CAM Practices Paper

CHAPTER 9 MIND-BODY MODALITIES

DENISE RODGERS

MARC S. MICOZZI

HISTORICAL OVERVIEW

Life and healing are inherently mysterious. The essential “stuff” of the universe, including the universe of the mind and body, remains essentially unexplained. The void inside every atom is pulsating with information or unseen intelligence. Molecular biologists and geneticists locate this intelligence within DNA, primarily for the sake of convenience. Life unfolds as DNA imparts its coded intelligence into a sequence in which energy and information are interchanged for the purpose of building life from matter.

The reality ushered in by quantum physics made it possible to manipulate the invisible intelligence that underlies the visible world. Albert Einstein taught that the physical body, as with all material objects, is like an illusion, and trying to manipulate it can be like grasping the shadow and missing the substance. The unseen world is a real world, and when we are willing to explore the immense creative power that lies within the mind, we can then access the unseen dimensions of the body.

Although mainstream consciousness seems highly aware of the inherent power of the mind, some of the earliest records of certain mind-and-body techniques were found in Babylonia and ancient Sumer well before the rise of experimental science. In the third century BC, Hippocrates was well versed in the art of mental healing. A serpent coiled around a staff is the Hippocratic symbol used today to portray the medical and healing profession. History reveals that the coiled serpent symbolizes the healing energy possessed by each of us, lying dormant at the base of the spine (as literally in Kundalini Yoga), with the staff representing life itself. Eastern philosophy posits that when the serpent is unleashed, healing energy spirals up the spine and out the forehead. This energy, said to be mental in nature, can then be used to heal the physical body.

Most ancient and indigenous medical systems make use of the extraordinary interconnectedness of the mind and body. Native American and Asian Indian cultures believe their members to be in contact with natural healing forces through their dreams, visions, and mystical experiences.

The ancient Greeks were also known for their healing temples. These centers existed for more than 800 years and endured until the rise of the Christian era. Patients would travel long distances to experience one of the Aesculapian healing temples. The first step in seeking a cure was to create inner cleanliness by taking a purifying bath. Patients then were put on a special diet or fast. They would attend one of the great dramas of Euripides or Sophocles, observing the tensions and movements of life. Later they were taken to visit one of the shrines, where healers used imagery to visualize the affected part of the body. During sleep the priests entered the patients’ rooms and touched the diseased parts. Thereafter, patients would dream and were said to awaken healed.

Philippus Aureolus Theophrastus Bombast von Hohenheim, known as Paracelsus, was a sixteenth-century Renaissance Swiss physician. Although considered the father of modern drug therapy and scientific medicine, he nevertheless opposed the idea of separating the mind from the healing processes of the body. Along with his esteemed medical theories, he held that imagination and faith were the cause of healing power:

Man has a visible and an invisible workshop. The visible one is his body, the invisible one is the imagination of the mind…. The spirit is the master, imagination the tool, and the body the plastic material. The power of the imagination is the great factor in medicine. It may produce diseases in man and it may cure them. Ills of the body may be cured by physical remedies or by the power of spirit acting through the soul.

Paracelsus believed that physicians could heal by tapping the power of God. He also believed that dreams gave humans clairvoyance and the ability to diagnose illness from long distances.

The philosophies of all these cultures had a common belief in a spiritual center that resides within. They believed in spirit over matter, mind over body. In contrast, modern allopathic medicine has regarded these connections as nonscientific and of secondary importance. Scientific healing, in the form of drug therapy and surgery, has grown to become a dominant Western form of treatment. Since the early 1900s, however, many medical scientists have begun to reinvestigate the role the mind plays in healing. In critical situations, physicians have been known to say, “We've done all we can do—it's in God's hands now,” or “It depends on the patient's will to live.”

Every physician has witnessed miraculous recoveries unexplainable by scientific understanding. Labeling a recovery as a “spontaneous remission” has become common to describe a healing that cannot be explained by medical standards. Physicians have also long recognized the effectiveness of placebos, substances with no known pharmacological action or benefit. In some cases, placebos can be as much as 70% effective in the treatment of illness, thereby proving the theory that a patient's therapeutic expectation is a contributing factor to healing.

During the past 35 years, the scientific community has made great strides in exploring the mind's capacity to affect the body. This movement has received its impetus from several sources. The rise in the incidence of chronic illness over the past few decades and the rapidly increasing cost of treatment have set the stage for deeper exploration of mind-body therapies. These therapies show great promise for mobilizing the body's inherent power to heal itself.

Recent studies have begun to further deepen our understanding of the effects of stress on the body. Convincing evidence supports the concept that the immune system, along with other organs and systems in the body, can be and is often influenced by the mind. These research efforts and clinical experiments suggest that the separation between mind and body, long taken for granted in Western philosophy, is difficult to quantify. These challenges are all part of a new approach to medical science: the challenge of proving that the mind—along with our thoughts and emotions—has a significant impact on the body's health.

For patients, this new synthesis has very practical significance. It suggests that by paying attention to and exerting some control over mental and emotional states, they may actually contribute to prevention of or recovery from disease. The conscious participation of the patient in the process of healing not only offers new insights but also raises new questions about the nature and reality of consciousness.

The predominant fundamental tenet of mind-body medicine is the concept of treating the whole person. Another significant tenet is that people can be active participants in their own health care and may be able to prevent disease or shorten its course by taking steps to manage their own mental processes.

Medical researchers are beginning to rediscover what other cultures have historically used in their healing systems, such as meditation, hypnosis, and imagery. Grounded in ancient philosophy, these interventions are capable of stimulating and often facilitating the mind's capacity to affect the body. Experimentation has given practitioners the opportunity to offer nontoxic therapies while examining the specific links between mental processes and autonomic, immune, and nervous system functioning.

Evidence grows that states of mind can affect physiology. No one is promising that people can cure themselves of disease by adjusting their mental attitudes; this idea is not the message of mind-body interventions. However, mind-body approaches can be used to reduce the severity and frequency of biological symptoms and can potentially help strengthen the body's resistance to disease.

The techniques of mind-body medicine are reasonably well accepted for treating certain chronic and difficult-to-treat medical conditions, from pain syndromes to hypertension. In well-designed studies, relaxation, guided imagery, biofeedback, hypnosis, and related strategies have been proven workable. New evidence is showing that mind-body interventions are consistently effective in improving psychological and medical outcomes after

Figure 9-1 Mesmerism and hypnotism were the object of satire and a number of caricatures during the nineteenth century.

(Courtesy Bibliothèque Interuniversitaire de Médecine, Paris.)

surgery. In a meta-analysis encompassing 191 studies and more than 8600 patients, psychosocial-behavioral interventions showed reliably moderate-sized effects in improving recovery, reducing pain, and decreasing psychological distress (Dreher, 1998). As discussed in this chapter, there is movement on all fronts. Mainstream medical institutions are beginning to take awkward “baby steps” toward implementing these approaches within departments of psychology, psychiatry, oncology, neurology, and rehabilitation. “Mind and body” departments are being established in medical schools and hospitals nationwide. More impressively, both conventional and holistic professionals are beginning to incorporate these approaches into their own personal regimens for greater health and wellness.

This chapter discusses evidence that supports mind-body approaches, describes some of the more widely used techniques, and summarizes the results of some of the most effective interventions. The approaches discussed in this section not only demonstrate dramatic results in specific areas but also help form the basis for a new perspective for medicine and healing. From this perspective, it becomes evident that every interaction between physician and patient has the potential to affect the mind and, in turn, the body of the patient.

ROLE OF CONSCIOUSNESS

Dismissal of the Mind

Although ancient mystics believed in the power of the human mind, Western science began to question such matters by the mid-1800s. Until that time, physicians believed the prevailing philosophy that the patient's inner life and social being were vital components of all diagnosis and treatment. They generally believed that medicine should take into account not only biological but also behavioral, moral, psychological, and spiritual factors.

These models and methods began to fade by the end of the nineteenth century, however, and a patient-specific model of treatment gave way to a disease-specific model. During the rise of this era of experimental science, four leading German physiologists (Hermann von Helmholtz, Carl Ludwig, Emil du Bois-Reymond, and Ernst Wilhelm von Brücke) pledged themselves to account for all bodily processes in purely physiological terms. They considered that any reported connection between mental states and bodily functions were biased, subjective, nonmeasurable, and scientifically unreliable (Figure 9-1). More than 15,000 American physicians traveled to Germany to study the fascinating laboratory experimentations being introduced at that time. These innovative breakthroughs were in direct contrast with the style of medicine that had been practiced for centuries. It was believed that proper research could be conducted only in laboratories on isolated constituents—microorganisms, components of blood and urine, tissue, and organs—with the focus on devising universal remedies independent of individual patients. This approach has put contemporary medicine in the position of having to learn the scientific basis of something it has known for centuries: that beliefs, thoughts, and feelings affect physiology.

Power of Placebo

The word placebo is Latin for “I please.” This concept is well illustrated by an anecdote concerning Sir William Osler. One of North America and England's busiest and most famous physicians, Osler brought new light to the power of placebo near the turn of the nineteenth century. Dr. Osler made a house call to a dying boy, who had been unresponsive to any previous treatments. Osler appeared at the boy's bedside dressed in magnificent scarlet academic robes. After a brief examination, Osler sat down at the boy's bedside, peeled a peach, sugared it, and cut it into pieces. He then fed it, bit by bit, with a fork to the entranced patient, telling him that it was a most special fruit and that if he ate it, he would not be sick. (Perhaps Osler had read the account of “Hanuman Eating the Magic Peach” in the Sanskrit creation epic, The Ramayana.)

Osler confided to the boy's father that his son's chances for survival were slim. He continued to visit the boy daily for more than a month, always dressed in his majestic scarlet robes and offering the boy nourishment with his own two hands. This dramatic presentation inspired magic and belief well beyond laboratory science and helped catalyze the boy's unexpected and complete recovery.

Eloquently summing up the placebo's power, Osler wrote the following:

Faith in the gods or saints cures one, faith in little pills another, hypnotic suggestion a third, faith in a plain common doctor a fourth…. The faith with which we work…. has its limitations [but] such as we find it, faith is the most precious commodity, without which we should be very badly off. (1953)

During World War II the anesthesiologist Beecher noted with surprise, as he examined men with serious shrapnel wounds at Anzio beach, that many of them refused morphine, something that he almost never saw in Boston when he tended to patients with the far less serious wounds produced by controlled surgery. How could such a phenomenon be explained? Under conditions that produce extreme stress or fear, higher emotional centers in the brain can activate a descending system that suppresses incoming pain signals. This descending analgesic system utilizes the body's own endogenous opiate-like neurotransmitters, the endorphins. The threshold for activation of descending analgesia by stress is high; otherwise pain would lose its survival value. But the nervous system appears to be organized so that in circumstances that produce the greatest stress or fear—for example, pursuit by a predator or mortal combat, circumstances in which the survival value of running or fighting far outweighs the risk of using already damaged limbs—pain can be completely suppressed (Hyman, 1998).

Among the early placebo studies documented are those conduced by Dr. Ronald Katz, chairman of the Department of Anesthesiology at the University of California at Los Angeles School of Medicine. Katz reported a series of observations involving patients who were informed that headaches were a complication of spinal anesthesia. At the last minute the patients were told that the choice of anesthesia had been changed from spinal to general. Despite the change, all the patients experienced the symptoms associated with spinal anesthesia (Katz, 1977).

Dr. J.W.L. Fielding conducted a study at the Department of Surgery at Queen Elizabeth Hospital in Birmingham, England, similar to Katz's study investigating expectations. In compliance with informed consent procedures, 411 patients were told they could expect to lose hair as a result of the chemotherapy being administered. Thirty percent of the patients unknowingly received placebos instead of chemotherapy and experienced hair loss even though the pills they had taken contained no medication (Fielding et al, 1983).

Although it has sometimes confounded as much as clarified, the mechanism of pain has provided fascinating clues to investigators of the mind-body healing response. In one landmark study in 1978, dental patients experiencing the aftereffects of an extracted tooth were given a sugar pill and told it was a powerful painkiller. They reported significant pain relief. Then experimenters added another agent: along with the placebo, a separate group of dental patients were given a chemical known to block the action of the brain's own endorphins. The second group experienced significantly less pain reduction than the first group (Levine et al, 1978).

