of his ego, and creatively sublimate it. This procedure can be applied in any of a variety of treatment modalities. In group therapy we make certain modifications. One is the use of the members as co-therapists.
There are several significant steps the therapist might take. To begin with, we mobilize the group's interest in a member's defense against aggression - the particular way a member wards off awareness of his unacceptable feelings. The aggression is not our initial concern: we are seeking out his protection against knowing he has it. This is no light task. As researchers discovered, cancer-prone people seem to be anything but hostile. They appear even-tempered, genuinely concerned about the comfort of others, friendly, and sometimes bordering on the heroic in their compassion.
Therefore, we spend our early contacts looking for, sensing out, or intuiting the ways a group member denies, represses, or avoids the feelings he senses are present. This may call for a free-floating, detached attention to his behavior or appearance. To the world he may seem no more than compliant, forbearing, or indifferent.
Having identified a member's particular survival mechanism, we do not jump in to change it. Instead, we silently study it. We observe, for example, when he uses his compliant response, how he repeats it, and the different forms it takes under different conditions.
Next we get confirmation concerning the mode of defense used. Other members are asked if they observed the pattern. When does it tend to be used? Can it be described?
After this, we mobilize the group interest in making the member aware of the defense. Members are encouraged not to hammer at the pattern but simply to apprise the person of this piece of his behavior.
We are now in position to separate the covert behavior from the underlying feeling. We encourage an investigation of all possible clues. Why did the member bite his lip and say "yes" when insulted outright? We pay detailed attention to subtly expressed attitudes, to intonation and to facial reactions. Sometimes the feeling emerges as soon as the defense is examined.
Often we have to show how the emotional state passes through the person's barriers. We watch for subliminal signs of leakage. Does the patient sense that his eyes are narrowing while the lower part of his face smiles? Is he aware that there is an edge of anger in his "helplessness?" Are there two messages being expressed at once?
With the softening effect of awareness, the inner world of the member comes to the fore. Now he may admit to inner torture. The despairer openly despairs; the griever grieves. Throughout this stage the member is encouraged to experience the unacceptable feeling.
All the while the members are training him to communicate his experience in words as fully as possible. Words are preferred, as an advance over "skin talk" and other, more primitive methods. Verbalizing establishes new neural pathways, outlets for inner stimuli, and opens up the way for fresh thoughts and ideas.
We want the member to direct his charged words toward a non-recriminating person in the group - one who will not punish or provoke guilt. The ideal target, of course, is the group analyst. His attitude and response can go a long way toward detoxifying devastating feelings.
While the member is struggling with these feelings, he may not acknowledge, or even know, that they are a cover for underlying aggression. Some members, especially prone to organic tension, need a form of communication that will reflect their own emotional state. These reflections help the member maintain his identity while permitting him to allow all his feelings their place. In reflecting, the analyst uses joining, mirroring, extending, role-reversal, devil-advocating, or out-crazying.
The analyst should use the group to do the work. In the following example, the analyst evoked the rage by mirroring it and used the group to mirror it further.
To a complaining woman, the analyst complained that she was taking up too much time with her woes. How could anyone get a word in edgewise? The woman took exception to this implied criticism. She contended that she was complaining only because she had a lot to complain about. What was wrong with the analyst? She proceeded to find fault with him. When he addressed her complaints, reflecting her attitude, she would let loose a stream of criticism. The other group members found the explosions a welcome change from her beseeching behavior. They caught the spirit of the analyst's reflection and began mirroring the member's behavior. Explosive confrontations went on for weeks. What Norman Mailer called "hatred that had never breathed the air of open rage" gave her a sense of personal elation and freedom.
With the aggression made manifest, the analyst encourages the group to investigate the feeling. Our purpose is to uncover erroneous ideas supportive of those emotional states and to plumb the foundations of negative feelings. Aggression can emanate from many sources - from frustration, rejection, abandonment, or counterphobic fear.
Members can help one another learn to tolerate all shades of aggression. They may encourage a new attitude toward it. Ideally, a patient learns to function effectively no matter how intense his irritability may be. Members never let him overlook his intolerance of it. So what if you are mad? Why can't you still speak in a civilized way? What makes you think you have to go into action or use four-letter words? We also have available other methods of intervention such as exploration, suggestion, education, and trial-and-error. Relying on them, we enable the patient to develop leniency toward his own aggression.
We can also relate present patterns to the climate of the patient's early life. The group itself may speculate about the relationship between a freed feeling and a physical symptom in a member. If the member himself cannot discover the crucial connections, the analyst can help him reconstruct the events of his formative years. The analyst can make use of the member's behavior in putting together a picture of his past. The group members, at this stage, become able to help the patient see his own aggression as valuable energy. Within the group setting, they can aid the patient to transform and refine it. For instance, they may show him how to convert anger that was previously destructive into socially acceptable wit, thus cultivating his new-found ability to put his aggression at the service of his best interest.
With the loosening and release of repressed feelings, made possible by the group's response and understanding, there occurs an enormous redirection of energy. The physical symptom loses much of its psychic charge. Then, as the feelings find verbal outlets and begin to abate in intensity and behavior changes, the malignancy seems to lose its virulence.
The Utilization of Group Therapy
Traditionally, the patient who seeks help has done so through individual analysis. This has certain obvious values. There is no better arrangement for searching deeply into the meaning of motives. However, this modality sometimes leaves the therapist with little leverage. His only ally is the patient, who oscillates between defying, drifting from, and denying all attempts to help him experience his emotions. The analyst is often rendered ineffective by the psychosomatically prone patient.
Group therapy has special advantages for working with the organically ill. Ulcer and colitis clubs have been notably successful in alleviating serious pathology. Though this writer has never conducted a group composed exclusively of cancer victims, it is conceivable that a shared setting could achieve the same results.
Group therapy offers a number of advantages so far as prevention is concerned, as it can exert pressure on the neglectful or self-destructive member.
In the following case, the group exercised its influence none too soon.
Some months after a hysterectomy, a woman in group mentioned in passing that she had abdominal discomfort and occasional bleeding. When questioned by certain members, she mentioned that she had not been back to see her gynecologist since the surgery. She brushed away their concern, construing her discomfort as a natural after-effect of her operation. She countered their every question with some seemingly plausible explanation for her torpidity.
However, one alarmed member would not be put off by her evasion and opened up each session with a prodding inquiry. She would promise to look into the matter but did not do so. The member observed, "You probably think something serious is going on. You are wishing it will go away by itself - counting on magic." The prodding member piped in, "I know what's wrong with us. We've been recommending that you go to a doctor. We should have pushed for a magician." A sharp exchange ensued. The next session she reported she had visited her gynecologist and a biopsy was scheduled. There was a malignancy, which, fortunately, was discovered in time.
The members had brought to her awareness the intense nature of her denial. Though she fought the group's reaction to her postponements, she had managed to glimpse the ludicrous nature of her own, endless rationalizations. It was not only this insight but also the release of her own anger that propelled her into taking care of herself. The value of the group was unmistakably evident in this case.
The sensitivity of a group enables it to provide early warnings and to repeat them. The patient with an incipient neoplastic growth is often reluctant to take the initiative in concern with his own health. There is a latent fear that the malignancy is already too advanced to be contained.
Even when the stress is not mentioned by the person, its vibrations can be felt by those who are attuned to the person's unconscious processes. Once these members are alerted to some smouldering crisis, they display uncanny skill in sifting out significant cues. Through their partial identification with the victim, they can often detect the faintest tremors of tension. One member may suspect the tension because of a particular side effect, another perceives it from a very different angle. For instance, the first discerns it in a dream, the second through its effect on an interpersonal exchange. If at times a member dashes off on a false lead, sooner or later another member is likely to call a halt and return the group to the basic track.
The following case illustrates the resilience of a group in its own pursuit.
A member presented the dream wherein termites were constructing a great hill on the plains of Africa. He kept tearing the hill down, but the insects persisted in rebuilding it. The group saw themselves as ants, constantly raising objections to his grandiose vocational schemes. They saw the dreamer as the undaunted builder of castles on the sand. Hearing this, the patient who had the dream lamented loudly that it was true: they were always fouling up his plans. There was a noisy interchange in which some of the interpretations went far afield.
Then a member, a woman with a borderline streak to her personality, expressed a more ominous view of the dream. She felt the hill was inside the dreamer. The termites were cells and were out of control.
At this, the dreamer blurted out that he did have a "funny sore" on his inner thigh that was not healing. A member asked if he had had it looked into. No, he had no physician. He would go to specialists with each body complaint. This was not specific enough. Members assailed him for holding such a negative attitude. By the end of the session he agreed to get a complete physical check-up from an internist. A lymphona was found, which could be contained.
By its understanding, empathy, and suggestion, a group can exert enormous effect. It provides an antidote to isolation. Perhaps its greatest asset for the organically ill is that it provides objects toward which the patient can direct strong feelings. The patient receives supportive acceptance within the group while he works through his conflicts. The consistency with which many members see that a person is doing is likely to provide him with a convincingly accurate picture.
On the other hand, the group's inherent weakness is its focus on the here-and-now at the expense of the highly pertinent there-and-then. This makes it difficult to relive a past experience intensely. Group does not provide the unlimited psychological space to a member which might enable him to explore his inner world. There is always a communal pressure, no matter how slight, to "get on with it" or reach some desired emotional response. The most restrictive aspect of group is its need to limit members to one part of the total talking time.
The ideal solution for the somatically vulnerable patient would be to reap the best of the two therapeutic worlds: that is, to enter conjoint therapy. While the patient is in individual treatment with one therapist, he attends a group with another therapist. In this approach his distortions, emotional communications, and behavioral manifestations are viewed from many angles and perspectives. The tendency to somatize tensions is carefully monitored under varied conditions.
