Category: Mental Health

Abstract

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.

Introduction

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).

Discussion

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]

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