Here was a study that indicated a specific mechanism for placebo—endorphins—without which the magic effect would not have occurred. These studies and many other similar ones led scientists to believe that endorphins mediate much of the mind-body effect, whether that effect is triggered by trauma, placebo, hypnosis, or any other mental agent.

There are likely many mind-body routes, with many mechanisms to create similar effects. Therefore, different states of mind may affect the body along different pathways, or the same substances may have multiple effects. In other words, relief of pain may also stimulate immune function, because pain-relieving endorphins are key messenger molecules that also “talk” to the immune system.

The natural conclusion emerging from placebo research is that expectation or belief affects biology. The emotional responses of individuals to the world around them, stimulating hopes and joys, fears and anguish, has a potential affect on the physical body. This understanding is fundamental to the treatment of illness. It does not mean that conventional medical treatment should be supplanted by psychological or emotional approaches. The most effective and comprehensive strategy of treatment should be expanded to include the awareness of emotional and psychological factors in concert.

Mind and Emotion Everywhere

Former chief of the Brain Biochemistry Section of the National Institute of Mental Health, Candace Pert, PhD, co-discoverer of endorphins, made some startling revelations regarding the existence of neuropeptide receptors throughout the entire body. Pert found that the endocrine system and even the immune system all have these messenger molecules. This means that neuropeptide molecules are involved in a psychosomatic communication network and that the biochemistry of emotion could be mediating the transference of information flowing throughout the body. Pert maintains that the emotions are the bridge between the mental and the physical, which makes them prime candidates for a variety of links between thought and healing.

BOX 9-1 Major Figures in Psychotherapy as Related to Complementary and Alternative Medicine Approaches

Carl Jung

Unconscious

Collective unconscious

Archetypes

Abraham Maslow

Humanistic psychology

Self-actualization

Hierarchy of needs

Carl Rogers

Person-centered psychotherapy

Humanistic psychology

Milton Erikson

Unconscious

Hypnosis

Family system therapy

Mind and Immunity

Psychoneuroimmunology, a term coined by Robert Ader, an experimental psychologist, was first introduced to the scientific community in 1981. Ader had previously conducted experiments with rats which showed that the immune system could be conditioned and therefore did not operate autonomously, but was actually under the influence of the brain (see Chapter 8).

In subsequent research at the University of Rochester, Ader and Nicholas Cohen continued to show that the immune system can be trained, or conditioned, to respond to a neutral stimulus (placebo). They found that the administration of an immune-suppressing drug and placebo together “conditioned” the immune system to respond to the placebo alone after the drug was discontinued. They also found that by alternating the administration of real medication and placebos, thus conditioning the body's physiological response to the placebo, the conditioning effects of a drug can be increased. They believed that side effects of dependence could be reduced in addition to costs (Ader et al, 1991).

Considering the brief time that psychoneuroimmunology has existed as an accepted field of research, a great amount of data has been collected in support of the idea that homeostatic mechanisms are the product of an integrated system of defenses of which the immune system is a critical component. Now that we understand that peptides and receptors are expressed by the nervous system, the digestive system, and the immune system, it is not surprising to learn that immunological reactivity can be influenced by stressful life experiences (Ader, 2003).

It has become increasingly clear that there must be an intricate network behind spontaneous remissions, which are known to occur in cancer more often than any other disease. Research will likely continue to raise more questions about the mechanics of how the power of the mind actually works. How can the anticipation of a physical effect actually bring about physical change? And if anticipation or attitudes do play a role in creating physical change, how can that knowledge be used to enhance medical treatment or promote good health? If we can answer these questions, can we determine how the human mind converts ideas and expectations into chemical realities? Mind-body practitioners and medical researchers alike must answer these questions.

PSYCHOTHERAPY

The word psychotherapy is derived from Greek words meaning “healing of the soul” and refers to treatment involving emotional and mental health, which is interwoven with physical health. Psychotherapy encompasses a wide range of specific treatments, including combining medication with discussion, listening to the patient's concerns, and using more active behavioral and emotional approaches. It should also be understood more generally as the matrix of interaction in which all health professionals operate (Box 9-1).

An average of “one in every five people in the United States experiences a major psychological disorder every six months—most commonly anxiety, depression, substance abuse, or acute confusion” (Strain, 1993). The rate is believed to be even higher among patients with a chronic illness and among elderly patients. Approximately three fifths of patients with psychological problems are seen only by primary care physicians, many of whom are not adequately trained in psychotherapy or do not have adequate time to spend with each patient discussing these psychological issues. Despite the enormous need for different forms of psychological care, most people who display the greatest need for such care receive less than adequate screening and treatment for their psychiatric conditions.

Research also indicates that primary care physicians recognize cases of depression in only one fourth to one half of the patients who experience it, and they recognize other types of mental illness in less than one fourth of cases. However, these same physicians write most of the prescriptions for antidepressant and antianxiety drugs and may often prescribe them inappropriately. Clearly, there is a significant need for better recognition and management of the psychiatric conditions that often accompany serious illness.

Methods of Psychotherapy

Mental health professionals are paying more attention to features shared by all effective forms of psychotherapy, especially collaboration between the therapist and patient in developing an account of the patient's emotional life that promotes confidence, heightens well-being, and suggests ways to overcome cognitive or emotional difficulties. The primary aim of psychotherapy is to transform the meaning of the patient's experience by improving emotional state through an intimate relationship with a helpful person. Conventional psychotherapy is conducted primarily through psychological methods such as suggestion, persuasion, psychoanalysis, and reeducation. Although research suggests that the methods do not differ greatly in effectiveness, several hundred types of psychotherapy are available, used individually or in groups. Generally, most forms of psychotherapy fall in the following general categories:

• Psychodynamic therapy. Psychodynamic therapy is derived from psychoanalysis and seeks to understand and resolve emotional conflicts that originate in childhood relationships and repeat themselves in adult life. Sessions usually are devoted to exploring current emotional reactions from past situations. This approach works best if the patient's goal is to make fundamental changes in personality patterns rather than to change one specific behavior. Psychodynamic therapy is often called interpretive therapy or expressive therapy.

• Behavior therapy. Behavior therapy emphasizes changing specific behavior, such as a phobia, by stopping what has been reinforcing it or by replacing it with a more desirable response. Sessions are usually devoted to analyzing the behavior and devising ways to change it, with specific instructions carried out between sessions. Behavior therapy is more effective with focused problems, such as a fear of public speaking.

• Cognitive therapy. Cognitive therapy is similar to behavior therapy in changing specific habits; however, it emphasizes the habitual thoughts that underlie those habits. The general strategy is similar to that of behavior therapy, and the two approaches are often used together. Cognitive therapy is effective therapy for treating depression and low self-esteem.

• Systems therapy. Systems therapy focuses on relationship patterns, either in couples, between parents and children, or within the whole family. This approach requires that everyone involved attend therapy sessions and often entails experiential practice aimed at changing problem-causing patterns. Systems therapies work well for a troubled marriage or intense conflicts between parent and child, where the problem is in the relationship between them.

• Supportive therapy. Supportive therapy concentrates on helping people who are in an intense emotional crisis, such as a deep depression, and may be used in combination with pharmacological support. It focuses on building tools to handle overwhelming day-to-day situations.

• Body-oriented therapy. Body-oriented therapy hypothesizes that emotions are encoded in and may be expressed as tension and restriction in various parts of the physical body. Various methods of therapy, including breathwork, movement, and manual pressure, are used to help release emotions that are believed to have been held in the muscles and tissues.

Recent research indicates that psychotherapeutic treatment can hasten recovery from a medical crisis and in some cases is the best treatment for it. Brief psychotherapy reduced time spent in hospitals for elderly patients with broken hips by an average of 2 days; these patients returned to the hospital fewer times and spent fewer days in rehabilitation (Strain, 1993). Other studies show that psychotherapy is most effective when begun soon after a patient is admitted to a hospital. At present, however, most psychological problems associated with physical illnesses remain undiagnosed or are not identified until near the end of a hospital stay.

One of the most common psychological problems of medical patients is “reactive” anxiety and depression—the emotional distress stemming from a patient's reaction to diagnosis. Those with serious or terminal illnesses are particularly vulnerable. In other cases, psychiatric symptoms are directly caused by the patient's physical disease. Still other patients experience a shift in their mental or emotional status as a direct result of a specific medication. For example, some patients taking high levels of steroids may react psychotically, whereas others may experience severe depression.

Role of Group Support and Psychological Counseling

Psychologists have known since World War II that social support and group consciousness greatly aid people in their attitudes and emotional resiliency. Over the past 10 years, clinical studies have shown that social support indeed has a significant influence on symptoms of stress for patients with chronic illnesses.

In an earlier yet still impressive study of patients with established coronary artery disease, group support and psychological counseling were combined with diet and exercise. Symptoms such as angina pectoris rapidly diminished or disappeared, and after 1 year the coronary artery obstructions were smaller. This evidence strongly suggested that the most deadly and expensive U.S. health care problem could potentially be reversible through a complementary, noninvasive, diet and behavioral modification approach that emphasizes group psychotherapy (Ornish, 1990).

A landmark case study was conducted in 1989 by David Spiegel, MD, a professor of psychiatry and behavioral sciences at Stanford School of Medicine, in which he investigated the benefits of group support on women with metastatic breast cancer. The women who participated in the group psychotherapy lived an average of 18 months longer than those who did not participate, doubling their survival time. The added survival time was longer than that any medication or other known medical treatment could be expected to provide for women with advanced breast cancer. The intense social support the women experienced in these sessions appeared to influence the way their bodies coped with the illness, which suggested that quality of life affected longevity (Spiegel et al, 1989).

In 1999, Spiegel conducted a multicenter feasibility study to examine the benefits of a supportive-expressive group psychotherapy intervention for patients with recently diagnosed breast cancer. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from 10 geographically diverse sites of the Community Clinical Oncology Program of the National Cancer Institute and two academic medical centers. Each patient who participated in the expressive psychotherapy group met for 12 weekly sessions of 90 minutes each. Results indicated a significant decrease in mood disturbance scores, anxiety, and depression in group participants (Spiegel et al, 1999).

A similar study was conducted involving 102 women with metastatic breast cancer who were randomly selected to receive 1 year of weekly supportive-expressive group therapy and educational materials. Control women received education materials only. Participants who received group therapy showed a significantly greater decline in traumatic stress symptoms and total mood disturbance than did control subjects (Classen et al, 2001).

Recent research suggests that the maintenance of emotional well-being is critical to cardiovascular health. People who feel lonely, depressed, and isolated have been found to be significantly more likely to suffer illnesses and die prematurely of cardiovascular diseases than those who have adequate social support (Williams et al, 1999). Consequently, the development of appropriate interventions to improve the emotional health of people with certain psychosocial risk factors has become an important research goal. It is anticipated that such interventions will increase life expectancy of people at risk and may also save millions of dollars in medical care costs.

A cross-sectional study conducted at Stanford examined whether coping styles of emotional suppression and “fighting spirit” were associated with mood disturbance in 121 cancer patients participating in professionally led, community-based support groups. The investigators concluded that expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce stress for cancer patients in support groups (Cordova et al, 2003).

Recent studies are beginning to show a convergence of significant psychological, health behavior, and biological effects after a psychological intervention for cancer patients. An Ohio State University study tested the hypothesis that a psychological intervention could reduce emotional distress, improve health behavior, and enhance immune responses; 227 women who had undergone breast cancer surgery were randomly assigned to receive an intervention that included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment. The control group received no intervention. The treatment group met in weekly sessions for 4 months. Patients who attended the weekly support group sessions showed significant lowering of anxiety, improvements in perceived social support, improved dietary habits, and reduction in smoking. Immune responses for the intervention group paralleled their psychological and behavioral improvements. T-cell proliferation remained stable or increased in the treatment group, whereas the responses declined in the control group (Andersen et al, 2004).

Cost-Effectiveness of Psychotherapy

Psychotherapy has been shown to speed patients’ recovery from illness. Faster recovery leads to reduced costs and fewer return visits to medical practitioners. In one study, patients who frequently visited medical clinics were offered short-term psychotherapy, and significant declines were seen in visits to their doctors, days spent in the hospital, emergency department visits, diagnostic procedures, and drug prescriptions. Their overall health care costs were decreased by 10% to 20% in the years after brief psychotherapy (Cummings et al, 1988).

A more specific example of cost effectiveness was provided by a 1991 study in which participation in 10 group sessions of 90 minutes of psychotherapy and relaxation techniques significantly reduced the severity of pain. In patients with chronic pain, those who participated in the outpatient behavioral medicine program had 36% fewer clinic visits than those who did not (Caudill et al, 1991).