No matter how organic the origin of the disease, the writer's assumption is that the process is inevitably accompanied by psychological and emotional stress. This position is holistic: it maintains that all functions, healthy or diseased, psychological and physiological, are intimately intertwined with one other. There is no point at which one ends and the other begins; rather, each affects the other.
A Note of Caution
The most evident limitation of the author's experience with cancer is his exposure to a population of only 38 cases, collected during a period of nearly 30 years. There were eight "cures," nine remissions, whose outcome is still in abeyance, 10 incomplete or prematurely terminated cases, and 11 failures. The types of carcinoma ranged from liver cancer to lymphoma.
The writer did not find a specific personality pattern that matched a specific type of malignancy. For example, cancer of the bowels was not a necessary correlate to an anal retentive character structure. Nor could a characteristic course of treatment be pinpointed. Every case followed a path different from the others. The only thing common to them all was the therapist's approach: an intensive study, analysis, working through, and resolution of the defenses against the verbal communication of buried aggression.
Also, since the writer's practice has been essentially with groups, the material is presented solely from what was revealed in the shared setting. The only way of corroborating what a group member reported was to see if his communications and actions in the group supported or confirmed it.
Despite enthusiastic endorsements and fervent testimonials from recovered patients, the writer cannot say there is any hard evidence that group psychotherapy, by itself, was the single curative agent; for in addition to chemotherapy, surgery, and radiation therapy, there were many other interventions being attempted at the same time.
A tightly controlled experiment would, of course, be impossible to conduct. When other therapeutic interventions were introduced, either by the group member or his medical specialists, the writer did not feel it his prerogative to interfere with them.
Two Case Histories
With these reservations in mind, let us consider several cases. We may learn most by comparing our successful outcomes with our unsuccessful ones. First, a case which had a successful outcome.
When her marriage fell apart, a woman, then thirty-five years old, began group treatment. Her self-effacing manner won ready acceptance from the others. She liked them. When she would present a problem that concerned her children or her job, she always found them helpful. They, in turn, appreciated her sensitivity and concern for them.
After about a year, she discovered a lump on her breast and went to a specialist. It turned out to be cancer. She was shattered by the news. So were the members, who rallied to her support. They seemed to suspend all other matters, in order to discuss the specialist she was seeing, the hospital she was to enter, her fear of mutilation, and the medications she was taking. They took seriously her doubts and left nothing untouched if it involved her anxiety over the cancer. In addition, they demanded that she mobilize her strength. They took instant exception when she spoke of "conserving energy" through passive acceptance of her condition or total dependence on some authority.
Her post-operative prognosis was only fair, and chemotherapy was instituted. It was physically debilitating and seemed to weaken her resolve. Once again, the members rallied to buoy up her spirits. For example, to help her bear her acute apprehension, a member taught her techniques for relaxation. She learned to utilize them well.
Before long she saw the group as the only stable force in her life. The members knew everything; she knew nothing. Life seemed composed of group meetings with breathless pauses in between. She became deeply dependent upon them and experienced a profound need to do the right thing for their approval. When they did approve, she felt loved and hopeful. She lived by their suggestions and according to their directions.
Still, the doctors indicated the malignancy might be spreading; further treatment was indicated. She fell into a state of desperation and became greedier than ever for the group's advice. However, the members were experiencing mounting frustration. Though she would follow their suggestions to the letter, she ignored the spirit behind what they said. They began to see her as doing everything to please, to feel good, to calm herself, but nothing to improve her lot.
Her response to their dissatisfaction caught them by surprise. Instead of contritely agreeing as usual, she became offended. She countered that the members were smug and unfair to her; none of them had a sense of what it was like to face death.
With the analyst's help, she began to fight for more attention. After each hostile encounter with a member, she could recall incidents from her past, and how she felt about them; most of these had previously eluded her.
She remembered that throughout her marriage she had been on the phone for hours with her mother, who played a dominant role in her life. Not surprisingly, her husband fretted about this and felt neglected. Finally, he insisted that she break with her mother. Somewhat relieved, she did. But she immediately replaced that relationship by commencing a telephone life with her nanny three thousand miles away. Her husband was furious and told her he would leave her if she did not stop her over-reliance on other people. In an effort to save the marriage, she stopped the calls. But she could not stop over-reaching and complying when anxious, and the marriage soon ended.
Recalling these incidents, she realized that being good had not given her much - a realization that appeared to deepen her despair. She had been living a charade. But another group member pointed out that she had been her own architect. She retorted, "What do you know about life? You've never even had a husband or children!" As this slipped out, she felt a pang of guilt. How could she have said such a thing? She apologized profusely.
However, the members were made of sturdier stuff than she expected. They confronted her in return. One person wanted to know "What's the big deal? Can't you say anything you want to say?" Their acceptance of her anger reduced her need to turn it on herself. She felt free to criticize them. And the offended members felt free to fight back. When the session ended, she was feeling exhilarated. Emboldened in the following sessions, she hurled stinging insults at the members, and being the object of their vehemence did not daunt her. One session after another was marked with acrimonious skirmishes. A member protested to the analyst, "The pussy cat's turned into a tiger!" Indeed, it did appear that all restraints had been broken. Her wild ideas and lack of verbal control bewildered everyone. member was especially
At one point, when her assault on another member was especially harsh, the analyst intervened. He told her that she was not there to attack people. This outraged her. Who was he to tell her what to say? He asked her to turn the question into a statement. She told him to drop dead. She would do what she wanted to do. He replied that he would do what he wanted to. And at the moment, he was thinking of asking her to leave. She stared at him in shocked silence. The rest of the session she sat sullenly.
Distressed, she opened the next session with a complaint. Didn't the analyst know that what she was doing in group was helpful to her? She was taking better care of her children than ever. She was cleaning her house. Indeed, her whole life seemed better in hand. If she could not be her rotten self, how could she continue to work in group or even live? He told her she could be anyone she wanted to be as long as she stuck to the contract: identify her feelings, put them into words, tell others why she had them.
This structure was too much for her. She ignored his words and regressed to petty complaining. She spent most of the next session on a mistake that had been made in her electric bill. She wanted the group's advice on how to handle it. Many gave their practical opinions and she seemed grateful. But then, a member questioned why she invested so much in a trivial matter. As she continued to talk about it, the group brought out that her thinking was burdened by concepts such as "must," "should," and "have to." As before, they found themselves up against her severe super-ego. But this time they knew there was more to her. They barraged her with questions. Who wanted her to do what? Suppose she refused? What would her preference be? Why wasn't she pursuing it? They refused to accept any self-demeaning rationale for her helplessness.
In this atmosphere, she soon recaptured her emerging freedom and confidence. Now, however, she was much more cooperative and less combative. For the first time, she showed some conflict-free curiosity about the physical details of her condition. She attended health conferences; she read copiously; she pursued a number of off-beat approaches in treating the carcinoma.
Soon she found a doctor who specialized in nutrition. Spreading her medical records in front of her, he explained in detail how cancer develops and progresses. He showed her actual pictures, slides and specimens of diseased tissue. When she came to him with techniques she had learned elsewhere, he was always interested. They talked about the seriousness of her condition. Several such conversations helped her discharge accumulated tension.
One technique she used effectively was visualization. It consisted of picturing healthy lungs. The physician helped by explaining how people breathe and what would interfere with it. This put her in intimate touch with the malignant process. She began to "think its death." Another exercise was to picture the cancer in her mind's eye as an octopus with a thousand tentacles. She visualized her "healthy cells" chopping away at them, gnawing at each tentacle. This exercise was followed by peaceful scenes of meadows through which she would go for a stroll with the group members. In her mind they told her that all was well and she could relax.
She described these healing exercises to the group. The members encouraged her to write them down in a journal. She began one, enlarging upon her fantasies and relating them to her malignancy. Occasionally, she read excerpts to the group, and members offered their impressions.
Though her real life appeared to be at a stalemate, her mind was a cauldron of activity. One session she came a half-hour early and eagerly waited for the group to arrive. She announced that she had a dream. In it, the world was as flat as a pancake in a frying pan. With a skillet she flipped it over. Some members seemed to know at once the dream's message. It was time for a change. They encouraged her to talk about the options open to her. Others helped her clarify what she wanted to do, and what could be done. An immediate decision was to quit her job, which had put constant pressure on her.
With this done, she phoned her estranged husband. He had moved to another city. She told him she wanted him to come back; she needed him. When he wavered, she decided to go off to see him. She spent three days persuading him that things were different. With misgivings, he returned on a trial basis. He made the provision that he himself visit her group to be sure the members knew the "true story." She might appear an independent person in public, but at home she played helpless and was excessively needy. He was reassured to discover that the group was already aware of these traits in her. And he appreciated their standing invitation to return when he wanted to.
That experience was crucial for their relationship. Until then, they had been on somewhat formal terms with each other; they had handled disagreements mainly by not dealing with them. Now there were spats, but there was also plenty of physical affection. The two of them gave up their concern over coming across to their neighbors as an "All American Couple."
To her it ceased seeming necessary that she do everything by herself. With the group's help, she overcame her fear of asking for her husband's co-operation with daily chores, such as helping with the Friday shopping; she dropped three friends who were "more of a drain then a gain". She joined a new church and took an active role in its art program, teaching a drawing class. Her husband supported her search for a part-time job and felt more comfortable about her resumed relationship with the nanny. He also helped her cultivate and maintain an independent attitude toward her mother.
She was no longer a victim of the desperate need for others. When the old passivity crept into her talk in group, the members were quick to point it out.
She developed a strong conviction that the total treatment was succeeding. Indeed, her enthusiasm took on a missionary drive. In hospitals, offices, wherever she met sick people, she urged them to assume a more optimistic attitude. Her vitality communicated itself to others.
Within this patient's mind, it would seem, lay the inherent power to inhibit the progress of her own malignancy. She rid herself of burdensome emotional baggage and established firm pathways for the future discharge of her energies, and thus freed her body to mobilize its weapons against the proliferating neoplastic material. Her revitalized system restored the natural order of physical functioning. It reestablished its capacity to cope with the malignancy through the immunological system. Medically, her prognosis went from guarded to excellent.
