In addition to the studies cited, experience with our patients leaves no reasonable doubt in our minds of a link between certain emotional states and cancer.

One of our earliest experiences occurred while Carl was still in residency and we had not yet begun to use the approach described in this book. Betty Johnson, a forty-year-old woman, came to the hospital with an advanced cancer of the kidney. She had been widowed during the preceding year but continued to live and work on the ranch left to her by her husband. An exploratory operation revealed that she had cancer that had spread outside the kidney, and that it would be impossible to remove the cancer surgically. She was treated with minimal doses of radiation but there was little expectation for improvement. Then she was sent home to her ranch, given only a few months to live.

Once home, she fell in love with one of the men who worked on her ranch and they were soon married. Despite the prognosis of imminent death, she showed no further signs of the illness for five years. Then her second husband left her after running through her money. Within a few weeks Betty had a major recurrence of the cancer and died shortly thereafter.

It would seem that her remarriage played a significant role in her apparent recovery, and that being deserted precipitated the recurrence of the disease and her death.

Day after day we find similar evidence of the link between emotional states and disease in the lives of the people we see, and one important result is that we have learned to listen to our patients more closely. When we considered cancer a purely physical problem, we viewed patients' descriptions of their emotional states as something to be responded to with sympathy and understanding but having little to do with the course of the disease. As we learned that the "whole person" participates in the course of disease, we began to pay very close attention to everything our patients said. One of the patients who taught us was Millie.

Millie Thomas was unique among our early patients in that she came to us already convinced that she had participated in her illness. She had been sent to see Carl by her physician, a thoracic surgeon, who had attended a lecture Carl had given. Millie was seventy years old, although she held herself so erect that she seemed younger. She had already been diagnosed as having cancer and had undergone surgery once to remove the diseased tissue.

Millie's opening statement to Carl was that she had brought the disease upon herself and she was afraid she would cause it to recur or to spread. She wanted help. She spoke so directly and with such force of intelligence that we had no immediate reply, except to ask her to explain.

Millie related that as she approached seventy and neared her mandatory retirement age as an elementary schoolteacher, her students seemed to annoy her more and her work became unpleasant. Unmarried, she shared her apartment with another older woman, whom she also found increasingly annoying. Her whole world seemed to be deteriorating.

She noticed that she had begun smoking more and that, as she inhaled the smoke, she was thinking it wouldn't be long until she would be dead. At night when she went to sleep, she was also aware of thinking that this was one less day she would have to live, that she had completed another day and there wouldn't be many more. For several months, she continued to smoke and to become more and more depressed. Then she developed an increasingly severe cough that eventually produced some blood.

When she saw her physician she was found to have lung cancer and underwent surgery. After the operation, her depression recurred and, as a result, she became apprehensive about the possibility of re-creating the disease that she strongly believed she had participated in developing in the first place. When she voiced this fear to her surgeon, he remembered Carl's lecture and referred her for consultation.

Millie was the first patient to tell us that she had made herself ill" and could relate the actual thought processes she had experienced. Having previously undergone some psychotherapy, she was more aware of her thoughts and feelings than many people. She required very little help in overcoming her fear and depression.

Although Millie was unusual in the degree of access she had to her inner self, we find that many of our patients—once they understand that their emotional states may have played a role in their disease—remember similar thoughts and feelings. Often they recall wishing they were dead or feeling hopeless and thinking that death was the only way out. Frequently these feelings occurred either because of a new demand that had been placed on them or because of an apparently unresolvable conflict.

For many of our patients, the conflict occurs when they discover their spouses have had affairs, particularly if they will not consider marriage counseling or if their religious beliefs prevent them from accepting the idea of divorce, but they nevertheless feel unwilling to stay in marriage. Edith Jones faced this problem in the extreme when she discovered that her husband, the father of their six children, was having extramarital affairs. She did not believe she could tolerate the situation but she also did not believe in divorce. There appeared to be no alternatives and so she felt trapped. She contracted cancer and soon died. For Edith, death represented a solution. Other women might have found a basis for continuing the relationship, and still others might have given themselves "permission" to obtain a divorce.

Several of our male patients have had conflicts centering on relatives in their businesses. This was the case with Rod Hansen, who singlehandedly had developed his small company into a successful enterprise. Because of close family ties, Rod took a relative into the business in a major supervisory role. The relative turned out to be incompetent to handle this level of responsibility, the business began to deteriorate, and the enterprise that Rod had poured himself into heart and soul ceased to be a pleasure—indeed, it became an intolerable problem to which he saw no solution.

Rod received his cancer diagnosis approximately one year after his business began deteriorating. After working with us at our clinic for some time, Rod learned how to confront his problems more directly. At one point he actually fired the relative, then subsequently brought him back in a lower position more appropriate to his abilities.

Another frequent life pattern found in the cancer patient is that of a woman who has invested all her emotional and much of her physical energy in her family. As chauffeur, cook, nursemaid, and counselor to her four offspring, June Larsen's days were a whirl of ballet classes, music lessons, football games, slumber parties, and P.T.A. meetings. Because her husband was a successful executive with a major corporation and had to travel a great deal, responsibility for the children fell almost entirely on her. When she looked back on those years, she admits that she and her husband had come to have little in common other than the children.

As each child grew up and left home for college or marriage, June would go through a short bout of despondency, but soon she would snap back and throw herself with renewed energy into her remaining children's endeavors. When the last child went away to college, June felt "as if a part of my life had been cut out of me." She was deeply depressed and at a loss as to what to do with her time. She also made increasing demands on her husband, which he resented. Nothing seemed to lift her spirits, and within a year she was diagnosed as having breast cancer with bone metastases.

June's primary identity had been tied up in her children. When thrown back on her own resources she discovered that most of her skills were for nurturing others rather than for meeting her own needs. She felt forced to accept that there was little left of her marriage. While the actual external stress—the blow of her last child's leaving for college—may seem small, it totally undercut the role that had defined her for many years.

Because June's situation is so typical, we have seen many patients like her and have observed a number of different responses to this particular stress. Some women are able to establish a new identity apart from that of mother. In several cases, the marriage has been rebuilt so that it once again provides meaning. In our experience, the women patients who make the transition to a new role or who reestablish important relationships not only live longer—some now show no signs of illness—they-also live much more active and rewarding lives.

For men and women who have had active careers, retirement often poses a number of problems. Sam Brown was an executive who did not really want to retire at age sixty-five, but it was such an established practice in his firm that he never questioned it. After the round of retirement parties wore off, however, Sam felt himself getting increasingly bored, and then depressed. As an executive in his firm, he had always felt important. Now he felt he had lost stature. When people asked what he did and he answered "retired," he didn't get the spark of interest and respect he was used to. In addition, he found he missed the excitement and stimulation of his work and of an occasional business trip. Although he had prepared financially for retirement, inflation had forced him to reduce his standard of living.

To complicate matters, Sam and his wife had not been close for a number of years. Conflicts that had been hidden while he spent many hours at the office now emerged, and he saw himself as a captive audience to her steadily increasing complaints. He came to realize how much of his self-esteem had been tied up in his work, and without it he felt useless and unproductive. He began to wonder whether he had really accomplished much in life after all. Finally, when several friends died a short time after their own retirements, Sam began to think more about death. Fourteen months after he retired he was diagnosed as having cancer of the bowel.

In addition to the sources of stress which we have seen in the preceding cases (loss of a spouse, financial difficulties, Unwanted retirement, significant business setbacks, loss of life's purpose through children leaving home and deterioration of a marriage), another stress that we have seen frequently in our patients' lives prior to the onset of cancer is what has come to be called "the mid-life crisis."