Mind, Body, Spirit

"The mind steadfastly refuses to behave locally, as contemporary scientific evidence is beginning to show. We now know, for example, that brain like tissue is found throughout the body.... So, even from the conservative perspective of modern neurochemistry, it is difficult if not impossible to follow a strictly local view of the brain."

In the conduct of medical research, the existence of mind/body interactions has over the years been treated as a sort of hindrance. Such interactions are often lumped under the somewhat disparaging name of the placebo response. "Placebo" is a Latin term whose original meaning is "I shall please," and it refers to the mysterious and uncharted mechanisms by which the power of suggestion can result in a physiological change.

Ironically, the very scientific methods championed by mainstream medicine in the testing of drugs have provided the greatest scientific support for the existence and power of the mind/body connection. In fact, the mechanisms involved are so formidable that the standard research procedure requires separating out their effects from those of the drug.

Hence the power of mind/body mechanisms has been examined and measured in virtually thousands of drug studies. It is in this sense that they have been verified and acknowledged by medical research to be a real and powerful phenomenon.

In the 1970s and 80s, researchers trained their sights more directly on these mechanisms. Herbert Benson, M.D., and his colleagues at Harvard Medical School led the way with the discovery of the relaxation response.

This work has led to a cascade of findings about how mind/body mechanisms can be used for medically significant impact on hypertension, heart disease, cancer, and other conditions.

Today, leading edge programs for both patients and professionals are now conducted at Harvard's Mind/BodyMedical Institute, New England Deaconess Hospital, Boston. And under Benson's direction, the institute is collaborating in the creation of other such programs at major medical centers around the nation.

Indeed he may be right. In early 1993, a widely reported study documented the surprising popularity of alternative medicine this country. Published in The New England Journal of Medicine and led by Harvard researcher David Eisenberg, M.D., the study found that one in three adults had used some form of unconventional medicine. Of the varieties reported, mind/body technique were the most frequently used.3

The creation of the Office of Alternative Medicine at the National Institutes of Health followed a few months later. Shortly thereafter, mind/body medicine was brought into the living rooms of millions of Americans by a television series on PBS called Healing and the Mind, hosted by the popular journalist Bill Moyers. The PBS series symbolized a highly visible milestone in the mainstreaming of what critics had previously considered a form of fringe medicine. Mind/body medicine (also known as behavioral medicine) is of course

nothing new. The influence of the mind in healing is addressed in virtually every medical tradition, from the ancient teachings of Ayurveda to modern allopathy. What is new is the legitimization of research in this field to the point of government funding and the incorporation of mind/body programs into the offerings of major medical institutions, many of which are noted for their conservatism and scientific bent.

Benson regards it as an integral part of comprehensive health care. He offers the metaphor of a three-legged stool: "One leg is pharmaceuticals, another is surgery, and the third is what you can do for yourself. Mind/body medicine is strengthening the third leg, integrated with the other two legs.

In the late 1970s the eminent medical researcher George Engel of the University of Rochester made the bold statement that modern medicine needed a new way of thinking about health and illness.5 He proposed what he called the biopsychosocial model, in which health is the outcome of many factors interacting together.

In this view, health is not just a matter of "the drugs keeping up with the bugs." Rather, health is determined by an interaction among our genetic vulnerabilities; environmental inputs such as germs, viruses, or pollutants; psychological factors such as stress, lifestyle, attitudes, and behavior; and social factors such as supportive relationships, economic well-being, access to health care, and family and community patterns of behavior.

Jim is a forty-six-year-old assembly line worker who received a disc injury in his neck and developed a chronic pain syndrome involving head, neck, arm, and shoulder pain. He was referred by his physiatrist to Karen Carroll, a biofeedback clinician practicing in Waterloo, Iowa, for pain control.

Carroll used EMG, first for general muscular tension and then for muscular tension around the upper body and neck. Jim was able to discover a direct connection between his thoughts, his level of nervous system arousal, muscular tension, and eventually his pain level.

After eight sessions spaced progressively further apart and accompanied by home practice of breathing exercises and progressive relaxation, his headaches and neck pain completely disappeared. He was then able to use physical therapy to further strengthen his neck and shoulders, and subsequently returned to work. He stated, "I never really knew what it felt like to relax until now." According to Carroll, this case illustrates the benefits of commitment to self-regulation and daily practice at home for someone who was motivated to avoid medication and surgery if possible.

Engel's perspective is gradually penetrating the thinking of mainstream medicine. When we look at the big picture of all the factors that influence health, we can see that many are within our direct control. Along with this new way of thinking has come a growing openness and receptivity to the contributing of mind/body approaches.

Our thoughts and feelings influence the body via two kinds of mechanisms: the nervous system and the circulatory system. These are the pathways of communication between the brain and the rest of the body.

The brain reaches into the body via the nervous system. This allows it to send nerve impulses into all the body's tissues and influence their behavior. The brain can thus affect the behavior of the immune system with its nerve endings extending into the bone marrow (the birthplace of all white cells), the thymus, the spleen, and the lymph nodes.

It also reaches into all the glands of the endocrine system, all the bones, muscles, all the internal organs, and even the walls of veins and arteries. It can influence the behavior of the heart with its nerves penetrating the heart tissue, affecting heart rate and other aspects of the heart's functioning.

The brain is also a gland. It manufactures thousands of different kinds of chemicals and releases them into the bloodstream. These chemicals circulate throughout the body and influence the activity and behavior of all the body's tissues. The brain could be described as the ultimate apothecary, producing many more drugs than science has ever invented.

The cells of the body have receptors on their surfaces that function somewhat like satellite dishes. These receptors receive the chemical messages being released by the brain and respond accordingly.