In a 1987 study conducted jointly by Mount Sinai Hospital and Northwestern Memorial Hospital, psychiatrist George Fulop of Mount Sinai and his colleagues observed that patients hospitalized for medical or surgical reasons had significantly longer hospital stays if they also had concurrent psychiatric problems, especially if they were elderly. In other words, a patient who had a heart attack and who was also depressed tended to remain in the hospital for more days than a similar heart attack patient whose mood was normal. Fulop's study suggested that treating a medical patient's psychological conditions with psychotherapy in conjunction with medication could not only improve psychological well-being but also affect the patient's physical condition (Fulop et al, 1987).

Another well-known study, published in 1983 by psychologists Herbert J. Schlesinger and Emily Mumford and their colleagues at the University of Colorado School of Medicine, investigated patients with four common chronic diseases: asthma, diabetes, coronary heart disease, and high blood pressure. The researchers examined a group of Blue Cross/Blue Shield enrollees who underwent some form of psychotherapy after having been identified as having one of these physical conditions, then compared them with a control group who did not receive psychological treatment after similar diagnoses were made (Schlesinger et al, 1983). Three years after they received their medical diagnoses, patients who had undergone 7 to 20 mental health treatment visits had incurred lower medical charges than those who did not have psychological treatment. The total charges for the psychotherapy group, including those incurred for psychotherapy and counseling, were more than $300 less than for the control group. In other words, the savings on medical bills offered by psychotherapy more than compensated for its costs. After 21 sessions the savings began to diminish as the cumulative cost of mental health care increased.

Although this study is often cited as “proof” of psychotherapy's financial advantages for medically ill patients, it was a retrospective study rather than a prospective study. More scientifically controlled studies are needed in which subjects are selected at random from the beginning of treatment and closely followed after treatment. Another limitation of this particular research approach was that the investigators could not clearly define the type of mental health problems the patients experienced or the specific treatment they received. The information gathered encompassed a large variety of psychiatric interventions.

More rigorous research on specific forms of psychotherapy, including precise diagnoses, will be needed to reach firm conclusions about the economic benefits of psychological treatment for medically ill patients. However, there is already sufficient evidence to suggest that this cost-benefit research is important to pursue. For example, during the period from 1965 to 1980 patients who underwent psychotherapy used other medical services significantly less than patients who did not receive psychotherapy.

The concept of what constitutes appropriate areas for psychiatric intervention should be expanded. Many people, including health care professionals and academicians, consider psychotherapeutic intervention in physical illness a peripheral concern. Important research questions regarding unexplained mind-body events have long existed but are generally ignored. However, the studies previously cited suggest that psychological intervention can be most beneficial when used early in the disease process and can affect mortality in certain illnesses.

Although research continues to mount on the effects of psychotherapeutic interventions, further studies are needed to continue researching how the mind and body are interconnected and how these methods can offer genuine opportunity to improve health and limit costs simultaneously.

Research on Social Support and Mortality

Thanks to a growing number of large-scale studies, evidence of a link between social support and physical well-being has been abundant. This research shows that having many close social relationships is associated with a lower risk of dying at any age. Research that has looked specifically at sick people shows that once serious illness strikes, social support continues to affect their chances of staying alive.

Over 30 years ago, medical researchers were drawn to the tight-knit Italian community of Roseto in eastern Pennsylvania. Its late-middle-aged citizens seemed nearly immune to heart disease, seemingly in defiance of medical logic. The men of the town smoked, and drank wine freely. (This same effect observed in Europe would later become known as the French Paradox.) They worked in slate quarries 200 feet down in the earth. At home their tables were laden with Italian food modified in a way that would horrify a dietitian. To save money, they had replaced olive oil with … lard! Yet their hefty bodies contained healthy hearts. Why?

Every aspect of their health was examined in a comprehensive series of tests, observations, and interviews; however, traditional medical science did not offer any answer.

The answer lay in social science, not medicine. Stated simply, it was found that people nourish other people. Households contained three generations; everyone had a place. The community had stability and predictability. Everyone had a part in his or her society. Similar “Roseto effects” have been documented from Israel to Borneo, as well as in France (as noted earlier).

The researchers who came to study it also predicted that the Roseto effect would disappear. Indeed, as suburbs appeared, with fences and satellite dishes, the rate of heart attacks in time came to reflect the national averages (“A new ‘Roseto Effect,’” 1996). Even the success of the Ornish diet in preventing and reversing heart disease has been thought by some observers to be, at least in part, due to the social support of the dieters’ cooking, eating, and interacting together (especially because the diet itself is thought by many to be too high in carbohydrates for optimal health; see Chapter 25) (Egolf et al, 1992).

Internist James Goodwin at the Medical College of Wisconsin studied cancer survival in several thousand patients. The married cancer patients did better medically and had lower mortality rates than the unmarried patients (Goodwin et al, 1987). Similarly, in a study of 1368 patients with coronary artery disease, Redford Williams at Duke University found that having a spouse or other close confidant tripled the chances that a patient would be alive 5 years later (Williams et al, 1999).

In an overview of research concerning mortality and social relationships, James House observed that the relationship between social isolation and early death is as strong statistically as the relationship between dying and smoking or having a high serum cholesterol level. Therefore the data suggest that it may be as important to one's health to be socially integrated as it is to stop smoking or to reduce one's cholesterol level (House et al, 1988).

In 1990, epidemiologists Peggy Reynolds and George Kaplan at the California Department of Health Services studied the number of social contacts that cancer patients had each day. Women with the least amount of social contact were 2.2 times more likely to die of cancer over a 17-year period than were the most socially connected women (Reynolds et al, 1990).

People who feel lonely, depressed, and isolated have been found to be significantly more likely to experience illnesses and to die prematurely of cardiovascular diseases than those who have adequate social support (Williams et al, 1999). Naturally, many other potential social factors can account for why one patient survives longer than another. Therefore, most such studies have been careful to eliminate the obvious confounding variables, such as smoking and alcohol use, differences in socioeconomic status, and access to health care. In general, however, the studies still consistently show that more and better social support from family and friends is associated with lower odds of dying at any given age.

Although the relationship between social support and health outcome has been largely underestimated by medical science, two studies recently examined social support and its relationship to mortality. The Department of Community and Preventative Medicine at the University of Rochester School of Medicine found that certain aspects of informal caregiving are important factors in enhancing the survival of frail nursing home residents. Several social support variables were statistically significant predictors of mortality. Participants whose caregiver was a spouse had a significantly lower risk of mortality than those whose caregiver was not a spouse (Temkin-Greener et al, 2004). Researchers at the Mayo Clinic recently reaffirmed many of these finding in a systematic overview of recent evidence related to the social support network, specifically the role of social support in cardiovascular disease–related outcomes (Mookadam et al, 2004).

A number of studies have demonstrated a relationship between depression and low perceived social support and increased cardiac morbidity and mortality in patients with heart disease. Evidence also suggests that depression increases the risk of acute myocardial infarction as well as the level of resulting morbidity and mortality (Malach et al, 2004).

RELAXATION

Stress Management

The popular term stress was brought into use by Professor Hans Selye, director of the Institute of Experimental Medicine and Surgery at the University of Montreal. He defined stress as “the rate of wear and tear on the body.” Confusion and debate continue as to whether stress is the factor that causes the wear and tear or is the resulting damage. Selye described a “general adaption syndrome,” which has three phases: an alarm reaction, a stage of resistance, and a stage of exhaustion. A stress cause, or stressor, activates the sympathetic branch of the autonomic nervous system. Hormones bring about physiological changes in the body, often referred to as the “fight-or-flight response” (Selye, 1978).

The problem of stress has received wide publicity in the media in recent years. The cliché has also been heard that “stress” was the epidemic of the 1980s and 1990s. Consequently, the term stress has become a buzzword that has acquired a highly negative connotation. Much advice has also been received over the last few years, from all sorts of sources, about the many different approaches to controlling stress. All the alarmist and negative publicity has stimulated further anxiety and concern in many people's minds—a fear of stress, which in itself can lead to further stress. Having become aware of it, everyone now wants to manage his or her stress, and many cater to this growing demand. This rapidly expanding market is served by various experts, consultants, and therapists. Vitamin regimens, herbal supplements, fitness programs, relaxation techniques, and personal development courses are being offered, all in the name of stress management. Numerous experts, both qualified and self-appointed, are convinced that their particular product or service will banish stress for good.

The fact remains that there are no magic cures and no magic bullets. Stress is essentially a result of an interaction between a negative environment, unhealthful lifestyles, and self-defeating attitudes and beliefs. Therefore, in contrast to what is believed by stress management consultants, no one particular technique, method, program, or regimen of vitamins or herbs can reduce long-term stress.

Stress is most often viewed as the outside pressures and problems that encroach on our busy lives: deadlines, excessive workload, noise, traffic, problems with spouse or children, and excessive demands made by others. Stress is the unconscious response to a demand. Stress is not “those things out there,” but rather what happens inside the mind and body as we react unconsciously to those things or people. Normally, we experience some degree of stress in everything we do and everything that happens to us.

In The Magical Child, Joseph Chilton Pearce states, “Stress is the way intelligence grows.” He explains that, under stress, the brain immediately grows massive numbers of new connecting links between the neurons that enable learning. Although the stressed mind/brain grows in ability and the unstressed mind lags behind, the overstressed brain can collapse into physiological shock. Something is essential to maintain the optimal level of stress, and this is relaxation (Pearce, 1992).

When the stress response is minor, we do not notice any symptoms. The greater the stimulation, the more symptoms we notice. Holmes and Rahe's scale of life changes provides a guide to the amount of stress attached to major events, such as marriage, relocation, emigration, loss of a job, death of a spouse, or birth of a child. These significant life events can quickly overload our ability to cope (Holmes et al, 1967).

In The Human Zoo, Desmond Morris posits that modern humans are engaged in the “stimulus struggle”: “If we abandon it, or tackle it badly, we are in serious trouble.” We are trying to maintain the optimal level of stimulation—not the maximum, but the level that is most beneficial, somewhere between understimulation and overstimulation (Morris, 1995).

Stress becomes a problem when it reaches excessive levels, when the demands exceed our ability to respond or to cope effectively. When we are under excessive, prolonged stress and no longer able to cope or adjust, the “stress” becomes “distress.” Symptoms then develop that lead to stress-induced illnesses. The physical body “engine” begins to rev at high speed, totally absorbing restricted, unproductive energy. Over extended periods, this wear and tear begins to take its toll, and disease can creep into the body.

We can learn to control our responses to stress by changing the ways that we think. “Stress management” is developing the ability to assert control over our behaviors. When we become aware of our ability to control attitudes and behaviors, we naturally begin to assert control over the life situations that seem to be stressful. It is not the stress itself that is harmful but our reactions to it that create havoc in the body and mind.

The greatest stressor that most people experience daily is change. Challenges, frustrations, conflicting demands, and occasional loss, grief, and suffering are among the many unconscious responses to change. These life events are inevitable and require us to adapt to new situations. If we do not adapt to change by altering our attitudes, our minds and bodies suffer. When changes take place in our environment, career, and personal relationships, it becomes essential to learn how to behave, think, and feel differently to cope with the new situation effectively.

We are all continuously adjusting to changing conditions, rather like an air conditioner controlled by a thermostat. As the temperature outside increases, the thermostat turns on the air conditioner, which begins to bring the interior temperature back to a specified normal level of comfort. The greater the changes outside, the harder the machine has to work to keep up with them. If the external temperature moves into extreme ranges, the machine will be pushed to the limit. If it exceeds its specified limit, it will eventually break down, and the motor will burn out.

So it is with the human machine. Our bodies continuously react to whatever is happening around us or inside of us. We respond physically, mentally, and emotionally to even the most minute changes. This process occurs all the time, whether we are consciously aware of it or not.

Different individuals respond differently to stress. We know people who can remain cool, calm, and collected under the most trying circumstances, and we know others who are unable to cope when faced with even minor situations. The differences are mostly a result of the differences in upbringing, past understandings, present experiences, attitudes, belief structures, family values, perceptions, and coping skills developed over years and generations. Furthermore, when different individuals experience distress, the symptoms they develop are also different; different people seem to channel their excessive stress into different parts of the body. The long-term effects of such different responses include physical illnesses such as ulcers, headaches, chronic backaches, and high blood pressure, which ultimately results in heart disease, cancer, or other chronic disorders.

