Journal of Religion and Health, Vol. 27, No. 4, Winter 1988
I s s u e s of H o p e and Faith in the Cancer Patient E L L E N C A R N I , Ph.D. ABSTRACT: Akira Kurosawa's 1952 film about a man with a terminal gastric cancer introduces
a discussion of hope and faith in the oncology patient. A psychodynamic relationship between hope and faith is explored, using Lawrence LeShan's research in cancer psychotherapy and Erik Erikson's lifespan developmental theory. LeShan describes a cancer personality characterized by hopeless despair, while Erikson formulates a psychogenetic framework for the development of hope and despair. Hope and faith are linked through the individual's earliest strivings toward basic trust in the world and his or her own self-efficacy. Accordingly, cancer psychotherapy may aim at restoring adult patients' faith in life and inner creative resources.
In the p s y c h o t h e r a p y of i n d i v i d u a l s with a p o t e n t i a l l y t e r m i n a l illness, spirit u a l a n d psychological issues converge in t h e most profound ways, for b o t h p a t i e n t a n d t h e r a p i s t are impelled to give practical consideration to t h e f u n d a m e n t a l e l e m e n t s of t h e h u m a n c o n d i t i o n - - l i f e a n d death. For the patients, questions and conflicts a b o u t t h e i r own m o r t a l i t y surface w i t h r e l a t i v e i m m e d i a c y . The m e a n i n g f u l n e s s of t h e i r existence, the q u a l i t y of t h e i r lives, t h e i r sense of connectedness to o t h e r h u m a n beings, are a few of t h e i r concerns. For the t h e r a p i s t , t h e existential concerns are d i l e m m a s of faith a n d hope: I n w h a t do these p a t i e n t s believe t h a t is life-affirming a n d t h a t affirms t h e i r own i n n e r life? W h a t gives t h e s e p a t i e n t s hope in face of this personal t r a g e d y ? This p a p e r explores a p s y c h o g e n e t i c r e l a t i o n s h i p b e t w e e n hope and f a i t h in t h e context of individuals w i t h a l i f e - t h r e a t e n i n g illness, specifically, of i n d i v i d u a l s w i t h cancer. The a n a l y s i s is based on t h r e e sources: a film m a d e b y A k i r a K u r o s a w a in 1952 a b o u t a m a n w i t h a t e r m i n a l s t o m a c h cancer, t h e r e s e a r c h in c a n c e r p s y c h o t h e r a p y of L a w r e n c e L e S h a n , a n d t h e d e v e l o p m e n tal psychology of E r i k Erikson. F o u r core ideas c o n s t i t u t e the thesis. The first idea is the proposition t h a t f a i t h in the spiritual r e a l m is a derivative of hope in the psychological r e a l m a n d h a s its roots in t h e q u a l i t y of t h e i n d i v i d u a l ' s e a r l y object relationships, p a r t i c u l a r l y , of i n t e r p e r s o n a l t r u s t . F a i t h is i n t e r p r e t e d here not as a n a d h e r e n c e to a specific religious creed, b u t Ellen Carni, Ph.D., is a clinical psychologist in private practice in New York City. Address requests for reprints to the author, 545 West lllth Street, New York, NY 10025. 285
~(~ 1988 Institutes of Religion and Health
286
Journal of Religion and Health
as a belief in something t h a t is life-affirming and t h a t affirms the inner life of the believer and gives meaning to his or her life. The second idea is the proposition t h a t persons with a life-threatening illness such as cancer must at some point, consciously or unconsciously, grapple with issues of hope and faith in order to sustain themselves emotionally through the vicissitudes of their disease and course of medical treatment, and the uncertain prospects for their future. Third is the proposition that such persons bring to their illness not just a physiological or genetic history but an emotional history, and that this history disposes them for better or for worse for dealing with issues of hope and faith. Fourth is the proposition that psychotherapists working with seriously ill people can draw from the above ideas a valuable perspective on understanding their patients' experience and can derive from these ideas useful clinical interventions. The research on personality and cancer raises a controversial issue: whether and to what extent a person's emotional history may actually influence the formation of his or her disease. The position taken here is that there seems to be evidence suggestive of a psychosomatic component in the development of cancer, particularly in the work of Lawrence LeShan. However, this evidence should be interpreted with caution. The danger is t h a t patients may come to feel burdened with guilt for bringing on their disease. We know from studies of women with breast cancer that, once diagnosed, those with the most hope had the best prognosis. This knowledge is potentially countertherapeutic. Those patients who do not get better may blame themselves for not trying hard enough, despite putting out their best effort under the circumstances. The focus here is on how cancer patients' emotional disposition affects the quality of their lives: What gives these persons integrity and dignity in face of illness and the threat of death? In Kurosawa's film Ikiru, meaning "to live," the protagonist, Watanabe, learns he has