Despite the basic physical pathology of neoplastic disease, the evidence exists to suggest that it does not evade the reach of psychosomatic influences. This discussion focuses on the intersection of cancer with family emotional dynamics in precipitating the onset of clinically definable cancer and in influencing the course of the disease and length of survival. The dynamics of the "paranoid process"1,2 as it operates in both individual and family contexts serves as a framework for discussion.
But first, some cautionary remarks. Much of the formulation and many of the findings remain relatively nonspecific, i.e., the patterns of psychological dynamics and the currents of interaction are generally not exclusive to metastatic disease but can be found in a variety of psychophysiological contexts. Consequently, rather than specific causal factors in the incidence of cancer, we will be discussing general factors that may play a role across a broad spectrum of forms of pathological reaction. In addition, the very nature of these processes is probabilistic, that is, they do not entertain a universal validity and their interplay with other significant causal and influential factors is always a matter of degree. Therefore, they may be found at work to a greater or lesser extent in any patient, and their understanding must always be taken in the context of a complex interplay with other important variables.3
At this stage of our knowledge we can offer little more than hypotheses that require further exploration, validation, and testing. In addition, that exploration requires a more sophisticated differentiation of subgroups of patients in which the various factors that come into play in the disease process and influence its course and outcome may differ considerably. A variety of findings and hypotheses that have been generated over the course of the past 25 years suggest the role of psychological factors and their influence on metastatic disease. With some sense, then, of the variety of psychological influences and their impact on cancerous processes, we can extend our discussion to the role of family dynamics, both in their potential impact on the disease process and in the reverberations within the family system of such catastrophic disease. Usually, when we think of cancer, we think of it primarily as an organic disease process, but nonetheless, psychological factors can play an important role in both its incidence and progression, and in the exacerbation or modulation of the process of the disease.
THE ROLE OF PSYCHOLOGICAL INFLUENCES
Psychological factors may play a role in precipitating the cancerous process, but their role is minor and nonspecific.4 At the same time, psychological influences may come into play in the early recognition of the disease, or in the patient's willingness to admit to symptoms and to subject them to examination by a physician. Psychological factors may also influence the course of the disease, whether progressive and deteriorating, or tending toward remissions or less virulent or malignant effects, possibly mediated by the effects of emotions and stress on the immune system.5-6 The psychological impact on the patient can be severe; he is confronted with his own mortality, often provoking severe anxieties, regression, and development of primitive defenses.7
The disease process also has an impact on the patient's family system, which contains an immense potential for either supporting the patient's efforts to cope and adjust to the disease and the rigors of its treatment, or alternatively, to intensify and complicate the disease process by its pathological ramifications in the family system.
The influence of psychological factors on the occurrence of cancer is not primary, but rather secondary to the primary distortion in cellular metabolism. The analogy to tuberculosis may be pertinent. The tuberculosis bacillus is widespread and endemic in the population, but many individuals who carry the bacillus may never develop the clinical disease. Consequently, there must be a conjunction of particular factors within a given time phase that allows for a change in the body's capacity to limit the disease process. Similarly, in cancer, if one accepts the hypothesis that the formation of nonclinical or subclinical mini-cancers is a common phenomenon in response to a wide variety of carcinogenic genetic, viral, hormonal, or environmental insults, one can then hypothesize that a specific conjunction of factors affect the host-cancer interface, so that in certain individuals the cancer escapes natural limiting controls and becomes clinically apparent.
There is evidence to suggest that personality factors play a role. Cancer patients often tend to be relatively selfless and understanding,8 easy to please, unaggressive, self-sacrificing, patient, and selfeffacing. They often display preneoplastic feelings of hopelessness, helplessness, and despair.9 Other findings suggest that depression has a significant relation to the development and spread of malignant disease.10 Tendencies to deny and repress conflictual impulses and emotions are significantly higher.11
The interplay between personality factors and their role in the production of cancer is a complicated matter indeed, and one that stimulates considerable controversy. One of the consistent findings, however, in addition to a general tendency to a certain personality configuration, is the incidence of loss prior to the onset of neoplastic disease. Feelings of hopelessness or despair, frequently associated with a prior loss of a significant person in the lives of these individuals, seems to be a common and repeated finding. Engel and Schmale12 have argued that there is an identifiable psychological reaction of helplessness and hopelessness that can be identified in the life situation of many of these patients, which seems to be linked to significant changes or losses in their lives, and which precedes the onset of neoplastic disease. Recent evidence supports the idea that psychosocial interventions dealing with these issues can even prolong survival rates.13
All these individual psychological dynamics related to the patient's experience of and reaction to the cancer process take place in a matrix provided by the family emotional system and interact with it in various forms. The patient, psychologically speaking, does not exist as a totally independent, self-sufficient, or self-contained entity. Rather, his psychological functioning and his capacity for adaptation is carried on within a matrix of personal and social relationships. The most immediate and important context within which such relationships are carried out, and in which such influences are given and received, is the family.