Decades of research have linked stress, either directly or indirectly, to coronary heart disease, cancer, strokes, lung ailments, accidental injuries, cirrhosis of the liver, immune system deficiencies, and suicide. Stress is often a component of chronic illness, either as a precursor of disease or as an outcome. People who manage stress are more resilient, experience fewer symptoms, and experience an improved quality of life (Kabat-Zinn, 1990).

In looking at 26 randomized controlled trials testing the effect of cognitive-behavioral techniques (including meditation) on hypertension, Eisenberg et al (1993) found that no single technique appears to be more effective than any other in treating essential hypertension. When prescribed in the absence of other behavioral interventions, cognitive-behavioral techniques were not nearly as effective as standard antihypertensive pharmacotherapy.

Harvard-trained cardiologist Herbert Benson began investigating the benefits of relaxation in the late 1960s and continues to delve into the effects of stress on various disease-specific populations. Benson's group has examined the stress phenomenon and its effect on cardiovascular diseases and neurodegenerative diseases (Esch et al, 2002a, 2000b). They found that stress has a major impact on the circulatory and nervous systems, playing a significant role in susceptibility, progress, and outcome of both cardiovascular and neurodegenerative diseases. However, they also found that some amounts of stress can actually improve performance and thus can be beneficial in certain cases.

According to the American Institute of Stress in New York, workplace stress leads to $300 billion in health care costs each year as a result of missed work (Schwartz, 2004). The Organizational Science and Human Factors Branch of the National Institute for Occupational Safety and Health claims that stressed workers incur health care costs that are 46% higher, an average of $600 more per person, than other employees (Sauter, 2004).

TABLE 9-1 Relaxation Response

Technique

Oxygen consumption

Respiratory rate

Heart rate

Alpha waves

Blood pressure

Muscle tension

Transcendental meditation

Decreases

Decreases

Decreases

Increase

Decreases*

(Not measured)

Zen and yoga

Decreases

Decreases

Decreases

Increase

Decreases*

Autogenic training

(Not measured)

Decreases

Decreases

Increase

Inconclusive

Decreases

Progressive relaxation

(Not measured)

(Not measured)

(Not measured)

(Not measured)

Inconclusive

Decreases

Hypnosis with suggested deep relaxation

Decreases

Decreases

Decreases

(Not measured)

Inconclusive

(Not measured)

* In patients with elevated blood pressure.

The Relaxation Response

Convinced that the benefits of meditation could potentially lower high blood pressure, Benson continued his research into a variety of psychological and physiological effects that appear common to many mind-body practices. He later identified the relaxation response, which is similar to the response common to meditation, prayer, autogenic training, and some forms of hypnosis (Benson, 1975). He later described his method in a book of the same name.

Benson's research indicated that excessive stress can cause or aggravate hypertension and the related diseases of atherosclerosis, heart attack, and stroke. He then examined the nature of the relaxation response, showing that physiological changes as remarkable as those seen in the fight-or-flight response also occur during true relaxation, including a decrease in oxygen consumption, metabolic rate, heart rate, and blood pressure, as well as increased production of alpha brain waves. A marked decrease in blood lactate level was also found. Blood lactate has often been linked with anxiety. According to Benson, following these guidelines can help in achieving the relaxation response:

1. Try to find 10 to 20 minutes in your daily routine; before breakfast is generally a good time.

2. Sit comfortably.

3. For the period you will practice, try to arrange your life so that you will have no distractions. For example, let the answering machine handle the phone, or ask someone to watch the children.

4. Time yourself by glancing periodically at a clock or watch (but do not set an alarm). Commit yourself to a specific length of practice.

Expanding on these guidelines, Benson suggests the following as one of several approaches that can be used to elicit the relaxation response:

Step 1: Pick a focus word or short phrase that is firmly rooted in your personal belief system. For example, a nonreligious individual might choose a neutral word such as one, peace, or love. A Christian person wanting to use a prayer could pick the opening words of Psalm 23, “The Lord Is My Shepherd”; a Jewish person could choose shalom.

Step 2: Sit quietly in a comfortable position.

Step 3: Close your eyes.

Step 4: Relax your muscles.

Step 5: Breathe slowly and naturally, repeating your focus word or phrase silently as you exhale.

Step 6: Throughout, assume a passive attitude. Do not worry about how well you are doing. When other thoughts come to mind, simply say to yourself, “Oh, well,” and gently return to the repetition.

Step 7: Continue for 10 to 20 minutes. You may open your eyes to check the time, but do not use an alarm. When you finish, sit quietly for a minute or so, at first with your eyes closed and later with your eyes open. Then do not stand for 1 or 2 minutes.

Step 8: Practice the technique once or twice a day.

Benson's subsequent research into the relaxation response investigated several efficient techniques of relaxation training, including Transcendental Meditation, Zen and yoga, autogenic training, progression relaxation, hypnosis, and sentic cycles (Table 9-1). He found that these methods had four common elements: a quiet environment, an object on which to focus the mind, a passive attitude, and a comfortable position. Some practices are more effective than others, and some are easier to learn and practice than others (Benson, 1993).

Benson's group also found that patients with chronic pain who meditated regularly had a net reduction in general health care costs, which suggests that the use of relaxation techniques is cost effective (Caudill et al, 1991).

Deepak et al (1994) found that 11 patients with drug-resistant epilepsy who practiced Benson's relaxation response for 20 minutes each day experienced a decrease in absolute frequency of seizures, and that the decrease became significant at between 6 and 12 months of continued practice. Duration of seizures declined over the 12 months to a more significant degree than did frequency of seizures.

The value of Benson's technique for patients with congestive heart failure was evidenced in a study of 57 veterans with this disorder who received relaxation response training. Approximately half the group reported physical improvements that went beyond disease management and into lifestyle changes and improved relationships (Chang et al, 2004).

Exercise for Stress Reduction

Michael Sacks, MD, professor of psychiatry at Cornell University Medical College, found that various forms of exercise can be powerful methods of relaxation effective for dealing with the stress of daily life. Researchers have found in various studies that exercise can decrease anxiety and depression, improve an individual's self-image, and buffer people from the effects of stress. Not every study has shown the precise benefits for which researchers were looking, but taken as a whole, the research strongly supports the common experience that exercise can elevate mood and reduce anxiety and stress (Sacks, 1993).

Although most research has focused on the physical benefits of exercise, any exercise can help people feel more focused and relaxed as long as the activity is enjoyable. Regular exercise does seem to affect one aspect in particular: the ability to withstand stress. Exercise and physical fitness can act as a buffer against stress, so that stressful events have a less negative impact on psychological and physical health.

MEDITATION

In 2003 the Centers for Disease Control and Prevention announced that chronic diseases affect more than 90 million Americans and account for one third of the years of potential life lost before age 65. The financial burden of treating chronic diseases now amounts to more than 60% of the total medical care costs in the United States. Evidence is accumulating that chronically ill patients gain much benefit from using meditation, including a decrease in the number of visits to physicians (Sobel, 1992).

Complementary and alternative medicine (CAM) encompasses a broad group of interventions, such as meditation, that are not taught widely at U.S. medical schools or generally available at U.S. hospitals (see Chapter 1). In 1997, however, more than 42% of the adult U.S. population used CAM to manage cancer and other chronic diseases, and meditation is one of the most common practices (Eisenberg et al, 2001).

Although meditation is ancient in its roots, the science of meditation and its physiological effects is in its infancy. Only recently has the concept of meditation been introduced into the realm of modern Western medicine. As a results of the Cartesian split between the mind and body in the early seventeenth century, science emphasized the body and medicine went in the direction of science. The term mind-body connection relates to an understanding that the two are not separate (they have always been together) and have an interactive influence on each other. Meditation is said to realign the two, the consciousness with the physical body, creating a more harmonious interaction.

Like the word medicine, the word meditation suggests something to do with healing. The root in Latin means “to cure” but that its deepest root means “to measure” (Bohm, 1983). But what does medicine or meditation have to do with measure? The ancient Greeks said, “Man is the measure of all things.” According to Jon Kabat-Zinn, PhD, founder and director of the Stress Reduction Clinic at the University of Massachusetts Medical Center, meditation has to do with the platonic notion that every shape, every being, every thing has its right inward measure. In other words, a tree has its own quality of wholeness that gives it particular properties. A human being has an individual right inward measure, when everything is balanced and physiologically homeostatic. That is the totality of the individual at that point in time” (1993a, 1993b, 1993c). He believes that medicine is the science and art of restoring right inward measure when it is thrown off balance. From the meditative perspective and from the perspective of the new mind-body medicine, health does not have a finite or static destination. Health is a dynamic energy flow that changes over a lifetime, with health and illness coexisting.

Most meditative practices have come to the West from Asian religious practices, particularly those of India, China, and Japan. Others can be traced to the ancient cultures of the world. Although Western meditators practice a contemplative form of meditation, there are also many active forms of meditation, such as the Chinese martial art t'ai chi, the Japanese martial art aikido, and the walking meditations of Zen Buddhism.

Until recently, the primary purpose of meditation has been religious or spiritual in nature. During the past 20 years, however, meditation has been explored as a means of reducing stress on both mind and body. Many studies have found that various practices of meditation appear to produce physical and psychological changes. Meditation is a self-directed practice for the purpose of relaxing and calming the mind and body. Many methods of meditation include focusing on a single thought or word for a specific time. Some forms of meditation focus on a physical experience, such as the breath or a specific sound or mantra. All forms of meditation have the common objective of stilling the restlessness of the mind so that the focus can be directed inwardly.

Meditation is thus a technique used to calm mental activity, endless thoughts, and ways of reacting to one's circumstances. As long as these accumulated impressions linger in the inner recesses of the mind, pushing for attention, it remains difficult to experience an inner state of peace, calm, and health. Fast-paced Western society, filled with external stimuli, has conditioned us to push our minds and bodies to the point of exhaustion, often to the detriment of our own well-being. To be still, to experience the peace and contentment that lies within, we must free ourselves from this external materiality. Meditation is the process of calming and releasing the distractions from the mind for the purpose of opening up and awakening to our true inner natures.

Eastern Techniques and Transcendental Meditation

In the mid-1960s, a popular trend in meditation called Transcendental Meditation (TM) began to emerge. The Vedic philosophy and practice was brought from India to the United States by its founder, Maharishi Mahesh Yogi. The Maharishi had eliminated ancient yogic elements that he considered would be unpopular in a contemporary twentieth century western society . Omitting difficult physical postures and mental exercises, his modified version became easily understood, accepted, and practiced by Westerners (see Chapter 32).

TM is relatively simple in application. A student is given a mantra (a word or sound) to repeat silently over and over again while sitting in a comfortable position. The purpose of repeating the sound or word is to prevent distracting thoughts from entering the mind. Students are instructed to be passive and, if thoughts other than the mantra come to mind, to note them and return the attention to the mantra. TM is generally practiced in the morning and in the evening for approximately 20 minutes.

On the Maharishi's first visit to America in 1959, a San Francisco newspaper heralded TM as a “nonmedicinal tranquilizer” and praised it as a promising cure for insomnia. TM soon began to ride a crest of popularity, with almost half a million Americans learning the technique by 1975, and it was embraced by many celebrities of that day, such as the Beatles. It is believed that more than 2 million people currently practice TM.

In 1968, Harvard's Herbert Benson was asked by the Maharishi International University in Fairfield, Iowa, to test TM practitioners on their ability to lower their own blood pressure. Benson initially refused to participate but was later persuaded to do so. Benson's studies and other research showed that TM was associated with reduced health care costs, increased longevity, and better quality of life (Benson et al, 1977); reduced anxiety, lowered blood pressure, and reduced serum cholesterol levels (Cooper et al, 1978); viable treatment of posttraumatic stress syndrome in Vietnam veterans (Brooks et al, 1985); and reduction in chronic pain (Kabat-Zinn et al, 1986).

In a study aimed at linking TM practice to longevity, 73 elders were randomly assigned to either a TM program, mindfulness training, a relaxation program, or no treatment. Both the TM and mindfulness training groups showed significant reductions in systolic blood pressure compared with those receiving mental relaxation training or no training. As reported by the nursing staff, TM and mindfulness training improved patients’ mental health. Longevity was defined as the subjects’ survival rate over a 36-month period, which was found to be greater for those using TM than for those receiving mental relaxation training and control subjects (Alexander et al, 1989).