a terminal gastric cancer and six months left to live? Watanabe is a petty bureaucrat who has spent his entire work life pushing papers behind a desk. He once had ambitions, but ideas for his projects were long since buried in his files. He was widowed early and invested his energies in raising a son alone. When the son married and became involved in his own life, Watanabe was left feeling emotionally alone. He adapted to his life experiences with apathy and stagnation. When he learns of his diagnosis, however, he has deep regrets over how he has l i v e d - - o r has not lived. He searches desperately to find meaning and gratification until he befriends a young woman who is dirt poor but happy because of her success in making dolls. In a dramatic turnaround, Watanabe marshals all of his energies, pushes past bureaucratic attempts to sabotage him, and has a park built for the citizens of the town. He dies a happy and fulfilled man. He has learned to find deep meaning through faith in and use of his inner creative resources.
Ellen Carni
287
Watanabe in his early phase resembles the personality of the cancer patient described by Lawrence Leshan. 2 According to Leshan, adults who develop cancer have typically lost their joy in life and reason for being. They are, beneath whatever exterior, apathetic and fatalistic. Psychodynamically, these are people who are said to have suppressed great inner energies because of early failures to find appropriate outlets. After experiencing lonely childhoods with real or perceived abandonment by their caretakers, the pre-cancerous individuals come upon a relationship or activity in which they overinvest. When this pursuit is lost, through no fault of their own, they fall into a despair that is followed by the development of a malignancy. They are then faced, because of the life-threatening nature of their disease, with the existential task of reviewing their lives and weighing their relative successes and failures. Am I satisfied with the w a y I have lived? Did I do the best I could? What do I regret? What gives me meaning and dignity? What gives me hope? In what do I believe? These questions are about the individual's balancing of integrity and despair, a balance described by Erik Erikson as the ultimate task of psychological growth2 Erikson proposes eight psychosocial tasks the normal individual must go through during the course of the lifespan. By a task, he means a balancing of positive and negative emotions that are the outcome of core life experiences the individual has in interacting with the social world. From infancy, these experiences center around: trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus identity diffusion, intimacy versus isolation, generativity versus stagnation, and integrity versus despair. The emotional outcomes of these experiences influence the development of eight psychic forces in the individual. These are hope, will, purpose, competence, fidelity, love, care, and wisdom. For example, hope is said to emerge from the infant's balancing of experiences of trust and mistrust of the caretaker. Relatively hopeful infants trust in the reliability of their caretaker, despite certain experiences where their needs are not met by that caretaker. Hope depends on the possibility of disappointment. Relatively hopeless infants do not trust in the reliability of their caretakers, and this m a y result in pathological states. Here one is reminded of the work of Ren~e Spitz on anaclitic depression in infants seven to 12 months of age. 4 The infants Spitz described were separated from their caretakers with no appropriate substitutes. They became weepy, then withdrawn and apathetic. With extended separation, these infants never returned to normal, and many succumbed to various childhood illness. Erikson's eight tasks are neither fixed in time nor self-limiting. Rather, they accumulate so that at any point in development an individual can rework issues from earlier tasks and repair a negative balance. Hence, infants with an unreliable caretaker can still be potentially hopeful, depending on how they integrate or later reintegrate their early experiences. Within this model, the restorative power of psychotherapy rests on the reworking of the
288
Journal of Religion and Health
individual's experience through the corrective experiences of the therapeutic relationship. Adults with life-threatening illnesses are thrown, perhaps prematurely, into a Stage 8 task, balancing integrity and despair. Individuals with relative integrity have a sense of respect and dignity about how they have lived, having come to good terms with their successes and their failures and those of their parents with regard to their upbringing. Individuals feeling despair, contempt, or disgust about how they have lived feel that time is too short, if not altogether too late, for corrective experiences, in the face of the prospect of their death. The nature of the issues they are satisfied with or despair about depend on the developmental stage they are at. A young adult may be relatively satisfied with or m a y despair about establishing identity, while an older adult may experience these feelings about being productive or genera~ tive. Whether integrity or despair wins out