Finishing Psychodiagnostic Practicum

At this point in my clinical training, I have spent nearly a year on what is called the psychodiagnostic practicum. What that means is that my main job for the last year, as a psychodiagnostic extern at the Diamond Headache Clinic inpatient unit, has been to figure out what psychological factors are playing a role in our patients’ headache pain.

This is a tricky thing to do, for a number of reasons:

  • It’s tricky to figure out what’s going on with anybody, psychologically. People are pretty complicated; when things go wrong, they rarely go wrong for just one reason. Typically any psychological problem will have some genetic components, some environmental components, some relational components, and some intrapsychic components. You don’t really get the luxury of pointing to one thing in someone’s past and saying you’ve found the answer.
  • These people tend to be especially complicated. There’s some research to suggest that chronic pain patients are more likely to meet criteria for personality disorders than other types of patients. In my experiences, I’ve found that even those who don’t meet criteria for those diagnoses usually have pretty deep-seated ways of interacting with the world that unintentionally serve to maintain their pain status.
  • Headache patients, in particular, are usually pretty resistant to psychological asssessment. This is mostly because they have gotten used to being told that the very real pain that they experience on a daily basis is “all in their head.” Usually they hear this from physicians who are simply frustrated that none of their tests come back positive and nothing they do seems to change anything. The same goes for any other type of chronic pain patient, and probably many people with IBS as well.

So what I do currently is I go into each patient’s hospital room and spend about 30-60 minutes finding out how they feel, what their life is like, what it was like growing up, what kinds of relationships they have, and what kinds of stress they experience. From this, I try to draw connections between all of the different factors, in order to figure out what kinds of psychological treatments might be effective in reducing their headache pain. If a case is particularly complicated, and if we have the time, I will administer the patient an intensive 8-hour battery of psychological tests which help me to pin-point exactly what kinds of cognitive and personality issues they face.

It’s actually quite beautiful: my entire job is to find out how people are put together and what makes them tick. What I’m especially looking for, when I conduct a psychological interview, are the parts that the patients themselves cannot possibly allow themselves to know. And when I say this, I want you to know that I am not only talking about chronic pain patients. We all have parts of ourselves and our lives that we cannot know, that we must defend against at all costs.

For now, I’d like to announce a new clinical practicum! After I finish up at Diamond Headache in June, I’ll begin a new one-year psychotherapy externship at Chicago Lakeshore Hospital’s Valeo Program, which is Chicago’s only inpatient and intensive outpatient therapy for GLBT individuals. About 50% of my patients there will be HIV positive, and about 50% of them will suffer from substance abuse disorders in addition to their other psychological troubles, which will run the gamut from anxiety and depression, to eating disorders, to identity disturbances, to personality disorders. I’ll be taking on anywhere from 4 to 8 individual patients per week, and doing 2 or 3 therapy groups each week as well.

The Valeo program is a very competitive training site, and I was selected from more than 60 applicants!

Knowing Your Tells: Body Language and Unconscious Communication

People communicate with each other constantly, and in ways we hardly ever even realize. You heard that right: even a truly prolific writer is unlikely to ever match in written words the sheer volume of information that is constantly transmitted to the people around them, in the form of body language, expressions, small gestures, barely detectable fluctuations in muscle tone, in vocal cadence. Beyond these measurable types of physical communication, there’s another level of communication buried under and between the language itself. It occurs just as automatically as body language and just as pervasively. And, like body language, we usually don’t even realize we’re doing it.

Let’s look at an example. You’re walking down a busy street, and someone is walking toward you in the opposite direction. But for some strange reason, you can’t figure out which way he’s going to go. Left? Right? He’s looking at you as if you should know. You become confused and enraged. In your mind you are calling him a schmuck. So you tell him to watch where he’s going.

What a strange thing to say. Why would you want him to watch where he’s going? It seems like you only want him to make up his mind about what side of the sidewalk he’s going to walk on and then do it. Actually, the failure in this situation is not really a failure of decision-making, but of communication.

When we’re walking on a crowded street, we’re constantly looking into the spaces that we want to navigate our bodies into and between. At the same time, we are unconsciously noting the spaces that other people are eyeing and making automatic adjustments to accommodate them. When we ask someone to watch where they’re going, we’re effectively asking them to tell us where they’re going so that we can act accordingly. And even though we don’t know exactly what we mean—at least on any conscious level—we tell them in plain language exactly what to do. And they usually do it, too.

There are many more perfectly concrete expressions like this that we use all the time while never understanding or even feeling a need to understand their meaning. We don’t question them because they already make perfect sense to the parts of us that know what they mean. Which means, of course, that the conscious mind that you identify as “me” is not the only part of you that communicates with the other people in your life. Much of the time, it’s ‘someone else’.

This has real implications for our relationships, and for those parts of our livelihood which depend upon communication with others. It is not uncommon for people to unconsciously sabotage themselves by thoughtlessly communicating their fears, insecurities, or hidden motives. The way a poker player displays “tells” indicating the type of hand they are playing, and the way a pedestrian on a crowded street gives signals indicating their next steps, so are all of us constantly telling each other what kind of internal experience we’re having, what we want, and what we’re doing.

The only way to improve the chances that your unconscious communications will be in line with your conscious goals is to work on improving the overall integration of your personality. As daunting as that may sound, it can be accomplished through the use of things like meditation, spiritual practices, and psychotherapy.

Is Chronic Stress Ruining Your Health?

For thousands of years, life was simple. You spent most of the day dawdling around with your family. You dozed, made arts and crafts, tended fires, gathered nuts and berries. The only time this lifestyle got hectic was when it was time to track and kill an animal, or when it was time for you to run away from an animal that had it in mind to track and kill you. Simple, acute stressors that you could fully recover from within an hour. There were other sources of stress, of course: fighting for dominance within your group, and fighting against other groups. These probably occurred relatively infrequently, and probably usually didn’t last that long.

When we are presented with something stressful, our physiology responds fairly dramatically. Stress hormones like cortisol are pumped into the bloodstream, inducing a variety of physical changes: increase in heart rate, increase in blood pressure, increased blood flow to the major muscle groups, decreased blood flow to the extremities, down-regulation of immune functioning, decreased digestive activity.

These all happen to be very good things when immediate survival is threatened. The changes in blood flow work to ensure that your major fighting and running muscles have an adequate supply of oxygen and glucose to either fight to the death or run away. The decreases in immune and digestive functioning ensure that no precious energy is wasted on functions that, while necessary in the long run, have no bearing on survival in a fight-or-flight situation.

The problem is that our modern lifestyles expose us to a new and different type of stress, while our bodies continue to use the age-old adaptations to manage it. The stressors most of us encounter these days tend to be somewhat less severe, and much more frequent. They also lack the clear boundaries of their ancient predecessors. We no longer worry about the kill; now we worry about the bills. We worry about the number of crimes committed in our neighborhood, we worry about problems communicating at home, we worry about our self-esteem. The problem has shifted from an acute biological one to a chronic psychological one.

The physiological effects of the stress, however, remain the same. This is why your doctor will tell you that your stressful lifestyle can give you a heart attack. Prolonged increase of heart rate and blood pressure increase the risk that your heart and blood vessels will fail to withstand the pressure, resulting in heart attack and stroke.

There are subtler effects as well. Most people realize that the immune system plays a role in the eradication of pathogenic invaders, but many do not understand that it is also involved in the body’s natural housecleaning processes. Cells that are dead, dying, or poisoned must be cleared out in order to avoid resource waste, to reduce the risk of infection, and to prevent mutations. If the immune system is not functioning optimally, your risk for all of these outcomes is proportionately increased.

The same goes for digestive processes. If your guts are being mostly shut down most of the time, you’re likely to suffer various forms of malnourishment. This further reduces your defense against stress by reducing your energy levels, and further reduces your defenses against disease by inhibiting immune functioning some more. It’s generally a bad state to be in.

Life, of course, is going to continue to be chronically stressful, and so we will all continue to be placed at risk for the medical events and degenerative diseases that chronic stress facilitates. However, there are a ways to reduce the effects of that stress. They all involve the invocation of your body’s natural relaxation response.

Just the way your body has a fully integral stress response, it also has a relaxation response. The relaxation response reverses the effects of stress by clearing out the stress hormones from your blood, reducing your blood pressure and heart rate, and returning your digestive and immune functioning to normal. In short, the relaxation response returns your functioning to its normal, healthy, resting state.

The relaxation response can be invoked through any type of active relaxation activity, such as relaxation exercises, mindfulness meditation, or self-hypnosis. Passive relaxation such as listening to music or watching TV—while enjoyable—do not seem to activate the body’s relaxation response, and so do not have the same positive health impact as active relaxation.

In upcoming articles, I’ll talk about specific methods for activating your body’s relaxation response, as well as ways to use those same techniques to improve your mind-body relationship in ways that can have a direct impact on your physical health.

Mind-Body Medicine: 5 Surprising Ways Psychology Can Improve Your Physical Health

On some level, most people recognize that psychological factors affect physical health. People basically seem to know, for example, that a stressful career or a ‘Type A’ personality might give them a heart attack, or that an abrasive colleague can give them a headache.

What most people aren’t fully aware of is the profound interconnection between the mind and the body. The past twenty or thirty years have seen an explosion of research on the ways that the mind and the body relate to each other. The further the research goes, in fact, the less it looks like there is a mind apart from the body, or a body apart from the mind. Everything that happens to your body has an effect on your thoughts and feelings, and every emotional or intellectual event has effects on your body.

The upshot of this is that you can improve your physical well-being through purely psychological means—just by talking to someone, or by thinking a certain way. There are purely psychological ways to:

Prolong your life

Traditional and Stylish! U saw her before in B&WPsychotherapy doesn’t just improve your emotional health and well-being, it actually tends to improve your physical health as well. A particularly dramatic example of this is the effect of psychotherapy on the terminally ill.

At least six good studies so far have examined the potential benefits of psychotherapy for terminal cancer patients by randomly assigning some of these patients to participate in individual or group psychotherapy. We’re not talking about any specific, cancer-focused therapy or mind-body voodoo, just good old regular psychotherapy. So these patients, who had been told they were definitely going to die talked about their feelings, and their backgrounds, and what they were going through and how it related to their past experiences, and so on.

And you know what? These patients ended up living twice as long as their counterparts in the control group. The control group received the exact same medical care, administered by the same staff, in the same setting. But they only lived an average of about 9 months, versus a full year and a half for the psychotherapy group. Imagine if you could double your lifespan just by talking to someone.

Reduce your symptoms

137: this is where i spent xmasWhile those kind of results definitely seem pretty fantastic, I can assure you that psychotherapy can be extremely effective for a wide range of physical illness. A great example is irritable bowel syndrome, or IBS. Psychotherapy is not only an effective treatment for IBS, it is now the preferred treatment for IBS. Psychotherapy is better at calming down an irritable bowel than any medication or combination of medications that have yet been tested.

The patients I saw at the Diamond Headache Clinic suffered from chronic headache pain. Naturally, they tended to have a lot of resistance to the idea of going to psychotherapy, oftentimes because their medical doctors have been telling them the pain is “all in their head” when in fact they feel actual physical pain right there inside of their actual bodies. “I’m not crazy,” they object, “I just have headaches.” And they do. But the fact remains that the patients who seek out and regularly attend psychotherapy tend to improve more than the patients that don’t.

Prevent and control pain 10 / year 2Some of the more targeted psychotherapeutic techniques can have particularly amazing results. Clinical hypnosis, for example, involves nothing more than talking to someone in order to help them achieve a state of extremely focused relaxation. And yet, people who cannot tolerate anesthetic drugs can often achieve the same effect through hypnosis.

When I say the same effect, I actually mean a better effect. Patients who undergo surgery using hypnosis instead of anesthetic drugs not only experience no pain, they actually usually enjoy the experience very much. There are also a number of side benefits: these patients tend to bleed less during the surgery, resulting in faster surgery times and lower cost; they tend to require much less pain medication after the surgery; they tend to experience far less physical and emotional discomfort overall; they also tend to heal up much faster, and much nicer.

Convince your body to cooperate

Today´s Mood!When I talk about improved quality of healing, I’m especially thinking about all the great research that’s been done on spinal surgery. Spinal surgery is one of the most delicate and difficult surgeries to perform, because the tissue itself is so complex, unique, and fragile. But you can be an absolute artist of a spinal surgeon, and perform the surgery completely flawlessly, and close everything up so that it looks beautiful and perfect. And in a couple months, the corrected area might very well just heal up into a gnarled mess of scar tissue. Or, it could still look great.

It turns out there are measurable psychological factors involved in this healing process. By administering a quick psychological test before the surgery, we can actually predict how well your surgery is going to heal. By using psychological techniques to modify the factors that interfere with proper healing, we can actually improve the healing of surgical wounds.

Make right what once went wrong

Eggistentialism VIII saw a man with an alcohol burn over 90% of his face. He arrived at the ER with his whole face a big red swollen mess. He was fortunate enough to find himself at a hospital where someone trained in clinical hypnosis was on staff. This doctor placed the man into a nice hypnotic trance, and suggested that his pain and swelling would both begin to reduce and simply go away.

Within a half hour, this guy was voluntarily turning down pain medications. He simply wasn’t in pain. Not only that, but the inflammation response in his skin actually turned off. His face stopped swelling and began returning to its normal size. The damaged layers of skin then began to reattach to the rest of his face, and the affected cells slowly began to be cleared out.

Within two weeks, you couldn’t even tell that this guy had ever been burned. There was one tiny red patch above his eye; that was all that was left. Ordinarily, this type of injury would have resulted in severe and prolonged pain, extensive scarring, and risk of infection that would lead to extremely painful cleaning procedures.

As crazy as it all sounds—and it does sounds crazy—just having someone talk to you in the right way at the right time can do all of these incredible things. Psychological interventions can alter the course of a disease, regulate digestive and immune functioning, alleviate existing pain, prevent new pain, control bleeding, improve healing times, and turn off the types of inflammation responses that happen when you’re burned or have an allergic reaction. In many situations, seeking help from a psychologist could be the best health decision you could make.

Hypno-Oncology: Hypnosis in the Treatment of Cancer


Clinical hypnotherapy has been soundly established as an effective treatment for the symptoms associated with cancer and its related therapies, including chronic and acute pain, nausea and vomiting, fatigue, insomnia, anxiety, and mood disturbances. Its use produces strong tendencies toward improvement of patients’ quality of life and of treatment cost. As the etiology and progression of various forms of cancer become better understood, the potential of hypnotherapy for increasing survival rates by improving medication response and even slowing or reversing the progression of the disease increases. Given the lack of risks to patients and the wide potential for benefit, additional research and clinical experimentation into this area are encouraged, and recommendations for this type of hypno-oncological exploration are discussed.


Cancer presents the patient with a wide variety of symptoms and challenges. Many types of cancer cause intractable and chronic pain or other organ-specific symptoms in the areas they affect. Patients frequently experience a variety of nonspecific symptoms as well, such as fatigue, malaise, and insomnia. Hypnosis and self-hypnosis are extremely flexible and highly effective treatments for all types of cancer-related symptoms (Sunnen, 2004), and also aid in the numerous psychological adjustments that are required of cancer patients: “adjustment to the condition itself, to its treatments, and to the poignant intrapsychic, family, and social changes it may induce” (Kubler-Ross, 1969, as cited in Sunnen, 2004, p.15).

One recent study of 20 terminally ill cancer patients allowed each patient to choose the symptom they would most like to address using hypnotherapy. As a result, 19 of those 20 patients reported dramatically improved quality of life, anxiety status, and ability to cope, as well as better sleep and more energy. The symptoms they successfully addressed during the course of the study included pain, fatigue, malaise, irritability, insomnia, nausea and vomiting (NV), anticipatory NV (ANV), food aversions, anxiety, depression, guilt, anger, hostility, frustration, isolation, reduced self-esteem, and helplessness. Additionally, significant cost savings were realized in the form of reduced need for medication and nursing (Peynovska, Fisher, Oliver, & Mathew, 2005).

