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These cases typify the kinds of conflicts our patients have faced in the months preceding their illness. From our experience and from the research of others, we can identify five steps of a psychological process that frequently precedes the onset of cancer.

1. Experiences in childhood result in decisions to be a certain kind of person. Most of us remember a time in childhood when our parents did something we didn't like and we made an internal pledge: "When I grow up I'm never going to be like that." Or a time when some contemporary or adult did something that we regarded highly and we made an internal pledge to behave in a similar way whenever we could.

Many of these childhood decisions are positive and have an overall beneficial effect on our lives. Many of them, on the other hand, do not. In some cases, these decisions were made as the result of traumatic or painful experiences. If children see their parents engaged in terrible fights, for example, they may make the decision that expressing hostility is bad. Consequently, they set rules for themselves that they must always be good, pleasing, and cheerful, no matter what their real feelings are. The decision that the only way to be loved or receive approval in the family is to be a certain kind of all-loving person may last a lifetime, even when it makes life a terrible strain.

Or some children make an early decision that they are responsible for the feelings of other people, and whenever other people are unhappy or sad around them, it's their responsibility to help them feel better. Possibly such decisions are the best ones children can make at the time they are made, because the decisions enable them to get through" difficult situations. However, in adult life these decisions of accommodation are probably no longer appropriate, since life circumstances are different from those that existed when the decisions were made.

Our main concern is that the decisions made in childhood limit a person's resources for coping with stresses. By adulthood, most of these childhood decisions are no longer conscious. The same ways of acting have been repeated so many times that awareness of our ever having made a choice is lost. But unless these choices are changed, they become the rules of the game of our life. Every need to be met, every problem to be solved must be handled within these limited choices made in early childhood.

Most of us tend to see ourselves as being the way we are just because "that's the way we are." But when the history of our choices is made conscious, new decisions can be made.

2. The individual is rocked by a cluster of stressful life events. Both the research and our own observations of patients indicate that major stresses are often a precursor to cancer. Frequently, clusters of stresses occur within a short period of time. The critical stresses we have identified are those that threaten personal identity. These may include the death of a spouse or loved one, retirement, the loss of a significant role.

3. These stresses create a problem with which the individual does not know how to deal. It is not just the stresses that create the problem, but the inability to cope with the stresses given the "rules" about the way he or she has to act and the role decided upon in early life. When the man who is unable to permit himself close relationships, and therefore finds meaning primarily in his work, is forced to retire, he cannot cope. The woman whose principal sense of identity is tied up in her husband cannot cope when she finds out he has been having an affair. The man who learned to rarely express his feelings finds he feels trapped when in a situation that can be improved only if he will express himself openly.

4. The individual sees no way of changing the rules about how he or she must act and so feels trapped and helpless to resolve the problem. Because the unconscious decisions of the "right way" to be form a significant part of their identity, these people may not see that change is possible or may even feel that to change significantly is to lose their identity. Most of our patients acknowledge that there was a time prior to the onset of their illness when they felt helpless, unable to solve or control problems in their lives, and found themselves "giving up."

They saw themselves as "victims"—months before the onset of cancer—because they no longer felt capable of altering their lives in ways that would resolve their problems or reduce their stresses. Life happened to them; they did not control it. They were acted upon rather than actors. The continued stresses were final proof to them that time and further developments Would not improve their lot.

5. The individual puts distance between himself or herself and the problem, becoming static, unchanging, rigid. Once there is no hope, then the individual is just "running in place," never expecting to go anywhere. On the surface he or she may seem to be coping with life, but internally life seems to hold no further meaning, except in maintaining the conventions. Serious illness or death represents a solution, an exit, or a postponement of the problem.

Although many of our patients remember this thought sequence, others are not consciously aware of it. Most, however, will recall having had feelings of helplessness or hopelessness some months prior to the onset of the disease. This process does not cause cancer, rather it permits cancer to develop.

It is this giving up on life that plays a role in interfering with the immune system and may, through changes in hormonal balance, lead to an increase in the production of abnormal cells. Physically, it creates a climate that is right for the development of cancer.

The crucial point to remember is that all of us create the meaning of events in our lives. The individual who assumes the victim stance participates by assigning meanings to life events that prove there is no hope. Each of us chooses— although not always at a conscious level—how we are going to react. The intensity of the stress is determined by the meaning we assign to it and the rules we have established for how we will cope with stress.

In outlining this process it is not our intention to make anyone feel guilty or frightened—that would only make matters worse. Instead, we hope that if you can see yourself in this psychological process, you will recognize it as a call to action and make changes in your life. Since emotional states contribute to illness, they can also contribute to health. By acknowledging your own participation in the onset of the disease, you acknowledge your power to participate in regaining your health and you have also taken the .first step toward getting well again.