depends, at least in part, upon how these people have dealt with previous life tasks and how they can reintegrate their experiences to transcend their histories. In Erikson's paradigm, LeShan's cancer patient and Kurosawa's Watanabe appear to be fixated at Task 1 - - t r u s t versus mistrust. Their early experiences led them to distrust the continuity of significant relationships and their own ability to have their needs met through significant relationships. They had not successfully balanced their experiences of trust and mistrust when they encountered an object that appeared to compensate their feelings of loss and deprivation, that is, of mistrust. When they lost this object, they despaired of recovering or replacing it, this loss of hope preceding the development of the cancer. Here are echoes of Spitz and others who wrote on pathological states of mourning. Anna Freud observed this sequence of childhood response to the loss of a love object: protest, despair, detachment. ~ Bowlby refers to these reactions as mechanisms of defense against an unconscious urge to recover the love object. ~ He argues that the open expression of ambivalent feelings toward the love object, anger at the loss, and yearning for the return of the lost object enable the child eventually to relinquish grief and restore hope. When this does not occur, the feelings and urge to recover the lost object become repressed and unconscious, while the individual appears despairing or detached. It is conceivable that the patients described by LeShan experienced a loss of their caretaker but were unable to resolve their feelings adequately, leaving them as lonely apathetic children. They later overinvested in a new relationship in an unconscious attempt to recover the lost love object. With the loss of the second object the unconscious yearning and rage would escalate, but, being hidden from awareness, would throw them back into the early pattern of despair. These individuals would appear to be struggling with an unconscious urge to recover the loss of an early love object and a loss of hope of ever recovering it. The emergence of a malignancy might be seen
Ellen Carni
289
as an analogue of the development of childhood illnesses among Spitz's anaclitically depressed infants. The emotional loss makes them somehow more physically vulnerable. An anecdote on the psychosomatic hypothesis comes from a study by Bruno Klopfer, cited by LeShan. Klopfer claims to be able to predict with 80% accuracy which of a group of individuals with cancer had slow-growing malignancies and which had fast-growing malignancies on the basis of projective personality tests alone. Klopfer says: If a good deal of vital energy the patient had at his disposal is used in the defense of an insecure ego, then the individual seems not to have the vital energy to fight off the cancer. If, however, a minimum of vital energy is consumed in ego defensiveness then the cancer has a hard time making headway.7 Klopfer refers to a "symbiotic" relationship between an individual and his or her cancer. It is easy to speculate t h a t the repression of emotion or vital energy LeShan found to be so characteristic of cancer patients goes back into the cells and is released in the form of cancer, which is literally a cell gone wild. This might account for the direct correspondence between the degree of felt loss of meaning and the growth rate of the cancer t h a t LeShan claims to find among his patients. Clinically, LeShan observed t h a t these patients seem to have a strong undercurrent of "61an vital." To return to Erikson, these are individuals for whom issues of trust and mistrust and their outcome, hope and hopelessness, pose lifelong problems. In this sense, when their diagnosis throws them into the Stage 8 task, integrity versus despair, they are already disposed to despair. Thus, integrity or despair from Stage 8 may be seen as derivative of hope or hopelessness from Stage 1. Another way of putting it is t h a t integrity and despair in adulthood depend on the psychogenesis of early hope or hopelessness into faith or fatalism: Infants with hope trust in the loving care of another and in their own ability to have their needs met through t h a t other. Adults with faith or integrity believe in something t h a t gives them lasting meaning and in their own ability to derive meaning from t h a t object. The object of faith m a y be a warm and loving God or divine principle or an activity like fellowship, artistic or scientific pursuits, as well as their own self-efficacy.8 True faith has the inner conviction of the basic worthiness and trustworthiness of the self. In developmental terms, its roots are in the child's capacity to feel t h a t he or she is worthy of the love of the caretaker, and can do things to produce pleasurable experiences for himself or herself despite not always meeting with success. Basic faith in life in adulthood corresponds to the child's capacity for basic trust. It is the opposite of fatalism, which implies mistrust of life, of relationships, and of self, by virtue of a feeling of pernicious control from without. Faith is life-affirming. Fatalism is lifethreatening and is literally, what is so deadly to the cancer patient, w i t h i n this paradigm.