Finally, the mind/body connection is a two-way street. In addition to sending messages into the body's tissues, it also receives feedback, both in the form of nerve impulses and its own receptors that sense what chemicals are being released by other tissues in the body.

Research into how the brain can influence immune responses has given rise to the new field called psycho-neuro-immunology (PNI). Findings in this field have brought great hope to people dealing with such difficult illnesses as cancer, AIDS, CFIDS (chronic fatigue immune dysfunction syndrome), and other immune-related diseases.

It is only a matter of time before similar acronyms are defined for other fields such as psycho-neuro-cardiology (PNC), the study of the mind-heart connection, or psycho-neuro-hematology (PNH), the study of how the mind can influence blood related disorders, such as clotting problems in hemophilia.

-One of the most stirring stories about the power of the mind/body connection concerns a man diagnosed with terminal cancer. Reported by Dr. Bruno Klopfer in the Journal of Projective Techniques in 1957, it involved a man with metastatic cancer and tumors that had spread throughout his body. The patient had tried every available form of medicine and his condition had hopelessly deteriorated to the point where he was bedridden and gasping for air. His doctors agreed that he had only a few days to live. Then the man heard about an experimental drug called Krebiozen, which was in the process of being tested. He insisted on being included in the experimental trials. His doctors, feeling he had nothing to lose and would soon be dead anyway, out of compassion agreed to give him the experimental drug. To their amazement, the man's tumors soon began to shrink dramatically and he was discharged from the hospital.

Two months later, the man read news accounts of the research on Krebiozen that reported serious doubts with the drug. Within a matter of days, the man's tumors had returned and were again threatening his life. His doctor cleverly convinced him that new and more potent shipment had been received and proceeded to give him injections of plain water. His tumors once again began to shrink dramatically. He remained healthy for seven more months until another news report declared "Nationwide AMA Tests Show Krebiozen to Be Worthless as a Cancer Treatment." The man died within two days.6

The magnitude of these changes is influenced by how serious the person thinks the situation is and what they think about their ability to handle the threat effectively (their appraisal of their ability to respond). Of course, the more confident the person is in their ability to handle a challenge easily, the less stress is involved. The more the person appraises the challenge as a threat-even at the subconscious level-the more intense will be the stress response.

Commonly called the fight-or-flight reaction, the stress response has the beneficial effect of preparing the body to function at a higher level of efficiency, which of course enhances the likelihood of survival.

While all these changes clearly contribute to one's ability to fight or flee in an emergency, they also have a downside. If the person is experiencing the stress response regularly and for extended periods of time, these physiological changes have the effect of weakening the body's resistance to illness and lowering the effectiveness of its mechanisms of self-repair.

Another key principle is the relaxation response, which was discovered and named by Herbert Benson, M.D., and his colleagues in 1974.7,8 They were studying a pattern of physiological changes that occurs in people practicing transcendental meditation (TM).

The relaxation response is an antidote to the effects of the stress response and it has also been found to enhance the effectiveness of the body's defenses and self-repair mechanisms. Regular practice of techniques that elicit this response also brings improved emotional well-being and better handling of stressful life events.

The relaxation response is a physiological state, not a technique as such. As we shall see later, there are many techniques that can be used to produce it and, indeed, learning to do this is at the heart of mind/body medicine.

Researchers have identified how the ways we cope with emotions and stressful situations-our coping styles-can influence our physical health. Most firmly established are the links between coronary heart disease and the Type A behavior pattern.

A more recent concept is the Type C pattern, which in many ways is the polar opposite of Type A. It involves the non-expression of anger and other unpleasant emotions such as fear and sadness, unassertive and overly appeasing behavior in relationships with others, and a preoccupation with meeting the needs of others, often to the point of extreme self-sacrifice. The theory of the Type C pattern was put forward by Lydia Temoshok, Ph.D., a leading health psychologist and PNI researcher. She has found compelling evidence for a link between emotional expressiveness and the progression of cancer.

The middle ground, or Type B. is considered a more balanced way of coping that involves appropriate expression of all emotions and the ability to meet one's own needs while responding to those of others.

People who cope in this more balanced way tend to be less at risk for serious illness. The cultivation of these behaviors is often a goal in mind/body medicine programs, especially for heart disease and cancer.

The use of mind/body medicine takes place within a broader context of changing one's lifestyle to promote health. Making a daily practice of mind/body techniques is but one of several areas of lifestyle change that work together in a synergistic way. Other areas include proper diet, exercise, and social support.

While the health benefits of diet and exercise are obvious, there is a growing body of research now indicating that supportive interpersonal relationships are strongly associated with better health. They seem to ameliorate or buffer the harmful effects of stress on the body.

Alice, suffering from chronic fatigue syndrome (CFS), undertook a two-week intensive treatment of intravenous Acyclovir therapy in the hospital. Acyclovir is a drug that inhibits the reproduction of herpes viruses, a family of viruses thought to be cofactors in CFS. One of the side effects of this therapy is elevated blood pressure, which needs to be closely monitored.

Alice was about halfway through her treatment protocol when she enrolled in a group mind/body medicine program. She brought her stainless steel drip apparatus with her from the hospital and stood it up beside her in the circle with the other patients and their spouses.

The first day involved a series of relaxation and deep breathing exercises. The next day Alice returned to the group bubbling with excitement. She reported that the previous evening her blood pressure had returned to normal. The nursing staff were mystified and wanted to know how she had done it.

Its variety of techniques may be used by medical doctors, nurses, physician's assistants, naturopaths, osteopaths, practitioners of Chinese medicine and Ayurveda, bodyworkers, homeopaths, and chiropractors.