Additional research showed TM's effectiveness in the reduction of substance abuse (Sharma et al, 1991), blood pressure reduction in African Americans (Schneider et al, 1992), and lowering of blood cortisol levels initially raised by stress (MacLean et al, 1992).

In a follow-up study of 127 African American elders, Schneider again found that blood pressure decreased significantly in those practicing both TM and progressive muscle relaxation compared with the control group, and that TM was significantly more effective than progressive muscle relaxation techniques (Schneider et al, 1995).

In a study to examine the effects of TM on nine women with symptoms of cardiac syndrome X, those who practiced TM for 3 months showed an improvement in quality of life, exercise tolerance, and angina episodes (Cunningham et al, 2000). An experiment to determine the effects of TM-based stress reduction on carotid atherosclerosis in 60 hypertensive African Americans used B-mode ultrasound to measure carotid intima-media thickness, a surrogate measure of coronary atherosclerosis. The group practicing the TM technique group showed a significant decrease in thickness, whereas thickness increased in the control group (Castillo-Richmond et al, 2000).

Herron and Hillis broke new economic ground by conducting a quasi-experimental, longitudinal study of the impact of a TM program on government payments to physicians in Quebec. They found that payments to physicians treating practitioners of TM were lower than payments to physicians treating a randomly selected and matched control group over a 6-year period, with a 13.78% mean annual difference in payments. A true experimental design with randomization would be needed to control for social factors that may have confounded study results (Herron et al, 2000).

Western Techniques and Mindfulness Meditations

The term mindfulness was coined by Jon Kabat-Zinn, known for his work using mindfulness meditation to help medical patients with chronic pain and stress-related disorders (1993a, 1993b). Like other mind-body therapies, mindfulness meditation can induce deep states of relaxation, at times can directly improve physical symptoms, and can help patients lead fuller and more satisfying lives. Although Asian forms of meditation involve focusing on a sound, phrase, or prayer to minimize distraction, the practice of mindfulness does the opposite. In mindfulness meditation, distractions are not ignored but are focused on. This form of meditation practice can be traced originally to the Buddhist tradition and is about 2500 years old. The method was developed as a means of cultivating greater awareness and wisdom, with the aim of helping people live each moment of their lives as fully as possible.

Kabat-Zinn points out that mindfulness is about more than feeling relaxed or stress free. Its true aim is to nurture an inner balance of mind that allows an individual to face life situations with greater clarity, stability, and understanding and to respond more effectively from that sense of clarity.

An integral part of mindfulness practice is to accept and welcome stress, pain, anger, frustration, disappointment, and insecurity when those feelings are present. Kabat-Zinn believes that acknowledgment is paramount. Whether pleasant or unpleasant, admission is the first step toward transforming that reality.

As noted earlier, Kabat-Zinn founded the Stress Reduction Clinic at the University of Massachusetts Medical Center in Worcester, where he is an associate professor of medicine. The Center for Mindfulness in Medicine, Health Care, and Society established in 1995, is an outgrowth of the clinic. Since the clinic was founded, more than 10,000 medical patients have gone through Kabat-Zinn's mindfulness meditation programs, almost all referred by their physicians.

To date, the Center for Mindfulness has produced 15 peer-reviewed papers on mindfulness-based stress reduction. Current research pursuits of the center include a prostate cancer study funded by the U.S. Department of Defense; a cost-effectiveness study; development of an innovative substance abuse recovery program for young, low income, inner city mothers; and a wide variety of other collaborative research endeavors in various states of development.

Unlike in standard medical and psychological approaches, the clinic does not categorize and treat patients differently depending on their illnesses. Their 8-week courses offer the same training program in mindfulness and stress reduction to everyone. They emphasize what is “right” with their patients, rather than what is “wrong” with them, focusing on mobilizing their inner strengths and changing their behaviors in new and innovative ways. Facilitators maintain that the programs are not held out as some kind of magical cure when other approaches have failed; rather, they provide a sensible and straightforward way for people to experience and understand the mind-body connection firsthand and use that knowledge to better cope with their illnesses.

In the practice of mindfulness, the patient begins by using one-pointed attention to cultivate calmness and stability. When thoughts and feelings arise, it is important not to ignore or suppress them or analyze or judge them by their content; rather, the thoughts are observed intentionally and nonjudgmentally, moment by moment, as events in the field of awareness.

This inclusive noting of thoughts that come and go in the mind can lead to a detachment from them, which allows a deeper perspective about the stresses of life to emerge. By observing the thoughts from this vantage point, one gains a new frame of reference. In this way, valuable insight can be allowed to surface. The key to mindfulness is not the topic focused on but the quality of awareness brought into each moment. Observing the thought processes, without intellectualizing them and without judgment, creates greater clarity. The goal of mindfulness is to become more aware, more in touch with life and what is happening at the time it is happening, in the present.

Acceptance does not mean passivity or resignation. Accepting what each moment offers provides the opportunity to experience life more completely. In this manner, the individual can respond to any situation with greater confidence and clarity.

One way to envision how mindfulness works is to think of the mind as the surface of a lake or ocean. Many people think the goal of meditation is to stop the waves so that the water will be flat, peaceful, and tranquil. The spirit of mindfulness practice is to experience the waves.

The consistent practice of mindfulness meditation has been shown to decrease the subjective experience of pain and stress in a variety of research settings. One study found a 65% improvement in pain symptoms and an approximately 60% improvement in sleep and fatigue levels from before to after the intervention in a sample of 77 patients with fibromyalgia, an illness known to have psychosomatic components (Kaplan et al, 1993).

Dunn et al (1999) used electroencephalographic recordings to differentiate between two types of meditation, concentration and mindfulness, and a normal relaxation control condition. They found significant differences between readings at numerous cortical sites, which suggests that concentration and mindfulness meditations may be unique forms of consciousness and not merely degrees of a state of relaxation.

In a pilot study using mindfulness of movement as a coping strategy for multiple sclerosis, patients attended six individual one-on-one sessions of mindfulness training. Results showed that balance improved significantly in those who underwent the training compared with those who did not (Mills et al, 2000).

Eighty cancer patients were followed for 6 months after attending a mindfulness meditation group for 1.5 hours each week for 7 weeks. They were also asked to practice meditation at home on a daily basis. Results showed significantly lower mood disturbances and fewer symptoms of stress at the 6-month follow-up for both male and female participants. The greatest improvement, however, occurred on subscales measuring depression, anxiety, and anger. Results for various mindfulness meditation techniques are consistent with those for other meditation-based interventions (Carlson et al, 2001).

Nurses are often known to make mindfulness practice part of their continuing education. They find that this technique often prevents compassion fatigue and burnout, enhances health, and increases awareness of holism within the self.

HYPNOSIS

Modern hypnosis is said to have begun in the eighteenth century with Franz Anton Mesmer, who used what he called “magnetic healing” to treat a variety of psychological and psychophysiological disorders, such as hysterical blindness, paralysis, headaches, and joint pains. The famous Austrian neuropathologist Sigmund Freud initially found hypnosis to be extremely effective in treating hysteria and then, troubled by the sudden catharsis of powerful emotions by his patients, abandoned its use.

The word hypnosis is derived from the Greek word hypnos, meaning “sleep.” It is believed that hypnotic suggestion has been a part of ancient healing traditions for centuries. The induction of trance states and the use of therapeutic suggestion were a central feature of the early Greek healing temples, and variations of these techniques were practiced throughout the ancient world.

In more recent years, hypnosis has experienced a resurgence. Initially, this form of therapy became popular with physicians and dentists. At present, hypnosis is widely used by mental health professionals for the treatment of addictions, anxiety disorders, and phobias and for pain control. During hypnosis a patient enters a state of attentive and focused concentration and becomes relatively unaware of the immediate surroundings. While in this state of deep concentration, the individual is highly responsive to suggestion. Contrary to popular folklore, however, people cannot be hypnotized against their will or involuntarily. They must be willing to concentrate their thoughts and to follow the suggestions offered. Essentially, all forms of hypnotherapy are actually forms of self-hypnosis.

Hypnosis has three major components: absorption (in the words or images presented by the hypnotherapist), dissociation (from one's ordinary critical faculties), and responsiveness. A hypnotherapist either leads patients through relaxation, mental imagery, and suggestions or teaches patients to perform the techniques themselves. Many hypnotherapists provide guided audiotapes for their patients so that they can practice the therapy at home. The images presented are specifically tailored to the particular patient's needs and may use one or all of the senses.

Physiologically, hypnosis resembles other forms of deep relaxation. It is known to decrease sympathetic nervous system activity, decrease oxygen consumption and carbon dioxide elimination, and lower blood pressure and heart rate, and it is linked to increase or decrease in certain types of brain wave activity.

Hypnotherapy's effectiveness lies in the complex connection between the mind and the body. It is now well understood that illness can affect one's emotional state and, conversely, that one's emotional state can affect one's physical state. For example, stress, an emotional reaction, can make heart disease worse, and heart disease, a physical condition, can cause depression.

Hypnosis carries this connection to the next logical step by using the power of the mind to bring about change in the body. No one is quite sure how hypnosis works, but with more sophisticated imaging techniques, that is changing.

Clinical Applications

One of the most dramatic early uses of hypnosis was for treatment of skin disorders. In the mid-1950s an anesthesiologist, Arthur Mason, used hypnosis to effectively treat a 16-year-old patient who had warts. Within 10 days after the youth underwent hypnosis, the warts fell off and normal skin replaced it (Mason et al, 1958). Since that time, hypnosis has been used to dramatically improve other skin disorders, such as ichthyosis, and the importance of the role of the skin in the development of the immune system has been recognized (see Chapter 8).

Depending on the individual's situation, hypnotherapy can be used as a complement to medical care or as a primary treatment. Many people find that hypnotherapy's benefits are enhanced by the use of biofeedback to induce physiological changes. Biofeedback helps patients see that they can control certain bodily functions simply by altering their thoughts, and the added confidence helps them improve more rapidly.

There is little doubt that the regular practice of self-hypnosis is helpful to people with chronic disease. The benefits include reduction of anxiety and fear, decreased requirements for analgesics, increased comfort during medical procedures, and greater stability of functions controlled by the autonomic nervous system, such as blood pressure. Training in self-hypnosis also enhances the patient's sense of control, which is often affected by chronic illness. Hypnotherapy may also have direct clinical effects on certain chronic diseases, such as reducing bleeding in hemophiliac patients, stabilizing blood glucose level in diabetic patients, and reducing the severity of asthmatic attacks.

Irritable Bowel Syndrome

For many years, W.M. Gonsalkorale has been researching the benefits of hypnotherapy for management of irritable bowel syndrome at the University Hospital of South Manchester, United Kingdom. In only 3 months, symptoms such as pain and bloating, as well as the level of “disease interference” with life, improved profoundly for most of 232 patients who underwent hypnotherapy (Gonsalkorale et al, 2002). Good evidence now supports the long-term benefits for up to 6 years following hypnotherapy. In 204 patients, of the 71% who responded to therapy, 81% maintained their improvements, and the remaining 19% claimed that deterioration of symptoms had been slight (Gonsalkorale et al, 2003). Besides improving physical symptoms, hypnotherapy has also been shown to decrease cognitive symptoms such as anxiety and depression, and to improve quality of life (Gonsalkorale et al, 2004).

Preoperative Therapy

In 1997, Mehmet Oz, a cardiothoracic surgeon at Columbia Presbyterian Medical Center, received a great deal of attention for advocating and using complementary medical approaches in his surgical practice. Oz took 32 patients scheduled for coronary bypass surgery and randomly assigned them to two groups. One group received instruction on self-hypnosis relaxation techniques before surgery, and the other group received no instruction. Results showed that patients who practiced the self-hypnosis techniques were significantly more relaxed than the control subjects in the days after surgery (Ashton et al, 1997). There was no significant difference between the two groups in length of hospital stay and postoperative morbidity and mortality.

Postoperative Therapy

Carol Ginandes, a Harvard instructor, investigated how hypnotherapy can help people heal more quickly after surgery. Each of 18 women undergoing breast reduction surgery was placed in one of three groups. One group received standard surgical care. The second group received the same care and also received psychological support. The third group underwent hypnosis before and after surgery in addition to receiving standard care. Those who underwent hypnosis healed more rapidly, felt less discomfort, and had fewer complications (Ginandes et al, 2003).