290
Journal of Religion and Health
Within this psychodynamic context of hope and faith, the psychotherapists treating cancer patients should be alert to their patients' history of and reactions to loss and to their strengths as well. Like Watanabe, individuals grappling with integrity and despair need to have or to find creative pursuits that enrich their lives and make them feel inner-directed. Kierkegaard said, "To get rid of despair one must get rid of one's self, the self one despairs of." LeShan talks about helping cancer patients to "find their own song to sing." In the present terms it would be helping the patients to define their own area of faith. Psychotherapists treating cancer patients may also help their patients rework the early developmental phase of trust versus mistrust through the therapeutic relationship. Though they may not be able to complete this process, whether because of the patients' illness or degree of psychopathology, they can encourage it by themselves serving as a model of hope and faith, hope for their patients' psychic recovery and faith in the process of psychotherapy.
References 1. Kurosawa, A., Ikiru. Japan, Toho/Kurosawa Productions, 1952, Filmscript. Great Britain, Lorimer, 1968, 1981. 2. LeShan, L., You Can Fight For Your Life. New York, M. Evans and Co., 1977. 3. Erikson, E., Childhood and Society. New York, W.W. Norton, 1950. 4. Erikson, Identity, Youth, and Crisis. New York, W.W. Norton, 1968. 5. Spitz, R., "Anaclitic Depression," Psychoanalytic Study of the Child, 1946, 46, 312-342. 6. Bowlby, J., "Pathological Mourning and Childhood Mourning," J. American Psychoanalytic Association, 1963, 11,500-541. 7. Ibid. 8. LeShan, op. cit., p. 93. 9. For a more general discussion of psycho-spiritual development, see Erikson, E., Adulthood. New York, W.W. Norton, 1978; Rizzuto, A.M., The Birth of the Living God. Chicago, University of Chicago Press, 1979.
I s s u e s of H o p e and Faith in the Cancer Patient E L L E N C A R N I , Ph.D. ABSTRACT: Akira Kurosawa's 1952 film about a man with a terminal gastric cancer introduces
a discussion of hope and faith in the oncology patient. A psychodynamic relationship between hope and faith is explored, using Lawrence LeShan's research in cancer psychotherapy and Erik Erikson's lifespan developmental theory. LeShan describes a cancer personality characterized by hopeless despair, while Erikson formulates a psychogenetic framework for the development of hope and despair. Hope and faith are linked through the individual's earliest strivings toward basic trust in the world and his or her own self-efficacy. Accordingly, cancer psychotherapy may aim at restoring adult patients' faith in life and inner creative resources.
In the p s y c h o t h e r a p y of i n d i v i d u a l s with a p o t e n t i a l l y t e r m i n a l illness, spirit u a l a n d psychological issues converge in t h e most profound ways, for b o t h p a t i e n t a n d t h e r a p i s t are impelled to give practical consideration to t h e f u n d a m e n t a l e l e m e n t s of t h e h u m a n c o n d i t i o n - - l i f e a n d death. For the patients, questions and conflicts a b o u t t h e i r own m o r t a l i t y surface w i t h r e l a t i v e i m m e d i a c y . The m e a n i n g f u l n e s s of t h e i r existence, the q u a l i t y of t h e i r lives, t h e i r sense of connectedness to o t h e r h u m a n beings, are a few of t h e i r concerns. For the t h e r a p i s t , t h e existential concerns are d i l e m m a s of faith a n d hope: I n w h a t do these p a t i e n t s believe t h a t is life-affirming a n d t h a t affirms t h e i r own i n n e r life? W h a t gives t h e s e p a t i e n t s hope in face of this personal t r a g e d y ? This p a p e r explores a p s y c h o g e n e t i c r e l a t i o n s h i p b e t w e e n hope and f a i t h in t h e context of individuals w i t h a l i f e - t h r e a t e n i n g illness, specifically, of i n d i v i d u a l s w i t h cancer. The a n a l y s i s is based on t h r e e sources: a film m a d e b y A k i r a K u