Other human service providers such as psychologists, clinical social workers, marriage and family counselors, ministers, and hypnotherapists also use these tools. And of course there are very specialized applications for midwives, physical therapists, exercise physiologists, respiratory therapists, and others.

Mind/body approaches are generally taught either in office practice via private consultation with a health care provider or in group programs. Hospitals and other institutions offer various kinds of support groups or group therapy programs for people with cancer, heart disease, organ transplantation, and other conditions. Almost all such programs incorporate some use of mind/body techniques, such as relaxation exercises or imagery.

There are hundreds of varieties of meditation. The most basic approach for facilitating the relaxation response is that described by Herbert Benson. The process should take place in a quiet environment, a setting where one can be quiet, undisturbed, and in a comfortable position for at least fifteen to twenty minutes. Given this setting, there are only two essential steps: the silent repetition of a word, sound, phrase, or prayer and the passive return back to the repetition whenever other thoughts intrude.

Variations on these instructions are at the core of many forms of meditation from diverse spiritual traditions. The simplicity of these instructions, however, makes the approach available to virtually anyone, regardless of their spiritual or religious beliefs. This is because the person can use as their repetitive focus a prayer or any other words that reinforce their beliefs (e.g., "God is love"), thereby adding a further dimension of comfort to the experience.

This is actually another approach to meditation, which involves the ability to focus completely on only one thing at a time. In other words, in mindfulness the mind is full of whatever is happening right now. This can include walking, cooking, sweeping the floor, dancing, watching a bird, hearing the sound of a river, or any other focus you may choose. Whenever thoughts intrude, you simply return your attention back to the focus.

This is a traditional Buddhist approach and has been widely popularized by Jon Kabat-Zinn, Ph.D., in the Stress Reduction Clinic, University of Massachusetts Medical Center, Worcester.

This is another common approach to eliciting the relaxation response. In this technique the body itself is used as the focus of attention. It may be done either lying down or sitting. They technique involves progressing through the body one muscle group at a time, beginning with the feet, moving up the legs, and so on, spending approximately a minute in each area. For each muscle group, you hold or clench the muscles in the area for a count of ten and then release for a count of ten before moving on to the adjacent The remaining techniques described below, while they also can lead to induction of the relaxation response, are also used for other purposes.

This involves using symbols to imagine that the changes you desire in your body are actually happening. For example, you might imagine that pain is melting away and dripping like a warm liquid out of your fingertips.

Or you might develop an image of your immune cells actively subduing and preying on cancer cells or viruses, like birds of prey swooping down to engulf field mice in a meadow. This is a highly personalized technique and you would use images that are uniquely exciting and meaningful to you.

Studies of mental imagery have found that people can actually influence their immune functioning as well as significantly reduce pain and tension in the body with this method. But aside from the physiological benefits, which take some practice to achieve, there is also the knowledge that you are doing something to help yourself, channeling your energy into a healing activity. This in itself helps to improve emotional well-being and build a sense of self-efficacy or confidence, which research has found to improve immune functioning.

This approach involves using a combination of autosuggestion and imagery. Phrases are used to describe to oneself what changes in the body are desired as if they are happening now. For example, "My legs are warm and heavy," "All the muscles of my back are softening and melting," "I am calm," and "Warm, peaceful relaxation is flowing throughout my body." These phrases are repeated while maintaining one's focus on those parts of the body being addressed. Whenever the mind wanders, the attention is gently and passively returned to the focus.

A variety of breathing exercises can help one to release tension, anxiety, and pain. They can be used in conjunction with imagery or autosuggestion. They can also be used to encourage fuller breathing in general and give the body a greater supply of energy, which it can use for healing. It takes energy to fuel the body's self-repair mechanisms including the immune system. Since we take a thousand breaths every hour, each breath is an opportunity to contribute to a healing process.

Some breath therapy techniques use the breath in a calm, peaceful way to induce relaxation, to release pain, or to prepare for imagery. Another variety is Evocative Breath Therapy (EBT), which uses stronger breathing, sometimes accompanied by music, to stimulate emotions and emotional release.

A simple description of hypnosis is offered by Karen Olness, M.D., of Case Western Reserve University who calls it "a form of self-induced, focused attention that can make it easier for you to relax or learn to control your

Larry was a successful forty-two-year-old architect at the time he developed pancreatic cancer with metastases in 1978. He integrated meditation and imagery into his chemotherapy treatment and though the road was long, he recovered completely, with no further signs of cancer three years later.

"My girlfriend at the time and I had taken a backpacking trip to the Grand Tetons. This was nine months into my treatment. We'd get out there on the trail and after lunch, which was one of my times, I'd want to sit on the trail or on a rock, or lean against a tree and do my visualization.

This woman was go-go-go, very achievement oriented. She was a very dynamic and pushy and controlling person. 'We're going to hike to this point, have lunch . . . by such and such a time we'll be at the campground,' and she would get terribly impatient with my after-lunch visualization.

It started leading to more and more friction, but I maintained my ground. I was insistent that this is what I was going to do. By the time the trip was over, we weren't speaking. We flew back from Wyoming, not even sitting together on the plane, but that was very important for me, because I didn't often put myself first when it came to her."

Since his recovery, Larry has remained involved with a cancer self-help program as a lecturer in imagery. His story inspires many others to challenge difficult odds. There is no medical explanation for his recovery. The chemotherapy of the day was not considered curative for his condition, yet somehow he was able to marshall the resources to heal.

When in a hypnotic state, the mind is perfectly aware of the surroundings and the situation, but because it is so highly focused, it is able to concentrate on a task without being easily distracted. This enables the person to use imagery, relaxation, or autogenic suggestions in a richer, more powerful way.