On top of being proven effective for symptom management (Liossi, 2006), the beauty of hypnosis is that it can be readily adapted to the needs of the patient, can be used to address physiological as well as psychosocial issues, and is extremely well-tolerated. Christina Liossi explains:

“It is safe and does not produce adverse effects or drug interactions. Patients enjoy the hypnotic experience. They obtain relief without destructive or unpleasant effects. There is no reduction of normal function or mental capacity and no development of tolerance to the hypnotic effect. It is a skill that individuals can easily learn, that provides a personal sense of mastery and control over their problems and that counters feelings of helplessness and powerlessness. An additional benefit is that hypnosis can be generalized to many circumstances. The person who learns hypnosis for management of pain or nausea and vomiting may apply their skills to lessen the distress of insomnia and anxiety, to address dysphagia for pills or to enhance their performance in their favourite sport. For a clinician, hypnosis is an opportunity to be inventive, spontaneous and playful and to build a stronger therapeutic relationship with a patient while providing symptom relief” (2006, p. 55).

This paper will briefly review the literature regarding the efficacy of hypnotherapeutic interventions for symptoms management, and will explore issues surrounding the psychotherapeutic treatment of cancer in general. A general understanding of the etiologies and biomechanics of cancer as they are relevant to hypnotherapeutic treatment will be attempted, and this treatment’s implications and potentials for improving survival rates and directly influencing
the course of the disease will be discussed.

Hypnotherapy for the Control of Pain

Hypnotherapy is particularly effective for the control of primary and treatment-related cancer pain, and has achieved the status of an evidence-based treatment for this purpose (Liossi, 2006). Multiple studies have found it to be superior to acupuncture, massage, or CBT in the treatment of pain and anxiety (Peynovska, Fisher, Oliver, & Mathew, 2005). One randomized, controlled study, for example, found hypnosis highly effective for the prevention of post-operative pain in patients receiving bone-marrow transplants, while an intensive cognitive-behavioral skills program was ineffective for this purpose (Liossi, 2006).

A randomized clinical trial to examine the effects of a single 15-minute hypnotherapy session administered to breast cancer patients immediately prior to lumpectomy surgery found that the treatment group experienced significantly less pain intensity, pain unpleasantness, nausea, fatigue, discomfort, and emotional upset. In addition these obvious benefits to the patients, the intervention was found to be extraordinarily cost-effective: patients in the treatment group costed the hospital 9% less (almost $775 less per patient) than those in the control group, owing to their significantly reduced surgery times and significantly reduced need for anesthesia and analgesics during the procedure.

There is evidence that hypnotherapy can be highly effective with pediatric patients, who experience much less pain from the primary effects of cancer than their adult counterparts—owing to the varieties of cancer to which they are most susceptible, such as leukemia—but are subjected to repeated, painful and invasive procedures and usually consider this to be “the most difficult part of their illness” (Liossi, 1999). Children appear to be far less capable of using self-hypnosis to manage procedure-related pain and distress than adult patients, and so it is necessary for the therapist to remain present with them during the procedures (Liossi & Hatira, 2003).

The hypnotic technique for pain relief typically begins with relaxation, which significantly assists in analgesia by reducing anxiety and thereby dampening the perception of unpleasant sensory experience. After a standard hypnotic induction is used, many patients will respond to direct suggestions that their pain will simply “diminish in intensity to the point of becoming unnoticeable” (Sunnen, 2004, p. 16). Another technique for eliminating pain involves first producing “glove anesthesia,” or a deadening of all sensations in one hand. As Sunnen explains, “the hand is ideally suited as a starting point for hypnotic anaesthesia because it is so richly endowed with sensory innervation and occupies such a prominent place in the cortical homunculus. Once the anaesthetic experience is established in the hand, it is a relatively small step to transfer it to other parts of the body.”

The patient’s mental representation of their pain can also be altered such that it occupies a smaller portion of their phenomenological experience, and the pain’s qualitative aspects may be modified so that they no longer correspond with the patient’s conceptions of what substantial pain is like. If the patient experiences the pain as hot and stabbing, for example, the therapist might suggest that it is becoming cool and soft. Some individuals achieve extremely good results from the use of hypnotic imagery, while others are able to dissociate from the experience by imagining that the pain is falling away from their bodies and out of sight (Sunnen, 2004). It is highly beneficial to assess the patient’s cognitive style and hypnotic ability prior to the intervention in order that the techniques used can be matched to the patient’s own inner experience.

Hypnotherapy for the Control of Nausea and Vomiting

Hypnosis has achieved status as an evidence-based treatment for chemotherapy-induced NV (CINV), with numerous controlled studies attesting to its efficacy (Liossi, 2006). A comprehensive meta-analysis of hypnotherapeutic treatment for CINV found it significantly more effective than the standard treatment, and at least as good or better than CBT (Richardson et al., 2007). The researchers also noted that none of the studies they examined had evaluated the hypnotic ability of their participants. For reasons that will be discussed in a later section, it is reasonable to expect that a clinician who assessed and utilized their patients’ individual hypnotic abilities would achieve even more impressive results.

About 30% of patients receiving chemotherapy experience NV not only following the administration of the chemotherapy, but in anticipation of its administration as well. The most widely accepted model for understanding ANV is a classical conditioning model, in which NV becomes a conditioned response to procedures surrounding the administration of the chemotherapy. Anxiety plays a role in this effect not only by increasing sensitivity to environmental stimuli but also by potentiating the learning of conditioned responses (Marchioroa et al., 2000).

Marchioroa et al. (2000) conducted a study of 16 consecutive adult cancer patients affected by chemotherapy-induced ANV, in which they examined common personality factors of participants in order to surmise traits that may predispose patients to ANV. Common factors identified included “a strong need for approval, a tendency to reveal emotions in an exaggerate or unsuitable way, superficiality, inconstancy and difficulty in giving a detailed description of situations or people.” Each patient was subjected to a two-hour progressive muscle relaxation training session preliminary to hypnotic treatment. The treatment itself consisted of a one-hour hypnotic session immediately prior to chemotherapy administration, using an eye-fixation induction followed by suggestions intended to induce organ anesthesia. The hypnotherapy treatment prevented ANV in all 16 patients, and actually produced significant reduction in post-chemotherapy NV as well for 14 of the 16 patients.

Hypnotherapy for the Improvement of Overall Quality of Life

A number of meta-analyses have demonstrated the profound efficacy of hypnosis in improving cancer patients’ quality of life (Walker, 1998). This improvement involves the alleviation of the intense anxiety and depression that are common among patients diagnosed with cancer, as well as control of the physical symptoms that cancer and its medical treatments produce.

In 1999, Walker and his Behavioral Oncology Unit team randomized 96 consecutive breast cancer patients into a control group receiving general support and a treatment group receiving the same type of support along with guided imagery and relaxation training. As chemotherapy progressed, the quality of life and mood of the control group declined significantly, as expected. The mood and quality of life of the treatment group, however, actually improved. By the end of chemotherapy, members of the treatment group were not only suffering lower levels of anxiety and depression that they had been at the time of diagnosis, they were actually less depressed and anxious than the general population in their community.

A 2001 study of 50 terminally ill cancer patients found that patients receiving hypnotherapy in addition to standard medical care and psychotherapy enjoyed significantly better quality of life, in addition to reduced anxiety and depression. Another study even found that just giving patients tapes teaching hypnotic muscle relaxation and light, slow breathing alleviated anxiety attacks in all 35 study participants (Liossi, 2006).

The flexibility of hypnotherapeutic treatments allow them to accommodate the very specific needs of various groups of cancer patients. For example, post-operative breast cancer patients frequently suffer from “hot flushes” that “cause discomfort, insomnia, anxiety, and decreased quality of life.” They can be treated fairly effectively with a hormone replacement therapy, but that treatment increases the risk of breast cancer recurrence. Compelling case evidence indicates that hypnotherapy may be the preferred treatment for this problem (Liossi, 2006).

Some general hypnotherapeutic techniques for improving psychological adjustment include: learning relaxation and self-hypnosis, which help to improve self-efficacy and self-empathy among patients who often feel that they have lost control and that their bodies have turned against them; hypnotic ego strengthening, in which the adaptive functions of the patient’s personality are brought to the foreground for them and utilized in novel ways; hypnotic imagery, which the patient can play an active role in developing so that it suits their unique style; and enhancement of spiritual practice through the connection to favored religious symbols and ideas and deepening of the feeling of spiritual connection (Sunnen, 2004).

Understanding Etiologies

Connections between temperament and cancer growth have been suspected since ancient times, and have been repeatedly reexamined as new medical paradigms have developed (Harris, 2006). British surgeon David Kissen studied the relationship between emotional repression, cigarette smoking, and the development of lung cancer in the early 1960s. He concluded that smokers who exhibited a repressive coping style were five times more likely to develop cancer, and that the level of cigarette smoking necessary to induce cancer in a smoker was furthermore conversely related to their level of emotional repression. (Kissen and Hysenk, 1962, as cited in Harris, 2006, p. 5). These findings were replicated “in a most spectacular way” in a ten-year Yugoslavian study in which smokers who endorsed fewer than 10 or 11 items on a “rationality and anti-emotionality(R/A)” survey demonstrated no incidence of cancer, “suggesting that smoking alone is not sufficient to cause cancer” (Gossarth-Maticek, 1985, as cited in Harris, 2006, p.5). Harris suggests that the requisite emotional factors are the imprints of childhood experiences, and as such are intertwined with physiological as well as personality development. Clinical success in the treatment of maladaptive personality factors over the last few decades (McWilliams, 1994; Sperry, 2003) may therefore have profound implications for the emerging field of primary care psychology.

Harris (2006, p. 6) goes on to cite research implicating the repression of anger (RA) as a major factor in the development of breast cancer, and demonstrating correlations between this type of cancer and childhood disturbances or feelings of emotional disconnection. Researchers are not in agreement about the existence of such connections. While acknowledging that the link between breast cancer and psychosocial factors has been popular among medical theorists since pre-Christian times, Bleiker and van der Ploeg (1999) found the current evidence insufficient to establish any significant relationship in their informal review. A meta-analysis published the same year (McKenna, Zevon, Corn, & Rounds) found moderate correlations between breast cancer and “denial/repression coping (g = .38), separation/loss experiences (g = .29), and stressful life events (g = .25),” (p. 520) but concluded that the associations were too modest to provide confirmation of “the conventional wisdom that personality and stress influence the development of breast cancer” (p. 520). Butow et al (2000) confirmed this assessment in their own meta-analysis, stating that “evidence for a relationship between psychosocial factors and breast cancer is weak,” with the strongest acknowledged predictors of breast cancer being “emotional repression and severe life events” (p. 169). More recent research, however, continues to implicate life stress in breast cancer incidence and recurrence (Palesh et al, 2007). Participants in one recent prospective study who went on to be diagnosed with breast cancer had suffered significantly more severe stress in the 10 years prior to the study, as well as significantly more moderate and severe personal losses. (Ollonen, Lehtonen, & Eskelinen, 2005). Recent studies also continue to find significant correlations between repressive coping styles and breast cancer incidence (Manna et al., 2007) and survival rates (Reynolds et al, 2000).

A 35-year longitudinal study of Harvard students found a dramatic correlation between perceived familial love and caring and the likelihood of diagnosis with serious diseases (including cancer, cardiovascular disease, and asthma) in mid-life (Harris, 2006, p.6). On the other hand, when Dr. Bert Garssen of the Helen Dowling Institute, a Dutch center for psycho-oncology, reviewed the longitudinal, prospective studies available in 2004, he completely discounted these and other findings, stating that “there is not any psychological factor for which an influence on cancer development has been convincingly demonstrated in a series of studies” (p. 315).

Regardless of these wide discrepancies in findings, it is certain that the basic mechanism for an underlying psychosocial involvement in the development of cancer—damage to DNA, resulting in mutated cells—is present (Gidron, Russ, Tissarchondou, & Warner.) In a critical review of 21 human and animal studies, Gidron et al. find direct causal relationships between acute stressors and DNA damage, as well as significant correlations between DNA damage and ongoing psychological factors such as depression and repressive coping. Ernest Lawrence Rossi (2002) has compiled extensive research on the relationships between psychological factors and gene expression, finding not only significant effects from measurable psychosocial conditions but also psychotherapeutic potential for modifying these responses.

As an example, Rossi cites Stanford University researchers (Zhao et al., 2000, as cited in Rossi, 2002, p. 199-201) in their studies of the changing molecular dynamics of prostate cancer as it transitions from the early, controllable stage to the later, terminal stage. Specifically, this transition involves two genetic mutations which modify the affected prostate cells’ aberrant androgen receptors, which had heretofore been the instigators of uncontrolled growth, into pseudo-androgen receptor sites which can be activated by glucocorticoid stress hormones. From the time this mutation occurs, the advancement of the cancer is very clearly susceptible to psychosocial stressors and to psychological mediation.

It is difficult, on one level, to make any inferences at all regarding the etiology of “cancer,” simply because there are as many different types of cancer as there are types of cells in the human body—more than 200—and at least as many methods of action by which cancer might come about. Finish researchers Vauhkonen et al. (2007) summarize the current genetic understanding as such:

Cancer results from multiple genomic changes that affect DNA and its gene expression. The DNA sequences may be gained, lost or amplified, or translocated into different parts of the genome to form a fusion gene with oncogenic properties. The occurrence of specific chromosomal aberrations may be restricted to only one cancer type and it may be considered a primary carcinogenic event. Furthermore, the aberration profiles may be used to cluster tumors with similar origins. A variety of techniques exist for the detection of specific chromosomal and gene expression changes. However, the etiology of these molecular alterations remains unclear (p. 277).

Vauhkonen et al. investigate the roles of certain bacteria and chemical substances which may play key roles in carcinogenesis. Other researchers have established reliable connections between certain viral infections and almost 15% of all human malignancies, with a substantial number of additional viral etiologies suspected (Butel, 2000; Boccardo & Villa, 2007). Furthermore, it is known that viruses “are usually not complete carcinogens, and the known human cancer viruses display different roles in transformation. Many years may pass between initial infection and tumor appearance and most infected individuals do not develop cancer, although immunocompromised individuals are at elevated risk of viral-associated cancers” (Butel, 2000, p. 405).

These causal linkages between infectious disease, immune functioning, and cancer formation provide a clear inroad for the influence of psychological factors; research in the field of psychoneuroimmunology has soundly demonstrated the profound interrelationship between psychosocial and immunological functioning (Coe & Laudenslager, 2007). To add to this, solid evidence of direct immunological involvement in the phenomena of spontaneous regression of human cancer has been reported (Saleh et al., 2005). This finding gains enormous significance when it is considered that spontaneous regressions have been observed in nearly every type of human malignancy (Chodorowski et al., 2007).

Hypnotherapeutic Treatment of Cancer and Improvement of Survival Rates

It is clear that hypnosis and visualization are capable of having a direct effect on human immune functioning, including differential expression of T-cell subsets and disease-specific immunological activation (Gruzelier, 2002; Wood et al, 2003). It is also clear that these types of immune system changes take place when hypnotherapy and guided imagery are used specifically with cancer patients: natural killer cell counts are improved (Hudacek, 2007);  lymphokine activated killer cell activity is increased, total T-cell count (CD2+) is increased as are mature (CD3+) and activated (CD25+) T-cell counts; circulating levels of tumor necrosis factor alpha (TNF-α) are even decreased. Furthermore, these changes reliably occur in direct proportion to the perceived vividness of the patient’s visualizations (Ogston, et al, 1997, as cited in Walker, 2004).