Pain Control

Hypnosis can also be effective in reducing the fear and anxiety that accompanies pain. It is said that anxiety increases pain, and hypnotherapy helps a patient gain control over the fear and anxiety, thereby reducing the pain. Many controlled studies have demonstrated that hypnosis is an effective way to reduce migraine attacks in children and teenagers. In one experiment, 30 schoolchildren were randomly assigned to receive a placebo or propranolol (a blood pressure–lowering agent) or were taught self-hypnosis. Only the children who used the self-hypnosis techniques experienced a significant decrease in severity and frequency of headaches (Olness et al, 1988). A study of chronically ill patients reported a 113% increase in pain tolerance among highly hypnotizable individuals compared with members of a control group who did not receive hypnosis (Debenedittis et al, 1989).

Researchers at Virginia Polytechnic Institute found that during induction of a hypnotic state aimed at bringing about pain control, the prefrontal cortex of the brain directed other areas of the brain to reduce or eliminate their awareness of pain (Gordon, 2004). A technique used for pain control during surgery in people with little or no tolerance for chemical anesthesia, called “spinal anesthesia illusion,” was developed by Philip Ament, a dentist and psychologist from Buffalo, New York. In this method a deep state of relaxation is induced by having the patient count mentally or focus on a specific image. The patient is given the suggestion that he or she will feel a growing numbness begin to spread from the navel to the toes as he or she counts to a higher and higher number. Once the patient feels numb, the surgery can proceed. After the surgery the therapist gives the patient suggestions that lead to the gradual return of normal sensations (Perlman, 1999).

Dentistry

Some people have learned to tolerate dental work (e.g., drilling, extraction, periodontal surgery) using hypnosis as the sole anesthesia. Even when an anesthetic is used, hypnotherapy can also be used to reduce fear and anxiety, control bleeding and salivation, and lessen postoperative discomfort. Used with children, hypnosis can decrease the chances of developing a dental phobia (Perlman, 1999).

Pregnancy and Delivery

It is believed that Lamaze and other popular breathing techniques used during labor and delivery may actually work by inducing a hypnotic state. Women who have used hypnosis before delivery tend to have a shorter labor and more comfortable delivery than other pregnant women. There are even reports of cesarean sections performed with hypnosis as the sole anesthesia. Women are taught to take advantage of their body's natural anesthetic abilities to make childbirth a less painful, more positive experience (Goldman, 1999).

Anxiety

Hypnosis can be used to establish a new reaction to specific anxiety-causing stimuli, such as in the treatment of stage fright, fear of airplane flight, and other phobias. Typically the hypnotherapist helps the patient undo a conditioned physiological response, such as hyperventilation or nausea. This method can also be used to help calm athletes who are preparing to compete. Hypnotherapy can be used to quell almost any fear, whether associated with examinations, public speaking, or social interactions.

Allergies and Asthma

Ran Anbar, a pediatric pulmonologist at the State University of New York's Upstate Medical University in Syracuse, teaches children self-hypnosis to help them control their allergies and asthma (Gordon, 2004).

BIOFEEDBACK

Biofeedback therapies emerged in the 1960s and 1970s, when advances in psychological and medical research converged with developments in biomedical technology. Improved electronic instruments could convey information to patients about their autonomic nervous systems and their muscles in the form of audio and visual signals that patients could understand. The word biofeedback became the general term to define the procedures and treatments that make use of these instruments (Green et al, 1977).

Biofeedback therapy uses special instruments and methods to expand the body's natural internal feedback systems. By watching a monitoring device, patients can learn by trial and error to adjust their thinking and other mental processes to control bodily processes previously thought to be involuntary, such as blood pressure, temperature, gastrointestinal functioning, and brain wave activity. In fact, biofeedback can be used to influence almost any bodily process that can be measured accurately.

Biofeedback does not belong to any particular field of health care and is used in many disciplines, including internal medicine, dentistry, physical therapy and rehabilitation, psychology and psychiatry, and pain management. As with other forms of therapy, biofeedback is more useful in addressing some clinical problems than others. For example, biofeedback is a useful treatment in Raynaud disease, a painful and potentially dangerous spasm of the small arteries, and certain types of fecal and urinary incontinence. It has also become an integral part of the treatment of many other disorders, including headaches, anxiety, high blood pressure, teeth clenching, asthma, and muscle disorders.

More recently, researchers have been experimenting with biofeedback treatments for conditions believed to stem from irregular brain wave patterns, such as epilepsy, attention-deficit disorder (ADD), and attention-deficit/hyperactivity disorder (ADHD) in children, with promising results.

Biofeedback is successful in helping people learn to regulate many physical conditions, partly because it puts them in better contact with specific parts of their bodies. For example, biofeedback can help teach people to tighten the muscles at the neck of the bladder to better control impaired bladder function. It can help postoperative patients learn to reuse the muscles of the legs and arms. It can help teach stroke patients to use alternative muscles to move a limb if the primary ones can no longer do the job. Biofeedback is also helpful in training patients to use artificial limbs after amputation.

In a normal biofeedback session, electrodes are attached to the area being monitored. These electrodes feed the information to a small monitoring box that registers the results aurally by a tone that varies in pitch or visually by a light that varies in brightness as the function being monitored decreases or increases. A biofeedback therapist leads the patient in mental exercises to help the patient reach the desired result. Through trial and error, patients gradually train themselves to control the inner mechanism involved. For some disorders, training requires 8 to 10 sessions; however, a single session often can provide symptomatic relief. Patients with long-term or severe disorders may require longer therapy. The aim of the treatment is to teach patients to regulate their own inner mental and bodily processes without the help of a machine.

Five Common Forms of Biofeedback Therapy

1. Electromyographic biofeedback. Electromyographic feedback measures muscular tension. Sensors are attached to the skin to detect electrical activity related to muscle tension in a given area. The biofeedback instrument amplifies and converts this activity into useful information, displaying the various degrees of muscle tension. This form of biofeedback therapy is most often used for reduction of tension headaches, physical rehabilitation, treatment of chronic muscle pain, management of incontinence, and promotion of general relaxation.

2. Thermal biofeedback therapy. In thermal biofeedback therapy skin temperature is measured as an index of changes in blood flow from the constriction and dilation of blood vessels. Low skin temperature usually means decreased blood flow in that area. A temperature-sensitive probe is taped to the skin, often on a finger. The instrument converts information into feedback that can be seen and heard and can be used to reduce or increase blood flow to the hands and feet. Thermal biofeedback is often used for management of Raynaud disease, migraine headaches, hypertension, and anxiety disorders, and to promote general relaxation.

3. Electrodermal activity therapy. In electrodermal activity therapy, changes in sweat activity too minimal to feel are measured. Two sensors are attached to the palm side of the fingers or hand to measure sweat activity. They produce a tiny electrical current that measures skin conductance on the basis of the amount of moisture present. Increased sweat can mean arousal of part of the autonomic nervous system. Electrodermal activity devices can be used to measure the sweat output stemming from stressful thoughts or rapid deep breathing. Electrodermal activity therapy is most often used in the treatment of anxiety and hyperhidrosis.

4. Finger pulse therapy. In finger pulse therapy, pulse rate and force are measured. A sensor is attached to a finger and helps measure heart activity as a sign of arousal of part of the autonomic nervous system. Finger pulse therapy is most often used for management of hypertension, anxiety, and some cardiac arrhythmias.

5. Breathing biofeedback therapy. In breathing biofeedback therapy, the rate, volume, rhythm, and location of breathing are measured. Sensors are placed around the chest and abdomen to measure air flow from the mouth and nose. The feedback is usually visual, and patients learn to take deeper, slower, lower, and more regular breaths using abdominal muscles. This simple form of biofeedback is most often used for management of asthma and other respiratory conditions, hyperventilation, and anxiety.

Goals and Appeal

The general goal of biofeedback therapy is to lower body tension and change faulty biological patterns to reduce symptoms. Many people can and do reach goals of relaxation without the use of biofeedback. Although biofeedback may not be necessary, it can potentially add something useful to any treatment.

A major reason that many patients find biofeedback training appealing is that, as with behavioral approaches in general, it puts the patient in charge, giving the patient a sense of mastery and self-reliance with regard to the illness. It is believed that such an attitude can play a critical role in shortening recovery time, reducing incidence, and lowering health care costs.

Research Considerations

Biofeedback-assisted relaxation training has been shown to be associated with a decrease in medical care costs, a decrease in the number of claims and costs to insurers in claims payments, reduction in medication and physician use, reduction in hospital stays and rehospitalization, reduction of mortality and morbidity, and enhanced quality of life (Basmajian, 1989).

An unpublished study involving 241 employees of a Siberian metal company showed promising results for the integration of biofeedback training into occupational medicine as a method to increase workers’ ability to work with few errors while increasing labor productivity levels. The employees had psychosomatic disorders presenting with symptoms of headache, sleepiness, and periodic blood pressure fluctuations. Workers attended 10- to 40-minute biofeedback sessions over 2 weeks. The results clearly indicated that the workers were able to control the brain's blood flow. Furthermore, a follow-up biofeedback session was repeated 1 month later and showed that all workers in the initial group could recall their strategies for producing positive change.

In another study, 30 patients with fibromyalgia syndrome received biofeedback and experienced statistically significant improvements in mental clarity, mood, and sleep (Mueller et al, 2001). However, future research using controlled trials is needed to understand disease mechanisms better.

Biofeedback, both sensory and augmented, has been used with some degree of success to treat patients with fecal incontinence. Forty women with fecal incontinence were randomly assigned to receive either augmented biofeedback or sensory biofeedback. After 12 weeks of treatment the augmented form of biofeedback was found to be superior, although fecal incontinence improved in both treatment groups (Fynes et al, 1999). Another study compared biofeedback to standard care for treatment of fecal incontinence. Results showed that biofeedback was not superior to standard care in improving incontinence, but those who received biofeedback had significantly better scores on tests of hospital anxiety and depression (Norton et al, 2003).

More recently, 92 patients with systemic lupus erythematosus were assigned randomly to receive biofeedback-assisted cognitive-behavioral treatment, a symptom-monitoring support intervention, or usual medical care. Those who received biofeedback experienced significantly greater reductions in pain and psychological dysfunction than those who did not receive the biofeedback-assisted therapy. At 9-month follow-up, the biofeedback group continued to exhibit relative benefit compared with the control group (Greco et al, 2004).

In a randomized United Kingdom study, 38 patients with fecal incontinence were assigned to undergo sphincter repair or sphincter repair plus biofeedback. Although the results were not statistically significant, continence and satisfaction scores improved in the biofeedback group, and these improvements were sustained over time. Quality-of-life measures also improved in the biofeedback group (Davis et al, 2004).

The Department of Psychiatry at Robert Wood Johnson Medical School in New Jersey evaluated the effectiveness of heart rate variability (HRV) biofeedback as a complementary treatment in 94 patients with asthma. Patients in the two groups receiving biofeedback were prescribed less medication than those in the two control groups (placebo and wait list), which indicates that HRV biofeedback may be a useful adjunct to asthma treatment and may help to reduce dependence on steroid medications (Lehrer et al, 2004). Biofeedback techniques have also been used with some success to treat epilepsy and attention problems, such as sleeplessness, fatigue, and body pain.

Research on exactly how biofeedback works is somewhat inconclusive. Some studies link its benefits directly to physiological changes that the patient learns to make voluntarily. Other experiments find benefits even for patients who do not make the desired changes in the physiological measures. Biofeedback appears to help some patients increase their sense of control, heighten their optimism, and lessen feelings of hopelessness triggered by chronic health problems (Hatch et al, 1987). It appears that biofeedback used as adjunct therapy could add something beneficial to an existing therapy.

GUIDED IMAGERY

Since human societies began analyzing human experiences, philosophers have tried to define and explain the interior processes of the mind—all those experiences that are invisible to another person because they do not have physical referents. Philosophers have speculated at length on the nature of mental imagery, and scientists have found the phenomenon difficult to verify or measure. Behavioral psychologists of the 1920s went so far as to say that mental images simply do not exist.

Since 1960, psychologists have done a great amount of work exploring and categorizing mental imagery and inner processes. Contemporary psychologists distinguish several types of imagery. Probably the most common form of imagery that people experience is memory. If a person tries to remember a friend, the bed in his or her room, or the feel of the seats of his or her car, that person immediately perceives an image in his or her mind, the “mind's eye.” People refer to this experience as “forming a mental picture.” Some people believe that they do not “see” the scene but simply have a strong sense of the scene and “know” what it looks like.