Hypnotic states can be self-induced or facilitated by a hypnotist or hypnotherapist. Finally, it can help in overcoming one's resistance to healthful behavior change, such as reducing smoking or changing one's eating habits.

Biofeedback uses special instruments attached to the body to give the person information about what is happening in the body. The instruments serve to amplify the signals that the person may not otherwise be able to detect so they can then use this visual or auditory feedback to learn to regulate certain bodily functions. Many people find this form of assistance very helpful for learning to relax.

The most commonly used form is electromyographic (EMG) biofeedback. An EMG sensor is attached to the skin and reveals the amount of electrical activity related to muscle tension in the area of the sensor. This is very useful in helping people learn to relax the muscles, for they have direct feedback-which may be visual readouts, lights, beeps, or tones-as to the degree of tension. This approach is often used for tension headaches and chronic pain conditions.

Other kinds of biofeedback include thermal, sensing the temperature of the skin as an indication of blood flow and relaxation; electrodermal (EDR), measuring subtle changes in amounts of perspiration; finger pulse, for measuring heart rate and force, useful for anxiety or cardiovascular symptoms; and monitoring breathing patterns-rate, volume, rhythm, and location (belly or chest) of each breath.

Biofeedback has many applications, such as headache and migraines, anxiety, chronic pain, teeth grinding and clenching, Raynaud's disease (vascular disorder causing cold hands and feet), incontinence, asthma, and muscle disorders (including helping people learn to reuse arms or legs that have been traumatized).

There are four areas of research that support mind/body medicine: studies describing the physiology of mind/body interactions, those measuring the effects of mind/body therapy techniques, research on the health outcomes of structured mind/ body programs employing a variety of techniques, and studies of cost effectiveness.

The Mind/Heart Connection. Scientists have pieced together how stress affects the heart. This work is well summarized by Cynthia Medich, Ph.D., R.N., a cardiovascular specialist and researcher at the Mind/Body Medical Institute, Harvard Medical School and New England Deaconess Hospital, Boston. What Medich describes as the mind/heart connection involves the release of two kinds of stress hormones into the bloodstream: corticosteroids and catecholamines.

These hormones set off a cascade of changes in the body including increased platelet aggregation (tendency for blood clotting); increased coronary artery tone; a surge in coronary artery pressure; increased blood pressure, glucose levels, and lipid levels; a more rapid and powerful heartbeat; and, paradoxically, a constriction in the coronary arteries. In short, the demands on the heart all increase.11

Biofeedback. Angele McGrady of the Medical College of Ohio in Toledo is studying the use of biofeedback-assisted relaxation in reducing the dosage of insulin required in type I insulin-dependent diabetes mellitus. The method is being studied as an alternative to increasing the dosage when the person is under stressful conditions. Richard Sherman at Fitzsimmons Army Medical Center in Aurora, Colorado, is evaluating biofeedback in treating chronic musculoskeletal low back pain and muscle-related orofacial pain.

Blair Justice of the University of Texas Health Sciences Center in Houston was funded to conduct a controlled study examining the effects of a group imagery/relaxation process on immune function and quality of life in breast cancer patients.

Hypnosis. Helen Crawford of Virginia Polytechnic Institute and State University in Blacksburg is examining how the use of hypnosis affects the electrophysiology of the brain in patients with low back pain. Carol Ginnandes of McLean Hospital in Belmont, Massachusetts, is studying whether hypnosis can be used to speed the healing of broken bones. Patricia Newton of the Good Samaritan Hospital and Medical Center in Portland, Oregon, is conducting a pilot study of the effects of hypnotic imagery on psychological and immunological factors in breast cancer patients.

With this understanding it is easy to see how individuals who experience stress on a chronic basis are at greater risk for heart diseases. This connection was dramatically illustrated in a study of air traffic controllers, considered to be in a very stressful occupation, who were found to have five times the incidence of

Other research has been able to anticipate who will develop hypertension and heart disease. One study followed 1100 adults for twenty years. Those who had the highest levels of anxiety at the beginning of the study turned out to have the highest rates of hypertension two decades later.13

A study of patients with a history of heart disease found that those who were also depressed were eight times as likely to develop ventricular tachycardia as the patients who were not depressed. (Ventricular tachycardia is a condition of abnormal and potentially deadly heart rhythms.)15

A ten-year study was conducted to follow the mortality rates of people who had experienced stroke. Those who had been diagnosed with either major or minor depression were 3.4 times as likely to have died within the follow-up period. The death rate among depressed patients with few social contacts was especially high: over 90 percent had died.16

In a study of 194 heart attack patients, those who reported lower amounts of emotional support in their lives were nearly three times as likely to die within six months as those with higher levels of emotional support.17

The Mind and Immunity. In addition to affecting the heart, the chemistry of the stress response has been found to lower immune functioning. This is illustrated by studies of the effects of exam stress on medical students that have found significant drops in the activity of natural killer (NK) cells18 as well as in the numbers19,20 of NK cells (NK cells are a key in fighting cancer cells and viruses) and a significantly lower percentage of T-helper cells in the blood21,22 (the cells that arouse the immune response to fight off an infection). In a study of recently divorced people, those who wanted the divorce, for whom it brought relief, were found to have better immunity than those who did not want the divorce.23

A study of the effects of stress on salivary immunoglobulin A (S-IgA, the antibody that fights infections in the mouth and throat) found that a higher frequency of daily hassles was significantly associated with lower levels of S-IgA. However, the effects were less severe in people who scored higher on a scale measuring sense of humor. This suggests that sense of humor can counter the negative effects of stress on the immune system.24

