Connecticut Society for Bioenergetic Analysis

THE SPLIT SELF: CANCER AND PSYCHOLOGICAL PROBLEMS WITH BOUNDARIES* by Elizabeth Rablen, M.D.

BRIEF REVIEW OF THE LITERATURE

 There is increasing evidence that the occurrence and growth of malignancies is influenced, both positively and negatively, by psychological factors, as well as by the more generally recognized factors of genetics, immunology, virology and environmental toxicity.

 The following personality patterns have been identified as being associated with the occurrence of cancer: Melancholia, (Galen 200 A.D.)¹, Serious Depression and Anxiety, (Gendron 1701)¹, having "chronically fragile or non-existent affective relationships" and a "basic bleak hopelessness about ever achieving any real feeling or finding true meaning in life" as well as having "no ability to express hostile feelings" and "showing tension over the death of a parent, usually an event that had occurred many years previously", (LeShan, 1956-1966)¹, and "inappropriate handling of anger, mostly by suppression, but also by extreme expression of it", (S. Greer and T. Morris, 1975)^2.

 A prospective study by C.B. Thomas (1974)³, begun in 1946, showed as a surprise finding a strong similarity between the psychological profiles of those who developed cancer and those who committed suicide. (With psychological tests plus yearly questionnaires about living habits, Dr. Thomas discovered the precursors of five conditions: suicide, mental illness, hyper-tension, coronary heart disease and cancer. She used cancer as a disorder that presumably was not related to psychological factors). Furthermore, comparing the five groups on a closeness to parents scale she found that the cancer patients rated lowest as did mental patients. However, mental patients rated highest, and cancer patients lowest, on matriarchal dominance.

D.M. Kissen (1962)⁴ did a psychological study of industrial workers (all of them smokers), comparing those with various lung ailments, but primarily tuberculosis, with those whose diagnosis subsequently was found to be cancer. He found that cancer victims suffer from denial and repression of their emotions. They had "poor outlets for emotional discharge", as measured by personality tests used to gauge "neuroticism". He concluded that the more depressed the individual the fewer cigarettes it took to induce cancer.

 The loss of a major emotional relationship a few months to eight years prior to the development of cancer was noted by many researchers: Evans (1926, LeShan and Worthington (1956), Schmale (1964) and Green (1966)1. Ditmar Richter reported such antecedent losses at the Fifth International Congress of Psychosomatic Obstetrics and Gynecology in 1978.

 Some light is shed on the question as to why most people who experience loss do not develop malignancies by considering the type of personality who suffers the loss. With poor emotional outlets, particularly for negative feelings, and fragile affective relationships, the patient is ill;prepared to accept and mourn the loss of an important relationship, established through hard struggle in the first place. This difficulty in establishing relationships reflects the coping mechanisms learned early in life. The cancer patients experienced their parents as distant and "less loving, protective and rewarding, and more rigid and stereotyped" than controlled subjects experienced their parents (Bahnson)^1. They coped with this experience by developing a "double self within which realistic and adaptive ego operations unfold, separated and independent of the parallel shadow self that feels isolated, unloved, hurt and deserted". (Bahnson)¹. In adolescence and young adulthood the future cancer patient struggles hard to achieve a connection to the real world through love or work. On losing either (Kowal, 1955 ⁶ "loss of significant figure or loss of life goal") they give up of ever achieving it again, become emotionally flattened and turn inward, while their "surface self" continues to appear well adapted. They regress to a "self contained mode of discharge" (Bahnson)¹ described as "stasis" by Wilhelm Reich (cited by Margot Robinson 1976)7 whose view was that the bottling up of vital energy, primarily, but not solely, sexual energy, was the essence of a lifelong process that ends with cancer. (W. Reich the Cancer Biopathy 1948).

 There are studies that show which psychological conditions lead to rapid progression of tumor growth and which lead to arrest or regression of such growth. Nicholas Rogentine 1979 S found that among those successfully operated on for melanoma stage 1 and 2, patients who relapsed had tended to minimize the significance of their illness (denial). At John Hopkins Medical School, Leonard Derogatis and Martin Abeloff (1978)⁹ found that among 35 women with breast cancer those lived longer who were experiencing a high degree of anger toward their disease and their doctors. Michael Kerr (1978)¹⁰ described remissions in malignancies when family crises were resolved. Carl Simonton and Associates (1977)¹¹ described 12 patients who outlived their predicted life experiences. They had the following characteristics: they showed non-conformity on the MMPI (Psychopathic Deviancy) reflecting their tendency to fight rather than to conform (for instance, to their fateful prognosis), and great ego-strength on an experimental scale of the MMPI revealing a strong sense of reality as well as of personal adequacy and vitality. A "locus of control scale" revealed that they see themselves as having influence or control of the events in their life and on the "firo-B inclusion" scale they revealed their low need to maintain relationships, associations and inter-actions. They could let go of people when necessary. 