In this case, every step in combating the neoplasm was marked by a bout with her aggressive impulses. Whenever her anger, overt or covert, was overlooked her therapeutic movement ground to a halt. In various ways the group offered her a corrective opportunity to direct toward them the noxious attitudes that she formerly repressed, denied, contained, rationalized, or directed toward herself. She was permitted to be "bad" without being punished.
It may be that once they settle for a static state of existence, the bodies of certain people rebel against it. There is an inborn drive to move forward. If the body cannot break through the entrenched patterns, it redirects its basic drive into cellular tissue on a primitive level. The result is cancer.
Naturally, it is an open question as to how or why the neoplasm started. There may be a connection between the loss of needed objects - mother, nanny, husband - and the later onset of the carcinoma. What reversed the malignant process is an even more intriguing question. The patient's physicians attributed the improvement largely to chemotherapy; the group members saw their own understanding of the patient as curative. One even had the idea that it was a diet he had urged on her. The woman herself put a different construction on the cause. "Pain and death; these were my real motivators. And in a way my allies. They pushed me. It was the cancer or me."
Our failures are, of course, many and baffling. Yet some of our defeats would seem to illustrate the importance of getting in touch with one's own aggression. We seem to be hamstrung when the patient fails to develop an awareness of his hostility, is unable to release it, and thus cannot utilize it.
Sometimes we have the impression we are helpless spectators of a tragedy that plays itself out before our eyes. We experience our efforts as futile when the toxic effects of unexpressed aggression unfold before us.
A young actress held her father in awe. But his sudden death from cancer of the brain seemed hardly to affect her. She went off to attend his funeral and returned within the week. On the surface this seemed odd. He had encouraged her singing and acting career and given her money to further it, and she seemed very appreciative. But in another respect, her relief was understandable. She had to call him regularly. He wanted to know every detail of her professional career but would express great discontent with its progress. When he visited her, he was critical of her friends, her apartment, and her appearance. His carping was threatening to her. It implied that he might cut off his financial support. Of two areas he knew nothing: her group experience (which she paid for by teaching singing) and her uneven love life.
She entered group because of her penchant for turning chance attractions to men into compulsive involvements. These would last until the affair foundered on the rocks of distrust about six months later. She seemed sure the object of her love would sooner or later disappoint her, and indeed, at some point she would come across indications confirming her fears. At once, she would find the man wanting on a number of scores. In dissatisfaction, she herself would break up each relationship.
When members questioned her about the last of these, she replied that there had been nothing to the involvement in the first place. But she felt bitter and generally disillusioned, and these feelings manifested themselves elsewhere in her life. Within the next six months she suffered a number of professional reversals, one of which was mortifying. She almost landed and then lost a lead in a musical that opened to smash reviews. This epitomized a career in which she had repeatedly been the stand-by for some recognized star, never quite making it herself.
A few weeks later, she developed hoarseness. Being prone to hypochondriacal reactions in the face of reversals, she had remedies on hand and resorted to them. But this time the rasp worsened. Friends and group members urged her to see a physician. Always on some pretext, she kept postponing the visit. Finally, when she could no longer speak above a whisper, she consulted one doctor, and then several others.
Her vagueness and hesitancy confused the members. One insisted on knowing exactly what took place. Apparently, she had told each doctor that she did not want to know the "fancy name" of her ailment. All she wanted was a prescription. If she did not like the import of what the doctor said, she tuned him out and ignored his recommendations. She was discontent with all of them.
A member told her of a relative with a rare tropical disease, who could get no help from local doctors. He had finally cleared up the malady by going to a medical center for a "read-out and treatment." This tale sparked interest. The rest of the group prevailed on her to enter a well-known clinic, where a number of specialists would examine her and then consult among themselves. Reluctantly, at the tail end of a vacation to the Bahamas, she went.
The clinic made the differential diagnosis of malignancy of the throat, involving the thyroid, pharynx, and surrounding tissues. Because there was a familial history of neoplasms, and the growth had already metastasized, her prognosis was poor. The news of her condition devastated her. Upon returning to New York City, she closeted herself in her apartment and would see few people. She systematically restricted the arena of her life, pulling the social drawstrings so close together that she became virtually alone. She dropped out of acting classes, theatre going, and travel. Even her teaching, to which she was unswervingly committed, suffered. She missed appointments, rejected new students, and neglected to return phone calls.
Members were able to get her to attend group by picking her up on the way to the analyst's office, bombarding her with reminders, and alerting her answering service. During the sessions, she would question fate. Why her? What did she do to deserve it? It was not fair. There was no rhyme nor reason to life. There was little give-and-take with the members. But they kept confronting her with her self-pity and preoccupation. She began to make some contact with them and in the real world, as well.
Her reconstituted daily routine consisted of seeing doctors and talking to a few friends on the phone who were ever peppering her with novel medical nostrums. She studied pamphlets and literature she picked up at health food stores. There were missions to Bermuda, Mexico, and the Philippines, seeking healers. Just over the horizon there must be a new technological discovery or drug. She undertook a desperate search for anything that offered hope.
In a health food store she ran into a former member. He had left group a year before to go on the road with a show but had never returned to treatment. They had been attracted to each other, and she made it clear back then that she was quite fond of him. Naturally, he was distressed to see the disordered state she was in. He took her to dinner, had her apartment cleaned, demanded she take physical care of herself. He even set appointments at beauty parlors for her and brought her to the best clothing stores. He tossed her nostrums out of the window, insisted that she go to physicians he personally checked out, and forced her to attend group sessions regularly. He lectured to her about her self-neglecting habits, encouraged her in every way to live in the moment, and actively rejected her script of doom. He called the group analyst. After a consultation with him, he decided to see what he could do "to at least put the pieces together."
Initially this man had reminded her of her father, and now he actively behaved like him.
She began to mobilize an impressive amount of energy to deal with her problems. At each session she would arrive before the members, often with an agenda which she had rehearsed with her new lover. Her voice, though cracked and wavering, came across clearly. Members gave her space, sensing her courage and fragility. She made it clear that she did not want to hear what they thought would be helpful, only what she thought would be helpful. They sympathetically restricted their responses to telling her what she wanted to know.
Within a few sessions she revealed that she hated her voice. It had forced her life along restrictive lines. She felt her singing was instrumental in her father's death. He once had aspirations to be on stage and had hoped she would fulfill them, but she had let him down.
A member suggested another possibility. The reason she had never reached stardom in her singing was that her father would have taken credit for it. It would not be her achievement. Because she would not recognize her anger toward him for forcing her to live out his aspirations, all she could feel was guilt. After a long silence she broke into body-wracking sobs.
With this insightful experience, she became more accessible to group influence. For the first time she began to show a lively curiosity about her buried self. Everything became possible. It was possible that she had ambivalent feelings toward her father, that the growth might be the organic equivalent of mourning, that hating the cancer only paralyzed her, that dashing after folk remedies was just another avoidance of feelings - substituting hope for despair. She began to consider that her self-blame might be an evasion of her anger at the world, that her cancer was not a punishment for sexual liaisons or for her deceiving her father, and that if anything, her father might have muddled up her life (an idea she found freeing). Each time she discharged some anger, her guilt lessened.
With drugs, diet, and buoyed by the concern of the group and the insistence of her lover, she took a turn for the better. This development was aided by treatment with a hypnotherapist who helped calm her many paralyzing fears. Her vigor returned. Her voice regained part of its original timbre. She felt an awakened interest in the theater and returned to teaching.
Then a disguised calamity descended on her. Her father's will was read. Provision had been made for her to receive a half-million dollars. Instead of celebrating the news, she nosedived into grief again. With that descent went every sign of her emerging resentment to her father. Compounding calamity, her brother contested the will. Because he embodied aspects of her father, she could not bring herself to effectively counter his legal legerdemain. Group members were unable to activate any anger toward him.
Her boyfriend was equally frustrated by her passivity. An acting job on the road opened for him. He wanted her to come along. But she was too deeply immersed in self-recriminations to respond. They had a quarrel. He broke off the relationship and left the city.
With her staunchest ally gone, her shaky defenses fell apart. Though she did not deny she had a role in the rupture, she complained about her own state. She had been abandoned and felt vulnerable with her lover gone. But her primary cry had to do with her inability to do anything constructive.
Under group pressure she called a highly recommended lawyer. He was briefed by a member who told him about the extenuating circumstances under which he had to function. But she undermined the lawyer's efforts by not consulting him or keeping him abreast of developments. When her brother arrived in person, she capitulated to his demands.
The rasp returned to her voice. She reported a series of dreams to the group in which various kinds of snakes were throttling her. Their recurrence distressed her, and the group's interpretations had no effect on changing them.
Her dreams ended when she found a new figure to lean on. He was a young cancer specialist with definite ideas about the course of treatment. First, he instituted a radical form of radiation. Secondly, he prescribed a strict regimen of rest and sleep. He was firmly opposed to anything that might tax her reserves.
He had serious reservations about psychotherapy. In several phone conversations the analyst was careful to describe the group treatment as an adjunctive approach. The specialist still felt it was stressful. After all, she had been in treatment for some time and no remarkable changes had occurred. He ruled out the psychosomatic factor in her disorder. But he said he would not interfere with her therapy as long as she was "enthusiastic" about it.
She was definitely not enthusiastic about anything. Often she would fail to appear at the therapy sessions. When members managed to get her there, it was again difficult to stimulate any interest in the ongoing exchanges. No one could lift her out of her listless state. Several wondered why they expended themselves trying to get her to a meeting since they had so little effect on her.
The more helpless she felt, the more convinced she became that her specialist was omnipotent. He filled the role well. He was never at a loss for a new medication. He told her exactly what to do and how to do it. He was unconcerned with her secret yearnings or murmurred whims.
