The Efficacy of Behaviour Therapy as a Cancer Treatment (and Preventative)
By Don Benjamin
CISS - The Cancer Information and Support Society, 13/1A Berry Road St Leonards NSW 2065 AUSTRALIA. Phone: +61-2+9906 2189 Website: www.ciss.org.au Email: firstname.lastname@example.org
Randomised trials show the dramatic effect of a particular form of psychotherapy, viz behaviour therapy, on survival and mortality with cancer. The three major papers demonstrating the efficacy of group or individual behaviour therapy in the treatment of cancer are those by David Spiegel et al from Stanford University School of Medicine (Calif)1; Hans J Eysenck and R Grossarth-Maticek from the University of London2; and Fawzy I Fawzy from the Department of Psychiatry and Biobehavioural Sciences, UCLA School of Medicine1.
1. In David Spiegel’s paper results were from randomising 86 women with metastatic breast cancer, 50 into the treatment group and 36 into the control group. The treatment group met weekly for ninety minutes for one year and received group therapy. This involved expressing their feelings, learning to cope with their cancer and its effect on their lives, learning to grieve and become more assertive. Self-hypnosis was taught for pain control. This approach indirectly helped the patients counter social isolation and put them back into control of their lives.
Results: After 10 years follow up three were still alive, all from the treatment group. None of those in the untreated (control) group lasted more than four years. Mean survival time from randomisation was 36.6 months for the therapy group and 18.9 for the control group, a difference of nearly 18 months. From initial diagnosis mean survival time was 94.6 months for the treated group and 81.2 months for the control group, a difference of more than 12 months. Quality of life was also improved in the therapy group. An unusual phenomenon observed was that the increased survival did not become apparent until six months after therapy had finished. The authors attributed this to a mild cumulative effect.
Two possible shortcomings of this trial were not knowing how representative the patients were of the wider community; and the limitation of matching in small groups. For example the intervention group had a slight advantage over the control group in relation to the interval between initial diagnosis and entry into the trial, viz, 58.0 months vs 62.3 months. However the large differences in survival could not be explained by these small differences.
2. In the Eysenck and Grossarth-Maticek paper, published two years after Spiegel’s, there was improved randomisation. Patients suffering stress were first matched into pairs based on sex, age, smoking, cholesterol level, blood pressure and personality type. Only after both members of a matched pair had agreed to participate in the trial were they randomised into therapy and control groups. This guaranteed that the therapy and control groups were accurately matched despite their small sizes. Cancer prone (Type 1 or “Type C”) and coronary heart disease (CHD) prone (Type 2 or “Type A”) patients were treated separately in some of the studies.
They carried out five studies related to cancer to test various hypotheses –
two treatment studies:
· the effect of behaviour therapy on survival of terminal cancer patients; and
· a comparison of the effects of behaviour therapy and chemotherapy on the survival of cancer patients; and
three prevention studies:
· the effect of individual therapy on the prevention of cancer;
· the effect of group therapy on the prevention of cancer; and
· the effect of bibliotherapy (learning the therapy from a text) on the prevention of cancer;
The results of the treatment studies were as follows:
Study 1 - Therapy on Terminal Cancer Patients: This study involved 24 pairs of cancer patients with six different types of inoperable cancer, including scrotal (1), stomach (2), bronchiolar (7), corpus uteri (4), cervical (5) and colorectal (5).
Survival times of the treated group averaged 5.07 years (ranging from 1.7 yrs for bronchiolar to 9.5 yrs for colorectal). For the control group survival averaged 3.09 years (ranging from 1.0 yrs for bronchiolar to 4.9 yrs for colorectal) – Increased survival 64%
This study therefore involved 100 women with metastasised breast cancer, in four similar groups of 25 who received chemotherapy + psychotherapy, chemotherapy alone, psychotherapy alone and no therapy. Of the 50 who received psychotherapy 24 received creative novation behaviour therapy (as in studies 3 and 4 described below), 12 received depth psychotherapy and 14 received orthodox behaviour therapy (relaxation training and desensitisation). 30 hrs of psychotherapy was given.
Results: Mean survival times for the 100 patients was 15.7 months, ranging from 11.28 for those who received no therapy (having refused chemotherapy), to 14.08 for chemotherapy alone, to 14.9 for psychotherapy alone to 22.4 months for chemotherapy + psychotherapy.
The authors state that chemotherapy alone increased mean survival by 2.80 (14.08-11.28) and psychotherapy alone increased it by 3.64 (14.9-11.28). Theoretically by adding these two effects, chemotherapy + psychotherapy should have increased survival by only 6.44 months to 17.72 months. In fact it increased it to 22.4 months exceeding the additive value by 4.68 months, suggesting a synergistic interaction between these two therapies.
It was also observed that the lymphocyte count of those receiving psychotherapy continued to rise over time whereas those not receiving psychotherapy fell, suggesting that the psychotherapeutic intervention may have had its effect through the involvement of the immune system.