CASE HISTORY 

My patient, whom I shall call Helen, showed the characteristic personality and life history patterns as described in the literature reviewed above.

Helen was born into an extended family. Her maternal grandparents lived upstairs. She described them as "happy, cheerful and life-giving people". Her father was a gambler since his boyhood. After the marriage he promptly gambled away the $40,000 her mother had saved. There were great marital difficulties when Helen's mother was pregnant with her. She wanted to leave her husband but was persuaded to stay for the sake of the children.

 Helen's three-years-older sister was always close to her mother, perhaps as a result of her father's absence in the service when she was small. Her father didn't want to miss out on his second child, Helen, and paid a great deal of attention to her, competing with his wife for Helen's love. Helen remembered him throwing her mother down the stairs in order to rescue her from her mother who wanted to give her an enema. A brother, four years younger, was born with CP and given dedicated care by his mother.

 During frequent family fights the family tended to be divided into two camps: mother, brother and sitter against father and his "special" child Helen. As long as the maternal grandparents lived, Helen thrived. They died within a month of each other, when Helen was a little over three years old, just before her brother was born. Helen was unable to cry over this loss, instead she tried to kill herself by drinking a permanent wave lotion. She wanted to "join her grandmother in heaven". Helen said that she remained sad and lonely thereafter. She began to get into constant trouble with her mother who seemed to invade and overpower her with her care. Helen rebelled: She ate poorly, vomited, grew thin and tall, causing the relatives to accuse her mother of not feeding her properly. She did her chores destructively: burned the shirts she ironed, broke the dishes she washed. During her violent temper outbursts she smashed windows and cut up venetian blinds. Her rebelliousness was combined with a severe and continued inability to separate from her home: She could not even stay overnight at her best girlfriend's home. 

Helen's reaction to the loss of her grandparents seemed to initiate a split in herself: The inner part, the "deep self", continued to feel sad and lonely, longing to join her grandmother and causing her to be unable to separate from home in spite of wanting to do so. The surface self showed strength, managing reality well, doing well with school and friends and giving support and compassion to her father, who felt criticized and not understood by her mother. In spite of being overprotective and rigid Helen's mother managed to satisfy the needs of her other two children. Helen used her mother's short-comings to "hang on them" her projections. However, neither the successes nor the emotional outlets achieved by the surface self touched the deep self which remained sad and unable to let go and mourn her grandparents. 

There was one exception to her difficulty in forming relationships and that was in her relationship to nature, which touched her depths. It began when her grandparents were still alive, with a love for the extended family's garden, the beauty of its flowers and the goodness of the food grown there, and continued with her love for a wild apply tree which she found one day not far from her new home, to which her family had moved when she was six. From its branches she could see the ocean. She went to this tree whenever she needed comforting and peace.

 When she was 10 years old the family moved again. With the loss of her apple tree, her girlfriend and the familiar school, Helen repressed her deep sad self even further because her need to be strong and in control increased. Her separation difficulty intensified as well and showed itself as a school phobia: While she had loved school and done well before the move she now disliked school and refused to take the school bus. She had frequent absences due to respiratory illnesses. Because of painful menses which started at age 12, she was placed on birth control pills at age 14 and kept taking them until the carcinoma of the breast was diagnosed just before her 30th birthday. At age 25 a chronic bronchitis with emphysema was diagnosed and she stopped smoking, which she had begun at age 15. 

The period of loneliness ended at age 21 when she met the first man with whom she fell in love. He was 13 years older, a drifter and an alcoholic. On first meeting him she was "turned off by his audacity", then conquered by his "tenacity" and his "savoir vivre". She had her first sexual intercourse with him and discovered that she had a "ravenous appetite" for sex. This relationship was superceded, though not completely ended, a year later by a second, still more intense involvement with a teacher and artist who was just divorced from his wife. She devoted herself totally to his care, foregoing all her own endeavors, including her studies at college. She lived with him half of the week and spent the other half at home. 

Her loves represented a compromise for her. In her total sacrifice to her lover and fusion with him she expressed her helpless dependency, while she gained a sense of separation and strength by chosing a man and a style of living of which her parents strongly disapproved.

 After three years, approximately four years before the discovery of the carcinoma of the breast, this relationship ended abruptly: her lover suddenly became deeply involved with another woman whom he soon married. Helen was devastated. Only with great difficulty did she keep going, but did not decide to seek help from a therapist or friend. The following year when she was 26, Helen changed her job and became a nursery school teacher, a job she found rewarding though sometimes quite strenuous. She held this job until she no longer could work because of the advanced stage of the cancer. At the nursery school she formed a close relationship with another woman teacher who persuaded her to seek help with me. 

Helen showed an interesting way of expressing her anger "inappropriately": she expressed none with her lover, her father and at work, but excessive anger with her mother. 