Her attendance in group became even more erratic. If a member's call happened to find her in, she would answer flatly. It seemed as if all her medical appointments were scheduled at exactly the hour the group met. Members felt they were combating a suicidal surrender. There was no fight left in her. It was as if the clock in her world had stopped ticking. She died soon afterwards.
We may speculate about the psychogenic causes of this failure, by contrasting it with successful cases. From the group dynamic point of view, there was minimal interaction between the patient and the rest of the members. Her interpersonal involvement with them tended to be shallow. She could cut off her own feelings as easily as she could cut off the other members.
Her behavior was explicable in transferential terms. She treated the group the same way her father treated her mother. She was fond of the members but they were not in any way central to her life. Initially, what kept bringing her back to the group was bewilderment over one unfortunate affair after the other. Later she returned to the group to deal with the malignancy. Never did she investigate in depth her relationships with the members. For the most part, she was aloof and artificially even-tempered.
The loss of her father had been overwhelming; the replacement was revitalizing. The former member who entered her life had afforded her a temporary spur toward health. He provided her with support, admiration, and he ministered to her narcissism. She was at her best when he was in her life. With him, she had learned to articulate her negative feelings. When he left, she lost touch with this important part of her emotional life.
There is no doubt that the mechanism of denial can be protective. It limits the input that can penetrate a person's insulation barrier. But there was so much denial in this patient that at times it was difficult to pinpoint what she was actually experiencing, particularly her negative feelings. Her uncommon social charm, when closely studied, appeared to have a plastic quality.
On the outside, she appeared poised and intact; on the inside there was chaos. The two sides seemed not to be in communication with each other. When her mechanisms of repression, displacement, and rationalization failed her, she retracted her ego boundaries, and withdrew into isolation.
If we assume the development of the cancer had something to do with her inability to deal with her aggression, the death of her father certainly set into motion a process that was as insidious as it was deadly. While her father lived, she at least had the tenuous possibility of surfacing her latent hatred and directing it toward him.
Once he died, the anger had nowhere to go. She could not mobilize it in the service of separation; her grief returned her to a state of helpless fusion with him. This dilemma forced her to turn her aggression against herself. The inwardly directed anger may have furthered complete collapse of the immunological system. Very possibly, it was not the pain of parental abandonment that set off the cancer, but rather her denial of enormous rage at being abandoned.
Identification with her father, followed by introjection of his image, may have been a precipitating factor in the malignancy. She had lost part of herself with his death, and had been unable to substitute another emotional object for him. Perhaps her body made a final heroic effort to regenerate this part of her lost self, sought to recover that part through the prolific growth of tissue. Some archaic pattern may have been set in motion, a tendency that existed before the central nervous system could organize, control and regulate the organism as a whole. From this point of view, we might view cancer as an expression of a deeply regressed urge as a drive to regenerate a psychologically amputated part of the self.
Naturally, de-differentiated cellular tissue cannot possibly replace a missing human being, an object of feeling. The effort was doomed to failure. Lower forms of life, such as the salamander, can, under stress, amputate a part of themselves and regenerate it later. The attempted reproduction by a human being under stress would, by analogy, be expressing itself through a neoplasm. However, as with any such speculation, this one leaves a number of questions unanswered. For instance, many people with cancer do not report the loss of a vital object, nor could such a loss be traced.
Another powerful factor would seem to be the patient's heredity. This is not to say that a person is marked for a malignancy. The majority of people so predisposed do not develop one. In fact, there seems a powerful potential in human beings to rise above their encoding, and this too invites the thesis that psychic factors are involved.
This patient's predisposition was doubtless stimulated by an expectation of the inevitability of cancer. It may have put her body into a state of prolonged resignation. This would be similar to the phenomenon known as the "anniversary syndrome," wherein a person gets the same illness or meets the same fate on the same day or date as a parent.
What does seem clear is that her malignancy coincided with the failure of her ego-coping dynamisms in the face of trauma. This coinciding of the onset of her disease and the deterioration of her defense mechanisms is at best an observation. If she had been able to keep in touch with her aggression and utilize it in life-preserving decisions and actions, would there have been a different ending to her case? Possibly. With further refining of our theory and technique, we may some day be able to answer this question.
Conclusion
It may prove valuable to regard cancer less as a disease than as a disorder in the body's biochemical signals. To alter these signals is to produce an impact on the body's immunological defenses. It would follow that any form of intervention designed to restore the body to physical health must use more than physical means.
Since emotions dramatically influence the biochemical system, one way of providing immunotherapy is by giving psychotherapy to patients. It should be flexible and interactional in content, constantly undergoing modification to satisfy the patient's needs.
It would seem that one effective way of meeting these needs is by group therapy. The primary aim of such treatment would be analysis and resolution of resistances to verbal communication. Its emphasis would be on the resolution of the patient's unwillingness to experience and to express negative feelings toward people important in his group life. With this accomplished, efforts can then be made to convert the freed energy so that it can be utilized in the self-assertiveness that defines our personalities and makes our lives productive and satisfying.
Notes
The thesis that emotions and cancer are related is neither novel nor startling. For centuries, the role that grief, frustration and despair play in neoplasms has impressed many outstanding physicians. In 1870, Sir James Paget1, the great oncologist of his day, wrote that deferred hope, disappointment, and deep depression were followed by an increase in cancerous tissue. Others - Cutter2, Hughes3, Snow4 - went beyond a positive correlation; they were convinced that "mental depression" was the direct cause of a cancer.
These clinical observations lay fallow because there was little physicians could offer their patients beyond reassurance and a regimen of diet, rest, and relaxation.
The treatment challenge was taken up by the cellular specialists. With microscopes, x-ray machines, and chemicals, they attacked the malignancies. Great advances were made in the local destruction of neoplasms. The total organism within which the cell resided with its neural and hormonal systems received scant attention.
However, each time they identified a specific cause-effect relationship, specialists found they had to account for some annoying fact. For example, their research demonstrated that tobacco was directly implicated in lung cancer. Yet only a small fraction of the addicted smokers developed a malignancy.
The specialists attacked the problem anew. Every year they stumbled on additional precipitants of lung cancer. Why, with so many people exposed to so many different kinds of irritants, did so few develop lung cancer?
Early in the twentieth century, theoreticians began an energetic search for a framework that would account for the bewildering array of facts. The result was the hormonal-immunological theory.
This construct starts with the assumption that the body is always turning out defects due to faulty constitution, viruses, or pollutants. Fortunately, its defense system has a way of detecting maverick mutants and destroying them. But stress disrupts this detection and protection process; the body cannot correct the imbalanced physiology. The defective cells are free to reproduce themselves at random. This theory was supported by the observation that a cancer patient has weaker immunological defenses than the average person; his body cannot quickly and effectively destroy defective cells.
During the 1950's, Hans Selye5 and others mustered enough data to support the contention that emotional tensions may act as stressors. Such emotional states as depression and disappointment can exhaust the adrenal gland. It is no longer able to produce the hormones the body needs to prime the immunological response. If the exhausted gland does manage to send out signals, they are inadequate or misleading.
At this point, any of a number of carcinogenic precipitants can set off a toxic train of reactions. The over stressed system cannot monitor mutant ells or neutralize invading substances. Parasitic penetration, chemical and pollutant contamination, or ionizing radiation can do deadly damage to the vulnerable cellular tissues.
This finding was corroborated by experiments on healthy subjects. Cancer cells died when implanted under the skin of vital and vigorous subjects [Boyd, 1957]6. Even if these subjects did develop foci of neo plasia, they contained them and held them in check. It appeared, therefore that the nineteenth century surgeons were right. Emotions do influence the body's defenses.
However, long before the physiologists constructed their immunological theory, psychotherapists were observing and writing about the psychological implications of organic disease. Therapists had noted that the tendency to somatize develops early in life. Persistent stress during the developing years or a psychic trauma could lead to a life-long tendency toward organic expression of tension.
But psychoanalysts had hit-and-miss results with their efforts to reverse the tendency to channel tensions into the body. Investigating and analyzing the emotional states of despair, hopelessness, and their noxious cousins did not guarantee desirable results.
It emerged that an underlying drive was being neglected: aggression. But knowing this fact and doing something about it were two different things. Psychoanalysts had a method of treating the effects of disordered love but not the effects of primal rage. Even uncovering this hatred was often a formidable task. Patients tenaciously held on to their acceptable social feelings.
Should the rage well up, many therapists found it difficult and frightening to confront the patient, and with good reason. First of all, an angryspeaking patient could turn into an angry-acting one. Secondly, the patient's hatred induced unacceptable counter-hatred in his therapist. The prevailing opinion was that psychotherapy could do little with irrational anger. Psychiatrists resorted to palliative drugs to keep the obstreperous patient calm. Failing that, the patient was committed to an asylum.
A new set of constructs with new attitudes was needed. Sparked by the insights of Winnicott (1958)7, Searles (1967) 8, Alexander (1948) 9, Rado (1956)10, and Spotnitz (1976)11, investigators began to use their own feelings to investigate what patients were experiencing. They used these feelings to reconstruct the past, which their patients could not recall. With these feelings they penetrated deeply into the embalmed years from birth to age two. The early psychological stimulus and physiological responses were directly related to each other. Psychosomatic patterns could be pinpointed and studied. They illustrated that people's fantasy life, distorted self and body images, primitive defenses, and unmet maturational needs played a critical role in the development of schizophrenia and organic illness.
The developmental pieces began to fall into place. Either through inherited predisposition or defective mothering, certain children are especially vulnerable during their earliest years. They cannot convert drives and tensions into identifiable feelings. Their psyches can only express these tensions along the most primitive paths of communication - through body language, symbolic gesture, frozen attitudes, and the like.
The thwarting and frustration that these people experience eventually culminate in all shades of aggression. But it is a rage that cannot be expressed. In their minds, this aggression is capable of destroying the people they need for survival.