Imagery is both a mental process and a wide variety of procedures used in therapy to encourage changes in attitudes, behaviors, or physiological reactions. As a mental process, it is often defined as “any thought representing a sensory quality” (Horowitz, 1983). In addition to the visual, it includes all the senses: aural, tactile, olfactory, proprioceptive, and kinesthetic. Imagery is often used synonymously with visualization. However, visualization refers only to “seeing” something in the mind's eye, whereas imagery can use one sense or combination of senses to produce an image.

Creating images with the mind is also a way of communicating with the deeper-than-conscious aspects of the mind. This is apparent when one considers the dream state, which communicates mainly in images that are then interpreted to make a story. This communicative quality of imagery is important, because feelings and behaviors are primarily motivated by subconscious and unconscious factors.

Imagery can be taught either individually or in groups, and the therapist often uses it to accomplish a particular result, such as cessation of addictive behavior or bolstering of the immune system to attack cancer cells. Because it often involves directed concentration, imagery can also be regarded as a form of guided meditation.

Many practices discussed in this chapter use a component of imagery. Psychotherapy, hypnosis, and biofeedback all use various elements of this process. Any therapy that relies on the imagination to stimulate, communicate, solve problems, or evoke a heightened awareness or sensitivity could be described as a form of imagery.

Numerous early studies indicated that mental imagery could bring about significant physiological and biochemical changes. These findings have encouraged the development of imagery as a health care tool. Imagery was found to have the capacity to affect dramatically the oxygen supply in tissues (Olness et al, 1988), cardiovascular parameters (Barber, 1969), vascular or thermal parameters (Green et al, 1977), the pupil and cochlear reflexes, heart rate and galvanic skin response (Jordan et al, 1979), and salivation (Barber et al, 1984; White, 1978).

Clinical Applications

Communication with the unconscious had previously been the domain of hypnosis, which basically consists of two components: (1) the use of a technique to induce a state of consciousness in which there is freer access to the deeper part of the mind, and (2) a method of communicating with that deeper part of the mind. Often this communication involves making suggestions to the inner depths of the mind, suggesting items or behaviors that the individual desires for his or her betterment. In guided imagery, different techniques are used to induce the necessary state of consciousness, some quite similar to more common relaxation techniques and to meditation techniques (Jordan et al, 1979).

Self-Directed Imagery

Increased attention is being focused on the ability of individuals to use the principles of guided imagery. Through the practice of effective deep relaxation techniques, individuals can bring themselves into a state of consciousness in which they have increased access to deeper parts of the mind. Then, using imagery, they can “reprogram” new healthy images (Achterberg, 1985).

Self-directed imagery is powerful way in which individuals can have more control over their healing processes. Imagery can be used to contribute to the healing of physical problems and has been used extensively in the area of pain control. In one method the individual allows an image for his or her pain to emerge. For example, an individual may create an image that characterizes the area of pain, then create a second image to counteract the pain image. Once the images are formed, the individual uses a relaxation or meditation technique to open access to the levels where his or her self-healing power resides and to imagine the healing image. This process can be repeated as often as necessary, allowing changes in the healing image that either might appear spontaneously or might be appropriate if the image associated with the pain were to change.

Self-directed imagery can also be used to stimulate personal growth and change by repeatedly entering a relaxed or meditative state and strongly imaging a new desired behavior. Similarly, when one repeatedly images oneself as having already achieved a desired goal, the deeper mind gradually accepts this new image and works to bring it into reality.

Carl O. Simonton, MD, often regarded as the grandfather of guided imagery, and his wife Stephanie brought the use of meditation and imagery for cancer self-help to popular attention. They emphasized several aspects characteristic of a powerful healing image: (1) the image is created by the healee himself or herself, (2) it involves as many sense modalities as possible, and (3) it has as much dynamism and energy behind it as possible. The image must be vital, because that vitality is what stimulates the image to take root (Simonton et al, 1978).

Research Considerations

Early studies suggest a direct relationship between imagery and its corresponding effects on the body. Their findings include the following:

1. Correlations were found between levels of various types of leukocytes and components of cancer patients’ images of their disease, treatment, and immune system (Achterberg et al, 1984).

2. Natural killer cell function was enhanced in geriatric patients (Kiecolt-Glaser et al, 1985) and in adult cancer patients with metastatic disease (Gruber et al, 1988) after engaging in a relaxation and imagery procedure.

3. Specificity of imagery training was suggested by a study in which patients were trained in cell-specific imagery of either T lymphocytes or neutrophils. The effects of training, assessed after 6 weeks, were statistically associated with the type of imagery procedure used (Achterberg et al, 1989).

Of all the many mind-body modalities, guided imagery appears to be the most widely used and accepted in many nursing departments. The University of Akron College of Nursing conducted a study demonstrating that guided imagery was an effective intervention for enhancing comfort in women undergoing radiation therapy for early-stage breast cancer. In this study, 53 women were randomly assigned to either a control group or a treatment group. The experimental group listened to a guided imagery tape once a day for the duration of the study. The guided imagery group demonstrated significantly improved comfort compared with the control group, with the treatment group experiencing greater comfort over time (Kolcaba et al, 1999).

A community-based nursing study was recently conducted in Sydney, Australia, where 56 people with advanced cancer experiencing anxiety and depression were randomly assigned to one of four treatment conditions: (1) progressive muscle relaxation training, (2) guided imagery training, (3) both types of training, and (4) no training (control). Patients were tested for anxiety, depression, and quality of life. The guided imagery training led to no significant improvement in anxiety but was associated with significant positive changes in depression and quality of life (Sloman, 2002).

Nurses at Ephrata Community Hospital in Pennsylvania found that offering their patients guided imagery compact discs (CDs) was effective in a variety of ways. They reported that guided imagery (1) helped patients relieve pain and anxiety before and after surgery, (2) helped patients relax and sleep better during evening hours, (3) helped to lower blood pressure, and (4) reduced the need for breathing and respiratory devices. Nurses also reported that the CDs were often more effective than sedation for easing confusion in older patients. Each bedside had a packet of CDs and a CD player with earphones. Each CD focused on a major component of a successful hospital stay (e.g., health and healing, comfort, peaceful rest, courage, serenity). In addition, all the staff nurses, therapists, social workers, and managers were trained in the use of the CDs and employed them for their personal benefit (Miller, 2003).

Differences in pain perception with guided imagery were examined at Kent State's College of Nursing, where 42 patients were randomly assigned to treatment (guided imagery) and control (no imagery) groups. Those who participated in guided imagery experienced decreased pain during the last 2 days of the 4-day trial (Lewandowski, 2004).

In 1993 a study was conducted by Bennett to compare the effectiveness of various types of guided imagery in preoperative patients. Three outcomes were examined: intraoperative blood loss, length of hospital stay, and use of postoperative pain medication. A population of 335 surgical patients were randomly assigned to five groups. Each of the four experimental groups was provided with a guided imagery audiotape created by four different therapists. The control group received an audiotape with a “whooshing” noise that produced no meaningful physiological effect. Results showed that use of three of the four guided imagery audiotapes yielded no significant beneficial effects on any of the medical outcomes examined. By contrast, use of the guided imagery audiotape produced by Belleruth Naparstek, a highly regarded therapist and imagery practitioner, led to highly significant results for two outcomes, reduced postoperative blood loss and length of stay. Bennett found that Naparstek's tape was much more sophisticated than the others. Her imagery had been scored with specially composed music designed to highlight and accompany each image, with an emphasis on spiritual connectedness. Naparstek included visualizations of positive outcomes, faster wound healing, less pain, and no nausea (Bennett, 1996).

In two unpublished studies, guided imagery was used to reduce menopausal symptoms. The University Hospital in Linkoping, Sweden, found that menopausal women using guided imagery averaged 73% fewer hot flashes over 6 months and had a significant reduction in other symptoms. A study at New England Deaconess Hospital involving 33 menopausal women who were not using hormone replacement therapy found that guided imagery strategies produced a significant reduction in hot-flash intensity, tension and anxiety, and depression.

Cleveland Clinic researchers assessed 130 colorectal surgery patients for anxiety levels, pain perceptions, and narcotic medication requirements (Tusek et al, 1997). The treatment group listened to guided imagery tapes for 3 days before their surgery, during anesthesia induction, intraoperatively, after anesthesia, and for 6 days after surgery; the control group received routine perioperative care. Patients in the guided imagery group experienced considerably less preoperative and postoperative anxiety and pain, and they required 50% less narcotic medication after surgery than patients in the control group.

Not only has the use of guided imagery been shown to be effective for reducing pain and anxiety preoperatively and postoperatively, but it is now proving to be cost effective. In 1999 a cardiac surgery team implemented a guided imagery program and compared cardiac surgical outcomes in those who participated in guided imagery and those who did not. Patients who completed the guided imagery program had a shorter average length of hospital stay, a decrease in average direct pharmacy costs, and a decrease in average direct pain medication costs, while overall patient satisfaction with the care and treatment provided remained high (Halpin et al, 2002).

MENTAL HEALING

The idea that consciousness can affect the physical body is a time-honored concept with a respected historical base. The observation that “there is a measure of consciousness throughout the body” is scattered about in the 2000-year-old Hippocratic writings. The ancient Persians expounded on this concept, insisting that a person's mind can intervene not just in his or her own body but also in that of another individual located far away. The great Muslim physician Abu Ali ibn Sina (Avicenna in Latinized form, AD 980-1037) later postulated that it was the faculty of imagination that humans use to make themselves ill or to restore health.

The attitudes of the ancient Greeks and Persians toward the interaction between minds and bodies gave rise to two very different types of healing: local and nonlocal. The Greeks believed that the action of the mind on the body was a “local” event in the here and now. The Persians, however, viewed the mind-body relationship as “nonlocal.” They held that the mind was not localized or confined to the body but extended beyond the body. This implied that the mind was capable of affecting any physical body, local or nonlocal.

Implications of Nonlocality

Modern physicists have long recognized the concept of nonlocality. These developments rest largely on an idea in physics called “Bell's theorem,” introduced in 1964 by the Irish physicist John Stewart Bell and supported by subsequent experiments. Bell showed that if distant objects have once been in contact, a change thereafter in one causes an immediate change in the other, even were they to be separated to the opposite ends of the universe. Thus it is important to realize that nonlocality is not just a theoretical idea in physics, but that its proof rests on the results of actual experiments.

The idea prevalent in contemporary science is that the mind and consciousness are entirely local phenomenon, localized to the brain/body and confined to the present moment. From this perspective nonlocal healing cannot occur in principle because the mind is bound by the “here and now.” Research studies examining distant mental influence challenge these modern-day assumptions. Dozens of experiments conducted over the past 25 years suggest that the mind can bring about changes in nonlocal physical bodies, even when shielded from all sensory and electromagnetic influences. This suggests that mind and consciousness may not be located at fixed points in space (Braud, 1992; Braud et al, 1991; Jahn et al, 1987).

Some physicists believe that nonlocality applies not just to the domain of electrons and other subatomic particles but also to our familiar world consisting of dense matter. A growing number of physicists think that nonlocality may apply to the mind. Physicist Nick Herbert, in his book Quantum Reality, states, “Bell's theorem requires our quantum knowledge to be nonlocal, instantly linked to everything it has previously touched” (Herbert, 1987).

For the Western model of medicine, the implications of a nonlocal concept are profound and include the following:

1. Nonlocal models of the mind could be helpful in understanding the actual dynamics of the healing process. They may help to explain why in some patients a cure suddenly appears unexpectedly or a healing appears to be influenced by events occurring nonlocally.

2. Nonlocal manifestations of consciousness may complicate traditional experimental designs and require innovative research methods, because they suggest that the mental state of the healer may influence the experiment's outcome, even under “blind” conditions (Solfvin, 1984).

Nonlocality assumptions give rise to the idea that consciousness could prevail after the death of the body/brain, which suggests that some aspect of the psyche is not bound to points in space or time. This idea in turn leads toward a nonlocal model of consciousness, which allows for the possibility of distant healing exchange.

This nonlocal model of consciousness implies that at some level of the psyche, no fundamental separations exist between individual minds. Nobel physicist Erwin Schroedinger suggested that at some level and in some sense there may be unity and oneness of all minds (Schroedinger, 1969). In the nonlocal model, distance is not fundamental but is completely overcome. In other words, because of the unification of consciousness, the healer and the patient are not separated by physical distance.