The authors recognised that the trial was not one to test the effect of chemotherapy versus no chemotherapy, so there was no need to randomise patients into “chemotherapy” and “no chemotherapy” groups. This was done by self-selection: those refusing chemotherapy became the source for selecting and matching 50 women who would receive no chemotherapy but would be randomised to receive or not receive psychotherapy. This is in contrast to psychotherapy where in each case there was proper randomisation into the treatment and no treatment groups. Thus the only valid comparison of survival times is:
· between the psychotherapy alone (14.9 months) and no psychotherapy (11.28 months) group for those who had refused chemotherapy – increased survival 32%; and
· between the psychotherapy plus chemotherapy (22.4 months) and the chemotherapy alone (14.08 months) group for those who had accepted chemotherapy – increased survival 59%.
3. In Fawzy’s paper when psychotherapy was added to conventional treatment for melanoma there were only 3 deaths among the 34 in the treated group (9%) compared with 10 in the control group (29%), a 70% reduction in the number of deaths after 6 years.
The type of psychotherapy used by Spiegel, Eysenck and Fawzy incorporates a technique that enables cancer patients to break out of the hopeless/helpless situation and helps to put them back in control of their life and destiny. Hence the dramatic effect on survival and mortality.
Results of the Eysenck and Grossarth-Maticek prevention studies were as follows:
Study 3: Individual therapy: After 13 years of follow-up, none of the 50 treated in the cancer prone group had died compared with 16 of the 50 in the control group. 13 had cancer compared with 21 in the control group, 5 had died of other causes (cf 15) and 90% were still alive compare with 38% in the control group.
Personality retyping showed the therapy group's cancer proneness scores had fallen from 9.8 to 5.7. As expected there was no change in score (9.8) for the untreated control group.
Study 4 - Group Therapy: (This was similar to Study 3 except that 245 patients received therapy in groups of 20-25 people; the untreated control group also contained 245 people; sessions lasted several hours depending on the wishes and progress of the participants; there were 6-15 sessions altogether.) After 7 years follow-up there were 18 cancer deaths in the 239 treated group(7.5%) compared with 111 of the 234 in the control group (47.4%) (A few could not be contacted). Cancer incidence was 75 in the treated group (31.9%) compared with 129 in the control group (55.8%). 191 were still alive (79.9%) – 57 with cancer - in the treatment group compared with 56 (23.9%) –18 with cancer - in the control group; 10 had died of CHD (4.2%) compared with 36 in the control group (15.4%), CHD incidence was 29 (12.3%) compared with 45 (19.5%); 20 had died of other causes (8.4%) compare with 33 (14.1%).
Study 5 - Bibliotherapy (therapy described in an article and explained in 3-5 hours of discussion): (There were 600 in the study group and 600 in the control group. (The latter were given an article that did not include any treatment techniques for them to use.) After 13 years follow-up there were 27 cancer deaths in the 600 treated group compared with 128 deaths in the 600 in the control group; 72 were alive with cancer compared with 71 in the control group; 47 had died of CHD compared with 176 in the control group, CHD incidence was 132 (cf 243); 115 had died of other causes (cf 192) and 409 (68.4%) of those treated were still alive compare with 97 (16.2%) in the control group.
This type of psychotherapy is therefore capable of a significant reduction in mortality for those who already have cancer and a dramatic reduction in the incidence and mortality of cancer among those classified as ‘cancer prone’.
1. Spiegel, D et al. The effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, October 14 1989; ii: 888-891.
2. Eysenck, HJ & Grossarth-Maticek, R. Creative Novation Behaviour Therapy as a Prophylactic Treatment for Cancer and Coronary Heart Disease: Part II - Effects of Treatment. Behav Research and Therapy 1991; 29 (1): 17-31.
3. Fawzy FI et al. Malignant melanoma. Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch gen Psychiatry Sep 1993; 50 (9): 681-9.
Metastasised Breast Cancer (Spiegel, n=86)
36.6 vs 18.9 months = 94% - from start of treatment;
94.6 vs 81.2 months = 16% - from diagnosis.
Metastasised breast cancer (Eysenck)
14.9 vs 11.3 months = 32% - psychotherapy vs none
22.4 vs 14.1 months = 59% - Chemo + psycho vs chemo
Inoperable scrotal cancer (n=2)
5.8 vs 3.2 years = 81%
Inoperable stomach cancer (n=4)
3.6 vs 2.05 = 76%
Inoperable bronchiolar cancer (n=14)
3.7 vs1.5 = 148%
Inoperable corpus uteri cancer (n=8)
6.7 vs vs 3.9 = 71%
Inoperable cervical cancer (n=10)
4.4 vs 3.8 = 15%
Inoperable colorectal cancer (n=10)
6.8 vs 3.9 = 72%
Overall 5.07 vs 3.09 = 64% (n=48)
Melanoma (Fawzy, n=68)
3 deaths in 34 vs 10 deaths in 34 after 6 years
ie 9% vs 29% = 70% reduction in deaths
The Meaning of Behaviour Therapy
In the July/August 1998 Newsletter was an article entitled Psychotherapy – The Most Effective Cancer Therapy in which I summarised the results of randomised trials of behaviour therapy.