THE SPLIT IN THE SELF AND ITS RELATION TO THE DEVELOPMENT AND GROWTH OF MALIGNANCIES: 

Bahnson (1980)¹ describes cancer patients as developing a "double self within which realistic and adaptive ego operations unfold, separated from, and independent of, a parallel "shadow self" that feels isolated, unloved, hurt and deserted". Persons with such a split in the self, whose surface egos function well and rigidly, may be able to form realistic and conforming relationships to those around them, showing a good facade but will give indirect evidence of the presence of the repressed shadowy self's feelings of hurt and desertion by the fragility of relationships, and the poor emotional outlets, particularly for negative feelings. Thus, the split in the self, with the surface self being endowed with ego strength, can serve as a unifying concept permitting an understanding of the typical personality patterns of cancer patients, or those persons more likely to develop cancer. 

Their relationships are fragile and not satisfying because they are not anchored in the deep self which has become shadowy and undernourished because it is excluded and locked away. A cancer patient's core experience is therefore one of feeling lonely, hurt, sad and without hope of ever achieving any satisfaction through contact with the world. The seat of this core experience is the deep self.

 It seems that this split tends to occur early in life as an unadaptive coping with painful loss of a significant relationship. The split-off, deep self, is protected from future hurt by being locked up and repressed, while the surface self keeps trying to stay in control of events by holding onto reality and important relationships no matter what the cost. This results in a pattern of unrealistic self-sacrifice as described by Bacon (1952)¹². This sacrificial pattern of relationships can be described as a violation of the deep self and a fusion of the surface self as it gives over personal psychological territory for the significant other.

 The psychological factors that foster the growth of malignancies are the opposite of those that inhibit such growth. It can be said that the growth of malignancy is dependent on the state of the self: If the ego strength is only in the split-off, "superficial" part of the self, while the deep self is leading a "shadowy existence" in the unconscious, then the growth of malignancy is promoted. On the other hand if the self is integrated with its deep authentic roots then the growth of malignancy is inhibited. Such integration manifests itself in nonconformity, a sense of personal adequacy and vitality, and a lack of helplessness, all manifested by the "successful" cancer patients. It follows that I saw my task with my cancer patient Helen as helping her to discover and integrate her deep self. 

At first Helen was totally unaware of this deep self, except as a general sense of tension and anxiety and what she experienced as intrusions when her mother expressed concern for her. As she gradually became aware of her deep self she was surprised to notice how deeply afraid she was of interpersonal contact. She had believed herself to be quite comfortable with contact with others. There were two ways in which Helen began to experience her deep self. A static sense of self, simply experienced as the presence and existence of herself inside her body. She often experienced this self as small, sometimes in "little pieces", sometimes gone altogether, "I'm not there at all". A more dynamic self was experienced as a sense of having a source of spontaneous initiative inside, something "impinging from within". (Gerda Boyesen cited by C. Southwell)¹³, a sense of knowing what she wanted and needed. 

Both the static and dynamic aspects of the deep self were endangered during interactions with significant others. The self would shrink, disintegrate into little pieces or disappear, and be replaced by the partner's self. She could not longer differentiate between what she wanted and needed and what the partner wanted and needed. She would not notice that the partner's self had usurped the place of her own until a loss occurred. Then there was emptiness, helplessness and despair. When she fought rather than submitted in a confrontation with the significant other, the fight was desperate, with a sense of eventual doom.

I believe that a sense of reliable boundaries, capable of contact with others, develops and is maintained during interactions with significant others. As a person is moved from the depths to express an action for which a partner is needed, the partner will be in various states of readiness or resistance. People with poor boundaries will react to finding the partner in a state that does not completely correspond to their expectations by either completely adjusting to the partner's state, submission, or by trying to force the partner into the desired state, domination, or by rejecting the partner, withdrawal. Either submission or domination leads to the violation of psychological boundaries and fusion. Healthy boundaries, capable of full contact with the significant other, can only develop when the partners do not try to eliminate the difference in their need states by violating boundaries but instead permit the need states to harmonize into mutuality by constant authentic feedback with respect for both partners' boundaries.

 People with a split self have characteristic boundary problems when relating: they cannot maintain their integrity when in contact with significant others. They readily feel invaded and overpowered and show a need to be in control of significant relationships, often manifested as possessiveness and a propensity to jealousy as well as an inclination to self sacrifice. Persons with a split self relate to the significant other by forming a symbiotic "self object", fusing the surface self with the significant other's self. This means that the other person is part of the self system and this is the reason why loss cannot be tolerated.

They experience a double bind, no win situation in relating to the significant other: without him or her they are doomed, because loss is experienced as loss of part of the self, with him or her they feel invaded and overpowered. Persons whose self is integrated can maintain their integrity when in contact with significant others because they have viable boundaries. They experience temporary loss of the significant other with longing and a capacity to remember the absent person in a realistic way, not only as the cause of hurt and rage. When the loss is permanent such a person can mourn and let go of the lost person. 