What is not clear is the reason that these hypnotically-induced immunological changes do not appear to have a significant effect on the course of the disease or on clinical outcome (Hudacek, 2007; Walker, 2004; Spiegel & Moore, 1997), despite a small but compelling set of well-documented cases in which this type of treatment has apparently initiated spontaneous remission (Rossi, 2002, p.216; Chong, Smith Chong, & Fraser, 2001). This is particularly confusing when it is taken into account that standard, supportive-expressive group psychotherapy—which seems to be a less targeted treatment—can sometimes significantly impact the survival of cancer patients (Spiegel, Bloom, Kraemer, & Gottheil, 1989; Walker, 2004; Küchler, Bestmann, Rappat, Henne-Bruns, Wood-Dauphinee, 2007). For those cases in which psychotherapy does improve survival, Walker (2004) suggests enhanced treatment compliance, health-promoting lifestyle changes, improved mood-mediated chemotherapy response, improved host defenses, and amelioration of chemotherapy-induced immunosuppression as possible mechanisms. Other times, however, this type of treatment also appears to have no significant affect (Spiegel et al., 2007; Kissane et al., 2007).

The results are simply too strange for the problem to have been well-understood: there has to be a key ingredient which mediates the clinical success or failure of direct psycho-oncological interventions. Researchers at the University of Colorado Cancer Center, noting the proliferation of conflicting results in this area of research, came to essentially the same conclusion. They demonstrated that a highly significant factor in the success or failure of psycho-oncological treatment is the maturity of the individual patients’ styles of ego defense—a factor which is predictive of psychotherapeutic success in general (Beresford, Alfers, Mangum, Clapp, & Martin, 2006).

It could be noted, furthermore, that these findings are indicative of a confounding trend in psycho-oncological research which is likely responsible for many of the inconsistencies in its findings: failure to account for and accommodate psychological variables which are known to impact clinical outcomes. For example, Spiegel et al. (2007) suggest that their failure to replicate their previous findings may be due to differences between subgroups of breast cancer patients that are distinguished by receptivity to estrogen-replacement therapy. However, they did not report on the measurements of widely accepted therapeutic factors related to general group therapy treatment outcomes, such as group cohesiveness (Yalom, 1995), nor on the psychological
makeup of their participants.

As different styles of psychotherapy are indicated for patients operating at different levels of personality organization (McWilliams, 1994), it should go without saying that psychotherapeutic interventions specifically aimed at cancer must also take these variables into account. The fact that they are not being accounted for in the bulk of relevant research could reflect a basic disconnect between the required specificity of the medical model as a treatment metaphor and the contextual requirements and implications of psychological treatment (Wampold, Ahn, & Coleman, 2001), or perhaps some manner of entrenched condescension or apprehension toward psychotherapy as a potential medical treatment. The complexity of patients’ psychotherapeutic requirements, after all, should not be surprising: as pharmacological treatments have grown more complex, they, too, have acquired a greater need to accommodate individual factors in treatment. Depending on the type of cancer, degree of advancement, and other diagnostic features, a cancer patient may be administered any combination of surgery, radiation therapy, and more than 50 chemotherapy medications, and yet we study just a single mode of treatment called “supportive-expressive group psychotherapy”?

Likewise for hypnotherapeutic treatments: although individual differences in hypnotic susceptibility and absorption are clearly predictive of the efficacy of the treatment in up-regulating immunological functioning (Liossi, 2006), studies of hypnotherapy for cancer patients have almost uniformly failed to measure the hypnotic ability of their subjects (Richardson, et al., 2007). This oversight is problematic for three reasons:

  1. Hypnotizability is a normally distributed, stable personality trait with at least some genetic basis, which is known to be predictive of clinical success in hypnotherapeutic interventions (Wickramasekera, 2003). Hypnotherapy may therefore not be expected to be an appropriate treatment for individuals who fall in the low-hypnotizable range. Research which fails to identify these individuals will both underestimate the efficacy of hypnotherapy for those who can benefit from it and fail to discern elements of the treatment which may be beneficial to those lacking this trait.
  2. Low hypnotic ability may be modified or overcome. A number of techniques, such as biofeedback, have been found to at least temporarily improve hypnotic ability in low-hypnotizable individuals (Wickramasekera, 2002). Additionally, the application of multiple successive hypnotic techniques may be effective in patients who have failed to respond to standard hypnotic techniques (Crasilneck, 1995).
  3. Hypnotic ability is not a unitary trait. If overall hypnotic ability is not measured, then the interventions studied cannot be tailored to utilize the specific hypnotic abilities of each patient. Patients who are unskilled at hypnotic visualization but excel at kinesthetic representations, for example, will receive far less benefit from guided imagery-based interventions than they would from hypnotherapy that utilized their individual, measurable hypnotic strengths (Pekala, 2002).


Hypno-oncological interventions intended to directly alter the progression of the disease have not been yet been studied in controlled trials. However, the theoretical and biological bases for hypnotherapy’s potential as an effective adjunctive cancer treatment appear to be sound. Such interventions should be tailored to the individual hypnotic abilities of the patient and should be designed to foster the development and use of more mature ego defenses.

Additionally, it seems likely that a degree of biological specificity which has yet to be achieved in this type of hypnotic treatment could have the potential to significantly enhance its efficacy. The types of imagery used in the studies we’ve reviewed, when mentioned, have tended to be combative—as though the cancer cells were isolated intruders. Biologically, however, we know that the occurrence of cancer is far more complex. At least two genetic mutations are required to convert healthy cells into malignant ones, and viral, bacterial, or chemical interference is involved in some or all of these mutations a substantial percentage of the time. (Butel, 2000; Vauhkonen et al., 2007; Boccardo & Villa, 2007) Some cancers seem to result from ongoing viral infections and to reverse their course when the immune system is awakened to the presence of the intruder. Other types of cancers seem to occur systemically, with numerous precancerous lesions preceding the development of a site-specific, diagnosable cancer (Baker & Kramer, 2007). If hypnosis is able to directly influence biological events—which it does seem to be able to do (Rossi, 2002)—it would seem logical that more accurate therapeutic metaphors would yield more accurate treatment.

Hypnotic imagery involving the mobilization of cellular warriors does, in fact, increase the mobilization of natural killer and lymphokine activated killer cells (Gruzelier, 2002; Wood et al, 2003; Hudacek, 2007; Ogston, et al, 1997, as cited in Walker, 2004). That alone is essentially cause for celebration; the implications are staggering. Using hypnosis, we can tell our patient’s bodies what to do, and they will do it. Now all that is needed is to understand exactly what human bodies must do to be free of cancer. Increasing T-cell activity and focusing that activity on the site of the cancer is clearly not sufficient. If research in this area is conducted in such a way as to directly compare the efficacy of different pathogenic models for particular types of cancer, the results may very well have implications for the development of new biological treatments as well. Perhaps the body can tell us what it needs in order to heal.

There is presently no evidence of any downside to open experimentation in this area. Hypnotherapy is already conclusively established as a highly effective treatment for many primary and secondary symptoms of human malignancies—acute and chronic pain, chemotherapy-related nausea and vomiting, food aversions, fatigue, insomnia, anxiety and mood disturbances—and is currently under-utilized (Liossi, 2006). Furthermore, there is no evidence that the addition of far-fetched suggestions into existing empirically-based clinical hypnosis protocols would reduce the effectiveness of existing treatments, significantly increase treatment expense, or present additional risk to the patient.

Appendix I: “Hypnotherapy Script for Befriending a Cancer”

[Begin with your induction of choice]

And when you’re just about as deep, and as comfortable, as you know how to be, let me know you’re there…

Good, because now, we are going to learn something, that may at first seem foreign to you. Something that you already have, inside of you, as a skill, that you have not yet learned, to fully use. Learning can be very uncomfortable, at times, and I understand, that you have felt very uncomfortable, in the past. But you don’t have to feel that way. You don’t have, to feel anything, at all that you don’t want to.

And you can keep right on sitting there, just as you are, and you don’t even have to feel it. You don’t even have to feel, like it is even your own body. And you can notice your arms and legs, and you don’t even have to feel that they’re attached to you. And you can notice your breathing, the way it keeps right on breathing without you, automatically, all by itself, and it doesn’t matter where you go, or how far away you, wander off now, and everything back here will, just go on ahead, just the way it is, with no interruptions. And you can keep on hearing the sound of my voice, and you don’t even have to listen. And some part of you will continue listening to the words that I am saying, and you don’t even have to hear them. It’s really amazing, how wonderful it can feel, to let yourself wander off now, completely off the beaten path. And my voice will go with you, as I fade off into the gentle sounds of breezes, the quiet singing of birds nearby, the chirping, and whirring, and crackling of insects and tiny, natural, lively things all around you now.

And you can find yourself, almost as though you had been sleepwalking, wandering through a beautiful countryside now, without a care in the world. One little step at a time through the lush green grass you find here. And as you walk this way, you’ll begin to notice all the interesting scenery around you, And you can notice, if there aren’t too many clouds, how high up in the sky is the sun today? I wonder what time it might be. Take a look around you now, survey the landscape. If you listen carefully, you may be able to hear the sounds of water, bubbling and frothing. Is there a stream nearby? Maybe you’d like to take a closer look, to go and lean down over the warm, smooth, sun-baked stones, and run your fingers through the cool water there. This world is just full of wonderful feelings, that you can find, and you will find, that they all feel, wonderfully, familiar to you. And you can wander around like this for as long as you like. It may be a very long, and very lovely time, that you have here now, just wandering around, just discovering, all the sights, and sounds, sensations, smells, of your, own, private, countryside. Really feeling, right at home here by now. It’s lovely here.

And after, some time, has passed, two-more things, will come to your attention. There is someone else nearby, a stranger. And from a little ways away, this stranger can-sure make you feel, very apprehensive, because they look as though they may be—unusual? strange?—maybe even very, dangerous, to you. But you like most people, I know you’ve found, that you’ve gotten much farther, with people, when you find it in yourself, to be friendly and accepting. And so, knowing now that this place is your very own home, and knowing that you are very brave, you can decide to walk towards this stranger, in a friendly way, with the intention of learning, to understand them, and to befriend them, so that, they will listen to you, when you know the best things for them to do, and you can even, listen to them, when they know what might be best, for all of you. Because, you know, the more deep and meaningful friendships that you allow yourself to build, now, the healthier, and more fulfilling your whole, long and luscious life, will be.

And as you walk toward them and begin to come closer now, you’ll start to notice that the expression on this stranger’s face is not a malicious one at all. You’ll see instead, that they appear to be, simply, confused. And although something about them is very familiar to you, you’re going to find out, how your stranger is having trouble remembering just who they are, and just what their purpose started out to be. And so you can start by just, introducing yourself, and discovering, that the two of you have a great deal, to talk about together. And while you’re having that long, productive conversation with your stranger now, I’ll tell you the story of a stranger that I met.

My stranger was a person whom I happened to befriend, by a stroke of luck, actually, although at first it didn’t seem that way at all. Because, you see, in my college days I had rented a room in large house—it was much, much taller than it was wide. My room was at the very top of the stairs, it must have been at least six or seven stories, and during the summer it would become very very warm up there. But, I had a little window on either side of the room, and it was high enough that if I opened up the both of them then I could usually get a nice breeze in there. My neighbor downstairs was not so lucky, the window on their far wall was stuck closed, and the window on the wall by the bed was so close to the place where they would sleep or sit and study, that it couldn’t be opened either. You see, my friend downstairs was really very tremendously fat, sort of engorged really. I came to find out later that they had started out ordinarily enough, wanting ordinary things just like you, wanting to be a part of something larger than themselves, just like anyone, just like anything. But something had gone wrong for them along the way. You see, when they were small, they developed, like many kids, a real taste for sugar—just couldn’t get enough sugar. So, they started out begging their parents and friends for whatever cakes or candies could be found, and soon enough they had progressed to stealing candy bars in stores. It got to be, that they became so focused on getting and eating all the sugar they could find that, well pretty soon they had mostly forgotten all about their other, wishes, hopes, dreams. all the real purposes for living that they had had. So they floated through life, growing larger and larger, sucking up all the sugar they could get, starving out anyone unfortunate enough to get caught around them, but mostly they just didn’t get noticed much, until one day they were my little downstairs neighbor, and the building inspection committee came through, and was dismayed to find, that my little stranger had grown so large that they couldn’t even be removed from our little building. And what was worse, there was no way for me to even get down around them, so I was stuck with them, and I very upset and, even, actually frightened about what might happen to me being stuck there with this big fattened blob stuck down there beneath me. Would I be able to get out of there to eat, to finish school, to work, to see my family and friends again? What might become of me, I thought. It just got worse and worse for me. Well, a long time passed, with just me and the stranger up there in this tower. People managed to bring me food through my window, but the window wasn’t small enough for me to fit through and the building was too old for them to be able to make a hole in it and take me out, so I was stuck there with the stranger and nothing left to do now except learn to understand how they got to be the way they were so that I could help them get back to being something much more manageable. And you know what? I ended up talking with them for an awful long time, about all sorts of things; a great, long, productive conversation with this stranger, and we talked about life purposes, the way that every little part of everything has a part to play, a purpose of being, and how sometimes we each felt as thought we couldn’t quite remember who we were, or just what we had started out to be, or what task we were meant to be accomplishing. We each got caught in our respective ruts, you understand, and we would just get scared and start running away from our true selves—them eating their sugar all day and all night, stealing from all the folks around them, getting lodged into places they couldn’t fit out of and seeing no way out but to take in more sugar and become bigger and fatter and more malignant, and me, I found, that I was very much the same in my way, so focused on the tiny little aspects of my life that I thought were so important that I would do nothing but gorge myself on them all day long, throwing myself into my tiny personal interests and not being able to grasp the big picture of what my life was supposed to be, you know, my ultimate purpose, my, destiny. And so it was, for the stranger, they just hadn’t remembered, their destiny: and you know, of course, that their destiny was just, just like the rest of us, just to be a part of something larger than themselves, to find meaning, real meaning and worth, in functioning, in society, right there in the middle of the great body of people, making differences, building real deep meaningful relationships, enjoying the purpose of themselves and everyone around them, all the squirming, pumping, growing, healthy parts of a real live society. Of course, there was no way for them serve any kind of greater purpose while they were caged up there in their hot little room, stuck with no way out, caged in by their own appetites and loss of purpose. But as we talked, we both found that it was, irresistible, to follow our true purposes, to learn how we could truly interact with the great human body and live of life in which we were beloved and really integral parts of the systems we belonged to. And as we talked we found that our confusion abandoned us completely, and the stranger and I began to see things perfectly clearly, and found that it was just so easy now, to forget about, whatever it was that we had been distracted by. Day by day, the stranger started shrinking; I noticed all at once that they had stopped eating all their stores of sugary deliciousness, and were instead fully driven by a renewed desire to perform their original function. We became such good friends, as we both became increasingly excited about the potential that we could have and the impact that we could make with these beautiful lives that we had, that I barely noticed how small they were getting, even smaller than me! Shrinking down to just the right size and turning into something entirely different—turning into exactly what they always should have been, a working, thriving part of the system; something valuable and useful; completely and cleanly disappearing into the workings of a beautiful, and important system. When the building inspection committee came back later that term, they didn’t even recognize the stranger at all; my stranger-friend was just another student by then, just another healthy part of the student body, coming and going as they pleased, getting through all the work they had to get through, and better yet, they became so healthy and vital now and they started to impact the whole student body in a positive way—pretty soon I would come home from class and find them scurrying about the building, full of energy, actually cleaning that place up! Making sure that everything was in perfect, healthy, functioning order. The whole situation had a big impact on me, too, as I know you can imagine; I had learned what it was like to be isolated from everyone I knew and loved, locked away in scary place, and I had learned that the way out, the way to feel good again, even better than I had ever felt before, was by building stronger and better and deeper relationships than I had ever built before. I haven’t seen my stranger-friend for a long long time now; they shrank away into my past. But the things that I learned, from meeting them, from being stuck with them, and from surviving the ordeal in order to become a healthier and more active and integrated person, why I wouldn’t trade the experience for anything, no matter how scared I might have been.