Research has shown that depression can have an adverse effect on immunity. A study that took place in a mental hospital compared natural killer (NK) cell activity in depressed patients, schizophrenic patients, and staff members. The patients with major depressive disorder had significantly lower NK functioning than schizophrenic patients and staff members.25

A study involved 132 college students to determine the effects of positive emotions on S-IgA levels. Half watched a morbid documentary about power struggles in World War II, while the other half watched an inspiring film about Mother Teresa, a Roman Catholic nun selflessly serving the poor and sick in Calcutta. The latter group had significantly increased S-IgA concentrations, indicating heightened immune responsiveness.26

Mind/body researcher Lydia Temoshok, Ph.D., studied the psychological factors associated with malignant melanoma. Among her findings was the discovery that emotional expressiveness was directly related to the thickness of the patients' tumors as well as the course of their disease.27,28

Patients who were less emotionally expressive had thicker tumors and more rapidly dividing cancer cells. Patients who were less expressive had relatively fewer Lymphocytes invading the base of the tumor. These findings helped contribute to the formation of the concept of Type C coping.

Can the immune system be trained to respond, like Pavlov's dog was trained to salivate at the sound of a bell? In a well-designed, controlled study, participants were given a sherbet sweet along with a subcutaneous injection of a chemical known to increase NK cell activity (epinephrine). After several administrations of this regime, the epinephrine was replaced by a useless saline injection. Remarkably, the participants still increased their NK cell activity in response to eating the sherbet accompanied only by the saline injection!29

Some research on techniques has examined their effects on specific bodily functions such as immune responses, blood pressure, and heart rate. Other studies have looked at recovery from surgery, and still others have focused on psychological well-being and the quality of life.

This is by far the most widely studied subject in this tradition with hundreds of studies documenting its benefits. A few examples: Patients with ischemic heart disease who practiced the relaxation response daily for four weeks achieved significant reduction in the frequency of preventricular contractions.30

Patients receiving several kinds of elective surgery who were trained in relaxation had less surgical anxiety both before and after surgery. The intensity of their pain and their use of pain medication were both reduced.32

Also, a study of patients receiving angioplasty procedures showed significantly less anxiety, pain, and need for medication. In patients receiving heart surgery, those who received the training had significantly lower incidence of postoperative supraventricular tachycardia.34

A controlled study of women with premenstrual syndrome (PMS) using the relaxation response twice daily for three months found a 58-percent reduction in the severity of their symptoms.35

Two studies found increased NK cell activity as a result of practicing the relaxation response. One, involving geriatric residents in nursing homes, also found indications of lower activity of herpes viruses. In addition, there were significant reductions in symptoms of emotional distress.36

Of many various forms of meditation, TM has led the way in mind/body research. Over five hundred papers have been published in 108 scientific journals, authored by scientists at 211 research institutions and universities, in twenty-three countries worldwide. Studies of TM were instrumental in discovering the relaxation response and its benefits for hypertension. Other studies have found important benefits for such diverse populations as prison inmates, drug addicts, and Vietnam veterans suffering from posttraumatic stress disorders.

In one study, patients with hypertension who practiced TM twice daily for five to six months achieved significantly lower blood pressured.38 In another, the effects of TM were compared to those of progressive muscle relaxation and usual care in hypertension. For those using TM, the decreases in systolic and diastolic blood pressure were twice as great as those for the subjects in the other groups.39 As will be seen later, TM has also shown impressive effects in reducing the utilization rates of medical services.

Imagery is often used in combination with relaxation and meditation. A controlled study of fifty-five women examined the effects of imagery and relaxation on breast milk production in mothers of infants in a neonatal intensive care unit. They received a twenty-minute audiotape of progressive relaxation followed by guided imagery of pleasant surroundings, milk flowing in the breasts, and the baby's warm skin against theirs. They produced more than twice as much milk as those receiving only routine care.40

In another study, a group of metastatic cancer patients using daily imagery for a year achieved significant improvements in NK cell activity and several other measures of immune functioning.41

At Michigan State University, researchers found that students could use guided imagery to improve the functioning of certain white cells called neutrophils, important immune cells in defense against bacterial and fungal infection.

They could also decrease, but not increase, white cell counts. At one point in the study, a form of imagery intended to increase neutrophil count unexpectedly caused a drop instead. Subsequently, students were taught imagery explicitly intended to keep the neutrophil count steady, while increasing their effectiveness. Both of these goals were achieved.42

A study examined the effect of evocative breath therapy (EBT) on salivary immunoglobulin A (S-IgA). EBT involves abdominal breathing accompanied by music and posthypnotic suggestion to promote emotional arousal and release. Forty-five adults in a group therapy program for cancer showed an average 46-percent increase in S-IgA levels after an hour-long EBT experience.43

Findings included significant reductions in blood pressure, cholesterol, triglycerides, weight, body fat percentage, and psychological symptoms. Importantly, most of the benefits were intact when the patients were checked three to five years later.47

Patients recovering from myocardial infarction took a six-hour program of stress management training with mind/body techniques and emotional support. The result was a 50-percent reduction in subsequent rate of cardiac deaths.48

Reversing Heart Disease. A controlled study at the Preventive Medicine Research Institute, University of California, San Francisco, examined the effects of a multistrategy program on people with severe coronary heart disease. Patients were randomly assigned to either a usual care group or the experimental program. The latter involved a regimen of dietary changes, exercise, yoga, and group support that included the practice of mind/body techniques. Those in the experimental program almost universally showed reductions in coronary artery blockage, while those with usual care generally showed more blockage.49

A ten-week group program for infertile women included training in the relaxation response with instructions for daily practice and training in stress management, exercise, nutrition, and group support. Results included decreases in anxiety, depression, and fatigue and increased vigor. Also, 34-percent of the women became pregnant within six months of the program.50

Another group program for HIV found significant improvement in emotional expression, sense of control over health, tension, anxiety, fatigue, depression, and total mood disturbance.52

Fifty-nine patients took a ten-day, sixty-hour group program that includes imagery, relaxation training, lifestyle evaluation, emotional release therapies, group support, breath therapy, and exploring the personal meaning of illness. Results included significant improvements in emotional expressiveness, fighting spirit, quality of life, sense of control over health, and optimism--including patients with metastatic disease. These improvements were still present three months after completing the program.53

Sixty-six patients with malignant melanoma took a six-week structured group program that included health education, stress management, training in problem solving, and psychological support.