COURSE OF TREATMENT:

 Helen began thereapy with me at age 29, a little over six months before an infiltrating duct - carcinoma of the left breast with metastases in nine out of 11 auxiliary lymph nodes was found.

 In spite of having suffered much in her life, Helen never had gone for help. She always acted "strong". It was her failure to realize a long-held dream that brought her to me, aided by her friend's encouragement: she proved to be unable to live away from her parents. Just before coming to see me she moved into an apartment of very poor quality, being unable to afford anything better, because three months prior she had given to her father what she had saved for the purpose of living away from home. (The father had neglected to get insurance and could not pay for his hospitalization). She could not eat while living away from home. Spasms prevented her from eating and eventually even drinking. After three weeks and the loss of 35 lbs. she had to return home. Additional symptoms about which she showed little concern were the following: eating binges, fear of falling from heights, fear of bridges and of animals.

 Helen wanted to overcome her difficulties. Also, she was concerned about fatigue, the tiredness in her legs, particularly after work, often not being in touch with her body, and her experiences of inner tension which she could not release. She was also concerned about her frightening dreams which occurred after having given away all her savings to her father: "Her father and her brother were killed in an automobile accident. Her sister was so upset about it that she could not take care of her two children. Helen did it for her". Her other dream was the following: "I sat on a bag containing my mother who screamed and kicked inside (her mother was put into a bag for burial). I had a knife. My mother asked me to cut the bag open, but I could not do it". 

The first dream suggests her deep awareness of her rage against her father and her brother who took things away from her - money, her mother - and only their death could return the lost mother/child relationship. The second dream suggests to me that she perceived her mother as being in a fusion with her deep self, full of life, and that she was unable to permit freedom to her deep self - mother. 

Helen was a beautiful, tall, slim woman with an oval face, dark eyes and hair. Her mouth was strikingly small and so were her hands and feet. The shoulders were broad. Her arms looked tacked onto her body rather than natural parts of it. The trapezius and rhomboid muscles were extremely tight, as were the neck muscles, particularly under the skull. The chest was tight with the sternum bulging forward, creating the impression of a "chicken breast", about which her mother used to humiliate her by asking her to show it to relatives. In addition, there was a deviation of the sternum to the left. The pelvis was immobile, the knees locked and rotated inward. (Adductors spastic). 

Helen's eyes looked sad and longing most of the time. Sometimes her left eye looked terrified while the right eye remained sad looking. Her voice was melodious, often enthusiastic. Sometimes she talked under pressure. Her breathing was shallow, the diaphragm immobile, the stomach moving in during inspiration. (Paradoxical respiration).

We began with gentle exercises: "grounding" (see Appendix) with feet shoulder-width apart, slightly bent knees and concentrating on the experience of the total body weight being supported by the feet, after a while slowly bending down and then slowly coming back up by concentrating on the uncurling of the spine. I also had her do the yoga "plough" to help her release the tensions in her neck and back. Helen began to sob. At the end of the session she felt good, more in touch with her body but upset about not knowing why she had to cry. After the sessions she had a nightmare: "My mother came into my locked room". 

I believe by awakening her body through the exercises the muscular blocks were lifted which had aided in repressing her deep self and its awareness of being violated in her interactions with significant others.

 This vulnerability to being invaded, and the complimentary inability to separate, create a double bind, no win situation: contact with the significant other as well as loss of contact are deadly. As Helen put it once, "When I lose contact, I cease to exist; when I get into contact, I get swallowed up and controlled".  

This difficulty with boundaries in regard to significant other is typically linked with a poor sense of being grounded. When I asked Helen to change her natural locked posture into the opposite, she feared that her legs would give and she experienced her ankles as unreliable. During her first falling exercise (see Appendix) she felt the horror that there was no ground to support her if she let go and that she would fall down, endlessly. When she finally had to let go, she "survived" it by blocking and deadening herself. In other words she could not "reality test" her irrational belief that there was an engulfing abyss rather than a pillow at the end of her fall. This is comparable to the experience of a person who is left with a traumatic neurosis after surviving a disaster. In spite of succeeding to help her feel calm, in touch with herself and grounded at the end of the hour, she still had a difficult week after the session, with panic attacks, diarrhea, pain in her shoulders, and in her chest, an inability to breathe and a tension she could not discharge. Also, throughout the week she could feel only various parts of her body, never her total body. During the following session she described in more detail her experience during the falling exercise: having stood for a little while in a stress position, she began to experience pain. She thought "I can just stop this position and end my pain". To her dismay she could not resist my instructions despite her wish to do so. Just by giving her instructions, namely to wait until she falls instead of deciding to fall, I had gained dominion over her. She experienced this takeover as just and therefore felt guilt over her wish not to follow my instructions. 