And I don’t know whether you’re already starting to feel like your stranger has made that kind of impact on you and on your life, or whether you’re just beginning to feel that way as they shrink off into your memory for good now. But I do know, that it can be really amazing, how sometimes our greatest teachers, and the greatest promoters of our health, and vitality, can start out looking like insurmountable obstacles. And we often think, during those times, that someone is trying to harm us, and they might even think that too, but as you take a closer look, you can quickly discover, that in fact, they were only confused, and only needed a little bit of help, to get right back on track, and that as soon as that happens, then everything can come back together, all at once.

And you can-sur–reptitiously remind yourself… even the stranger, and more frightening parts of yourself, that they don’t have to be afraid and build themselves up into large, and, scary, things. You-, can-cer —, repetitiously, remind yourself… especially the stranger, parts, that there is enough warmth, and nourishment, for all of your parts, and that there is, enough friendliness, there inside, your little world, so that nothing has to grow, out, of proportion, to the rest. And you will be surprised, how quickly, balance will be restored, as you’re thinking this way, and feeling, finally, as though all of your parts, are finally working together, in perfect harmony now. And when you look, inside yourself, you’ll find a world full of friends for you, with no strangers left at all, and no parts left out of the loop, feeling needy, or greedy. You’ll find, instead, only your beautiful landscape running along, just perfectly, amazing everyone.

And when you return, from your wandering, you may find that you have been, filled with wonder, over all the new and delightful sensations, that have come, to replace those feelings of discomfort, that you had experienced, in the past.

[End with your re-emergence instructions of choice]


  • Baker, S.G. & Kramer, B.S. (2007). Paradoxes in carcinogenesis: new opportunities for research directions. BMC Cancer, 7, 151.
  • Beresford, T.P., Alfers, J., Mangum, L., Clapp, L., Martin, B. (2006). Cancer survival probability as a function of ego defense (adaptive) mechanisms versus depressive symptoms. Psychosomatics, 47(3), 247-53.
  • Bleiker, E.M. & van der Ploeg, H.M. (1999). Psychosocial factors in the etiology of breast cancer: Review of a popular link. Patient Education and Counseling, 37(3), 204-214.
  • Boccardo, E., & Villa, L.L. (2007). Viral origins of human cancer. Current Medicinal Cancer, 14 (24), 2526-2539.
  • Butel, J.S. (2000). Viral carcinogenesis: revelation of molecular mechanisms and etiology of human disease. Carcinogenesis, 21(3), 405-426.
  • Butow, P.N., Hiller, J.E., Price, M.A., Thackway, S.V., Kricker, A., & Tennant, C.C. (2000). Epidemiological evidence for a relationship between life events, coping style, and personality factors in the development of breast cancer. Journal of Psychosomatic Research, 49(3), 169-181.
  • Coe, C.L., & Laudenslager, M.L. (2007). Psychosocial influences on immunity, including effects on immune maturation and senescence. Brain, Behavior, and Immunity, 21(8), 1000-1008.
  • Chodorowski, Z., Anand, J.S., Wisniewski, M., Madalinski, M., Wierzba, K., & Wisniewski, J. (2007). Spontaneous regression of cancer–review of cases from 1988 to 2006. Przegl Lek, 64(4-5), 380-382.
  • Chong, D.K., Smith Chong, J.K., & Fraser, R.R. (2001). Cancer and the possibility to turn it. Australian Journal of Clinical Hypnotherapy and Hypnosis, 22(1), 47-57.
  • Crasilneck, H.B. (1995). The use of the Crasilneck Bombardment Technique in problems of intractable organic pain. American Journal of Clinical Hypnosis, 37(4), 255-266.
  • Garssen, B. (2004). Psychological factors and cancer development: Evidence after 30 years of research. Clinical Psychology Review, 24(3), 315-338.
  • Gidron, Y., Russ, K., Tissarchondou, H., & Warner, J. (2006). The relation between psychological factors and DNA-damage: a critical review. Biological Psychology, 72(3), 291-304.
  • Gruzelier, J.H. (2002). A review of the impact of hypnosis, relaxation, guided imagery and individual differences on aspects of immunity and health. Stress, 5(2), 147-163.
  • Harris, G.A. (2006). Early childhood emotional trauma: An important factor in the aetiology of cancer and other diseases. European Journal of Clinical Hypnosis, 7(2), 2-10.
  • Hudacek, K.D. (2007). A review of the effects of hypnosis on the immune system in breast cancer patients: A brief communication. International Journal of Clinical and Experimental Hypnosis, 55(4), 411-425.
  • Kissane, D.W., Grabsch, B., Clarke, D.M., Smith, G.C., Love, A.W., Bloch, S., Snyder, R.D., Li, Y. (2007). Supportive-expressive group therapy for women with metastatic breast cancer: survival and psychosocial outcome from a randomized controlled trial. Psychooncology, 16(4), 277-286.
  • Küchler, T., Bestmann, B., Rappat, S., Henne-Bruns, D., & Wood-Dauphinee, S. (2007). Impact of psychotherapeutic support for patients with gastrointestinal cancer undergoing surgery: 10-year survival results of a randomized trial. Journal of Clinical Oncology, 25(19), 2702-2708.
  • Liossi, C. (1999). Management of paediatric procedure-related cancer pain. Pain Reviews, 6(4), 279-302.
  • Liossi, C., & Hatira, P. (2003). Clinical hypnosis in the alleviation of procedure-related pain in pediatric oncology patients. International Journal of Clinical and Experimental Hypnosis, 51(1), 4-28.
  • Liossi, C. (2006). Hypnosis in cancer care. Contemporary Hypnosis, 23(1), 47-57.
  • Manna, G., Foddai, E., Di Maggio, M.G., Pace, F., Colucci, G., Gebbia, N., & Russo, A. (2007). Emotional expression and coping style in female breast cancer. Annals of Oncology, 18 (6), 77-80.
  • Marchioroa, G., Azzarellob, G., Vivianic, F., Barbatoa, F., Pavanettoa, M., Francesco, R., Pappagallob, & G.L., Vinanteb, O. (2000) Hypnosis in the treatment of anticipatory nausea and vomiting in patients receiving cancer chemotherapy. Oncology, 59(2), 100-104.
  • Mckenna, M.C., Zevon, M.A., Corn, B., & Rounds, J. (1999). Psychosocial factors and the development of breast cancer: A meta-analysis. Health Psychology, 18(5), 520-531.
  • McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York, NY: The Guilford Press.
  • Montgomery, G.H., Bovbjerg, D.H., Schnur, J.B., David, D., Goldfarb, A., Weltz, C.R., Schechter, C., Graff-Zivin, J., Tatrow, K., Price, D.D., & Silverstein, J.H. (2007). A randomized clinical trial of a brief hypnosis intervention to control side effects in breast surgery patients. Journal of the National Cancer Institute, 99(17), 1304-1312.
  • Ollonen, P., Lehtonen, J., & Eskelinen, M. (2005). Stressful and adverse life experiences in patients with breast symptoms; a prospective case-control study in Kuopio, Finland. Anticancer Research, 25(1B), 531-6.
  • Palesh, O., Butler, L., Koopman, C., Giese-Davis, J., Carlson, R., & Spiegel, D. (2007). Stress history and breast cancer recurrence. Journal of Psychosomatic Research, 63(3), 233-239.
  • Pekala, R.J. (2002). Operationalizing trance II: Clinical application using a psychophenomenological approach. American Journal of Clinical Hypnosis, 44(3), 241-255.
  • Peynovska, R., Fisher, J., Oliver, D., & Mathew, V.M. (2005). Efficacy of hypnotherapy as a supplement therapy in cancer intervention. European Journal of Clinical Hypnosis, 6(1), 2-7.
  • Reynolds, P., Hurley, S., Torres, M., Jackson, J., Boyd, P., & Chen, V.W. (2000). Use of coping strategies and breast cancer survival: Results from the Black/White Cancer Survival Study. American Journal of Epidemiology, 152(10), 940-949.
  • Richardson, J., Smith, J.E., McCall, G., Richardson, A., Pilkington, K., & Kirsch, I. (2007). Hypnosis for nausea and vomiting in cancer chemotherapy: a systematic review of the research evidence. European Journal of Cancer Care, 16(5), 402-412.
  • Rossi, E.L. (2002). The psychobiology of gene expression: Neuroscience and neurogenesis in hypnosis and the healing arts. New York, NY: W. W. Norton & Company.
  • Saleh, F., Renno, W., Klepacek, I., Ibrahim, G., Dashti, H., Asfar, S., Behbehani, A., Al-Sayer, H., & Dashti, A. (2005). Direct evidence on the immune-mediated spontaneous regression of human cancer: an incentive for pharmaceutical companies to develop a novel anti-cancer vaccine. Current Pharmaceutical Design, 11(27), 3531-3543.
  • Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality disorders, second edition. New York: NY: Brunner-Routledge.
  • Spiegel, D., Bloom, J.R., Kraemer, H.C., Gottheil, E. (1989). Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 2(8668), 888-91.
  • Spiegel, D. & Moore, R. (1997). Imagery and hypnosis in the treatment of cancer patients. Oncology, 11(8), 1179-1189.
  • Spiegel, D., Butler, L.D., Giese-Davis, J., Koopman, C., Miller, E., DiMiceli, S., Classen, C.C., Fobair, P., Carlson, R.W., & Kraemer, H.C. (2007). Effects of supportive-expressive group therapy on survival of patients with metastatic breast cancer: a randomized prospective trial. Cancer, 110(5), 1130-1138.
  • Sunnen, G.V. (2004). Hypnotic and self-hypnotic approaches: To comprehensive cancer care. European Journal of Clinical Hypnosis, 5(3), 14-19.
  • Vauhkonen, H., Heino, S., Myllykangas, S., Lindholm, P.M., Savola, S., & Knuutila, S. (2007). Etiology of specific molecular alterations in human malignancies. Cytogenetic and Genome Research, 118(2-4), 277-283.
  • Walker, L.G. (1998). Hypnosis and cancer:  Host defences, quality of life and survival. Contemporary Hypnosis, 15(1), 34-39.
  • Walker, L.G. (2004). Hypnotherapeutic insights and interventions: A cancer odyssey. Contemporary Hypnosis, 21(1), 35-45.
  • Wampold, B.E., Ahn, H., & Coleman, H.L.K. (2001). Medical model as metaphor: Old habits die hard. Journal of Counseling Psychology, 48(3), 268-273.
  • Wickramasekera, I. (2003). Hypnotherapy. In Moss, D., McGrady, A., Davies, T, & Wickramasekera, I. (Eds.), Handbook of mind-body medicine for primary care (pp. 151-166). Thousand Oaks, CA: Sage Publications.
  • Wood, G.J., Bughi, S., Morrison, J., Tanavoli, S., Tanavoli, S., Zadeh, H.H. (2003). Hypnosis, differential expression of cytokines by T-cell subsets, and the hypothalamo-pituitary-adrenal axis. American Journal of Clinical Hypnosis, 45(3), 179-196.

Meth Use & AIDS in The Gay Community

Methamphetamine use is highly prevalent among men who have sex with men (MSM) and presents a serious public health issue (Shoptaw & Reback, 2006). Use of the drug is associated with increased engagement in high-risk sexual behaviors with a greater number of partners, and therefore with increased transmission of HIV, hepatitis, syphilis, and other sexually transmitted illnesses (STIs) (Shoptaw & Reback, 2007; Mansergh, et al., 2006). Methamphetamine use may also directly increase the risk of STI contraction by suppressing immunological functioning (In, Son, Rhee, & Pyo, 2005; Mahajan, 2006). In this vein, it is relevant to note that immunological functioning may already be reduced in members of this population as a result of the increased social stress and discrimination that they encounter (Meyer, 2003; Richman, Bennett, Pek, Siegler, & Williams, 2007). Increased risk of psychological disorders is also a reality for this population (King & Nazareth, 2006; Meyer, 2003; Cochran, Mays, & Sullivan, 2003), and methamphetamine use dramatically increases this risk by negatively impacting neurophysiological health through several mechanisms (Scott et al., 2007). Furthermore, methamphetamine use actually potentiates the adverse neurological consequences of HIV infection (Cadet & Krasnova, 2007). Throughout the western world, MSM comprise the singular group most affected by the HIV epidemic (Herbst et al., 2006). It is possible that the increasing rate of high-risk sexual behavior that is responsible for recent outbreaks of HIV, syphilis, and gonorrhea among this group may be at least partly accounted for by the equally epidemic spread of methamphetamine use through its communities.

The perspectives and techniques of community psychology are vital to addressing this issue. It is important, first, to understand the unique psychosocial factors affecting members of the gay community in order to surmise the psychodynamic and sociocultural reasons for the drug’s appeal to this group. We will need to develop an understanding of the contexts in which methamphetamine is being used, and the purposes that its use may serve. What cognitive styles or personality components might be most predictive of methamphetamine use, and are their etiologies relevant from an interventionist perspective?

Due to the powerful immediate effects of methamphetamine and the wide array of cumulative neuropsychological effects that it exerts on its users, it is difficult to assess the premorbid psychological state of an individual methamphetamine user, or to assert causality in either direction with regard to behaviors that they exhibit. There do seem to be two readily identifiable groups of methamphetamine users in general: chronic users and binge users. Chronic users seem to use the drug as a part of an avoidant coping strategy, in order to evade unpleasant emotions and mediate the experience of social discomfort (Halkitis & Shrem, 2006). Binge users, on the other hand, tend to score much higher on measures of impulsivity and, notably, depression. These users tend to consume larger quantities of methamphetamine in a sitting, to have a larger number of sexual partners, and to engage in a greater number of sexual risk behaviors than users of the chronic type (Semple, Zians, Grant, & Patterson, 2005). Essentially, methamphetamine users seem to be divided between those self-medicating for anxiety and those self-medicating for depression. Methamphetamine bridges this divide by offering its users increased self-esteem and confidence, decreased inhibition and sexual ability, and feelings of euphoria (Halkitis, Fischgrund, & Parsons, 2005).

The causes of the dramatically disproportionate prevalence of anxiety and depression among the gay community (Meyer, 2003) are likely the same as those which have created a subculture conducive to methamphetamine abuse. On the surface, long-standing social stigmas surrounding homosexuality and the ‘minority stress’ of belonging to a group that is increasingly the target of discriminatory violence (Bello, 2007) nurture individual expectations of rejection and discrimination. The social attitudes which cause these types of psychosocial difficulties, however, are also internalized in many MSM—possibly owing to the concealable nature of sexual orientation, the psychosocial complexity of the ‘coming out’ process, and personal ambivalence resulting from negative conceptions of homosexuality acquired through socialization. The resulting “internalized homophobia” is itself significantly correlated not only with the occurrence of anxiety and depression in this population, but of substance abuse as well (Meyer, 2003).