Finding no outlet for this aggression, they turn it against themselves. Such a redirection of energy raises further havoc with the way the body functions. Our physical being becomes the target of every unexpressed and unacknowledged negative feeling. Our denied drives become expressed as physical symptoms, which can range from a canker to cancer.
Research Evidence of the Somatic Effects of Aggression
The ravaging effects of unexpressed aggression have been observed by many researchers. Cobbs (1954)12 found that conflicts around the discharge of activity were high among those with cancer-susceptible personalities. Passivity inhibits the release of anger, even under dire conditions.
Bacon et al. (1952)13 found a facade of pleasantness in many women with carcinoma. This masked an inability to deal effectively with their aggressive impulses, as well as those of others. The victims felt resigned to an inverted expression of rage in the form of "passive suicide."
Kissen and Eysenck (1962)14 found that certain people who tended to "bottle-up" emotional difficulties also tended to contract cancer.
LeShan and Worthington (1955)15 observed that cancer-prone personalities tend to push down feelings of hostility rather than bring them to the surface and work them through. They suggested that this tendency lowers resistance to a malignancy.
LeShan (1966)16 noted again that one condition predisposing to cancer was the inability to use aggression as a self-protective tool. Envy, jealousy, competition, and resentment are squelched. The person, unable to find an interpersonal outlet for these emotions, comes to feel lonely and unloved.
Goldfarb et al. (1967)17 connected this inability to express hostility with the "hopeless-helpless syndrome." Because the victims think their condition unsalvageable, they allow themselves to sink into a bottomless despair. Electroshock therapy, aimed at clearing up the depression, often led to a remission of the neoplasm. They concluded that depression affects the immunological system. Depression is classically defined as aggression directed at oneself.
Simonton and Simonton (1975)18 confirmed that a predisposing condition for cancer was a marked tendency to hold back resentment. They also noted such correlates of stunted aggression as self-pity and a poor selfimage.
Mode of Attack
Such findings lead us to ask: How can psychosomatically entrenched aggression be approached, released, and resolved?
Modern psychoanalysts, especially Spotnitz (1969)19 offer an approach to the problem. First they deal with the way the person defends himself against the awareness and release of aggression. Then they help him redirect this raw energy away from his body, discharge it verbally, harness it at the service of his ego, and creatively sublimate it. This procedure can be applied in any of a variety of treatment modalities. In group therapy we make certain modifications. One is the use of the members as co-therapists.
There are several significant steps the therapist might take. To begin with, we mobilize the group's interest in a member's defense against aggression - the particular way a member wards off awareness of his unacceptable feelings. The aggression is not our initial concern: we are seeking out his protection against knowing he has it. This is no light task. As researchers discovered, cancer-prone people seem to be anything but hostile. They appear even-tempered, genuinely concerned about the comfort of others, friendly, and sometimes bordering on the heroic in their compassion.
Therefore, we spend our early contacts looking for, sensing out, or intuiting the ways a group member denies, represses, or avoids the feelings he senses are present. This may call for a free-floating, detached attention to his behavior or appearance. To the world he may seem no more than compliant, forbearing, or indifferent.
Having identified a member's particular survival mechanism, we do not jump in to change it. Instead, we silently study it. We observe, for example, when he uses his compliant response, how he repeats it, and the different forms it takes under different conditions.
Next we get confirmation concerning the mode of defense used. Other members are asked if they observed the pattern. When does it tend to be used? Can it be described?
After this, we mobilize the group interest in making the member aware of the defense. Members are encouraged not to hammer at the pattern but simply to apprise the person of this piece of his behavior.
We are now in position to separate the covert behavior from the underlying feeling. We encourage an investigation of all possible clues. Why did the member bite his lip and say "yes" when insulted outright? We pay detailed attention to subtly expressed attitudes, to intonation and to facial reactions. Sometimes the feeling emerges as soon as the defense is examined.
Often we have to show how the emotional state passes through the person's barriers. We watch for subliminal signs of leakage. Does the patient sense that his eyes are narrowing while the lower part of his face smiles? Is he aware that there is an edge of anger in his "helplessness?" Are there two messages being expressed at once?
With the softening effect of awareness, the inner world of the member comes to the fore. Now he may admit to inner torture. The despairer openly despairs; the griever grieves. Throughout this stage the member is encouraged to experience the unacceptable feeling.
All the while the members are training him to communicate his experience in words as fully as possible. Words are preferred, as an advance over "skin talk" and other, more primitive methods. Verbalizing establishes new neural pathways, outlets for inner stimuli, and opens up the way for fresh thoughts and ideas.
We want the member to direct his charged words toward a non-recriminating person in the group - one who will not punish or provoke guilt. The ideal target, of course, is the group analyst. His attitude and response can go a long way toward detoxifying devastating feelings.
While the member is struggling with these feelings, he may not acknowledge, or even know, that they are a cover for underlying aggression. Some members, especially prone to organic tension, need a form of communication that will reflect their own emotional state. These reflections help the member maintain his identity while permitting him to allow all his feelings their place. In reflecting, the analyst uses joining, mirroring, extending, role-reversal, devil-advocating, or out-crazying.
The analyst should use the group to do the work. In the following example, the analyst evoked the rage by mirroring it and used the group to mirror it further.
To a complaining woman, the analyst complained that she was taking up too much time with her woes. How could anyone get a word in edgewise? The woman took exception to this implied criticism. She contended that she was complaining only because she had a lot to complain about. What was wrong with the analyst? She proceeded to find fault with him. When he addressed her complaints, reflecting her attitude, she would let loose a stream of criticism. The other group members found the explosions a welcome change from her beseeching behavior. They caught the spirit of the analyst's reflection and began mirroring the member's behavior. Explosive confrontations went on for weeks. What Norman Mailer called "hatred that had never breathed the air of open rage" gave her a sense of personal elation and freedom.
With the aggression made manifest, the analyst encourages the group to investigate the feeling. Our purpose is to uncover erroneous ideas supportive of those emotional states and to plumb the foundations of negative feelings. Aggression can emanate from many sources - from frustration, rejection, abandonment, or counterphobic fear.
Members can help one another learn to tolerate all shades of aggression. They may encourage a new attitude toward it. Ideally, a patient learns to function effectively no matter how intense his irritability may be. Members never let him overlook his intolerance of it. So what if you are mad? Why can't you still speak in a civilized way? What makes you think you have to go into action or use four-letter words? We also have available other methods of intervention such as exploration, suggestion, education, and trial-and-error. Relying on them, we enable the patient to develop leniency toward his own aggression.
We can also relate present patterns to the climate of the patient's early life. The group itself may speculate about the relationship between a freed feeling and a physical symptom in a member. If the member himself cannot discover the crucial connections, the analyst can help him reconstruct the events of his formative years. The analyst can make use of the member's behavior in putting together a picture of his past. The group members, at this stage, become able to help the patient see his own aggression as valuable energy. Within the group setting, they can aid the patient to transform and refine it. For instance, they may show him how to convert anger that was previously destructive into socially acceptable wit, thus cultivating his new-found ability to put his aggression at the service of his best interest.
With the loosening and release of repressed feelings, made possible by the group's response and understanding, there occurs an enormous redirection of energy. The physical symptom loses much of its psychic charge. Then, as the feelings find verbal outlets and begin to abate in intensity and behavior changes, the malignancy seems to lose its virulence.
The Utilization of Group Therapy
Traditionally, the patient who seeks help has done so through individual analysis. This has certain obvious values. There is no better arrangement for searching deeply into the meaning of motives. However, this modality sometimes leaves the therapist with little leverage. His only ally is the patient, who oscillates between defying, drifting from, and denying all attempts to help him experience his emotions. The analyst is often rendered ineffective by the psychosomatically prone patient.
Group therapy has special advantages for working with the organically ill. Ulcer and colitis clubs have been notably successful in alleviating serious pathology. Though this writer has never conducted a group composed exclusively of cancer victims, it is conceivable that a shared setting could achieve the same results.
Group therapy offers a number of advantages so far as prevention is concerned, as it can exert pressure on the neglectful or self-destructive member.
In the following case, the group exercised its influence none too soon.
Some months after a hysterectomy, a woman in group mentioned in passing that she had abdominal discomfort and occasional bleeding. When questioned by certain members, she mentioned that she had not been back to see her gynecologist since the surgery. She brushed away their concern, construing her discomfort as a natural after-effect of her operation. She countered their every question with some seemingly plausible explanation for her torpidity.
However, one alarmed member would not be put off by her evasion and opened up each session with a prodding inquiry. She would promise to look into the matter but did not do so. The member observed, "You probably think something serious is going on. You are wishing it will go away by itself - counting on magic." The prodding member piped in, "I know what's wrong with us. We've been recommending that you go to a doctor. We should have pushed for a magician." A sharp exchange ensued. The next session she reported she had visited her gynecologist and a biopsy was scheduled. There was a malignancy, which, fortunately, was discovered in time.
The members had brought to her awareness the intense nature of her denial. Though she fought the group's reaction to her postponements, she had managed to glimpse the ludicrous nature of her own, endless rationalizations. It was not only this insight but also the release of her own anger that propelled her into taking care of herself. The value of the group was unmistakably evident in this case.
The sensitivity of a group enables it to provide early warnings and to repeat them. The patient with an incipient neoplastic growth is often reluctant to take the initiative in concern with his own health. There is a latent fear that the malignancy is already too advanced to be contained.
Even when the stress is not mentioned by the person, its vibrations can be felt by those who are attuned to the person's unconscious processes. Once these members are alerted to some smouldering crisis, they display uncanny skill in sifting out significant cues. Through their partial identification with the victim, they can often detect the faintest tremors of tension. One member may suspect the tension because of a particular side effect, another perceives it from a very different angle. For instance, the first discerns it in a dream, the second through its effect on an interpersonal exchange. If at times a member dashes off on a false lead, sooner or later another member is likely to call a halt and return the group to the basic track.