I thought it essential to provide Helen with experience of her deep self, remaining alive even when differing in her wishes with mine. For this purpose I engaged Helen in what I called "boundary exercises" (see Appendix) : we both stood up, in the grounded position as described, facing each other. Her first task was to become aware of her deep inner self. Often I asked her to close her eyes to help with this process. With her eyes still closed I would ask her to imagine my presence, while remaining aware of her deep self. Sometimes she found that to imagine both of us caused her self to shrink. On opening her eyes her self might shrink still further. I asked her to become physically active without moving away from her spot. To her surprise she found that she regained lost territory. However, it was exceedingly difficult to maintain her self's territory when the contact became more dynamic and confrontative: to prevent panic from overwhelming her, she would reduce her breathing or dissociate and become "unreal". I encouraged her to defend herself against me, who seemed to engulf her, by stomping her feet, shaking her first and yelling at me to leave her alone. This helped her regain her territory but brought tears for she feared she would lose me. She showed difficulties in reality testing that this loss had not actually occurred: she kept experiencing me as distant. However, she could correct this misconception with the help of grounding exercises.

 As Helen became less repressed and more aware of herself she seemed better able to manage her daily life with more pleasure and self-assertion. However, she had a frightening dream: "I yeas hiding behind a dirt mount and taunting my mother to drive over me with her motorcycle. My mother finally did it. I felt safely protected by the dirt mound. Suddenly I realized that the mound was getting worn down by the motorcycle wheels. My mother kept going faster and faster, laughing. The mound got smaller and smaller, the wheels began to go over my chest and cracked a rib. I began to bleed internally. My mother kept going over my chest, over my limbs and finally over my head". At that point Helen woke up.

 In retrospect I wonder whether the dream revealed her unconscious knowledge that the carcinoma was growing in her breast. She had noticed the lump in her breast half a year before, gone to the doctor and was reassured that she had cystic mastitis. In her sensitivity she had even felt ridiculed for her concern and avoided paying any more attention to her breast. I regret that the dream did not make me suspicious. It occurred three months before the carcinoma was found and was diagnosed as being a rapidly progressive infiltrating duct carcinoma of stage 2 at the minimum.  

We continued with the boundary exercises. A repetition of the falling exercise two months after the first one showed the progress she had made. She not longer felt that I gained power over her by my instructions but was able to continue feeling that it was her decision to engage in this task. But she still felt the fear of an abyss waiting for her and a sense of utter aloneness during the fall, at the end of the fall she found herself safely on the ground with her real self in-tact. In other words, the aloneness during the fall (the sense of desertion for having let go of the mother, so to speak) no longer led to death (sense of unreality) but to her "real self", at home in the reality of life (safely on the ground). Mother's arms were replaced by mother earth and its gravitational safe hold on her. 

Christmas vacations were exceptionally good. She felt somewhat more distant from her family but succeeded in preventing invasions.

 It was around this time that Helen said "Only now do I realize how afraid I was of contact".

 Other aspects with her difficulties with contacts and boundaries became apparent during our boundary exercises: contact seemed to lead to "defeat and humiliation", to being "entombed in stiffness", to "burdening the other"; loss of contact to "being compressed into nothingness", to "being in little pieces". She had dreams about being squeezed in an arena full of people or about being squeezed out from a bus. The main themes remain: Assertion led to desertion and to death, contact to defeat, humiliation and constriction, and letting go to aloneness and death. Confrontation exercises set up by my saying, with her consent, "Yes you will", and her "No I won't" - continued to be deadly for her: either she or I became "unreal", sometimes alternatingly.

She learned to be herself when she had permission to be herself, when she had some "space", When she truly had to fight she could not do it. Later when the cancer was found I did Carl Simonton's meditation and imagery with her. Only in my presence could she imagine that her white blood cells could destroy the cancer cells. When she was alone the cancer cells always won. Once she told me she felt it was wrong to "kill the life of the cancer cell".

 Just before going to the hospital to have a now sizeable lump in her breast removed and diagnosed she told me of a dream and a daydream. I remember the pain of sadness I felt on hearing them because they seemed to express her knowledge and acceptance of her death. 

The dream: a rope ladder bridge led across a broad river. People walked across. She hesitated but finally began her passage but the ladder gave. She sank down to the river, gulped water, struggled by pulling on the ladder with her arms and legs to take off some slack and finally made it. She then struggled to get on a tower. When she finally reached her goal she had to laugh because she realized that she had to get back to the other side. But she knew she would fly there. 

Daydream: her life force left her body and went into the earth through her feet. She had had such experiences in the past but they always frightened her. This time she felt very peaceful and enjoyed the spring as never before.

 A few days later she was operated on and had a radical left mastectomy. She received a poor prognosis. The physician gave her one year to live. She actually lived for almost two years thereafter.