In addition to the self-medication aspect of methamphetamine use, the majority of meth-using MSM report using the drug for sexual enhancement (Halkitis, Fischgrund, & Parsons, 2005). For many users, methamphetamine induces a profound sexual disinhibition, relief from feelings of shame and isolation, increased physical and emotional pleasure and vitality, delayed and prolonged ejaculation, and the ability to take part in sexual marathons sometimes lasting a dozen hours or more. The intensity of these internal and external experiences in combination frequently produces a situation in which the drug becomes integrated into the individual’s sexual identity. Methamphetamine becomes idealized as a means to “reclaim a sense of pre-AIDS sexuality” (Reback & Grella, 1999, as cited in Halkitis, Fischgrund, & Parsons, 2005, p. 1332). Methamphetamine is therefore experienced as an agent of social connection and cohesion for many members of this embattled community, and so is deeply embedded in the social fabric of many gay bars, clubs, and commercial sex venues. As individuals become socialized into this subculture, they identify more strongly with the drug and find it more difficult to remove themselves from the pattern of high-risk behaviors it encourages.

Review of the Historical and Contemporary Scientific and Theoretical Literatures

The Centers for Disease Control (CDC) have recognized social marketing campaigns as an effective means of promoting health within a targeted population, but the use of this technique for minority groups is relatively new. The movement toward using social marketing campaigns as an intervention for methamphetamine use within the gay community began with a New York activist named Peter Staley who used his own money to fund the placement of a variety of cheeky yet ominous ads in gay areas and gay magazines. A follow-up study (Nanín et al., 2006) revealed that the results of Staley’s experiment were not ideal, but definitely promising: placement of the ads was highly effective in targeting groups at the highest risk, and most respondents reported feeling glad that “someone was doing something about crystal use in the gay community.” About half were inspired to “think about not starting to use crystal or cutting down on my use.” More than a third of respondents reported wanting to “talk to my friends/partner about their use of crystal” and to “get help to stop using crystal or avoid starting use” as a result of viewing the ads. However, 11% of all respondents, and 27% of those at the highest risk, reported that the ads actually increased their urges to partake of methamphetamine.

In exploring the potential weaknesses of early Meth/HIV social marketing campaigns, Nanín et al. (2006) cite a meta-analysis of HIV interventions by Albarracín et al. (2005) in support of their hypothesis that the campaigns’ emphasis on fear of HIV may have undermined their effectiveness. This meta-analysis and several other studies have demonstrated the general ineffectiveness of fear-based community interventions, possibly due to the avoidant nature of many self-destructive behaviors. The results of the meta-analysis should prove extremely useful, because it examines not only the effectiveness of attempted interventions, but the implications that those results have for acceptance of the interventions’ theoretical underpinnings. In addition to finding poor support for the idea that enhancing individuals’ perception of threat will result in behavioral change—even when effort is made to improve coping skills in conjunction with disseminating the threat-based messages—the researchers found little support for approaches which focus on the modification of behavioral norms within a target community. They found instead that models which aim to modify attitudes, motivations, and perceptions of self-efficacy, and to provide information and behavioral skills, can probably be expected to have more desirable effects. Furthermore, they found that the specific types of approaches which will tend to have the greatest effect on an individual are those which are congruent with the individual’s current stage of behavior change.

Dissemination of information, as a tactic for behavioral change, appears to have some efficacy for individuals at all stages of methamphetamine use, including those who have yet to make use of the drug (Albarracín et al., 2005). Campaigns which seek to modify attitudes also appear to possess this quality, while interventions focusing on behavioral and coping skills are likely to prove beneficial for only individuals who have already reached the stage of contemplating behavioral changes. This information complicates our efforts due to the finding that informational and attitudinal arguments for condom usage tended to be successful only for female recipients, whereas males were more responsive to behavioral skills-based arguments and training. MSM, in particular, responded very poorly to attitudinal arguments but tended to respond better than other males to all other types of interventions.

Alberracín et al. conclude that condom provision is, overall, a particularly effective method of preventing the spread of HIV due to the long-term attitudinal changes that can result from an individual’s reflection on their own convenience-based usage of the condoms they have been provided. That is, based on their own previous usage, individuals estimate their attitudes toward condom use much more positively than they otherwise would. These individuals are then likely to extend those attitudes forward into more active roles in obtaining and using condoms. These findings leave us with the task of discovering the types of arguments that will be effective for individuals who are male, gay or bisexual, and users of or at risk for using methamphetamine. Although the distribution of condoms to high-risk populations should still be considered a sound component of comprehensive community intervention, the overconfidence and impulsivity that methamphetamine use incites may negate the effectiveness of efforts to promote general condom use.

Another large, systematic review of behavioral risk reduction interventions for MSM was conducted by an independent Task Force on Community Preventive Services with the support of the CDC and the U.S. Department of Health and Human Services (Herbst et al., 2006). This study focused on person-to-person interventions operating at the individual, group, and community levels. Individual interventions reduced the incidence of unprotected anal intercourse (UAI) by 43% overall, including a 59% reduction in UAI with non-primary partners. Overall HIV contraction rates for the treatment groups were 38% lower than for controls. Surprisingly, individual interventions produced no significant changes in the number of sex partners. Also, no data was available regarding the cost-effectiveness of this type of intervention.

Interventions at the group and community levels were both found to be not only cost-effective but cost-saving, and both were effective in decreasing UAI by significant margins (Herbst et al., 2006). Effective group interventions were comprised of more than one meeting, were led by MSM, and included a skill-building component such as condom use training. Unfortunately, the most difficult aspect of implementing the group interventions tended to be recruiting and retaining participants. Use of “club drugs” (including methamphetamine) tended to be predictive of attrition. Community-level person-to-person interventions, on the other hand, may show some promise for our purposes. They involve the recruitment of MSM from key demographics who will act as peer-leaders by initiating discussions about sexual safety with their own personal contacts, and by then recruiting their contacts to do the same in order to continue the spread of risk reduction messages from peer to peer. These interventions reduced overall UAI by a very respectable 35%, and reduced the average number of sexual partners by 20%. Particularly given the strong social component of methamphetamine use among MSM, a person-to-person intervention at the community-level seems a natural choice for attempting to curb the spread of methamphetamine use and its associated high-risk sexual practices.

These and other types of community-based interventions for reducing methamphetamine use among MSM must be informed by factors that are specific to the subcultures in which the behaviors typically arise. Citing an under-emphasis on the “symbolic and interactional spheres,” Green & Halkitis (2006) set about collecting and analyzing qualitative interviews with MSM living in Manhattan in order to understand the meanings that sexual “circuit parties” and similar sociosexual events hold for their participants, and the ways that interactional norms and pressures within the subculture may shape drug-taking motivations and behaviors. They found that individual motivations were largely inseparable from participation in “contexts of sexual sociality and their attendant interactional pressures” (p. 319), and that these pressures—“the need for sexual arousal on demand, sustained sexual endurance, and the ability to have sex with newly acquainted partners”—were in the direction of precisely those behaviors which are enabled and perhaps even instigated by methamphetamine use. Study participants reported a level of sexual arousal and activity that they sometimes characterized as ‘compulsive’ and which often resulted in UAI, but the researchers point out that methamphetamine alone does not always induce a sexual response. Rather, there is a socialization process involved in shaping the user’s response to the drug so as to fit the needs of the particular social environment.

A 2006 Gay and Lesbian Medical Association (GLMA) report points out that casual methamphetamine use becomes problematic for a majority of users, and that treatment for methamphetamine addiction is often a “difficult and long-term process” that requires ongoing methamphetamine-specific treatment (p. iii). The standard of care is CBT combined with some form of contingency-management program in which incentives are offered for demonstrated abstinence from the drug. Alternate treatment models have proven more effective in the short-term, but about the same in the longer term. As with any drug addiction treatment, it is helpful for the user to receive support for the exploration of specific issues and triggers that lead them to use and abuse the substance. The GLMA notes that the most common triggers for MSM tend to be sexual, and asserts that treatment should therefore be tailored to this group in order to prevent the post-treatment relapse that has been common in recovery programs that fail to address the unique needs of this population.

According to the GLMA (2006), there is disagreement about the usefulness of harm-reduction approaches which aim to reduce harmful behaviors resulting from and associated with methamphetamine use rather than directly attempting to promote abstinence from the drug. From the perspective of this examination, in which the potentiation of sexually transmitted disease is considered as the primary reason for elevating methamphetamine use among MSM to the status of public health crisis, harm reduction measures are clearly desirable. As we have already seen, members of this group—and particularly those at highest risk—are significantly less likely to visit their primary care physicians. The GLMA reports that they are also unlikely to report their methamphetamine use to their healthcare providers. However, the provision of methamphetamine use assessment training to healthcare professionals in high-risk areas may be a very effective way of intervening in both individual usage and community perceptions of methamphetamine usage.

Critical Discussion of the Literature Reviewed

Based on their interviews, Green & Halkitis (2006) concluded that the social characteristics of the Manhattan gay and bisexual subculture, due to their emphases on sexual disinhibition, arousal, and sustained performance, demonstrated an elective affinity for the specific psychophysiological effects of methamphetamine above all other drugs. While there is yet no empirical evidence that this holds true to for other gay communities, it makes intuitive sense that this should be a common feature of methamphetamine-rich gay subcultures.

Consider that we are examining a minority group whose entire identity, as separate from the majority, rests upon the performance of and desire to perform specific sexual acts. From this perspective, it seems natural that a significant proportion of these individuals would cohere into subcultures which relied upon enhancement of sexual performance and willingness as a means of establishing and maintaining a sense of belonging. Since methamphetamine readily provides these effects for many users, it becomes not only a natural choice for members of the subculture in question, but also a reinforcer and even accelerator of that subculture’s normative sexual behaviors.

Methamphetamine furthermore counteracts what must be an immense sense of fearfulness and alienation surrounding a sexuality that has been strongly associated with the spread of disease and which has been consistently subject to public perceptions of filth and moral ineptitude. We are examining a group that is widely discriminated against and frequently victimized, and which is at high risk for a range of psychological disorders that center around narcissistic deflation resulting in symptoms of anxiety and depression. Methamphetamine is a drug which temporarily alleviates these symptoms, and allows individuals who have been the subjects of unusually difficult and intolerant acculturative experiences—and who are therefore subject to feelings of isolation and awkwardness—to experience a sense of social belonging and efficacy. If not for the horrific psychophysiological effects of the drug, its high level of addictiveness, its tendency to induce high-risk sexual behaviors and to reduce both endogenous and exogenous forms of resistance to infectious disease, it would behoove us to recommend this drug. It is as though methamphetamine were created with the psychosocial plight of today’s gay community in mind.

These observations are not intended to promote the value of methamphetamine use, of course, but simply to illustrate the inherent sensibility of the current situation when the available data is understood holistically. The significance of this understanding is that any interventions which would curtail methamphetamine use within the gay community can probably be expected to succeed only to the degree that they are able to account for and counteract this basic sensibility underlying the drug’s use.

For example, the literature is clear that inducing fear of the harmfulness of methamphetamine or the behaviors that it supports is an unsuccessful strategy. Why should this be? It is because the social structure we are addressing has developed in reaction to a state of pervasive individual and collective fearfulness. Exacerbating that fear will, as the research bears out, actually reinforce the problem behaviors in those individuals for whom the risk is the greatest. Interventions must therefore focus on providing relief from fear, as well as from social and sexual alienation. Again, this is exactly what the research has shown: interventions which work to instill senses of efficacy, informedness, and community have reliably promoted behavioral change in this population.

It is interesting how difficult it has been for researchers to pin down the specific factors that enhance or detract from the effectiveness of interventions for MSM. It is currently unclear whether arguments targeting behavioral skills or those aimed at advancing coping skills may be more effective. More research that specifically targets this demographic may be helpful for optimal program design. It seems likely from other research, however, that the key ingredient has more to do with social and community factors than with either of those two studied elements. Researchers in this area would do well to examine methods for increasing the overall social interest of study participants—their feelings of community connectedness versus isolation—as a factor in the decisions to use methamphetamine and to engage in high-risk sexual practices.

Our basic task, given what is currently known and unknown, is to surmise what types of interventions are best suited to the purpose of discouraging methamphetamine use and its associated high-risk behaviors by undermining the psychological conditions from which they arise. A major problem in accomplishing this task, which we encounter throughout the literature, is that interventions aimed at reducing methamphetamine use among MSM are relatively new, and insufficiently studied. However, there is a good deal of useful information available in the existing research on HIV prevention, which has largely been targeted at this same population. For this reason, it has been possible to develop a reasonable understanding of the issues involved and the types of interventions best suited to addressing them by reviewing this body of existing literature in combination with the somewhat less robust fund of more specific research.

It is worth noting, for example, that the comprehensive meta-analysis we have discussed by Alberracín et al. (2006) found that the only community-based interventions that have ultimately been effective in reducing the spread of HIV were those offering HIV counseling and testing. It seems possible that the direct, visceral involvement that HIV testing facilitates could initiate and/or solidify attitudinal change. While it is difficult to see any way to directly apply this principle to the reduction of methamphetamine use, it may be possible to develop a system of cognitive conditioning within the context of HIV testing which implicitly links the two concepts. Such an intervention could be as simple as asking a few specific questions about methamphetamine-usage each time an HIV test is administered, as a way of impressing upon the individual being tested that their risk is much higher if they are using methamphetamine.

Much of the research focusing on interventions for methamphetamine use within the gay community has focused on social marketing. Targeted advertising campaigns of this type constitute a relatively cheap and effective form of intervention which can be implemented quickly. Unfortunately, it can be difficult to measure the effectiveness of any single ad campaign due to the unlimited range of confounding factors and the difficulty of designing followup studies. However, it is evident from examination of Peter Staley’s early and even fairly naive attempts at social marketing toward these ends that profound impacts are possible even when the ads being used succumb to the popular tendency to use fear as a motivating factor for behavioral change. With a higher level of psychological conceptualization, this type of intervention has the potential to be one of our greatest tools in advancing broad improvements within our target subculture.

The other extremely interesting intervention model that arose in the literature is the community-level, person-to-person intervention, which operates on a model much like viral or multilevel marketing by recruiting recipients of the intervention as its next level of administrators. In this way, the intervention has a far greater potential of eventually reaching those individuals with the least probability of actively becoming a part of any program—who, incidentally, are also at the greatest risk for methamphetamine addiction and for sexually transmitted infection. This model may also take advantage of the motivation that individuals who have recovered from addiction often find to help those who are currently under its sway, as well as the motivation of healthier members of the gay community to improve the overall health of their social support network. Recruitment practices that specifically aim to exploit these factors are definitely worthy of additional study.

Synopsis of Future Action

Given that a majority of current methamphetamine-using MSM have tried to quit or wish to try but have not sought professional assistance (GMLA, 2006), it is of central important that information regarding the availability of treatment services be made readily available. As the Gay and Lesbian Medical Association suggests, the family doctor’s office is an excellent place to start. The venue itself allows for the framing of methamphetamine use as a health issue at a time when members of affected subcultures likely consider it a primarily social one. Simply placing informative pamphlets in the physician’s office conveys, in a non-threatening way, that the doctor is knowledgeable about methamphetamine and can provide assistance in the case that the user should ever want or need it.

However, as we have seen, those most at risk are also the least likely to visit family physicians. While it is reasonable to expect that shifting community norms instigated by efforts to reach higher-functioning members of this group will exert some influence on the attitudes and behaviors of the lower-functioning members, it is important that informational campaigns also explicitly target those who are at the highest risk of methamphetamine-related sexual risk behaviors and sexually transmitted infections. This is the case not merely for altruistic reasons, but because the individuals who are most profoundly affected by the psychosocial factors which characteristically affect this group act as hubs for the transmission of sexually transmitted disease within the community. Any action which inhibits the self-destructive actions of this minority of individuals within the gay community—whose drug consumption is the greatest, who suffer the most exhaustive psychological disturbances, and who engage in UAI with the greatest number of often anonymous partners—has the potential to prevent an immense range of negative outcomes for the rest of the community.