The following case illustrates the resilience of a group in its own pursuit.
A member presented the dream wherein termites were constructing a great hill on the plains of Africa. He kept tearing the hill down, but the insects persisted in rebuilding it. The group saw themselves as ants, constantly raising objections to his grandiose vocational schemes. They saw the dreamer as the undaunted builder of castles on the sand. Hearing this, the patient who had the dream lamented loudly that it was true: they were always fouling up his plans. There was a noisy interchange in which some of the interpretations went far afield.
Then a member, a woman with a borderline streak to her personality, expressed a more ominous view of the dream. She felt the hill was inside the dreamer. The termites were cells and were out of control.
At this, the dreamer blurted out that he did have a "funny sore" on his inner thigh that was not healing. A member asked if he had had it looked into. No, he had no physician. He would go to specialists with each body complaint. This was not specific enough. Members assailed him for holding such a negative attitude. By the end of the session he agreed to get a complete physical check-up from an internist. A lymphona was found, which could be contained.
By its understanding, empathy, and suggestion, a group can exert enormous effect. It provides an antidote to isolation. Perhaps its greatest asset for the organically ill is that it provides objects toward which the patient can direct strong feelings. The patient receives supportive acceptance within the group while he works through his conflicts. The consistency with which many members see that a person is doing is likely to provide him with a convincingly accurate picture.
On the other hand, the group's inherent weakness is its focus on the here-and-now at the expense of the highly pertinent there-and-then. This makes it difficult to relive a past experience intensely. Group does not provide the unlimited psychological space to a member which might enable him to explore his inner world. There is always a communal pressure, no matter how slight, to "get on with it" or reach some desired emotional response. The most restrictive aspect of group is its need to limit members to one part of the total talking time.
The ideal solution for the somatically vulnerable patient would be to reap the best of the two therapeutic worlds: that is, to enter conjoint therapy. While the patient is in individual treatment with one therapist, he attends a group with another therapist. In this approach his distortions, emotional communications, and behavioral manifestations are viewed from many angles and perspectives. The tendency to somatize tensions is carefully monitored under varied conditions.
No matter how organic the origin of the disease, the writer's assumption is that the process is inevitably accompanied by psychological and emotional stress. This position is holistic: it maintains that all functions, healthy or diseased, psychological and physiological, are intimately intertwined with one other. There is no point at which one ends and the other begins; rather, each affects the other.
A Note of Caution
The most evident limitation of the author's experience with cancer is his exposure to a population of only 38 cases, collected during a period of nearly 30 years. There were eight "cures," nine remissions, whose outcome is still in abeyance, 10 incomplete or prematurely terminated cases, and 11 failures. The types of carcinoma ranged from liver cancer to lymphoma.
The writer did not find a specific personality pattern that matched a specific type of malignancy. For example, cancer of the bowels was not a necessary correlate to an anal retentive character structure. Nor could a characteristic course of treatment be pinpointed. Every case followed a path different from the others. The only thing common to them all was the therapist's approach: an intensive study, analysis, working through, and resolution of the defenses against the verbal communication of buried aggression.
Also, since the writer's practice has been essentially with groups, the material is presented solely from what was revealed in the shared setting. The only way of corroborating what a group member reported was to see if his communications and actions in the group supported or confirmed it.
Despite enthusiastic endorsements and fervent testimonials from recovered patients, the writer cannot say there is any hard evidence that group psychotherapy, by itself, was the single curative agent; for in addition to chemotherapy, surgery, and radiation therapy, there were many other interventions being attempted at the same time.
A tightly controlled experiment would, of course, be impossible to conduct. When other therapeutic interventions were introduced, either by the group member or his medical specialists, the writer did not feel it his prerogative to interfere with them.
Two Case Histories
With these reservations in mind, let us consider several cases. We may learn most by comparing our successful outcomes with our unsuccessful ones. First, a case which had a successful outcome.
When her marriage fell apart, a woman, then thirty-five years old, began group treatment. Her self-effacing manner won ready acceptance from the others. She liked them. When she would present a problem that concerned her children or her job, she always found them helpful. They, in turn, appreciated her sensitivity and concern for them.
After about a year, she discovered a lump on her breast and went to a specialist. It turned out to be cancer. She was shattered by the news. So were the members, who rallied to her support. They seemed to suspend all other matters, in order to discuss the specialist she was seeing, the hospital she was to enter, her fear of mutilation, and the medications she was taking. They took seriously her doubts and left nothing untouched if it involved her anxiety over the cancer. In addition, they demanded that she mobilize her strength. They took instant exception when she spoke of "conserving energy" through passive acceptance of her condition or total dependence on some authority.
Her post-operative prognosis was only fair, and chemotherapy was instituted. It was physically debilitating and seemed to weaken her resolve. Once again, the members rallied to buoy up her spirits. For example, to help her bear her acute apprehension, a member taught her techniques for relaxation. She learned to utilize them well.
Before long she saw the group as the only stable force in her life. The members knew everything; she knew nothing. Life seemed composed of group meetings with breathless pauses in between. She became deeply dependent upon them and experienced a profound need to do the right thing for their approval. When they did approve, she felt loved and hopeful. She lived by their suggestions and according to their directions.
Still, the doctors indicated the malignancy might be spreading; further treatment was indicated. She fell into a state of desperation and became greedier than ever for the group's advice. However, the members were experiencing mounting frustration. Though she would follow their suggestions to the letter, she ignored the spirit behind what they said. They began to see her as doing everything to please, to feel good, to calm herself, but nothing to improve her lot.
Her response to their dissatisfaction caught them by surprise. Instead of contritely agreeing as usual, she became offended. She countered that the members were smug and unfair to her; none of them had a sense of what it was like to face death.
With the analyst's help, she began to fight for more attention. After each hostile encounter with a member, she could recall incidents from her past, and how she felt about them; most of these had previously eluded her.
She remembered that throughout her marriage she had been on the phone for hours with her mother, who played a dominant role in her life. Not surprisingly, her husband fretted about this and felt neglected. Finally, he insisted that she break with her mother. Somewhat relieved, she did. But she immediately replaced that relationship by commencing a telephone life with her nanny three thousand miles away. Her husband was furious and told her he would leave her if she did not stop her over-reliance on other people. In an effort to save the marriage, she stopped the calls. But she could not stop over-reaching and complying when anxious, and the marriage soon ended.
Recalling these incidents, she realized that being good had not given her much - a realization that appeared to deepen her despair. She had been living a charade. But another group member pointed out that she had been her own architect. She retorted, "What do you know about life? You've never even had a husband or children!" As this slipped out, she felt a pang of guilt. How could she have said such a thing? She apologized profusely.
However, the members were made of sturdier stuff than she expected. They confronted her in return. One person wanted to know "What's the big deal? Can't you say anything you want to say?" Their acceptance of her anger reduced her need to turn it on herself. She felt free to criticize them. And the offended members felt free to fight back. When the session ended, she was feeling exhilarated. Emboldened in the following sessions, she hurled stinging insults at the members, and being the object of their vehemence did not daunt her. One session after another was marked with acrimonious skirmishes. A member protested to the analyst, "The pussy cat's turned into a tiger!" Indeed, it did appear that all restraints had been broken. Her wild ideas and lack of verbal control bewildered everyone. member was especially
At one point, when her assault on another member was especially harsh, the analyst intervened. He told her that she was not there to attack people. This outraged her. Who was he to tell her what to say? He asked her to turn the question into a statement. She told him to drop dead. She would do what she wanted to do. He replied that he would do what he wanted to. And at the moment, he was thinking of asking her to leave. She stared at him in shocked silence. The rest of the session she sat sullenly.
Distressed, she opened the next session with a complaint. Didn't the analyst know that what she was doing in group was helpful to her? She was taking better care of her children than ever. She was cleaning her house. Indeed, her whole life seemed better in hand. If she could not be her rotten self, how could she continue to work in group or even live? He told her she could be anyone she wanted to be as long as she stuck to the contract: identify her feelings, put them into words, tell others why she had them.
This structure was too much for her. She ignored his words and regressed to petty complaining. She spent most of the next session on a mistake that had been made in her electric bill. She wanted the group's advice on how to handle it. Many gave their practical opinions and she seemed grateful. But then, a member questioned why she invested so much in a trivial matter. As she continued to talk about it, the group brought out that her thinking was burdened by concepts such as "must," "should," and "have to." As before, they found themselves up against her severe super-ego. But this time they knew there was more to her. They barraged her with questions. Who wanted her to do what? Suppose she refused? What would her preference be? Why wasn't she pursuing it? They refused to accept any self-demeaning rationale for her helplessness.
In this atmosphere, she soon recaptured her emerging freedom and confidence. Now, however, she was much more cooperative and less combative. For the first time, she showed some conflict-free curiosity about the physical details of her condition. She attended health conferences; she read copiously; she pursued a number of off-beat approaches in treating the carcinoma.
Soon she found a doctor who specialized in nutrition. Spreading her medical records in front of her, he explained in detail how cancer develops and progresses. He showed her actual pictures, slides and specimens of diseased tissue. When she came to him with techniques she had learned elsewhere, he was always interested. They talked about the seriousness of her condition. Several such conversations helped her discharge accumulated tension.
One technique she used effectively was visualization. It consisted of picturing healthy lungs. The physician helped by explaining how people breathe and what would interfere with it. This put her in intimate touch with the malignant process. She began to "think its death." Another exercise was to picture the cancer in her mind's eye as an octopus with a thousand tentacles. She visualized her "healthy cells" chopping away at them, gnawing at each tentacle. This exercise was followed by peaceful scenes of meadows through which she would go for a stroll with the group members. In her mind they told her that all was well and she could relax.