She experienced the surgery as if her worse fears of invasion had come to pass, as if the surgeon and physicians were out to kill her rather than the cancer cells. She had dreams of struggling to get out of the coffin - as her mother had struggled to get out of the burial bag in a previous dream. Many dreams showed her, her mother or her grandmother being contained, held back, compressed.

 The cancer cells proved to be oestrogen dependent, therefore an oophorectomy was done a month later. She dreamed of being raped. In a session afterwards, after thawing her body out of her defensive rigidity, she felt rage and with my encouragement she yelled "Leave me alone, you took enough". In doing this she became aware of her vivid fantasy: her physicians were outside my office laughing sadistically at her (as her mother had done the dream of the motorcycle). This fantasy faded after she had expressed her rage for a while. 

Never having been able to use her healthy rage for self-assertion because of fearing desertion, she could not use it to conquer the cancer cells, but had to project onto physicians who, like her mother, gave her some cause for such projections.

 We kept working on grounding, boundary exercises and falling exercises. It was hard for her to remain hopeful and yet aware of having to fight the cancer. She tended to maintain hopefulness only through denial which made a confrontation unnecessary. Confrontations, to her mind, still would lead to the death of one or the other partner. She could not envision that such confrontation would lead eventually to synchronized mutual need satisfaction.

 There was a year that was good for her. She even achieved her goal of having her own apartment. Her relationships with family and friends improved. Half a year after the oophorectomy, metastases were found. She decided to undergo chemotherapy which brought about a reduction of the size and spread of the metastases. But she began to have difficulties with nausea and vomiting. She responded to reduction in dosage with a recurrence of the matastases. When the oncologist again increased the dosage giving her little support to help her put up with the severe vomiting, she rebelled, with the support of her mother, against any further treatment. I refrained from guiding her either way, feeling quite helpless, and just pointed out her choices and the probable consequences. Soon the cancer spread again and she became incapacitated. There were still touching moments when her mother could permit herself to cry in front of her, after I reassured her that her tears would not "burden" her daughter. It turned out as I predicted, that mother and daughter became closer after so many years of distance. Helen told me a few days later that she could feel her mother's love, that her mother loved her as best as she could. Once during these last days she said to me: "I think I needed this illness to permit myself being helped by my parents". 

There was also her painful discovery of her father's narcissism: when the metastases were discovered he asked her to sign over to him her car and increase her life insurance so he could start a business with the money. She was appalled that her father, the only person to whom she felt continued closeness after her grandparents' death, would use her as a "dollar sign". 

After her death, her father said to me: "Now I understand why Helen wanted to move into an apartment - she wanted me to get used to not having her".

SUMMARY AND DISCUSSION

 A 29 year old woman began therapy six months before a carcinoma of the breast was diagnosed. She had been exposed to a well known carcinogen - a birth control pill - since age 14. She also showed the personality features and life events typical of people who develop malignancies. Vulnerability to clinical cancer is heightened by the presence, in varying degrees, of several factors: genetic, environmental carcinogens, nutritional factors and the stage of the immune and endocrine system, which in turn are influenced by stress and psychological factors. 

Two and a half years of therapy with her permitted me so understand her personality and life history quite well. I found confirmation for what is described in the literature: the loss of a significant relationship a half to eight years before the discovery of a malignancy in the case of my patient, it was four years - experienced by a person with a typical coping style which antedates the loss, and which consists of a rigidly conforming, excessively pleasant style, with realistic and adaptive functioning, but poor outlet for emotional discharge, due to an excessive reliance on denial and repression.

 The conceptual construct of the split self clarified the interplay of loss experience and the typical coping mechanisms, her difficulties with boundaries and her proclivity to lose her ground, as well as her trouble with the falling exercise.

 The splitting of the self can be seen as the result of using repression and denial at a very early stage of ego development, before the differentiation of the self from its actions has occurred. Piaget ¹⁴ concluded from his observations that before 11/2 years of age, the young child is aware of himself only as he acts on objects, neither himself nor the objects being differentiated from his actions. Only at stage 6 of the development of the sensori-motor intelligence, beginning at age 11/2 years, is the child capable of conceiving of an object including his mother as existing quite independent of his own actions, and seeing himself as one of such objects ¹⁵.

 It follows that as the very young person is faced with the imperative need to repress his rage or lusty love, he could only do so by repressing a part of himself as well, thus splitting into two parts: a superficial self which is fighting desperately to hold onto whatever reality is acceptable, and a deep self, which is locked away into unconsciousness, into a prison where it languishes, feeling lonely, sad and hurt, without hope of ever achieving any satisfactions through contact with the world. The simultaneous use of denial and repression is also explainable by the occurrence of a need to eliminate part of his experience when the child is still at an early stage of ego development, because then objects as well as the self are not yet differentiated from actions. This denial shows up in adult cancer patients as an inability to see the negative aspects of the loved one, e.g. my patient's inability to perceive her father's and later her lover's narcissism.