Unfortunately, this group is most elusive—to the point of being nearly hypothetical. It is comprised of those individuals who are the least likely, as has been noted, to engage primary healthcare services. They are the least likely to participate in studies or focus groups, to seek out or utilize drug treatment or other psychological services, or to retain membership in education or support groups to which they have been recruited. This group is an essential bogeyman that lurks in the shadows of nearly all of the relevant literature. Identifying their characteristics, predisposing psychological traits, social tendencies, and responsiveness to various types of interventions is a vital task for researchers in this area to attend to. It seems likely that comparisons could be drawn to similar groups within other minority populations and/or within other groups of substance abusers, so there may already be a pool of literature to draw from in those areas.

Further evaluation of community reactions to the social marketing campaigns which have targeted MSM in major US cities over the last decade is also necessary, in order to understand the types of effects that they are having on different demographics within the highly heterogeneous gay community (Nanín et al, 2006). As several researchers have noted, the healthiest subgroups seem to reliably show the greatest response to all interventions. While primary prevention messages have dominated existing campaigns and may have some effectiveness, a majority of MSM methamphetamine users report no access to treatment services. Future campaigns should certainly provide information on the availability of these services for individuals who wish to stop using methamphetamine, as this can be included as a secondary function of any campaign. It is also possible that a review of existing literature in the field of consumer psychology might help to inform future marketing efforts to undermine methamphetamine use by helping to apply psychological understandings in ways that exert directed influence on key demographics. In this way it may be more feasible to manipulate the dynamics of this relatively delicate subculture toward the end of improving the personal security and social interest of involved individuals.

Proposal for an Innovative, Socially Responsible Action Plan

A certain ingenuity will be necessary in order to convey truthful messages about the horrific effects of methamphetamine without evoking additional fear in an already fearful population. After all, it is true that the drug causes anxiety, depression, psychosis, permanent damage to neurological and other soft tissues, erosion of the teeth and bones, failure of the immune system and resultant physiological susceptibility to the very sexually transmitted diseases which one is likely to become exposed to when participating in the behaviors that are conscious motivations for a large percentage of MSM to use the drug at all. Simply communicating these facts, however informative, is likely to heighten the anxiety and hopelessness of a group far too affected by those emotions already and to therefore undermine individuals’ abilities to rationally assess their social and behavioral choices.

To some extent, the problem may be bypassed through the selection of messages that focus on the reasons that MSM are using the drug, using consequences as merely supporting data. The core of any communication will have to convey the basic message that methamphetamine does not help MSM to feel well-adjusted, and that it does not help to overcome feelings of isolation or of alienation. People intuitively connect with the idea of something being ‘too good to be true,’ but may be unable to reconcile terrifying consequences with euphoric present realities, particularly when those realities are being sought for the purpose of drowning out a troubling social circumstance. Alternative means to that end are needed to soften the dissonance.

Social marketing campaigns seem to be an excellent tool, but it will be difficult to achieve the level of subtlety necessary to make an impact on the most troubled elements of our target population. Perhaps the best solution would be a combination of social marketing designed to deflate the perceived benefits of methamphetamine use coupled with community outreach efforts offering a safe alternative for achieving the sought-after benefits. Group psychotherapy, after all, is generally valued precisely because it addresses psychological issues which inhibit social relatedness. Even as cost-effective as group psychotherapy generally is, however, the condition of scarcity must be anticipated when thinking in terms of community psychological interventions. For this reason, long-term investment in individuals will be avoided in this plan in favor of broader community-level interventions. There is some evidence that methamphetamine-specific twelve step programs are effective in reducing meth use as well as sexual risk behaviors (Lyons, 2005), which could make such programs an ideal ‘landing pad’ for our community interventions if we chose to address those MSM who are already using methamphetamine. This has the benefit of affording our most direct attention to those individuals most in need of assistance, while influencing group norms by spreading messages which presuppose that methamphetamine use is undesirable.

Taking twelve-step program attendance as our intended destination for wayward MSM, then, it becomes much simpler to design interventions which target this outcome. From the literature we have reviewed, two excellent intervention methods for engaging the community have emerged: social marketing strategies, which we have already discussed; and community-level, person-to-person interventions. This latter type of intervention is the more difficult, but also provides a great deal more depth in terms of the messages that can be delivered and the level of community feeling which can be invoked and leveraged.

As with our social marketing strategy, negative and fear-inducing messages should be heavily downplayed in favor of positive and empowering messages. Individuals recruited into the program should receive thorough instruction in this manner of delivery and the reasons for it, as well as training in the manner of providing instruction to others who will extend the program. The experiences of the individuals involved, as members of the community, should be heavily utilized. It would be much less effective, for example, for an individual to simply list the benefits of attending Crystal Meth Anonymous to a peer, than to convey their own experience of being a member of the community who has felt oppressed and confused and troubled, and for whom an increased level of community involvement has provided a level of day-to-day relief that methamphetamine did not.

It is to our benefit in designing programs of this type that there are a large number of fairly autonomous gay communities scattered throughout the United States and throughout the world. With relatively small amounts of funding, we can institute pilot programs in smaller communities where benefits and shortcomings of the program can be easily assessed before enacting improved versions of the programs in larger cities.


  1. Albarracín, D., Gillette, J.C., Earl, A.N., Glasman, L.R., Durantini, M.R., & Ho, M. (2005). A test of major assumptions about behavior change: A comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychological Bulletin, 131(6), 856-897.
  2. Balsam, K.F., Rothblum, E.D., & Beauchaine, T.P. (2005). Victimization over the life span: a comparison of lesbian, gay, bisexual, and heterosexual siblings. Journal of Consulting and Clinical Psychology, 73(3), 477-487.
  3. Bello, M. (2007, November 19). FBI: Hate crimes escalate 8% in 2006. USA Today. Available at
  4. Cadet, J.L., & Krasnova, I.N. (2007). Interactions of HIV and methamphetamine: cellular and molecular mechanisms of toxicity potentiation. Neurotoxicity Research, 12(3), 181-204.
  5. Cochran, S.D., Mays, V.M., & Sullivan, J.G. (2003). Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71(1), 53-61.
  6. D’Augelli, A.R., Grossman, A.H., & Starks, M.T. (2006). Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. Journal of Interpersonal Violence, 21(11). 1462-82.
  7. Gay and Lesbian Medical Association (2006). Breaking the grip: Treating crystal methamphetamine addiction among gay and bisexual men. San Francisco, CA: GLMA. Retrieved December 7, 2007 from
  8. Green, A.I., & Halkitis, P.N. (2006). Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health & Sexuality, 8(4), 317–333.
  9. Halkitis, P.N., Fischgrund, B.N., & Parsons, J.T. (2005). Explanations for methamphetamine use among gay and bisexual men in New York City. Substance Use & Misuse, 40, 1331-1345.
  10. Halkitis P,N., & Shrem, M.T. (2006). Psychological differences between binge and chronic methamphetamine using gay and bisexual men. Addictive Behaviors, 31(3), 549-52.
  11. Herbst, J.H., Beeker, C., Mathew, A. McNally, T., Passin, W.F., Kay, L.S., Crepaz, N., Lyles, C.M., Briss, P., Chattopadhyay, S., & Johnson, R.L. (2006). The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: A systematic review. American Journal of Preventive Medicine, 32(4S), S38-S67.
  12. Huebner, D.M., & Davis, M.C. (2005). Gay and Bisexual Men Who Disclose Their Sexual Orientations in the Workplace Have Higher Workday Levels of Salivary Cortisol and Negative Affect. Annals of Behavioral Medicine, 30(3), 260-267.
  13. In, S.W., Son, E.W., Rhee, D.K., & Pyo, S. (2005). Methamphetamine administration produces immunomodulation in mice. Journal of Toxicology and Environmental Health, 68(23-24), 2133-2145.
  14. Jaffe, A., Shoptaw, S., Stein, J., Reback, C.J., & Rotheram-Fuller, E. (2007). Depression ratings, reported sexual risk behaviors, and methamphetamine use: latent growth curve models of positive change among gay and bisexual men in an outpatient treatment program. Experimental and Clinical Psychopharmacology, 15(3), 301-307.
  15. Johnson, W.D., Hedges, L.V., & Diaz, R.M. (2006). Interventions to modify sexual risk behaviors for preventing HIV infection in men who have sex with men. The Cochrane Database of Systematic Reviews, 4.
  16. King, M., & Nazareth, I. (2006). The health of people classified as lesbian, gay and bisexual attending family practitioners in London: a controlled study. BMC Public Health, 8(6), 127.
  17. Lyons, T. (2005). The varieties of recovery experience: HIV risk and Crystal Meth Anonymous. In Feldman, D. (Ed.), Culture, AIDS, and Gay Men. Gainesville, FL: University Press of Florida.
  18. Mahajan, S.D., Hu, Z., Reynolds, J.L., Aalinkeel, R., Schwartz, S.A., & Nair, M.P. (2006). Methamphetamine modulates gene expression patterns in monocyte derived mature dendritic cells: implications for HIV-1 pathogenesis. Molecular Diagnosis & Therapy, 10(4), 257-69.
  19. Mansergh, G., Purcell, D.W., Stall, R., McFarlane, M., Semaan, S., Valentine, J., & Valdiserri, R. (2006). CDC Consultation on Methamphetamine Use and Sexual Risk Behavior for HIV/STD Infection: Summary and Suggestions. Public Health Reports, 121, 127-132.
  20. Mausbach, B.T., Semple, S.J., Strathdee, S.A., Zians, J., Patterson, T.L. (2007). Efficacy of a behavioral intervention for increasing safer sex behaviors in HIV-positive MSM methamphetamine users: results from the EDGE study. Drug and Alcohol Dependence, 87(2-3), 249-257.
  21. Meyer, I.H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-697.
  22. Nanín, J.E., Parsons, J.T., Bimbi, D.S., Grov, C., & Brown, J.T. (2006). Community reactions to campaigns addressing crystal methamphetamine use among gay and bisexual men in New York City. Journal of Drug Education, 36(4), 297-315.
  23. Parsons, J.T., Kelly, B.C., & Weiser, J.D. (2007). Initiation into methamphetamine use for young gay and bisexual men. Drug and Alcohol Dependence, 90(2-3), 135-144.
  24. Richman, L.S., Bennett, G.G., Pek, J., Siegler, I., & Williams, R.B. (2007). Discrimination, dispositions, and cardiovascular responses to stress. Health Psychology, 26(6), 675-683.
  25. Rivers, I. (2004). Recollections of bullying at school and their long-term implications for lesbians, gay men, and bisexuals. Crisis, 25(4), 169-175.
  26. Scott, J.C., Woods, S.P., Matt, G.E., Meyer, R.A., Heaton, R.K., Atkinson, J.H., & Grant, I. (2007). Neurocognitive effects of methamphetamine: a critical review and meta-analysis. Neuropsychology Review, 17(3), 275-97.
  27. Semple S.J., Patterson, T.L., & Grant I. Motivations associated with methamphetamine use among HIV+ men who have sex with men. Journal of Substance Abuse Treament, 22(3), 149-156.
  28. Semple, S.J., Zians, J., Grant, I., & Patterson, T.L. (2005) Impulsivity and methamphetamine use. Journal of Substance Abuse and Treatment, 29(2), 85-93.
  29. Shoptaw, S. & Reback, C.J. (2006). Associations between methamphetamine use and HIV among men who have sex with men: A model for guiding public policy. Journal of Urban Health, 83(6), 1151-1157.
  30. Shoptaw S., & Reback C.J. (2007). Methamphetamine use and infectious disease-related behaviors in men who have sex with men: implications for interventions. Addiction, 102(Supp 1), 130-135.
  31. Wamala S, Merlo J, Boström G, & Hogstedt C. (2007) Perceived discrimination, socioeconomic disadvantage and refraining from seeking medical treatment in Sweden. Journal of Epidemiology and Community Health, 61(5), 409-15.

Mindfulness Meditation Tutorial

In working with sufferers of chronic pain, I’ve taught hundreds of people to practice mindfulness meditation. I do this not only because mindfulness meditation is in itself an effective treatment for chronic pain, but also because it helps the practitioner to manage their thoughts and emotions more effectively. It can help you to boost your creativity and can even improve your hypnotic ability.

Mindfulness meditation is probably the simplest form of meditation. It is deceptively simple; a lot of people have difficulty understanding how doing so little can have such deep and powerful effects on well-being. In studies with headache patients practicing mindfulness meditation every day for just 20 minutes a day, the most notable psychological effect of the practice was a pervasive sense of improved control. This is a common experience for people who take up the practice of mindfulness meditation:

  1. Mindfulness meditators experience an improved sense of control over their own physical sensations. For sufferers of chronic headaches or other types of chronic pain, this comes on as a noticeably higher pain tolerance. Other people who practice this type of meditation often find that their ability to comfortably exercise also improves, and that they begin to feel generally more comfortable in their own bodies.
  2. Frequent mindfulness meditators also begin to notice an improved sense of control over their thoughts—a growing ability to think with more intention and to pare down the types of racing thoughts that anxiety brings about. If you find yourself worrying all the time, being easily distracted, or feeling overloaded with information, this effect will be particularly useful to you.
  3. Similarly, frequent meditators typically experience an improved sense of control over their emotions. If you often feel moody or irritable, or become frustrated more easily than you wish, mindfulness meditation is a fantastic way to develop a more balanced and enjoyable emotional life.

The way that mindfulness meditation does all of this is by activating and exercising the frontal cortex of your brain, which is the command center of the entire brain. That means it is responsible for regulating almost all of your conscious activity. Anytime you’re feeling particularly focused, are engaged in problem-solving activity, or are working very hard to moderate your emotional expressions, the frontal cortex is at work. So by exercising this critical area of the brain, mindfulness meditation strengthens your ability to do all of these things. If you do it for long enough, the increased activity and bloodflow in the frontal cortex actually begins to physically alter the structure of your brain. After years of regular meditation practice, the cortical tissue actual grows thicker and more robust, like a muscle that has been regularly worked out.

I’ve already mentioned that this technique is deceptively simple. All you have to do is to pay attention to something. Anything, really—a very good place to begin is with your breath. Just paying attention to your breath.

  1. Begin by finding a comfortable position where your body can feel reasonably relaxed. If you know any relaxation exercises like diaphragmatic breathing or progressive muscle relaxation, you may find it easier at first if you first get yourself nice and relaxed before beginning.
  2. Now begin to pay full attention to your breathing. You don’t have to change anything about it, just pay attention to it. Notice all of the physical sensations associated with it. For example, you might notice the sensation of the air going in and then out through your nose or mouth. You’ll probably be able to detect some differences in the way the air feels going in, versus the way it feels going out. On the way in, you’ll probably notice that the air is a bit cooler. There may even be a little bit of a tingling sensation associated with it. On the way out, the air will probably have a warmer, softer quality to it. Notice any changes that you might be able to feel in your face as you breathe in and out, in and around your sinuses, through your cheeks and eyes. Notice the way the muscles naturally push and pull in your chest, and any sensations in your lungs. Just try to completely attend to any and every aspect of your breathing that you can notice.
  3. Inevitably something will distract you from this simple task at some point. Some people find it difficult to block out noises or commotion happening around them. This is perfectly okay. As soon as you realize that you are being distracted, simply take note that this has occurred and calmly return to your breathing. If you feel irritated or frustrated, that’s okay too. Just allow yourself to focus as fully as possible on your breathing and nothing else. Many people also find that their minds wander; one minute you will be attending to your breath and the next you will find you have been thinking about something else—worries, responsibilities, plans, ideas. This is also okay. When you notice that you have been distracted, simply return to your breathing, again paying attention to the simple, natural motion and all of the sensations which it brings about.
  4. Keep trying! Don’t get frustrated! When you get distracted, you should know that absolutely nothing has been lost. The whole point of this exercise is to train your brain to be able to focus more effectively, and it is a slow and easy process. Some days you will find it easier to focus, and other days it will be harder. Even on the days that it is completely difficult, however, the positive effects of the meditation that we have discussed here will still be taking place—perhaps even moreso! The struggle itself is the activity. So there, when you lose your concentration, you can even feel good about it, because by the time you realize that you have been distracted, you will already have realized, and then you can return to being mindful.