She described these healing exercises to the group. The members encouraged her to write them down in a journal. She began one, enlarging upon her fantasies and relating them to her malignancy. Occasionally, she read excerpts to the group, and members offered their impressions.
Though her real life appeared to be at a stalemate, her mind was a cauldron of activity. One session she came a half-hour early and eagerly waited for the group to arrive. She announced that she had a dream. In it, the world was as flat as a pancake in a frying pan. With a skillet she flipped it over. Some members seemed to know at once the dream's message. It was time for a change. They encouraged her to talk about the options open to her. Others helped her clarify what she wanted to do, and what could be done. An immediate decision was to quit her job, which had put constant pressure on her.
With this done, she phoned her estranged husband. He had moved to another city. She told him she wanted him to come back; she needed him. When he wavered, she decided to go off to see him. She spent three days persuading him that things were different. With misgivings, he returned on a trial basis. He made the provision that he himself visit her group to be sure the members knew the "true story." She might appear an independent person in public, but at home she played helpless and was excessively needy. He was reassured to discover that the group was already aware of these traits in her. And he appreciated their standing invitation to return when he wanted to.
That experience was crucial for their relationship. Until then, they had been on somewhat formal terms with each other; they had handled disagreements mainly by not dealing with them. Now there were spats, but there was also plenty of physical affection. The two of them gave up their concern over coming across to their neighbors as an "All American Couple."
To her it ceased seeming necessary that she do everything by herself. With the group's help, she overcame her fear of asking for her husband's co-operation with daily chores, such as helping with the Friday shopping; she dropped three friends who were "more of a drain then a gain". She joined a new church and took an active role in its art program, teaching a drawing class. Her husband supported her search for a part-time job and felt more comfortable about her resumed relationship with the nanny. He also helped her cultivate and maintain an independent attitude toward her mother.
She was no longer a victim of the desperate need for others. When the old passivity crept into her talk in group, the members were quick to point it out.
She developed a strong conviction that the total treatment was succeeding. Indeed, her enthusiasm took on a missionary drive. In hospitals, offices, wherever she met sick people, she urged them to assume a more optimistic attitude. Her vitality communicated itself to others.
Within this patient's mind, it would seem, lay the inherent power to inhibit the progress of her own malignancy. She rid herself of burdensome emotional baggage and established firm pathways for the future discharge of her energies, and thus freed her body to mobilize its weapons against the proliferating neoplastic material. Her revitalized system restored the natural order of physical functioning. It reestablished its capacity to cope with the malignancy through the immunological system. Medically, her prognosis went from guarded to excellent.
In this case, every step in combating the neoplasm was marked by a bout with her aggressive impulses. Whenever her anger, overt or covert, was overlooked her therapeutic movement ground to a halt. In various ways the group offered her a corrective opportunity to direct toward them the noxious attitudes that she formerly repressed, denied, contained, rationalized, or directed toward herself. She was permitted to be "bad" without being punished.
It may be that once they settle for a static state of existence, the bodies of certain people rebel against it. There is an inborn drive to move forward. If the body cannot break through the entrenched patterns, it redirects its basic drive into cellular tissue on a primitive level. The result is cancer.
Naturally, it is an open question as to how or why the neoplasm started. There may be a connection between the loss of needed objects - mother, nanny, husband - and the later onset of the carcinoma. What reversed the malignant process is an even more intriguing question. The patient's physicians attributed the improvement largely to chemotherapy; the group members saw their own understanding of the patient as curative. One even had the idea that it was a diet he had urged on her. The woman herself put a different construction on the cause. "Pain and death; these were my real motivators. And in a way my allies. They pushed me. It was the cancer or me."
Our failures are, of course, many and baffling. Yet some of our defeats would seem to illustrate the importance of getting in touch with one's own aggression. We seem to be hamstrung when the patient fails to develop an awareness of his hostility, is unable to release it, and thus cannot utilize it.
Sometimes we have the impression we are helpless spectators of a tragedy that plays itself out before our eyes. We experience our efforts as futile when the toxic effects of unexpressed aggression unfold before us.
A young actress held her father in awe. But his sudden death from cancer of the brain seemed hardly to affect her. She went off to attend his funeral and returned within the week. On the surface this seemed odd. He had encouraged her singing and acting career and given her money to further it, and she seemed very appreciative. But in another respect, her relief was understandable. She had to call him regularly. He wanted to know every detail of her professional career but would express great discontent with its progress. When he visited her, he was critical of her friends, her apartment, and her appearance. His carping was threatening to her. It implied that he might cut off his financial support. Of two areas he knew nothing: her group experience (which she paid for by teaching singing) and her uneven love life.
She entered group because of her penchant for turning chance attractions to men into compulsive involvements. These would last until the affair foundered on the rocks of distrust about six months later. She seemed sure the object of her love would sooner or later disappoint her, and indeed, at some point she would come across indications confirming her fears. At once, she would find the man wanting on a number of scores. In dissatisfaction, she herself would break up each relationship.
When members questioned her about the last of these, she replied that there had been nothing to the involvement in the first place. But she felt bitter and generally disillusioned, and these feelings manifested themselves elsewhere in her life. Within the next six months she suffered a number of professional reversals, one of which was mortifying. She almost landed and then lost a lead in a musical that opened to smash reviews. This epitomized a career in which she had repeatedly been the stand-by for some recognized star, never quite making it herself.
A few weeks later, she developed hoarseness. Being prone to hypochondriacal reactions in the face of reversals, she had remedies on hand and resorted to them. But this time the rasp worsened. Friends and group members urged her to see a physician. Always on some pretext, she kept postponing the visit. Finally, when she could no longer speak above a whisper, she consulted one doctor, and then several others.
Her vagueness and hesitancy confused the members. One insisted on knowing exactly what took place. Apparently, she had told each doctor that she did not want to know the "fancy name" of her ailment. All she wanted was a prescription. If she did not like the import of what the doctor said, she tuned him out and ignored his recommendations. She was discontent with all of them.
A member told her of a relative with a rare tropical disease, who could get no help from local doctors. He had finally cleared up the malady by going to a medical center for a "read-out and treatment." This tale sparked interest. The rest of the group prevailed on her to enter a well-known clinic, where a number of specialists would examine her and then consult among themselves. Reluctantly, at the tail end of a vacation to the Bahamas, she went.
The clinic made the differential diagnosis of malignancy of the throat, involving the thyroid, pharynx, and surrounding tissues. Because there was a familial history of neoplasms, and the growth had already metastasized, her prognosis was poor. The news of her condition devastated her. Upon returning to New York City, she closeted herself in her apartment and would see few people. She systematically restricted the arena of her life, pulling the social drawstrings so close together that she became virtually alone. She dropped out of acting classes, theatre going, and travel. Even her teaching, to which she was unswervingly committed, suffered. She missed appointments, rejected new students, and neglected to return phone calls.
Members were able to get her to attend group by picking her up on the way to the analyst's office, bombarding her with reminders, and alerting her answering service. During the sessions, she would question fate. Why her? What did she do to deserve it? It was not fair. There was no rhyme nor reason to life. There was little give-and-take with the members. But they kept confronting her with her self-pity and preoccupation. She began to make some contact with them and in the real world, as well.
Her reconstituted daily routine consisted of seeing doctors and talking to a few friends on the phone who were ever peppering her with novel medical nostrums. She studied pamphlets and literature she picked up at health food stores. There were missions to Bermuda, Mexico, and the Philippines, seeking healers. Just over the horizon there must be a new technological discovery or drug. She undertook a desperate search for anything that offered hope.
In a health food store she ran into a former member. He had left group a year before to go on the road with a show but had never returned to treatment. They had been attracted to each other, and she made it clear back then that she was quite fond of him. Naturally, he was distressed to see the disordered state she was in. He took her to dinner, had her apartment cleaned, demanded she take physical care of herself. He even set appointments at beauty parlors for her and brought her to the best clothing stores. He tossed her nostrums out of the window, insisted that she go to physicians he personally checked out, and forced her to attend group sessions regularly. He lectured to her about her self-neglecting habits, encouraged her in every way to live in the moment, and actively rejected her script of doom. He called the group analyst. After a consultation with him, he decided to see what he could do "to at least put the pieces together."
Initially this man had reminded her of her father, and now he actively behaved like him.
She began to mobilize an impressive amount of energy to deal with her problems. At each session she would arrive before the members, often with an agenda which she had rehearsed with her new lover. Her voice, though cracked and wavering, came across clearly. Members gave her space, sensing her courage and fragility. She made it clear that she did not want to hear what they thought would be helpful, only what she thought would be helpful. They sympathetically restricted their responses to telling her what she wanted to know.
Within a few sessions she revealed that she hated her voice. It had forced her life along restrictive lines. She felt her singing was instrumental in her father's death. He once had aspirations to be on stage and had hoped she would fulfill them, but she had let him down.
A member suggested another possibility. The reason she had never reached stardom in her singing was that her father would have taken credit for it. It would not be her achievement. Because she would not recognize her anger toward him for forcing her to live out his aspirations, all she could feel was guilt. After a long silence she broke into body-wracking sobs.
With this insightful experience, she became more accessible to group influence. For the first time she began to show a lively curiosity about her buried self. Everything became possible. It was possible that she had ambivalent feelings toward her father, that the growth might be the organic equivalent of mourning, that hating the cancer only paralyzed her, that dashing after folk remedies was just another avoidance of feelings - substituting hope for despair. She began to consider that her self-blame might be an evasion of her anger at the world, that her cancer was not a punishment for sexual liaisons or for her deceiving her father, and that if anything, her father might have muddled up her life (an idea she found freeing). Each time she discharged some anger, her guilt lessened.
With drugs, diet, and buoyed by the concern of the group and the insistence of her lover, she took a turn for the better. This development was aided by treatment with a hypnotherapist who helped calm her many paralyzing fears. Her vigor returned. Her voice regained part of its original timbre. She felt an awakened interest in the theater and returned to teaching.