Josephine, thirty-six, suffering from headaches, sought help from her physician. Her blood pressure was 150/100, she was twenty pounds overweight, and her cholesterol level was 280 mg/dl. She smoked a pack a day and did not exercise regularly. She was given a betablocker for high blood pressure, a cholesterol drug, and was told to lose weight and stop smoking.

Two months later her blood pressure was 160/102 She had lost no weight, she had not been able to stop smoking, and her cholesterol was 290 mg/dl. When asked why she hadn't cooperated with the recommendations she broke down in tears. She hadn't been able to afford the medications ($90/month). Her husband had left her and their two children after a stormy and abusive marriage, so she had been trying to work two jobs, felt depressed, was not sleeping well, and her headaches were now a daily occurrence.

She was referred to the Hypertension Clinic at the New England Deaconess Hospital, Boston, and participated in a twelve-week program of two-hour sessions with ten other participants. The program emphasizes the relaxation response, diet, exercise, and stress management. Her goals in the program were to control her blood pressure, lose weight, and stop smoking. During the program she regained some of her self-esteem, began to feel more hopeful, started sleeping better, was less irritable with her children, and was able to

find assistance for child care and vocational training. She monitored her blood pressure once a day, which dropped to 124/90, and her medication was stopped. She was headache-free. She started walking daily and lost five pounds. Her cholesterol dropped to 220mg/dl. She practiced the relaxation response once a day and signed up for an assertiveness training class at the YWCA.

Before leaving the program, she outlined the situations that might be associated with relapse and developed a plan for action that included returning periodically for the drop-in groups for reinforcement. She also signed up for a SmokeEnders group to start after the program ended.54

Six months after the program, there were significantly lower levels of psychological distress and higher levels of positive coping methods in comparison to patients who did not have the program. There were also

The patients who participated in the above study were followed for six years. A startling difference in death rates between the two groups was found. Of those who were in the control group (no group therapy), thirteen of thirty-four had a recurrence of cancer during the six years and ten died. For those who had the group program, only seven of thirty-four had recurrences and only three died.56

A ten-year controlled study was conducted with eighty-six women with metastatic breast cancer. Those who had a year of weekly group sessions had nearly double the survival time of those who did not have the group (averaging thirty-six months versus eighteen months). The group provided self-hypnosis and a form of therapy called "supportive-expressive therapy."57

Aside from the medical and psychological benefits, one of the most important contributions of mind/body medicine is in reducing the costs of health care by reducing the utilization rates of expensive inpatient and outpatient services.

Dr. Elizabeth Devine of the University of Wisconsin School of Nursing in Milwaukee conducted an analysis of 191 different scientific studies in which surgery patients were taught simple mind/body techniques. She found an average reduction in the length of hospital stay of 1.5 days (12 percent). This of course translates into enormous savings, considering the cost of a day of hospitalization. Results also included faster recovery from surgery, fewer complications, and reduced postsurgical pains.58

Other studies have found reduced utilization rates for outpatient medical services. For example, in one study 109 chronic pain patients took a ten-session outpatient group mind/body program. A 36-percent reduction in total monthly clinic visits for pain management was found in the first year after the program.59

Another study looked at the medical care utilization rates of two thousand regular practitioners of TM, comparing them with 600,000 other members of the same insurance carrier. For children and young adults the reduction for inpatient services was 50 percent and for older adults it was 69 percent. The reductions for outpatient services were 47 percent for children, 55 percent for young adults, and 74 percent for older adults.

The same pool of TM practitioners were compared to five other health insurance pools, showing 55 percent fewer visits for benign or malignant tumors, 87 percent fewer visits for heart disease, 30 percent fewer visits for infectious diseases, 31 percent fewer visits for mental disorders, and 87 percent fewer visits for diseases of the nervous system.60

The greatest strengths of mind/body medicine are in stress-related conditions and chronic illnesses. It also has a great deal to offer in terms of relief of the symptoms of acute illnesses as well as relief from the side effects of treatment such as surgery, radiation, or chemotherapy in cancer.

However, while it is usually thought of as supportive rather than curative, there are illnesses that do not respond to conventional medical treatment and for which mind/body medicine offers a way of gaining some relief and promoting recovery.

One point of controversy that often arises in this tradition is the question of whether its use implies an assumption that one's illness must have been caused by the mind in the first place. For example, there are those who question whether this approach should be applied to cancer because to use it might suggest that the person brought the cancer upon themselves. This is an unnecessary assumption since the mind/body connection can be exploited regardless of the cause of an illness.

The leading PNI researcher Alastair Cunningham, who holds Ph.D.s in both psychology and immunology, articulates this point well: "Although epidemiological considerations suggest that the contribution of psychological factors to cancer onset is small . . . no upper limit to what can be achieved by psychotherapy is necessarily thereby set: the relative influence of the psyche on outcome may be greatly expanded by such therapy, overriding the usual progression of disease."61

One limitation is that the methods require an ability to sit quietly and in some cases focus the mind on a technique. Some people suffering from extreme symptoms of disease may at times have difficulty following through with a routine of regular practice. Those who do best are able to sustain a regular practice and achieve cumulative benefits over time.