This is something that you can do in whatever amount of time you have available to you. Personally, I like to practice meditation on my morning bus commute—the time costs me nothing and the extra distractions give me something to work on! But literally any time that you have available to you will do. Ideally, you’ll spend at least 10-20 minutes at a time practicing mindfulness at least once or twice each day.

As your skill increases, you may find that you’re motivated to spend even more time meditating. It won’t be long at all before you will be able to comfortably sit for an hour or more, doing nothing but being mindful of your breath or whatever else you have chosen to be mindful of.

And that brings us to the final point of this lesson, which is that in time you will find that nearly anything you do can be done mindfully. When you begin practice, it will be beneficial to stay in one spot, and pay attention to a simple, natural, effortless process like breathing. But when you have become relatively proficient in this practice, you can begin to branch out into other more complicated forms of mindfulness meditation.

You can, for example, walk mindfully, by simply taking your time and paying attention to each muscle movement, to each exertion of pressure against the bottom of your foot, to the sensation of the breeze passing against your face, and to the faint sound of your clothing rustling against your body. You can eat mindfully by chewing slowly and deliberately, paying attention to each little explosion of flavor and texture on your tongue, by attending to the movements of your jaw as you tear or grind or perforate your food, by being mindful of the sensations of the food traveling down your esophagus toward your stomach.

If you try this technique for a little while and decide you’d like to get a little heavier into it or have some extra guidance, I recommend Jon Kabat-Zinn’s excellent audio program Guided Mindfulness Meditation. In the meantime, I’m here to help, so please post your comments here about your experiences. Let me know if you would like clarification on anything I’ve talked about here, tell me what parts of the experience you found particularly easy or difficult, and feel free to ask any questions about how to improve your practice for maximum effectiveness and enjoyableness!

The Medical Model of Psychology

The “medical model” that currently guides the majority of psychological research, assessment, and treatment is a deeply entrenched historical, social, and political phenomenon (Maddux, Snyder, & Lopez, 2004; Laungani, 2002) which has no empirical support whatsoever (Wampold, 2001). This article will outline some of the problems that the widespread acceptance of the medical model poses for the field of psychology.

Wampold, Ahn, & Coleman (2001) list five components of the medical model of psychotherapy: to begin with, the patient presents with symptoms of a classifiable disorder or disease; from the existing research and accepted materials, a psychological explanation for the disorder is available; the knowledge of this specific disorder and the theoretical conceptualization of such are sufficient that a potential mechanism for psychological change can be identified; having identified these properties, the therapist logically derives  a set of specific psychotherapeutic ingredients and administers them to the patient; these specific ingredients are responsible for the benefits of the psychotherapy thus administered. “The last component,” Wampold, et al. (2001) explain, “which is often referred to as specificity, is critical to the medical model of psychotherapy and gives primacy to the specific ingredients rather than common or contextual factors.” This is particularly significant in that no research has yet to provide any empirical backing for this principle of specificity in psychotherapeutic interventions, whereas a growing body of research is being accumulated in support of alternative, contextual models of psychotherapy (Wampold, 2001).

It is important to clarify the nature and purpose of the disorders being identified and treated within this context, because the illnesses, categories of illnesses, and entire conceptions of illness, as Maddux, et al. (2004) explain,

are not psychological facts about people, nor are they testable scientific theories. Instead, they are heuristic social artifacts that serve the same sociocultural goals as do our constructions of race, gender, social class, and sexual orientation—maintaining and expanding the power of certain individuals and institutions, as well as maintaining the social order as defined by those in power (Beall, 1993; Becker, 1963; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995; Rosenblum & Travis, 1996).

These criticisms are not new, but have been gaining momentum as part of the humanistic movement within psychology. Both Rogers and Maslow were strong critics of the medical model of psychology on the grounds that it “might serve to help people in one sense but that it also served to alienate and damage people in another” (Joseph & Linley, 2006).

Furthermore, as Reznek (1987, as cited in Maddux, et al. 2004) demonstrated, even our definition of physical disease suffers this type of socially constructed evaluation “because to call a condition a disease ‘is to judge that the person with that condition is less able to lead a good or worthwhile life.’” The tendency in applying this principle to psychology is therefore the gradual pathologization of all behaviors and characteristics that are not consistent with the ideals of the most powerful individuals and institutions, at the expense of diversity and social evolution, as well as the cause of social justice. This can be seen as a socialized parallel to the accelerating loss of biodiversity that has accompanied the development of civilization along the lines prescribed by the same scientific and modernistic worldview that gave shape to the medical community itself.

On this basis, a very strong argument could be made that the reliance on the illness ideology is proving equally problematic, and perhaps even equally at issue, in the medical community at large. This is evidenced by the last decade’s surge of interest in the areas of preventative and holistic medicine, which each attempt to draw the available store of medical knowledge into broader and more contextually relevant applications. The growing acceptance of health psychology as a specialization applicable to and relevant within the field of medicine is further evidence that a paradigm shift is in progress.

There are, however, powerful forces also at work to maintain the status quo. Laungani (2002) lists four major reasons that the medical model of mental illness maintains its dominant status despite its problems: political influence exerted by multinational corporations whose drugs are more likely to be used in treatment where a disease model is prevalent; increased income potential for psychiatrists due to the decreased consultation time necessary for drug therapy over “non-medical, non-drug related therapeutic intervention”; social and psychological factors which make it desirable for psychiatrists to avoid further alienation from the “medical fraternity” by rejecting the dominant paradigm in the medical field overall; and natural resistance to paradigm shifts in research programmes as described by Kuhn (1962), Lakatos (1971), and Laungani (1999) (as cited in Laungani, 2002).

The stakes in overcoming these obstacles are nothing less than the potential for developing an entire new framework for understanding and working with psychological issues on the individual and social levels. A critical junction in this new development will likely involve the psychological community’s long-delayed empowerment to prescribe medications, a privilege currently reserved for the field of psychiatry, which is settled firmly into the ideologies and traditions of western physical medicine. As such, there is an artificial division between psychotherapeutic treatments and psychopharmacological ones. As Nussbaum (2001) explains,

We psychologists cannot be bound by existing models that we know are not suited to behaviour. However, we need the freedom and expertise to develop integrative biopsychological models to inform our thinking and practice, even our psychotherapy. When psychotherapy is effective, let no one delude themselves into thinking that significant neurobiological alterations have not occurred to allow the beneficial behavioural or subjective experiential effect…..

However, we must also realize that for some individuals suffering from some conditions at some points in time, the regular mechanisms allowing intrinsic production of transmitters or receptor molecules necessary for learning and memory are not functional. At these times, psychotropic medications will be effective where psychotherapy will not, as there is no endogenous currency with which to allow information processing to proceed. Psychologists should be willing to pioneer these new ways of thinking and developing truly integrative psychobiological treatments to capitalize on the drug-behaviour interactions…

While the development and adoption of more appropriate and accurate models of psychology, psychological research, and psychotherapy are vital to the development of an effective and coherent field of clinical psychology, a number of barriers stand in the way of mainstream adoption of those models in exchange for the flawed and potentially damaging medical model. There are, however, many indications that the field is progressing in this direction, and we can remain hopeful that the coming decade will see an increasing empowerment of the psychological community to assert its authority in applying its increasingly well developed theories and methods toward more effective and consistent psychotherapies that are free from the outmoded frameworks of twentieth-century medicine.


  1. Joseph, Stephen & Linley, Alex P. (2006). Positive psychology versus the medical model? American Psychologist, 61(4), 332-333.
  2. Laungani, Pittu (2002). Mindless psychiatry and dubious ethics. Counselling Psychology Quarterly, 15(1), 23-33.
  3. Maddux, James E., Snyder, C.R., & Lopez, Shane J. (2004). Toward a positive clinical psychology: Deconstructing the illness ideology and constructing an ideology of human strengths and potentials. In Linley, Alex P & Joseph, Stephen (Eds.), Positive psychology in practice (320-334). Hoboken, NJ: John Wiley & Sons, Inc.
  4. Nussbaum, David (2001). Psychologists should be free to pursue prescription privileges: A reply to Walters. Canadian Psychology, 42(2), 126-130.
  5. Wampold, Bruce E., Ahn, Hyun-nie, & Coleman, Hardin L. K. (2001). Medical model as metaphor: Old habits die hard. Journal of Counseling Psychology, 48(3), 268-273.

Repressed Memory Phenomena

The issue of repressed memory is surprisingly heated, and comes loaded with the weight of several fundamentally different conceptions of the human mind. The real issue, hidden away in the word “repressed,” is whether a memory once repressed can be unleashed, or “recovered.” Thus we find ourselves in the awkward scientific predicament of having, for each paper published presenting evidence of repressed and recovered memories, at least a few papers published expressly to disclaim it. This article will attempt to make some sense of the available literature, drawing in alternative paradigms in addition to empirical studies.

Examples & Evidence

The issue of anecdotal versus experimental evidence becomes extraordinarily important in discussions of recovered memories, as we shall see, primarily because experimentalists have not managed to invent a way to replicate the phenomenon under controlled conditions. This creates a kind of paradigmatic crisis for experimental psychologists, for whom the temptation to discount uncontrollable phenomenon is a normal hazard of the workplace, so to speak. However, we may do well to consider, as Terence McKenna pointed out in an unrelated discussion, the etymology of “anecdote”, which stems from the Greek “anekdota”, meaning “unpublished items.” An anecdote then, can be thought of as a casually observed phenomenon; once that phenomenon is subjected to scrutiny, corroborated, and–specifically–distributed in a peer-reviewed publication, it ceases to be anecdotal evidence by definition and can instead be considered “medical history” (McKenna, 1998)

Probably the best source of this type of medical history of repressed-and-then-recovered memories is Dr. Ross E. Cheit’s Recovered Memory Project, which maintains an internet database of individual cases of recovered memory. “The cases are annotated and all have corroboration, including medical evidence, confessions, multiple victims, or even eyewitness testimony” (Cheit, in press). The database includes cases in three categories: those extracted from legal proceedings, in which the facts surrounding the repressed memories were subjected to extreme scrutiny and were in most cases corroborated; clinical accounts printed in scientific and academic journals; and other cases, drawn from sources such as legal proceedings that were not allowed to continue for various reasons, or from meticulous journalistic investigations.

One excellent example to be found in the Recovered Memory Project’s archive of clinical accounts is the case of “Claudia”, published in the highly respected journal Science News. Claudia had enrolled herself in an intensive inpatient weight-loss program to battle the severe obesity she was suffering from at that time. After losing more than one hundred pounds in the program, she began to experience flashbacks of sexual abuse at the hands of her older brother. While still an inpatient in the weight loss program, Claudia joined a therapy group for incest survivors at the hospital. During meetings, she remembered and revealed to the group that “from the time she was 4 years old to her brother’s enlistment in the Army three years later, he had regularly handcuffed her, burned her with cigarettes, and forced her to submit to a variety of sexual acts” (Bower, 1993). Upon returning home from the hospital, Claudia was able to examine her brother’s old room and belongings, which had remained untouched in the fifteen years since he had died in Vietnam. “Inside a closet she found a large pornography collection, handcuffs, and a diary in which her brother had extensively planned and recorded what he called sexual ‘experiments’ with his sister.” (again, Bower, 1993). Dozens of powerfully corroborated cases like this exist and are referenced within the archive.

There is a great deal of additional published work in which the recovered memory phenomenon is found to be not only very real, but also relatively common. Psychologists conducting a broad survey of British Psychological Society practitioners, for example, found that “memory recovery appears to be a robust and frequent phenomenon” in cases of total amnesia related to childhood sexual abuse as well as cases relating to other types of traumatic events (Andrews et al, 1995). A 1993 survey of 450 adult clinical subjects reporting histories of sexual abuse found that more than half of the subjects could identify a period of life before the age of eighteen when they had possessed no recall of the event (Briere & Conte, 1993). Another study (Feldman-Summers & Pope, 1994) interviewed a national sample of psychologists; of the psychologists from this sample who reported childhood abuse of any kind, about 40% reported a period during which they had forgotten some or all of the abuse. Of these, nearly half reported some form of corroboration for the occurrence of the abuse. Also significant was the finding that age and gender were not related to the occurrence of amnesia, but the severity of abuse was a strongly correlated factor. Finally, a particularly interesting study interviewed women with previously documented histories of sexual abuse, asking detailed questions about each of their abuse histories. “A large proportion of the women (38%) did not recall the abuse that had been reported 17 years earlier” (Williams, 1994).

Objections & Rebuttals

The major objection to reports of recovered memories is the difficulty in distinguishing them from false memories (Reisner, 1996). While this objection is certainly valid, and the potential for inducing false memories is a serious one for the therapist (Ofshe & Watters, 1996; Loftus, 1994), the preponderance of evidence in support of the existence of legitimate instances of repressed-and-then-recovered memory precludes any serious debate as to the general existence of recovered memories as a phenomenon. The recovered memory phenomenon has been sufficiently observed in a naturalistic environment that it is now fair to assume that any shortcomings in the way of controlled modeling or reliable detection of repressed information can be seen as problems of experimental science and therapeutic technique, rather than as invalidations of the existence of the phenomenon itself.

Furthermore, claims that individuals who report recovered memories are more likely to present symptoms of false memory syndrome (FMS) have been found by some studies to be grossly inaccurate. Hovdestat and Kristiansen (1996) found that FMS indicators were much less common in their sample than the hype surrounding FMS would suggest–no more common, in fact, for subjects reporting recovered memory than for those reporting that their memories of traumatic events had been continuous. In “the first direct investigation of suggestibility among patients who report recovered memory,” Rush Medical College’s Frank Leavitt used the Gudjonsson Suggestibility Scale to compare the overall suggestibility of subjects reporting recovered memories of childhood sexual abuse with that of subjects reporting no history of sexual trauma. “Results indicate that patients who recover memories were remarkably less suggestible than the clinical field has been led to believe by advocates of false memory…. Paradoxically, patients without a history of sex abuse were more at risk for altering memory to suggestive prompts” (Leavitt, 1997).

Models & Theories

Neuroscience, unfortunately, has little to offer us in the way of explaining this phenomenon thus far. While it is able to tell us that extraordinarily stressful conditions can lead to malfunctions of the hippocampus which prevent explicit memories of the surrounding events from being stored, and that implicit memory systems remain functional under these conditions, it is unable to explain how an explicit, conscious memory could be derived from an implicit, unconscious-emotional one. It would seem, in fact, that the implicit memories stored under such circumstances lack sufficient detail to reasonably allow for such a reconstruction to take place with any degree of accuracy at a later time (LeDoux, 1996). Therefore, the current research in this area leads us to assume–for the time being–that proper explicit memories are, in fact, being formed during the traumatic episodes in question and then repressed by way of an unknown mechanism. However, the research is incomplete. It is entirely possible that there is indeed enough information stored by emotional systems to reconstruct traumatic events in detail, and that neuroscientists have simply not yet discovered a way to reliably elicit such reconstruction. It is also possible that there are entire yet-unexplored memory systems at work.

The available research and case studies do, however, offer us significant clues as to the structure and function of memory repression. For example, the Feldman-Summers & Pope finding (1994) that personal indicators and demographics are generally unrelated to the occurrence of amnesia for traumatic events, and that this occurrence is instead reliant only on the severity of abuse, seems to support the hippocampal-interference model of memory formation under severe stress, suggesting that perhaps retrieval of and inference from implicit memory–or the storage of such memories in general–may be underestimated. Another study, however, indicates that the duration of the abuse is also a factor in the extent to which memory repression occurs in victims of childhood sexual abuse (Herman & Schatzow, 1987), which would seem to support the opposite hypothesis that explicit memories are in fact being stored (in the early stages of abuse at minimum), and then actively repressed at the psychological level.