The interaction between the illness process and family dynamics can be focused in terms of:
* influence of family interaction and conflict on the development of the illness;
* role of the family in learning modes of illness behavior, e.g., attitudes toward the sick role or forms of disability;
* impact of the illness in one or other member on the pattern of functioning in the family as a whole;
* patterns of interaction between the sick member and other members; and
* influence of family dynamics on the timing of medical consultation and treatment.14
The family in a sense stands at the interface between more far-ranging and broadly conceived social and cultural processes and the individual member. In a variety of ways, the family not only mediates social and cultural influences in the development of the child, but also continues to exercise important influences that affect individual psychological functioning and serve to mediate a variety of disruptive and stressful stimuli and thus modify their impact on individual psychological functioning and psychophysiological reactivity. A wide variety of influences deriving from family interaction and/or disruption, stresses arising from job conditions and relationships, patterns of progressive societal change reflecting increasing urbanization, deprivations of poverty, patterns of social movement and migration, the rapid change of value systems, lifestyles, economically derived concerns and stresses all have impact on the family system and tend to influence the patterns of emotional reactivity within the family.
Conversely, stresses and crises arising in these various social and environmental contexts can either be modified in a buffering and protective way by healthy resources of coping within the family system, or they can be intensified in their destructive impact on the individual by the failure of such coping mechanisms within the family. It is interesting that few of the studies of fife-change events, which give rise to stress and can often be related to episodes of psychosomatic disease, have been studied in the context of their influence and mediation by way of family systems. It is a work that awaits doing.
FAMILY INTERACTION AND PSYCHOPHYSIOLOGICAL FUNCTIONING
The so-called family affective system15-18 has been used to describe the emotional demand or the complex of emotional processes by which a given family member will respond unconsciously and almost automatically to the emotional state of another family member. This process of affective communication runs a silent and often unrecognized course between people who are emotionally close. It particularly manifests itself in conditions of conflict and stress, but also operates during periods of relative calm and harmony. It is closely allied to the unconscious fantasy system described by Shapiro and his group.19,20
Other aspects of the family affective system have been described in terms of the emotional dependence among family members and the characteristic pattern in which each individual's self-esteem and sense of identity seem to be dependent on the behavior and affective responsiveness of the other members. The members who are caught up in such a system feel an overwhelming sense of responsibility and even guilt for maintaining the self-esteem and identity of other members of the system, and at the same time feel the need to control the behavior of those others.21 Such family systems are characterized by enmeshment, overprotectiveness, rigidity, and a lack of conflict resolution. These family systems show a high degree of emotional responsiveness and involvement. Relationships are highly dependent and are characterized by frequent intrusions on personal boundaries and poor differentiation in the perception of self and others. Concern for each other's welfare is highly developed, protective and care-giving responses are easily mobilized, demands for care and attention elicit pacifying behaviors.22-25
Currents of emotional disruption within the family system can be generated from outside the family system and create disruptive effects within it, or may be generated internally by a variety of crises such as deaths, marriages, births, and illnesses, or may arise from emotional conflicts generated within the family system itself. The impact of cancer in a member of such a family system would have disruptive consequences beyond the obvious threat to the member's life and its social and economic effects.
The factors operating within any family system that give rise to such disruptions are poorly understood and require further study. But frequently the family system operates by selecting a member or members of the family to be the focus for the expression of the family pathology. The identified patient or patients are relatively unable to be spontaneous and assertive, and have difficulty in claiming their own individuality within the family system. They remain constantly reactive to emotional pressures derived from other family members and from the family system as a whole. Conversely, the selected patient is strongly motivated to perpetuate this mutually controlling and symbiotic involvement, since the alternative is fear of abandonment or, in the most severely disturbed cases, annihilation. The patient is then caught up in an emotionally loaded, often tense and conflictual interaction within the family.