r o s a w a in 1952 a b o u t a m a n w i t h a t e r m i n a l s t o m a c h cancer, t h e r e s e a r c h in c a n c e r p s y c h o t h e r a p y of L a w r e n c e L e S h a n , a n d t h e d e v e l o p m e n tal psychology of E r i k Erikson. F o u r core ideas c o n s t i t u t e the thesis. The first idea is the proposition t h a t f a i t h in the spiritual r e a l m is a derivative of hope in the psychological r e a l m a n d h a s its roots in t h e q u a l i t y of t h e i n d i v i d u a l ' s e a r l y object relationships, p a r t i c u l a r l y , of i n t e r p e r s o n a l t r u s t . F a i t h is i n t e r p r e t e d here not as a n a d h e r e n c e to a specific religious creed, b u t Ellen Carni, Ph.D., is a clinical psychologist in private practice in New York City. Address requests for reprints to the author, 545 West lllth Street, New York, NY 10025. 285
~(~ 1988 Institutes of Religion and Health
286
Journal of Religion and Health
as a belief in something t h a t is life-affirming and t h a t affirms the inner life of the believer and gives meaning to his or her life. The second idea is the proposition t h a t persons with a life-threatening illness such as cancer must at some point, consciously or unconsciously, grapple with issues of hope and faith in order to sustain themselves emotionally through the vicissitudes of their disease and course of medical treatment, and the uncertain prospects for their future. Third is the proposition that such persons bring to their illness not just a physiological or genetic history but an emotional history, and that this history disposes them for better or for worse for dealing with issues of hope and faith. Fourth is the proposition that psychotherapists working with seriously ill people can draw from the above ideas a valuable perspective on understanding their patients' experience and can derive from these ideas useful clinical interventions. The research on personality and cancer raises a controversial issue: whether and to what extent a person's emotional history may actually influence the formation of his or her disease. The position taken here is that there seems to be evidence suggestive of a psychosomatic component in the development of cancer, particularly in the work of Lawrence LeShan. However, this evidence should be interpreted with caution. The danger is t h a t patients may come to feel burdened with guilt for bringing on their disease. We know from studies of women with breast cancer that, once diagnosed, those with the most hope had the best prognosis. This knowledge is potentially countertherapeutic. Those patients who do not get better may blame themselves for not trying hard enough, despite putting out their best effort under the circumstances. The focus here is on how cancer patients' emotional disposition affects the quality of their lives: What gives these persons integrity and dignity in face of illness and the threat of death? In Kurosawa's film Ikiru, meaning "to live," the protagonist, Watanabe, learns he has a terminal gastric cancer and six months left to live? Watanabe is a petty bureaucrat who has spent his entire work life pushing papers behind a desk. He once had ambitions, but ideas for his projects were long since buried in his files. He was widowed early and invested his energies in raising a son alone. When the son married and became involved in his own life, Watanabe was left feeling emotionally alone. He adapted to his life experiences with apathy and stagnation. When he learns of his diagnosis, however, he has deep regrets over how he has l i v e d - - o r has not lived. He searches desperately to find meaning and gratification until he befriends a young woman who is dirt poor but happy because of her success in making dolls. In a dramatic turnaround, Watanabe marshals all of his energies, pushes past bureaucratic attempts to sabotage him, and has a park built for the citizens of the town. He dies a happy and fulfilled man. He has learned to find deep meaning through faith in and use of his inner creative resources.