In the January/February 2001 Newsletter I described briefly the way Behavior Therapy differs from Psychotherapy on the one hand (a label generally used to describe Freudian therapies based on theories of dreams and childhood sexuality) and Behaviour Modification on the other (based on Watson and Skinner’s instrument conditioning). In contrast to both of these, Behaviour Therapy, according to its main proponent Hans Eysenck1, relies on direct manipulation of emotions to eliminate symptoms by extinguishing the conditioned (eg Pavlovian) response. It uses densensitisation, flooding and modelling. The “symptoms” are considered as the problem, not symptoms of an underlying problem.
With Desensitisation the patient with specific fears or anxieties is given graduated tasks, starting with relatively easy tasks producing little anxiety, and working up to more difficult ones. The patient is also taught relaxation to minimise the anxiety produced by the task.
With Flooding (or response prevention) the patient is exposed to the conditioned stimulus in its full strength right from the beginning. Although apparently contradicting the principle of (gradual) desensitisation, it has been found that, provided the duration of flooding is relatively lengthy, the original enhancement of the anxiety reaction is followed by a gradual decrease. With this approach the patient is prevented from carrying out the usual response to the anxiety. This approach is particularly useful with patients with obsessive-compulsive disorders.
In Modelling the patient is shown other persons, as mush as possible like the patient, not reacting to the situation that produces the anxiety, such as handling snakes, touching dirty items, etc. So this is often used together with Flooding.
How is this relevant to cancer patients?
The two major personality traits that have been traditionally linked with cancer2 have been
(1) the repression of emotions, such as anger and anxiety, and the inability to show these emotions;
(2) failure to cope with stress and feelings of hopelessness-helplessness and depression in response to interpersonal stress, leading to an inability to find appropriate coping mechanisms to deal with the problems involve.
These two factors are claimed to contribute something like 50% of the cancer incidence.
The essence of this type of temperament is the absence of autonomy, ie emotional dependence, which prevents such people from making independent decisions in the light of their own best interests. The patient has become object-dependent and makes decisions involving needs-satisfaction and problem solving that are totally dependent on the behaviour of particular persons or objects, themselves persisting in a passive role. The patient’s own needs are blocked and remain unsatisfied with the result that symptoms like depression, hopelessness, anxiety, excitement and self-aggression appear.
It is this passivity in the face of stressful stimulation from the outside that constitutes the essential personality feature of the cancer-prone (Type 1 or Type C) individual. Their social relationships arouse conflict and they develop behaviours that are detrimental to their health, manifesting as cancer.
The aim of therapy is therefore to increase the patient’s autonomy, ie his/her independence and ability to make rational decisions that lead to long-term positive consequences, even though this might involve some short-term negative consequences. The aim is to teach the patient to avoid behaviours that lead to long-term negative consequences, even where these may be associated with short-term positive consequences.
Autonomy training usually includes the following steps:
1. Explanation of the concept – the person learns from the consequences of one’s behaviour methods of achieving long-term positive results.
2. Behavioural analysis – to pinpoint in a conversation the connection between stereotyped and self-perpetuating patterns of behaviour, and the resulting consequences.
3. Defining the desired behaviour – the person describes the behaviour considered desirable. This is written down and repeated from time to time.
4. Target areas are chosen for applying autonomy training –
· Improvement of the self-concept
· Practices in specific day to day behaviour
· Practice in hypnosis or deep suggestive relaxation – to minimise anxiety arising from changed behaviour
5. Application of behavioural techniques such as training
· in how to reduce dependent behaviour
· in alternative behaviours - This can be done with the help of imagining situations
· in integrating the cognition, emotions and intuition – eg verbalising emotional feelings
· in stable expression of feelings, independent of the behaviour of the other person or object
· in social skills to facilitate affecting the behaviour of others to produce the desired consequences
· in how to suppress stress-creating thoughts.
· In abolition of dependence reactions – to inactivate negative self-interpretations and make positive ones
There are very few therapists experienced in this type of behaviour therapy. Most develop a combination of therapies that might include some from the other two forms of psychotherapy described in Part 1, such as
· attempting to interpret dreams, from Freudian analysis to identify the essential “complex” caused in early childhood by a sexual trauma or event;
· attempting to teach the person how to act differently using different rewards or punishments based on behaviourism developed by Watson and Skinner;
whereas the essence of true behaviour therapy is that the person learns to think and feel differently.
1. Eysenck, HJ. You and Neurosis. Temple Smith, London, 1977 (pp 107-139).
2. Grossarth-Maticek, R & Eysenck, HJ. Creative Novation Behaviour Therapy as a Prophylactic Treatment for Cancer and Coronary Heart Disease: Part I - Description of Treatment. Behav Research and Therapy 1991; 29 (1): 1-16.