Then a disguised calamity descended on her. Her father's will was read. Provision had been made for her to receive a half-million dollars. Instead of celebrating the news, she nosedived into grief again. With that descent went every sign of her emerging resentment to her father. Compounding calamity, her brother contested the will. Because he embodied aspects of her father, she could not bring herself to effectively counter his legal legerdemain. Group members were unable to activate any anger toward him.
Her boyfriend was equally frustrated by her passivity. An acting job on the road opened for him. He wanted her to come along. But she was too deeply immersed in self-recriminations to respond. They had a quarrel. He broke off the relationship and left the city.
With her staunchest ally gone, her shaky defenses fell apart. Though she did not deny she had a role in the rupture, she complained about her own state. She had been abandoned and felt vulnerable with her lover gone. But her primary cry had to do with her inability to do anything constructive.
Under group pressure she called a highly recommended lawyer. He was briefed by a member who told him about the extenuating circumstances under which he had to function. But she undermined the lawyer's efforts by not consulting him or keeping him abreast of developments. When her brother arrived in person, she capitulated to his demands.
The rasp returned to her voice. She reported a series of dreams to the group in which various kinds of snakes were throttling her. Their recurrence distressed her, and the group's interpretations had no effect on changing them.
Her dreams ended when she found a new figure to lean on. He was a young cancer specialist with definite ideas about the course of treatment. First, he instituted a radical form of radiation. Secondly, he prescribed a strict regimen of rest and sleep. He was firmly opposed to anything that might tax her reserves.
He had serious reservations about psychotherapy. In several phone conversations the analyst was careful to describe the group treatment as an adjunctive approach. The specialist still felt it was stressful. After all, she had been in treatment for some time and no remarkable changes had occurred. He ruled out the psychosomatic factor in her disorder. But he said he would not interfere with her therapy as long as she was "enthusiastic" about it.
She was definitely not enthusiastic about anything. Often she would fail to appear at the therapy sessions. When members managed to get her there, it was again difficult to stimulate any interest in the ongoing exchanges. No one could lift her out of her listless state. Several wondered why they expended themselves trying to get her to a meeting since they had so little effect on her.
The more helpless she felt, the more convinced she became that her specialist was omnipotent. He filled the role well. He was never at a loss for a new medication. He told her exactly what to do and how to do it. He was unconcerned with her secret yearnings or murmurred whims.
Her attendance in group became even more erratic. If a member's call happened to find her in, she would answer flatly. It seemed as if all her medical appointments were scheduled at exactly the hour the group met. Members felt they were combating a suicidal surrender. There was no fight left in her. It was as if the clock in her world had stopped ticking. She died soon afterwards.
We may speculate about the psychogenic causes of this failure, by contrasting it with successful cases. From the group dynamic point of view, there was minimal interaction between the patient and the rest of the members. Her interpersonal involvement with them tended to be shallow. She could cut off her own feelings as easily as she could cut off the other members.
Her behavior was explicable in transferential terms. She treated the group the same way her father treated her mother. She was fond of the members but they were not in any way central to her life. Initially, what kept bringing her back to the group was bewilderment over one unfortunate affair after the other. Later she returned to the group to deal with the malignancy. Never did she investigate in depth her relationships with the members. For the most part, she was aloof and artificially even-tempered.
The loss of her father had been overwhelming; the replacement was revitalizing. The former member who entered her life had afforded her a temporary spur toward health. He provided her with support, admiration, and he ministered to her narcissism. She was at her best when he was in her life. With him, she had learned to articulate her negative feelings. When he left, she lost touch with this important part of her emotional life.
There is no doubt that the mechanism of denial can be protective. It limits the input that can penetrate a person's insulation barrier. But there was so much denial in this patient that at times it was difficult to pinpoint what she was actually experiencing, particularly her negative feelings. Her uncommon social charm, when closely studied, appeared to have a plastic quality.
On the outside, she appeared poised and intact; on the inside there was chaos. The two sides seemed not to be in communication with each other. When her mechanisms of repression, displacement, and rationalization failed her, she retracted her ego boundaries, and withdrew into isolation.
If we assume the development of the cancer had something to do with her inability to deal with her aggression, the death of her father certainly set into motion a process that was as insidious as it was deadly. While her father lived, she at least had the tenuous possibility of surfacing her latent hatred and directing it toward him.
Once he died, the anger had nowhere to go. She could not mobilize it in the service of separation; her grief returned her to a state of helpless fusion with him. This dilemma forced her to turn her aggression against herself. The inwardly directed anger may have furthered complete collapse of the immunological system. Very possibly, it was not the pain of parental abandonment that set off the cancer, but rather her denial of enormous rage at being abandoned.
Identification with her father, followed by introjection of his image, may have been a precipitating factor in the malignancy. She had lost part of herself with his death, and had been unable to substitute another emotional object for him. Perhaps her body made a final heroic effort to regenerate this part of her lost self, sought to recover that part through the prolific growth of tissue. Some archaic pattern may have been set in motion, a tendency that existed before the central nervous system could organize, control and regulate the organism as a whole. From this point of view, we might view cancer as an expression of a deeply regressed urge as a drive to regenerate a psychologically amputated part of the self.
Naturally, de-differentiated cellular tissue cannot possibly replace a missing human being, an object of feeling. The effort was doomed to failure. Lower forms of life, such as the salamander, can, under stress, amputate a part of themselves and regenerate it later. The attempted reproduction by a human being under stress would, by analogy, be expressing itself through a neoplasm. However, as with any such speculation, this one leaves a number of questions unanswered. For instance, many people with cancer do not report the loss of a vital object, nor could such a loss be traced.
Another powerful factor would seem to be the patient's heredity. This is not to say that a person is marked for a malignancy. The majority of people so predisposed do not develop one. In fact, there seems a powerful potential in human beings to rise above their encoding, and this too invites the thesis that psychic factors are involved.
This patient's predisposition was doubtless stimulated by an expectation of the inevitability of cancer. It may have put her body into a state of prolonged resignation. This would be similar to the phenomenon known as the "anniversary syndrome," wherein a person gets the same illness or meets the same fate on the same day or date as a parent.
What does seem clear is that her malignancy coincided with the failure of her ego-coping dynamisms in the face of trauma. This coinciding of the onset of her disease and the deterioration of her defense mechanisms is at best an observation. If she had been able to keep in touch with her aggression and utilize it in life-preserving decisions and actions, would there have been a different ending to her case? Possibly. With further refining of our theory and technique, we may some day be able to answer this question.
Conclusion
It may prove valuable to regard cancer less as a disease than as a disorder in the body's biochemical signals. To alter these signals is to produce an impact on the body's immunological defenses. It would follow that any form of intervention designed to restore the body to physical health must use more than physical means.
Since emotions dramatically influence the biochemical system, one way of providing immunotherapy is by giving psychotherapy to patients. It should be flexible and interactional in content, constantly undergoing modification to satisfy the patient's needs.
It would seem that one effective way of meeting these needs is by group therapy. The primary aim of such treatment would be analysis and resolution of resistances to verbal communication. Its emphasis would be on the resolution of the patient's unwillingness to experience and to express negative feelings toward people important in his group life. With this accomplished, efforts can then be made to convert the freed energy so that it can be utilized in the self-assertiveness that defines our personalities and makes our lives productive and satisfying.
Notes
- Paget, J., Surgical Pathology (2nd ed.), Longman's Green, London, 1870.
- Cutter, E., "Diet on Cancer," Albany Medical Annals, July-Aug. 1887.
- Hughes, C. H., "The Relations of Nervous Depression to the Development of Cancer," The St. Louis Medical and Surgical Journals, May, 1887.
- Snow, H., The Reappearance of Cancer After Apparent Extirpation, I. and A. Churchill, London, 1870.
- Selye, H., The Stress of Life, McGraw-Hill, N.Y. 1956.
- Boyd W., "The Spontaneous Regression of Cancer," Journal of Canadian Association of Radiology, 8, 45, 1957, 63.
- Winnicott, O., Hate in the countertransference. In Collected Papers, New York: Basic Books. 1958.
- Searles, H., Concerning the development of an identity. Psychoanalytic Review, 53:507 - 520, 1967
- Alexander, Frantz, Fundamentals of Psychoanalysis, New York, Norton, 1948
- Rado, S. & Daniels, G.E., Changing Concepts of Psychoanalytic Medicine, Harcourt Health, St. Louis , MO, 1956
- Spotnitz, H., Psychotherapy of Preoedipal Conditions, Jason Aronson, 1976.
- Cobbs or Cobb, B., "A Social-Psychological Study of the Cancer Patient," Cancer, 1954, 1-14.
- Bacon, C. L., Renneker, R. and Cutler, M. "A Psychosomatic Survey of Cancer of the Breast," Psychosomatic Medicine, 14, 1952, 453-460.
- Kissen, D. M. and Eysenck, H. G., "Personality in Male Lung Cancer Patients," Journal of Psychosomatic Research, 6, 1962, 123.
- LeShan, L. and Worthington, R. E., "Some Psychologic Correlatives of Neo-plastic Disease: Preliminary Report." Journal of Clinical and Experimental Psychopathology, 16, 1955, 281-288.
- LeShan, L. "An Emotional Life History Pattern Associated with Neoplastic Disease," Annals of the New York Academy of Sciences, 125, 1966, 780-793.
- Goldfarb, O., Driesen, J. and Cold, D., "Psychophysiologic Aspects of Malignancy," American Journal of Psychiatry, 123, June 1967, 1545-51.
- Simonton, O. C. and Simonton, S. "Belief Systems and Management of the Emotional Aspects of Malignancy," Journal of Transpersonal Psychology, 7(1), 1975, 29-47.
- Spotnitz, H., Modern Psychoanalysis of the Schizophrenic Patient. New York: Grune & Stratton, 1969.
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