Surprisingly, the most widely accepted model for this phenomenon may still be the Freudian one. It does appear that memory repression is a system of self-defense “by which an individual defends himself or herself against the conscious recollection of a traumatic memory and its associated consequences” (Golding, Sanchez, & Sego, 1996). Jennifer Freyd (1994) builds on this model by speculating that “victims may need to remain unaware of the trauma not to reduce suffering but rather to promote survival. Amnesia enables the child to maintain an attachment with a figure vital to survival, development, and thriving.” Individual cases like that of “Claudia”, in which memories were recovered during the course of extreme weight-loss (Bower, 1993), seem to point us in the direction of exploring externalized methods that individuals might use to assist them in this repression, such as abnormal weight gain. These could serve as a kind of emotional red herring, a reason for the emotions to exist without the necessity of remembering the events that actually created them.

Competing theories include the dissociative model, in which the memories are passively excluded from conscious awareness (Smith, 2000), and Philip T. Smith’s jigsaw-puzzle model: He provides a fairly eloquent description in a paper published in Memory in 2000:

According to the jigsaw model, unwanted memories can be rendered inaccessible in two different ways: by assigning a low importance value to their constituent fragments, or if the importance value is not sufficiently within a person’s control, by trying to ensure that few fragments are simultaneously encoded with the fragment to be forgotten. The former process shares features with repression, the latter process shares features with dissociation. What is novel about the jigsaw approach is that repression-like and dissociation-like phenomena could be seen to derive from initial encoding processes: there is no need to invoke active coping strategies in later storage and retrieval (Smith, 2000).

While this theory is compelling, it is clear that a great deal more research–particularly neuropsychological research–will be required to validate any model of memory recovery.

Practical Recovery

Finally, and perhaps most controversially, is the issue of inducing the recovery of lost memories. One study found that short-term group therapy “proved to be a powerful stimulus for recovery of previously repressed traumatic memories” (Herman & Schatzow, 1987), while another found that, in reality, “psychotherapy was the least commonly reported trigger” for such recall (Elliott, 1997). This study reported that most repressed events are actually recalled while watching television. In cases where recovered memories do arise during the course of psychotherapy, it would appear they do so “more typically during periods of positive rather than negative feeling toward the therapist, and they were more likely to be held with confidence by the abuse victim” (Dalenberg, 1996). At the present time, there simply does not appear to be a reliable way to elicit memory recovery, nor does there appear to be a reliable way to discern whether a “recovered” memory has any basis in truth, short of establishing external corroboration (LeDoux, 1996).


While it is clear that memories of traumatic events are in some cases lost or inaccessible for indefinite periods of time and then recovered, it is unclear what underlying neurological or psychological mechanisms might be responsible. A biological basis has been found for traumatic amnesia on its own, but this explanation is unable to account for–and would seem to preclude the possibility of–the potential of recovery. The major psychological models used to account for the phenomenon are repression and dissociation, although neither has much more experimental support than the other. What’s more, psychotherapy seems to be hit-or-miss at best when it comes to recovering lost traumatic memories, and the potential for the creation of false memories is profound. A great deal more research will be necessary, but a great deal more theoretical clarity will be necessary before research in this area is likely to be beneficial.


  1. Andrews, Bernice; Morton, John; Bekerian, Debra A.; Brewin, Chris R.; Davis, Graham M.; Mollon, Phil (1995). The recovery of memories in clinical practice: Experiences and beliefs of British Psychological Society practitioners. The Psychologist, 8, 209-214.
  2. Briere, John; Conte, Jon R. (1993). Self-reported amnesia for abuse in adults molested as children. Journal of Traumatic Stress, 6(1), 21-31.
  3. Bower, Bruce (1993). Sudden recall: adult memories of child abuse spark a heated debate. Science News, 144(12), 184-86.
  4. Cheit, R. E. (n.d.). Junk skepticism and recovered memory: A reply to Piper. Retrieved October 15, 2005 from the Recovered Memory Project:
  5. Dalenberg, Constance J. (1996). Accuracy, timing and circumstances of disclosure in therapy of recovered and continuous memories of abuse. Journal of Psychiatry & Law, 24(2), 229-275.
  6. Elliott, Diana M. (1997). Traumatic events: Prevalence and delayed recall in the general population. Journal of Consulting and Clinical Psychology, 65, 811-820.
  7. Feldman-Summers, Shirley; Pope, Kenneth S. (1994). The experience of “forgetting” childhood abuse: A national survey of psychologists. Journal of Consulting & Clinical Psychology, 62(3), 636-639.
  8. Freyd, Jennifer J. (1994). Betrayal trauma: Traumatic amnesia as an adaptive response to childhood abuse. Ethics & Behavior, 4(4), 307-329.
  9. Golding, Jonathan M.; Sanchez, Rebecca Polley; Sego, Sandra A. (1996). Do You Believe in Repressed Memories? Professional Psychology: Research and Practice, 27(5), 07357028.
  10. Herman, Judith L.; Schatzow, Emily (1987). Recovery & verification of memories of childhood sexual trauma. Psychoanalytic Psychology, 4(1), 1-14.
  11. Hovdestad, Wendy E.; Kristiansen, Connie M. (1996). A field study of “false memory syndrome”: Construct validity and incidence. Journal of Psychiatry & Law, 24(2), 299-338.
  12. LeDoux, Joseph E. (1996). The Emotional Brain: the mysterious underpinnings of emotional life. New York: Touchstone.
  13. Leavitt, Frank (1997). False attribution of suggestibility to explain recovered memory of childhood sexual abuse following extended amnesia. Child Abuse & Neglect, 21(3) 265-272.
  14. Loftus, Elizabeth F. (1994). The Repressed Memory Controversy. American Psychologist, 49(5), 443-445.
  15. McKenna, Terence; Sheldrake, Rupert; Abraham, Ralph (June 6, 1998). The Evolutionary Mind: The Sheldrake – McKenna – Abraham Trialogues. University of California, Santa Cruz. (available as audio from
  16. Ofshe, Richard; Watters, Ethan (1998). Making Monsters. Society, 35(2), 364-376.
  17. Reisner, Andrew D. (1996). Repressed memories: True and false. Psychological Record, 46(4), 563-580.
  18. Smith, Philip T. (2000) A jigsaw puzzle theory of memory. Memory, 8(4) 245-264.
  19. Williams, Linda Meyer (1994). Recall of childhood trauma: A prospective study of women’s memories of child sexual abuse. Journal of Consulting & Clinical Psychology, 62(6), 1167-1176.

Jonestown and The Social Psychology of Accepted Truth

Everybody “knows” what happened in Jonestown, Guyana in 1978. At the behest of their charismatic leader, all the members of the Peoples Temple religious cult—the residents of Jonestown—“lined up in a pavilion in front of a vat containing a mixture of Kool-Aid and cyanide” and  “drank willingly of the deadly solution” (Aronson, Wilson, & Akert, 2005, pp.4-5). That citation is taken from a popular Social Psychology textbook, and is a resounding demonstration of the phenomenon that this paper will attempt to explore: you see, the authors of that textbook feel so secure in their knowledge of the events surrounding the deaths in Jonestown that they feel no need to provide a reference for it. It is entered into the student consciousness as common knowledge. The fact that the popularly-accepted truth that Aronson, et al are parroting in this example is plainly false is almost beside the point, although this paper will provide a brief examination of some of the evidence which contradicts that accepted truth. The problem is much broader than the debunking of a single myth, and demands that some very important and difficult questions receive systematic evaluation: how is it that entire populations “know” things that contradict all available evidence, and what can be done to mediate this effect?

In considering the events of Jonestown, we might do well to start out by questioning our own credulity. What do we actually know about Jim Jones and The Peoples Temple, and from what sources? Does our understanding of the events stand up to logical scrutiny? Furthermore, as social psychologists, let us ask ourselves this very important question: In light of our current understanding of the power of social influence, do we believe it is plausible that 900 people took their own lives, simply because they were asked to? If so, are we willing to believe that we would behave in the same manner if subjected to similar social influences? As Aronson, et al (p.14) point out in their discussion of The Peoples Temple, “it is tempting and, in a strange way, comforting to write off the victims as flawed human beings. Doing so gives the rest of us the feeling that it could never happen to us.” The problem is that they use this rationale to imply that people would behave in a way that no empirical evidence has verified. Theirs is an argument from paranoia, having arisen out of its conclusion and stating as truism that which is both counterintuitive and unsupported. The idea here is not merely to pick on the authors of a textbook, but to pinpoint a mindset that is pervasive enough that it remains largely invisible in our society.

As Eileen Barker, the President of the Society for Scientific Study of Religions, has noted, “the belief in irresistible and irreversible mind-control techniques is so widespread that the democratic societies of Western Europe and North America appear to give ‘permission’ to citizens to carry out criminal attacks on someone merely on the grounds that he or she is a member of an unpopular religious group” (1996). Her research, however, does not support this belief. Furthermore, although there is very little research into the matter aside from her own, a small number of academics have taken up careers as “expert witnesses,” providing fervent yet unsubstantiated support to the idea. In the case of Jonestown, that man’s name was Dr. Hardat Sukhdeo. Jim Hougan writes:

Dr. Sukhdeo is, or was then, “an anti-cult activist” whose principal interests (as per an autobiographical note) are “homicide, suicide, and the behavior of animals in electro-magnetic fields.” His arrival in Jonestown on November 27, 1978 came only three weeks after he had been named as a defendant in a controversial “deprogramming” case. It is not entirely surprising, then, that within hours of his arrival in the capital, Dr. Sukhdeo began giving interviews to the press, including the New York Times, “explaining” what had happened.

Jim Jones, he said, “was a genius of mind control, a master.  He knew exactly what he was doing.  I have never seen anything like this…but the jungle, the isolation, gave him absolute control.”  Just what Dr. Sukhdeo had been able to see in his few minutes in Jonestown is unclear.  But his importance in shaping the story is undoubted: he was one of the few civilian professionals at the scene, and his task was, quite simply, to help the press make sense of what had happened and to console those who had survived.  He was widely quoted, and what he had to say was immediately echoed by colleagues back in the States. (1999)

The idea that a charismatic individual can completely overtake the decision-making power of random victims and use their mindless bodies to do his bidding even to the point of inciting a uniform mass suicide, with 600 adult individuals willfully—even joyously—killing themselves and their children is startling, anxiety-provoking, ambiguous, and enticing. It is, in short, good material for conversation. It is precisely the stuff of which rumors, gossip, and urban legends are made (Guerin & Miyazaki, 2006). It is not a realistic causal evaluation of plausible events, but is rather a good example of what is called “magical thinking,” the type of credulity typically associated with the pre-rational thought processes of young children. However, research indicates that as they mature, people tend to abandon magical beliefs in word only. “Indeed, in their general patterns of judgments, actions and justifications, adult participants seem to be prepared to respect both scientific and non-scientific causal explanations to an equal extent” (Subbotsky, 2001). By sharing rumors with amongst ourselves in the course of conversation and by receiving fantastical official versions through the media, this tendency toward fascination becomes manifest. Wherever mass media is the source of the information, we must also take into account the social component of individual judgement, which is a considerable influence (Joslyn, 1997). For, as McLuhan noted, sociality of mass media is profoundly experienced—when we watch television, we are influenced not only by the content of the programming but also by the knowledge that a large number of our peers are watching as well (1964).

This may help to explain why so many of us have accepted a version of the Jonestown events that are implausible. In addition to the psychological discrepancies we have already noted, let us observe that death by cyanide poisoning is a painful and grotesque affair. Central nervous system signals become scrambled, causing both voluntary and involuntary muscular systems to spasm violently. Twisted, contorted limbs and a terrible grimace known as cyanide rictus are typical of this cause of death (Jaffe, 1983 as cited in Judge, 1985). However, none of the more than 150 available photographs of the victims reveal these symptoms. Furthermore, the victims were laid out in neat rows, and some of the closer range photos reveal drag marks on the ground, indicating that the corpses were arranged in this way after their death. Based on an investigation that included the testimony of Dr. Leslie Mootoo, the top Guyanese pathologist who served as Chief Medical Examiner for the case and who personally examined many of the Jonestown bodies, a Guyanese grand jury concluded that only two of the 913 dead had committed suicide. Dr. Mootoo found fresh needle marks near the left shoulder blades of the vast majority of the victims he inspected, with some others exhibiting gunshot wounds or strangulation as the likely cause of death. The gun with which Jones himself is purported to have shot himself in the head was found lying nearly 60 feet from his body (Judge, 1985; Hougan, 1999; Schnepper, 1999). It is evident, then, that the supposed “mass suicide” was actually a massacre—but who would slaughter nearly a thousand U.S.citizens, nearly all of whom were African Americans, women, and underprivileged children?

There is a substantial body of evidence connecting Jim Jones and his Peoples Temple to the covert operations of the United States government intelligence community, not least of which are his longstanding ties with CIA operative Dan Mitrione, his adeptness at infiltrating and exploiting local governments, the suspicious circumstances surrounding the assassination of Congressman Leo Ryan in Guyana the evening before the massacre (whose escort was a high-ranking CIA officer), and the enormous cache of psychiatric drugs found on the premises of the Peoples Temple colony—all of the type being experimented with at that time under the CIA’s MKULTRA mind-control project (Judge, 1985; Hougan, 1999). Additional evidence of U.S.government involvement in the affair involves the self-proclaimed “anti-cult activist” psychiatrist Dr. Sukhdeo, whose own attorney has stated that his trip to Guyana was funded by the U.S. State Department.

The possibility exists that Jonestown, Guyana was indeed one of the many government experiments in mind-control of the 1970s. If it is, however, it would seem that the experimental subjects included not only the members of the Peoples Temple, but also the public at large. Regardless of intention, we have here a clear case of a governmental bureaucracy producing and disseminating misinformation for one reason or another, and the public—including the scientific community—accepting it without question, repeating it with authority, and even using it as a basis for social theory. The danger that this presents to free society is enormous, and the need for a concerted scientific effort to understand its limits and to develop safeguards is equally enormous.


  1. Aronson, Elliot, Wilson, Timothy D., & Akert, Robin M. (2005). Social Psychology, 5th Edition.New Jersey: Pearson Education, Inc.
  2. Barker, Eileen (1996). “The Freedom of the Cage.” Society, Vol. 33 Issue 3, pp53-59.
  3. Guerin, Bernard & Miiyazaki, Yoshihiko (2006). The Psychological Record, Vol. 56, pp.23-24.
  4. Hougan, Jim (1999). ‘‘Jonestown. The Secret Life of Jim Jones: A Parapolitical Fugue.’’ Lobster, Vol. 37, pp.2-20.
  5. Joslyn, Mark R. (1997). Political Behavior, Vol. 19 No. 4, pp.337-343.
  6. Judge, John (1985). ‘‘The Black Hole of Guyana: The Untold Story of the Jonestown Massacre.’’ In Keith, Jim (Ed.), Secret and Suppressed: Banned Ideas and Hidden History.Portland,OR: Feral House.
  7. McLuhan, Marshall(1964). Understanding Media: The Extensions of Man. Massachusetts: MIT Press.
  8. Schnepper, Jeff A. (1999). “Jonestown Massacre: The unrevealed story.” USA Today Magazine, Vol. 127 Issue 2644, p26.
  9. Subbotsky, Eugene(2001). British Journal of Developmental Psychology, Vol. 19, pp.23-46.