Ellen Carni
287
Watanabe in his early phase resembles the personality of the cancer patient described by Lawrence Leshan. 2 According to Leshan, adults who develop cancer have typically lost their joy in life and reason for being. They are, beneath whatever exterior, apathetic and fatalistic. Psychodynamically, these are people who are said to have suppressed great inner energies because of early failures to find appropriate outlets. After experiencing lonely childhoods with real or perceived abandonment by their caretakers, the pre-cancerous individuals come upon a relationship or activity in which they overinvest. When this pursuit is lost, through no fault of their own, they fall into a despair that is followed by the development of a malignancy. They are then faced, because of the life-threatening nature of their disease, with the existential task of reviewing their lives and weighing their relative successes and failures. Am I satisfied with the w a y I have lived? Did I do the best I could? What do I regret? What gives me meaning and dignity? What gives me hope? In what do I believe? These questions are about the individual's balancing of integrity and despair, a balance described by Erik Erikson as the ultimate task of psychological growth2 Erikson proposes eight psychosocial tasks the normal individual must go through during the course of the lifespan. By a task, he means a balancing of positive and negative emotions that are the outcome of core life experiences the individual has in interacting with the social world. From infancy, these experiences center around: trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus identity diffusion, intimacy versus isolation, generativity versus stagnation, and integrity versus despair. The emotional outcomes of these experiences influence the development of eight psychic forces in the individual. These are hope, will, purpose, competence, fidelity, love, care, and wisdom. For example, hope is said to emerge from the infant's balancing of experiences of trust and mistrust of the caretaker. Relatively hopeful infants trust in the reliability of their caretaker, despite certain experiences where their needs are not met by that caretaker. Hope depends on the possibility of disappointment. Relatively hopeless infants do not trust in the reliability of their caretakers, and this m a y result in pathological states. Here one is reminded of the work of Ren~e Spitz on anaclitic depression in infants seven to 12 months of age. 4 The infants Spitz described were separated from their caretakers with no appropriate substitutes. They became weepy, then withdrawn and apathetic. With extended separation, these infants never returned to normal, and many succumbed to various childhood illness. Erikson's eight tasks are neither fixed in time nor self-limiting. Rather, they accumulate so that at any point in development an individual can rework issues from earlier tasks and repair a negative balance. Hence, infants with an unreliable caretaker can still be potentially hopeful, depending on how they integrate or later reintegrate their early experiences. Within this model, the restorative power of psychotherapy rests on the reworking of the
288
Journal of Religion and Health
individual's experience through the corrective experiences of the therapeutic relationship. Adults with life-threatening illnesses are thrown, perhaps prematurely, into a Stage 8 task, balancing integrity and despair. Individuals with relative integrity have a sense of respect and dignity about how they have lived, having come to good terms with their successes and their failures and those of their parents with regard to their upbringing. Individuals feeling despair, contempt, or disgust about how they have lived feel that time is too short, if not altogether too late, for corrective experiences, in the face of the prospect of their death. The nature of the issues they are satisfied with or despair about depend on the developmental stage they are at. A young adult may be relatively satisfied with or m a y despair about establishing identity, while an older adult may experience these feelings about being productive or genera~ tive. Whether integrity or despair wins out depends, at least in part, upon how these people have dealt with previous life tasks and how they can reintegrate their experiences to transcend their histories. In Erikson's paradigm, LeShan's cancer patient and Kurosawa's Watanabe appear to be fixated at Task 1 - - t r u s t versus mistrust. Their early experiences led them to distrust the continuity of significant relationships and their own ability to have their needs met through significant relationships. They had not successfully balanced their experiences of trust and mistrust when they encountered an object that appeared to compensate their feelings of loss and deprivation, that is, of mistrust. When they lost this object, they despaired of recovering or replacing it, this loss of hope preceding the development of the cancer. Here are echoes of Spitz and others who wrote on pathological states of mourning. Anna Freud observed this sequence of childhood response to the loss of a love object: protest, despair, detachment. ~ Bowlby refers to these reactions as mechanisms of defense against an unconscious urge to recover the love object. ~ He argues that the open expression of ambivalent feelings toward the love object, anger at the loss, and yearning for the return of the lost object enable the child eventually to relinquish grief and restore hope. When this does not occur, the feelings and urge to recover the lost object become repressed and unconscious, while the individual appears despairing or detached. It is conceivable that the patients described by LeShan experienced a loss of their caretaker but were unable to resolve their feelings adequately, leaving them as lonely apathetic children. They later overinvested in a new relationship in an unconscious attempt to recover the lost love object. With the loss of the second object the unconscious yearning and rage would escalate, but, being hidden from awareness, would throw them back into the early pattern of despair. These individuals would appear to be struggling with an unconscious urge to recover the loss of an early love object and a loss of hope of ever recovering it. The emergence of a malignancy might be seen