 The assumption of an early undifferentiated psychological unit of self-acting-an-object, which only can be repressed in toto, gained support from my observation that Helen's deep self often emerged as a fused mother-self.

 Dr. Thomas's ³ study showed that cancer patients and mental patients were similar in that they both rated lowest intheir experience of closeness to their parents. They were different in that only the mental patients had experienced matriarchal dominance. I see the following explanation for this finding: a dominant mother gives the young child a way of safely expressing his anger - he is sure he cannot destroy or hurt her. The child with a nondominant mother does not have such an option. Instead of expressing his anger, he has to use denial and repression to cope with his rage over his parents' distance. Such hypothesis is given support by the observation that cancer patients who distort reality by projecting (thus getting a permission, a "cause", to express their rage) have a better prognosis than those who do not. Considering the above findings, it is of interest that Helen was the only child in her family who did not have a dominant mother, because her mother was replaced by her passive, narcissistic father. She was also the only one who developed cancer. Judging from my brief acquaintance with her sister and her brother and my cursory knowledge of their life history, they did not develop the cancer personality either.

 When Helen lost her mother as her primary parent, she was unable to mourn her, instead repressing the negative parts of herself and her mother in a still fused state, as a negative self-object. She chose her maternal grandparents as a partial substitute for her lost mother. When they died, the process of splitting was dramatically reinforced. Her attempt at suicide in order to join her grandparents in heaven was an attempt to avoid this splitting.

 After the grandparents' death the split in the self was far advanced. Her deep self led a restricted life, having minimal outlets through her contact with nature and her apple tree. Her surface self seemed to have replaced its connection with the deep self by a fusing relationship with her father and later her boyfriends. Their narcissistic quality made them perhaps particularly suited to function as a substitute for her deep self. This quality also tended to strengthen the surface self's independent and strong functioning (to satisfy the father's, (lover's) narcissistic needs) while fostering repression of the sad hurt, anger and neediness in herself. 

By sacrifically living for these men, Helen could discharge some tension via her sexuality (She never could masturbate). She also could discharge some tension through running, a capacity she lost with the loss of her "great love". 

A history of extreme self-sacrifice was found by Bacon (1952)¹² in his study of breast cancer patients.

The boundary exercises helped Helen become aware of her covert needs and wishes, rooted in her deep self, by breathing and grounding. They also activated her deep fused mother-self, and the strong developmental need to differentiate her self from the fused mother-self state. By unconsciously projecting the mother onto me she could again engage in the process of separation that had been interrupted when her mother had betrayed her. I became the betraying mother for whom she longed and whom she hated. I also became the vulnerable father, and the grandparents who deserted her by dying. She had learned to respond to such situations with inactivity, so as not to incur the loss again, for which she blamed herself. This left her in a terrified paralysis. With the boundary exercise she could protect her boundaries against me by becoming active. 

The terror of falling also has to do with this split: the deep self is the seat of autonomous, creative functioning which is not fully under ego control. 

Not being integrated with her deep self, she was terrified of losing ego control. As her trust in her deep self increased, as well as in mother earth, she could let go of control and let herself fall.

 I think it is this letting go of control which permitted her to make peace with her family and death, before she died.
 

APPENDIX 

THE BOUNDARY EXERCISE: 

I developed the boundary exercise to help patients explore experientially the conflict of intimacy vs. isolation (E. Erickson)¹⁶ . One way in which this conflict expresses itself is in the conflicting needs for closeness to and distance from a significant other. The neurotic solution to this conflict consists of letting one need win over the other. Either integrity is achieved by distancing oneself, but intimacy is sacrificed, or intimacy is achieved by proximity, but integrity is sacrificed. There is typically a decrease of awareness in respect to the sacrificed need.

In order to enhance self awareness, including awareness of the sacrificed need, the patient is asked to stand up with closed eyes, to breathe deeply and to become aware of the effect of gravity on the body, as it gives substance and weight to the body. 

The patient is asked to open the eyes once heightened awareness has been achieved, and make eye contact with the therapist, who is also standing, at some distance from the patient.

 Once eye contact has been made, the patient is instructed to note any changes bodily or psychologically, that might occur as the therapist slowly walks towards the patient. Once patient has noticed a change, he is to say "stop" or "go back" to the therapist until the noted change is reversed. Thus the boundary of the patient's needed space is found, as it manifests itself at this point in time. 

Some patients are so accustomed to violate their integrity, their need for space, that they permit the therapist to come extremely close. Only on detailed inquiry do they discover that, e.g. their hands had become cold, or that they experienced a vague discomfort, or that the therapist seemed to look different. On the other hand those who habitually sacrifice their need for intimacy, are surprised to discover that they feel truly comfortable and in contact only when the therapist stands far away, because they had preserved their integrity by no longer truly experiencing the other person's presence, thus violating their partner.