There is a close connection between depressive tendencies and the genesis of psychosomatic or hypochondriacal symptoms. Where depressive moods or the defenses against depressive affects dominate the family interaction, one can expect a high incidence of psychosomatic disturbance.26 Family members in such cases frequently have special difficulties in dealing with aggressive conflicts and particularly in expressing relatively intense separation anxiety. A similar pattern has been observed with regard to conflicts of aggression in cancer patients, as noted above.
The onset of disease symptoms can be related to periods of emotional disruption in the family, consequent to the loss of a significant person. Such loss of a significant relationship may be followed by a period of inadequate and morbid griefj which is then replaced by the disease state. Such patterns have been traced in cases of a variety of illnesses, including leukemia. One may even find examples of anniversary reaction, which express themselves in a psychophysiological form. In other cases, emotional disruptiveness that disturbs the emotional balance in the family system can be traced to a variety of disruptive influences that are not specifically connected to the loss of a significant object. The onset of symptoms may be tied to illnesses, separations, divorces, job changes, psychotic breakdowns, marriages, births, and even graduations.
Emotional disorganization within the family system does not affect all members in the same way, but rather differentially. According to this principle of selectivity, in proportion to the degree of involvement, the presence or absence of such involvement and its degree of intensity then become crucial issues in understanding the emotional factors that play a part in precipitating disease symptoms and thereby contribute to the total ecology of the disease process. Evidences of this sort point in a consistent direction, which allows us to formulate the notion of the family affective system as a mediating construct to pull together these various strands of evidence. The hypothesis can be summed up in the following points:
* The patient is an affectively vulnerable person, whose immaturity is directly proportional to the degree of emotional involvement in the family affective interaction.
* Through this emotional involvement, the patient is caught up in the affective system, which is constituted by the emotional involvement of the members of the immediate family. Involvement in the family may be reflected in patterns either of passive dependence and attachment or of rebelliousness and hostility; but the emotional involvement itself and its effects on the patient tend to remain relatively unconscious and implicit.
* The functioning of the involved individual depends on the balance of emotional forces within the family system. His own basic insecurity and instability is compensated and more or less stabilized through emotional interactions with other members of the family system.
* Certain emotionally significant events - such as the onset of a cancer in some member of the family system - can disturb the balance of emotional interrelationships within the family system, and create disorganization within it. This affects the patient on a deeply emotional level, consciously and/or unconsciously, since the stabilization of the patient's own emotional lability is achieved through and dependent on the balance within the system.
* Disorganization or emotional disruption in the family system can precipitate an emotional crisis in the deeply involved members. With the emotional supports withdrawn, the individual lacks sufficient ego resources to maintain adequate functioning on all levels. Consequently, the individual responds with some form of decompensation, which may manifest as somatic dysfunction.
The impact of disease, like cancer, on a family system depends on the intensity of the development ofthat family affective system and the degree of involvement between the patient and other members of the family system. When the disease erupts in the family system, there may be an extension or a reverberation of the disruptive effect, like shock waves running through the family system and affecting other members. For example, one member will develop a cancer; within three months, the mother may develop arthritis; in another month, the father loses his job; by the next month, a sibling is flunking out of school. One may also see an opposite pattern, namely, that when a disease emerges in the family system, it acts as a stimulus that allows the rest of the family to begin to function more adaptively and more maturely. In fact, instead of the family crumbling around the patient, disease seems almost to provide the nidus for a mobilization of latent resources in the family to begin to cope with the stress that has been created.
When the treatment team begins to recognize that important reverberations may be contributing to the patient's inability to cope with the disease process, then the whole family can become a focus for therapeutic intervention. It becomes important to know what this event means to that family and the individuals in it, how it has changed what is happening in their lives, and what kinds of emotional stresses and strains it has created in their relationships with each other, in their family life, and in their adaptation to the outside world. This broadened focus may not be indicated in every patient, but healers should be aware of what may be going on in the background of the treatment process. One can pick up the signs of an unfortunate set of reverberations and begin to address them, ultimately to the benefit of the patient, the family, and the treatment process itself.
To summarize, the cancer patient, like all patients, is subject to a multiplicity of psychological influences from the family system. These influences can be forces that sustain and support the patient in efforts to cope with a lifethreatening disease, or they can be destructive forces that undermine the patient's ability to cope and reinforce the helplessness and hopelessness that seem so detrimental to the treatment process. This provides an added dimension to our understanding of the cancer process and its impact on patient's lives. The better that understanding, the better our capacity to help patients to cope with their disease and to summon all the available resources to deal with it.
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