Ellen Carni
289
as an analogue of the development of childhood illnesses among Spitz's anaclitically depressed infants. The emotional loss makes them somehow more physically vulnerable. An anecdote on the psychosomatic hypothesis comes from a study by Bruno Klopfer, cited by LeShan. Klopfer claims to be able to predict with 80% accuracy which of a group of individuals with cancer had slow-growing malignancies and which had fast-growing malignancies on the basis of projective personality tests alone. Klopfer says: If a good deal of vital energy the patient had at his disposal is used in the defense of an insecure ego, then the individual seems not to have the vital energy to fight off the cancer. If, however, a minimum of vital energy is consumed in ego defensiveness then the cancer has a hard time making headway.7 Klopfer refers to a "symbiotic" relationship between an individual and his or her cancer. It is easy to speculate t h a t the repression of emotion or vital energy LeShan found to be so characteristic of cancer patients goes back into the cells and is released in the form of cancer, which is literally a cell gone wild. This might account for the direct correspondence between the degree of felt loss of meaning and the growth rate of the cancer t h a t LeShan claims to find among his patients. Clinically, LeShan observed t h a t these patients seem to have a strong undercurrent of "61an vital." To return to Erikson, these are individuals for whom issues of trust and mistrust and their outcome, hope and hopelessness, pose lifelong problems. In this sense, when their diagnosis throws them into the Stage 8 task, integrity versus despair, they are already disposed to despair. Thus, integrity or despair from Stage 8 may be seen as derivative of hope or hopelessness from Stage 1. Another way of putting it is t h a t integrity and despair in adulthood depend on the psychogenesis of early hope or hopelessness into faith or fatalism: Infants with hope trust in the loving care of another and in their own ability to have their needs met through t h a t other. Adults with faith or integrity believe in something t h a t gives them lasting meaning and in their own ability to derive meaning from t h a t object. The object of faith m a y be a warm and loving God or divine principle or an activity like fellowship, artistic or scientific pursuits, as well as their own self-efficacy.8 True faith has the inner conviction of the basic worthiness and trustworthiness of the self. In developmental terms, its roots are in the child's capacity to feel t h a t he or she is worthy of the love of the caretaker, and can do things to produce pleasurable experiences for himself or herself despite not always meeting with success. Basic faith in life in adulthood corresponds to the child's capacity for basic trust. It is the opposite of fatalism, which implies mistrust of life, of relationships, and of self, by virtue of a feeling of pernicious control from without. Faith is life-affirming. Fatalism is lifethreatening and is literally, what is so deadly to the cancer patient, w i t h i n this paradigm.
290
Journal of Religion and Health
Within this psychodynamic context of hope and faith, the psychotherapists treating cancer patients should be alert to their patients' history of and reactions to loss and to their strengths as well. Like Watanabe, individuals grappling with integrity and despair need to have or to find creative pursuits that enrich their lives and make them feel inner-directed. Kierkegaard said, "To get rid of despair one must get rid of one's self, the self one despairs of." LeShan talks about helping cancer patients to "find their own song to sing." In the present terms it would be helping the patients to define their own area of faith. Psychotherapists treating cancer patients may also help their patients rework the early developmental phase of trust versus mistrust through the therapeutic relationship. Though they may not be able to complete this process, whether because of the patients' illness or degree of psychopathology, they can encourage it by themselves serving as a model of hope and faith, hope for their patients' psychic recovery and faith in the process of psychotherapy.
References 1. Kurosawa, A., Ikiru. Japan, Toho/Kurosawa Productions, 1952, Filmscript. Great Britain, Lorimer, 1968, 1981. 2. LeShan, L., You Can Fight For Your Life. New York, M. Evans and Co., 1977. 3. Erikson, E., Childhood and Society. New York, W.W. Norton, 1950. 4. Erikson, Identity, Youth, and Crisis. New York, W.W. Norton, 1968. 5. Spitz, R., "Anaclitic Depression," Psychoanalytic Study of the Child, 1946, 46, 312-342. 6. Bowlby, J., "Pathological Mourning and Childhood Mourning," J. American Psychoanalytic Association, 1963, 11,500-541. 7. Ibid. 8. LeShan, op. cit., p. 93. 9. For a more general discussion of psycho-spiritual development, see Erikson, E., Adulthood. New York, W.W. Norton, 1978; Rizzuto, A.M., The Birth of the Living God. Chicago, University of Chicago Press, 1979.