It should also be remembered that while there have been many studies documenting significant effects of mind/body techniques, there are different kinds of significance. Statistical significance means that there is a

Heidi, thirty-five, was scheduled for a round of chemotherapy for breast cancer. The treatment was to take place on Friday and she and her husband had tickets to fly to Hawaii on Saturday for a week's vacation.

As is routine, she was called into the treatment center for a blood check on the Monday before to make sure her white cell count had recovered enough from the previous treatment to allow her to qualify for the next one. To her shock, she was told that her white count was only about half what it should be and she would probably have to forego her vacation.

For four days she practiced imagery intensively several times a day, concentrating on raising her white count. She used images of the bone marrow releasing a steady, strong flow of white cells into her bloodstream and spreading throughout her body. She also imagined directing her breath into the bone marrow and thereby nourishing the stem cells (that produce the white cells) so that they could grow and release more white cells.

On that Friday, she went in for another blood test. Her white count had more than doubled. She was able to have the treatment and the next day was able to walk on the beach with her husband.

Clinical significance, on the other hand, means that actual medical benefits have indeed been observed. The studies reporting a major change in the overall course of an illness or even longer survival time in cancer provide the best examples of clinically significant findings.

Hence a person may use mind/body techniques religiously and practice them perfectly with real commitment and still not get the medical benefits they desire. The degree of the contribution will vary from one person to the next, depending in part on the severity of the illness.

When people do not understand these limitations and have unrealistic expectations, they are at risk of feelings of failure, self-blame, depression, or disappointment that may arise when such expected results are not forthcoming. This is called the psychosocial morbidity of mind/body medicine. Patients and practitioners alike must endeavor to keep a realistic perspective on mind/body medicine, not overrating but also not underrating it.

Mind/body techniques are often used in the context of psychotherapy or group therapy. These situations offer the opportunity for addressing other important aspects of coping with an illness. Often it is important to deal with the emotional aspects of an illness before one can comfortably or confidently pursue use of the mind/body techniques.

In this sense, this is a relatively practitioner-dependent tradition. However, the professional is not so much a healer as a teacher. Once the methods are learned, you can use them on your own at home in the form of a daily practice. And of course there are other ways of learning the techniques such as books and tapes. Some highly motivated people are able to develop a fruitful practice without professional guidance, but such guidance is still advised, especially in using such methods with a more serious illness.

Carol Anne was scheduled to undergo a complicated abdominal surgery to remove a cancerous tumor. Her surgeon told her that patients undergoing this procedure typically lose ten to eleven units of blood.

For several days prior to the surgery, Carol Anne practiced a form of imagery in which she pictured her body going through the surgery without losing any blood, the tissues knitting back together smoothly, no complications, and a speedy recovery. She also imagined the look on the surgeon's face when he realized that no blood had been lost.

The day after the surgery, the surgeon came into her room and congratulated her on how well she had come through the ordeal. To his amazement, she had required only one unit of blood. When she told him of her preparations, he smiled and walked out shaking his head.

The results of mind/body techniques may be immediately apparent with changes in mood, pain, or physiological state. This is one of the things that is appealing about this tradition. The body gives direct feedback as to the impact of the technique. In fact, the subjective experience is the most important way of evaluating results.

This is consistent with the advice of Carl Simonton, M.D., who first popularized the use of imagery with cancer. According to Simonton, the criterion of successful imagery practice is whether the person feels hopeful, powerful, and optimistic after doing it. This is much more important than the details of the images or whether they followed someone else's particular guidelines.62 Research has also confirmed that feeling confident in one's ability to influence his or her health will in itself reduce the degree of stress they feel and

Mind/body medicine is usually used in the role of complementary therapy. This means it works alongside other treatment in a supportive way. I like this term because it communicates a cooperative partnership rather than being exclusive of other traditions. In fact, all medical traditions now include within them some attention to mind/body interactions and ways of working with them.

The economics of mind/body medicine are another source of its appeal. Other than for the individual consultations or training programs one might engage to use this approach, there are no inherent costs in using this tradition. Many hospitals or community agencies offer group support programs free of charge that teach the techniques. There are also nonprofit organizations such as the Centers for Attitudinal Healing and the Wellness Community, both with nationwide chapters, who offer free group programs that include mind/body techniques.

Beyond the free or low-fee services mentioned above, services provided by professionals are often covered by health insurance if offered by a licensed primary care provider or a licensed mental health professional (psychologist, clinical social worker, marriage and family counselor). Coverage by the latter disciplines would usually be under the category of individual or group psychotherapy. Typical fees range from $40 to $100 or more for individual sessions and $25 to $50 for group sessions.

Mind/body medicine knows no disciplinary bounds. There are no standardized credentials or requirements to use in evaluating one's preparation in these approaches. Because most techniques are not very complicated anyway, what is probably more important is that the practitioner is competent in having a therapeutic relationship and also has a healthy regard for the limitations and appropriate uses of mind/body techniques.

The techniques themselves are usually quite familiar to anyone who is trained in the mental health disciplines and other health care providers who received mental health training. Many training programs in the mental health disciplines include courses and experience in the field of behavioral medicine. Of course, licensing by the state is usually a good place to start for any such provider.

Beyond general licensing, there are numerous organizations and training programs in mind/body techniques that offer their own advanced certification. Such certification is by no means necessary in order for a person to be competent in a technique, although it can lead to a higher degree of skill and competence in specific techniques.