 The second part of the boundary exercise consists of enabling the patient to experience that there are options available that do not involve the violation of either their own or their partner's integrity. 

The exercise begins like the first one, with the following additional instruction: once the patient boundary is established, the therapist will advance one more step, into the patient's "space", causing the patient to experience discomforting changes. Once the patient has clearly become aware of these changes, he is to stomp his feet, shake his fists and yell "No" or "Leave me alone", or just yell without any words, for a minute or two. After this the patient is to check whether he feels different from the way he felt before the expression of assertion. Invariably, patients are amazed to find themselves relaxed and comfortable, despite the therapist's proximity, which had been discomforting before. The assertion behavior affirmed their boundary and integrity, so that greater proximity (intimacy) could be achieved without violation of either partner.
 

GROUNDING EXERCISE: 

Alexander Lowen 17 describes the concept of grounding as follows:

"In a healthy person there are no mood swings of elation and depression. He always has his feet on the ground - the base line from which he operates. He may become excited by some event or prospect which brings the energy strongly into his head, but his feet never really leave terra firma. His feeling may be one of pleasure or even joy, but rarely is it one of elation. If the event or the prospect proves ultimately disappointing, he may be saddened, somewhat dejected, but not depressed. He does not lose his ability to respond to new situations, as the victim of a depressive reaction does.

 "Grounding is a bioenergetic concept and not just a psychological metaphor. When we ground an electrical circuit, we provide an outlet for the discharge of its energy. In a human being grounding also serves to release or discharge the excitation of a body. The excess energy of the living organism is constantly being discharged through movement or through the sexual apparatus. Both are functions of the lower part of the body. The upper part is mainly concerned with the intake of energy either in the form of food, oxygen or sensory stimulation and excitation. These two basic processes of charging up and discharging down are normally in balance. 

"The first step toward grounding is to learn to stand with knees slightly bent. Standing with knees locked back as so many people do immobilizes the whole lower half of the body. Take a position with the feet parallel and about six inches apart and bend the knees so that the weight of the body is balanced between the heels and the balls of the feet. The rest of the body should be straight, with the arms hanging loosely at the sides. The best results will be obtained if one stands barefoot or without shoes. If possible, hold this position for about two minutes.

 "The mouth should be slightly open so that the breathing can develop easily and fully. Let the belly out but don't force it. Holding the belly in restricts breathing and is unnecessary work. You don't have to hold yourself up by your guts if you will allow your legs and back to serve this function, as they were intended to do. The breathing movements should extend into the belly. The back should be straight but not rigid, the buttocks and pelvis should be allowed to hang lose and free.

 "The purpose of this exercise is to bring you into touch with your legs and feet, and this will happen as sensation develops in them. Put your attention into your feet and try to maintain your balance between the heels and balls of the feet. As you do this, you may find some involuntary tremors occurring in the legs or body, your legs may begin to vibrate or to shake. These involuntary movements are an expression of the flow of feeling in your body. Allow them to develop to the extent that you are comfortable with them. Sense your body and see if you can feel its aliveness".
 

FALLING EXERCISE:

 Alexander Lowen 17 describes the falling exercise as follows:

 "Our lives do not depend on success, yet we must have gained the impression that they do. To uncover the source of this fear, use a simple exercise, asking the patient to stand on one leg and bend the knee as far as it will go without raising any part of the foot off the ground. The other leg is extended backward off the ground. The arms are extended and the hands rest lightly on two chairs placed alongside the person. The chairs are used for balance, not for support. On the floor six inches from the patient's foot is a folded blanket.

 "The patient is asked to hold this position as long as he can, breathing easily and deeply, and to feel the weight of his body on his foot. When he can no longer maintain it, he is directed to let himself fall on his knee onto the blanket. There is no danger of injury through this exercise, yet most people are afraid to let themselves fall. Some will struggle to maintain the position indefinitely, while others will fall prematurely as an act of will rather than surrender. Many lower themselves to the floor gradually. This exercise is repeated twice on each leg. On the fourth time I ask the patient to say, "I give up", as he falls. When this exercise is done in my office, I can gauge from the tone of the patient's voice and his manner of saying it whether his surrender is genuine or false, that is, whether he really felt like giving up or simply said it in response to instructions. In both cases, however, the implications of this action are discussed with the patient.

 "Exercise 3 is generally preceded by the other two exercises so that a certain amount of sensation and feeling have already developed in the person's body. It is not surprising, therefore, that many patients when they first fall or when they say "I give up" will break into sobs. To feel oneself fall and not be hurt seems to relive some deep anxiety. Having fallen, the patient feels secure in the closeness to the ground. Lying on the ground, one has temporarily abandoned the struggle against gravity and the compulsion to do something. But so few people seem capable of letting go in this simple way. They feel they have to be up and doing. 

(* copyright 1981)