Most but not all such programs of advanced certification require the practitioner to be licensed in a professional discipline. A noteworthy exception in this regard is hypnotherapy, which in many states is acknowledged as a distinct profession without being linked to a specific academic discipline. Some states limit the practice of hypnosis or hypnotherapy to licensed therapists. Others allow it to be practiced by lay hypnotists but limit the scope of problems that can be addressed.

The MindBody Medical Institute, Division of Behavioral Medicine, New England Deaconess Hospital offers group mind/body programs for different illnesses. They also have affiliate programs nationwide and conduct clinical training several times each year under the direction of Herbert Benson, M.D., and faculty. Address: 1 Deaconess Rd., Boston, MA 02215, phone (617) 632-9525, FAX (617) 632-7383.

The Cancer Support and Education Center conducts retreats and group programs for people with cancer and other serious illnesses. The program includes in-depth work with the emotional aspects of illness, as well as imagery, movement, deep relaxation, breath therapy, and nutrition. Address: 1035 Pine St., Menlo Park, CA

Commonweal Cancer Help Program conducts a week-long retreat several times each year for cancer patients. The program focuses on informed choice among both conventional and alternative cancer treatments, and also includes mind/body and other holistic therapies. Address: P.O. Box 316, Bolinas, CA

Stress Reduction Clinic, University of Massachusetts Medical Center, directed by Jon Kabat-Zinn, Ph.D., conducts an eight week program and a five-day residential program in mindfulness training and stress reduction. Address: UMMC, Worcester, MA 01655, phone (508) 856-1616.

Insight Meditation Society and Insight Meditation West offer workshops and retreats nationwide in mindfulness meditation, also called vipassana meditation. Address: IMS, Pleasant St., Bare, MA 01005,

A meditation teacher and mystic living in northern California came from a family with the hereditary condition of polycystic kidney disease. At age forty-four he began to have the typical symptoms of breakdown in kidney function and by age sixty-three he was on the waiting list to receive a kidney transplant.

He was expecting a two-year wait and had already been using kidney dialysis for ten months. However, a longtime student and devoted friend heard of his need and immediately volunteered to donate a kidney to him.

Having taught for many years how to understand and communicate with the subconscious, he developed his own plan to prepare his body to receive the foreign organ and accept it easily without being rejected by his immune system. He used meditation, inner dialogues with his subconscious, hypnosis, and affirmations to help his body "welcome the kidney like a long-lost brother." His quick recovery and the rapid rate at which his antirejection

According to John Soos, Ph.D., a clinical psychologist working with organ transplantations in Vancouver, Canada, mind/body medicine can indeed "instruct the immune system to improve its functioning against germs while at the same time recognizing and tolerating the transplanted organ as an integral part of the new body image.63,64

The Center for Mind/Body Medicine has both residential and outpatient programs. Developed under the guidance of Deepak Chopra, M.D., it also provides education and training programs in Ayurveda for laypeople

Maharishi Ayur-Ved Products International provides referrals to local resources for training in transcendental meditation (TM). Address: P.O. Box 49667, Colorado Springs, CO 80949-9667, phone (800) 255-8332.

The Academy for Guided Imagery provides training for professionals in the use of guided imagery. Address: P.O. Box 2070, Mill Valley, CA 94942, phone (800) 726-2070 or (415) 389-9324, FAX (415) 389-9342.

Biofeedback Certification Institute of America provides a directory of certified biofeedback practitioners, including their background and experience. Address: 10200 W.44th Ave., Suite 304, Wheatridge, CO 80033, phone (303) 420-2902.

American Chronic Pain Association manages a list of over five hundred support groups internationally, and publishes workbooks and a newsletter. Address: P.O. Box 850, Rocklin, CA 95677, phone (916) 632-0922.

American Society of Clinical Hypnosis (ASCH) is the largest and most highly accredited organization for hypnotherapists. The ASCH sponsors the American Board of Clinical Hypnosis, which certifies practitioners, and maintains a referral list of professionally trained and licensed hypnotherapists. Address: 2200 East Devon Ave., Suite 291, Des Plaines, IL 60018, phone (708) 297 - 3317, FAX (708) 297-7309.

Center for Attitudinal Healing has support groups throughout the nation for people with chronic or life threatening illness. Address: 33 Buchanan, Sausalito, CA 94965, phone (415) 331-6161.

Wellness Community has chapters throughout the nation that conduct support groups for people with chronic or life threatening illness. Address: 2716 Ocean Park Blvd., Suite 1040, Santa Monica, CA 90405, phone (310)314-2555

Audiotape programs applying methods of mind/body medicine are available from many individual practitioners throughout the country. See About the Author in the back of this book for one resource.

Above all, mind/body medicine is an approach that requires your own participation. It does not require working with a practitioner, but if you choose to, it is important that you work with someone with whom you have a good rapport and whose style and manner you find comfortable. Often the practitioner's voice alone is enough to either draw or repel some people.

Beyond the issues of appropriate licensing or certification, it is important that the practitioner have a balanced perspective of both the limits and possibilities of mind/body medicine. Anyone who promises a cure of a serious illness is immediately suspect. The wisest practitioners take a conservative approach in extolling the virtues of this tradition.

Finally, structured group programs have a lot of advantages over individual treatment. If you can find a group program, you can gain a great deal of reinforcement for healthful behavior change from the mutual support of

3. Eisenberg, D. M., R. C. Kessler, C. Foster, F. E. Norlock, D. R. Calkins, and T. L. Delbanco. 1993. Unconventional medicine in the United States: prevalence, costs, and patterns of use. The New England Journal of Medicine 328(4):246-52.