For 30 years, psychologist Lawrence LeShan investigated the local and nonlocal effects of prayer and mental healing. He taught these techniques to more than 400 people and ultimately became a healer himself. He maintained that healing changes were observed to have occurred 15% to 20% of the time but never could be predicted in advance of any specific healing (LeShan, 1966).

LeShan found that mental-spiritual healing methods can be categorized into the following two main types:

• Type I (nonlocal). The healer enters a prayerful, altered state of consciousness in which he or she views himself or herself and the patient as a single entity. There is no physical contact or any attempt to offer anything of a physical nature to the person in need, only the desire to connect and unite. These healers emphasize the importance of empathy, love, and caring in this process. When the healing takes place, it does so in the context of unity, compassion, and love. This type of healing is considered a natural process and merely speeds up the normal healing processes.

• Type II (local). The healer does touch the patient and may imagine some “flow of energy” through his or her hands to the area of the patient receiving the healing. Feelings of heat are common in both the healer and patient. In this mode, unlike type I, the healer holds the intention for healing.

Research into the origins of consciousness and how it relates to the physical brain is practically nonexistent. Although hypotheses purporting to explain consciousness do exist, there is no agreement among researchers as to its nature, local or nonlocal.

SPIRITUALITY AND HEALING

Throughout the ages, ancient mystical traditions have valued the spiritual qualities of humans over the physical, emphasizing the transcendence of one over the other. In the background of most mystical traditions is the idea that the body is somehow at odds with the spirit. A war wages, and one must battle the war to achieve an enlightened status. Still other theologians postulate that the greatest spiritual achievement of all may lie in the realization that the spiritual and the physical are but one, and that perhaps the ultimate spiritual goal is to transcend nothing but to realize the integration and oneness of our being.

A new quality of spiritual awakening has been emerging worldwide over the past 30 years. This innovative approach encourages people to develop faith in their own capacity to create their own reality in partnership with the “God-force within.” In many cultures, both Eastern and Western, prayer-based spiritual healing is an integral part of modern religious practices.

The premise of creating our own reality is, in essence, a spiritual one. This concept is sometimes contrary to many fundamental religious positions that embrace God as an external being, because spirituality emphasizes a “God-within” reality. Transcending the boundaries and limitations of specific religions, a spiritual practice honors the relationship between the individual and the God-force as a partnership.

When people consider the possibility that they create their own realities, the question that invariably arises is, “Through what source? What is the source of this power of creation that runs through my being?” The answer to this question is found not externally but internally. This internal source seeking to understand our own nature is divinity in action, incarnated in each person.

The blending of spirituality with the tenets of alternative and complementary therapies provides individuals with a means of understanding how they contribute to the creation of their illness and to their healing. This understanding does not come from a place of self-blame and does not view illness as a result of the will of God but rather is an attempt to understand a spiritual purpose for suffering in a physical body. The relationship that is cultivated ultimately transcends the human value system of punishment versus reward and grows into a relationship based on principles of co-creation and co-responsibility. Therefore the journey of healing for patients, as well as the journey of life, is freed of the burden of feeling victimized by fate, circumstances, or God, and patients are free to have faith and hope not only in God but in themselves as well.

Research in the last 10 years has made an indelible mark on the way health care professionals think about the role of spirituality and religion in physical, mental, and social health. Hundreds of studies have explored the relationship between body and spirit. Most studies have been cross-sectional, but some have also been longitudinal. Many studies now document an association between religious involvement and lower anxiety, fewer psychotic symptoms, less substance abuse, and better coping mechanisms. A comprehensive review found that 478 of 742 quantitative studies (66%) reported a statistically significant relationship between religious involvement and better mental health and greater social support. The review also found that almost 80% of those who are religious have significantly greater well-being, hope, and optimism compared with those who are less religious (Koenig et al, 2001).

At Duke University, studies were conducted examining the effects of religiousness on the course of depression in 850 hospitalized patients over age 60. Results showed that religious coping predicted lower levels of depressive symptoms at baseline and at 6 months after discharge (Koenig et al, 1992).

Koenig's studies and others have shown that spirituality and religiosity are clearly associated with longer survival, healthier behaviors, and less distress and are believed to have an effect on coping (Pargament et al, 1998; Tix et al, 1997), anxiety (Koenig et al, 1993), success in aging (Crowther et al, 2002), end of life issues (Daaleman et al, 2000), and cortisol levels in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome (Ironson et al, 2002).

Power of Prayer

The use of prayer in healing may have begun in human prehistory and continues to this day as an underlying tenet in almost all religions. The records of many of the great religious traditions, including the mystical traditions of Christianity, Daoism, Hinduism, Buddhism, and Islam, give the strong impression that enlightenment comes when one begins to explore the dynamic qualities of interrelation and interconnection between the self and the source of all beings.

The word prayer comes from the Latin precarious, “obtained by begging,” and precari, “to entreat”—to ask earnestly, beseech, implore. This suggests two of the most common forms of prayer: petition, asking something for one's self, and intercession, asking something for others.

Prayer is a genuinely nonlocal event, not confined to a specific place in space or to a specific moment in time. Prayer reaches outside the here and now; it operates at a distance and outside the present moment. Because prayer is initiated by a mental action, this implies that some aspect of our psyche also is genuinely nonlocal. Nonlocality implies infinitude in space and time, because a limited nonlocality is a contradiction in terms. In the West, this infinite aspect of the psyche has been referred to as the soul. Empirical evidence for the power of prayer therefore may be seen as indirect evidence for the soul.

Scientific attempts to assess the effects of prayer and spiritual practices on health began in the nineteenth century with Sir Francis Galton's treatise “Statistical Inquiries into the Efficacy of Prayer” (Galton, 1872). Galton assessed the longevity of people who were frequently prayed for, such as clergy, monarchs, and heads of state. He concluded that there was no demonstrable effect of prayer on longevity. By current scientific standards, Galton's study was flawed. He was successful, however, in promoting the idea that prayer is subject to empirical scrutiny. Galton did acknowledge that praying could make a person feel better. In the end he maintained that although his attempts to prove the efficacy of prayer had failed, he could see no good reason to abandon prayer.

Those who practice healing with prayer claim uniformly that the effects are not diminished with distance; therefore it falls within the nonlocal perspective discussed earlier. Claims about the effectiveness of prayer do not rely on anecdote or single case studies; numerous controlled studies have validated the nonlocal nature of prayer. Moreover, much of this evidence suggests that praying individuals, or people involved in compassionate imagery or mental intent, whether or not it is called “prayer,” can purposefully affect the physiology of distant people without the awareness of the receiver.

The medical community has recently begun to acknowledge the importance of exploring the association between spirituality and medicine. Many medical schools now offer courses in religion, spirituality, and health. According to a 1994 survey, 98% of hospitalized patients ascribe to a belief in God or some higher power, and 96% acknowledge a personal use of prayer to aid in the healing process. In addition, 77% of 203 hospitalized family practice patients believed that their physicians should consider their spiritual needs. In contrast, only 32% of the patients’ family physicians actually discussed spirituality with their patients (King et al, 1994).

Anecdotal accounts of the power of prayer are legendary, and countless books on the subject are available; however, literature of scientific value is still limited.

The now-famous prayer study involving humans was published in 1988 by Randolph Byrd, a staff cardiologist at San Francisco School of Medicine, University of California. Byrd randomly assigned 393 patients in the coronary care unit either to a group receiving intercessory prayer or to a control group receiving no prayer. Intercessory prayer was offered by interventionists outside the hospital. They were not instructed how often to pray but were told to pray as they saw fit. In this double-blind study, the prayed-for patients did better on several counts. Although the results were not statistically significant, there were fewer deaths in the prayer group; these patients were less likely to require intubation and ventilator support; they required fewer potent drugs; they experienced a lower incidence of pulmonary edema; and they required cardiopulmonary resuscitation less often (Byrd, 1988).

In 1999, W.E. Harris attempted to replicate Byrd's findings at the Mid America Heart Institute in Kansas City. Although the study did not produce statistically significant results, the researchers reported that patients received significant benefit from intercessory prayer, as reflected by a coronary care unit outcome measure (Harris et al, 1999). Critics have charged that performing controlled studies on prayer is impossible, because extraneous prayer for the control group cannot be eliminated.

Other studies have been conducted to assess the effect of intercessory prayer on the treatment of alcohol abuse and dependence (Walker et al, 1997), the well-being of kidney dialysis patients (Matthews et al, 2001), and feelings of self-esteem (O'Laoire, 1997). A prospective study of 40 patients with class II or III rheumatoid arthritis compared the effects of direct-contact intercessory prayer with distance intercessory prayer. Persons receiving direct-contact prayer showed significant overall improvement at the 1-year follow-up. The group receiving distant prayer showed no additional benefits (Matthews et al, 2000).

The benefits of spiritual healing were examined in 120 patients with chronic pain at the Department of Complementary Medicine at the University of Exeter, United Kingdom. Patients were randomly assigned to face-to-face healing or simulated face-to-face healing for 30 minutes per week for 8 weeks or to distant healing or no healing for the same time. Although subjects in both healing groups reported significantly more “unusual experiences” during the sessions, the clinical relevance of this is unclear. It was concluded that a specific effect of face-to-face or distant healing on chronic pain could not be demonstrated over eight treatment sessions in these patients (Abbot et al, 2002).

Although research problems will be difficult to overcome in evaluating the power of prayer, Byrd's initial prayer study broke significant ground in medical research. Many questions still remain unanswered, and further study is warranted to define the effects of intercessory prayer on quantitative and qualitative outcomes and to identify end points that best measure efficacy.

Although validated evidence continues to build concerning the efficacy of prayer, Dossey (1993) maintains that some serious questions arise in the wake of these experiments. Evidence shows that mental activity can be used to influence people nonlocally, at a distance, without their knowledge. Scores of experiments on prayer also show that it can be used to great effect without the subject's awareness. The question arises of whether it is ethical to use these techniques if recipients are unaware that they are being used. This question becomes even more compelling as one considers the possibility prayer, or any other form of mind-to-mind communication, may be used at a distance to harm people without their knowledge. Institutional review committees that oversee the design of experiments involving humans to ensure their safety have rarely had to consider these types of ethical questions.

COMBINED APPROACHES

Although evidence continues to mount regarding the efficacy of mind-body approaches used individually, more researchers and clinicians are beginning to combine various approaches to create a synergistic healing process.

Combining hypnosis with guided imagery yielded impressive results in improving the postoperative course of pediatric surgical patients. Fifty-two children were randomly assigned to an experimental group or control group. Children in the experimental group were taught imagery, which included hypnotic suggestions for a favorable postoperative course; children in the control group received no such training. The children in the imagery group had significantly lower postoperative pain ratings and shorter hospital stays than those in the control group. State anxiety was decreased in the guided imagery group but increased in the control group (Lambert, 1996).

A study at the University of Texas (Houston) School of Public Health was conducted to differentiate the effects of imagery and support on coping, life attitudes, immune function, quality of life, and emotional well-being after breast cancer. Forty-seven breast cancer survivors were randomly assigned to (1) standard care only, (2) standard care with six weekly social support sessions, or (3) standard care with guided imagery sessions. For women in both active treatment groups, interferon-γ levels increased, neopterin levels decreased, quality of life improved, and natural killer cell activity remained unchanged. Compared with standard care only, both social support and guided imagery interventions improved coping skills, increased perceived social support, and generally enhanced feelings of meaning in life. Imagery participants had less stress, increased vigor, and improved functional and social quality of life compared with the support group (Richardson et al, 1997).

In another study, Harvard's Mind/Body Institute randomly assigned 128 otherwise healthy college students to an experimental group or a wait-list control group. The experimental group received six 90-minute group training sessions in the relaxation response and cognitive-behavioral skills; the control group received no training. Significantly greater reductions in psychological distress, state anxiety, and perceived stress were found in the treatment group compared with the control group (Deckro et al, 2002).

California Pacific Medical Center conducted a study funded by the U.S. Department of Defense that examined the outcomes for 181 women with breast cancer. Women were randomly assigned to participate in a 12-week “mind, body, and spirit” support group or a standard support group. The women in the mind, body, and spirit group were taught meditation, affirmations, imagery, and ritual. In the standard group, cognitive-behavioral approaches were combined with group sharing and support. Both interventions were found to be associated with improved quality of life, decreased depression and anxiety, and spiritual well-being. Only women in the mind, body, and spirit group, however, showed significant increases in measures of spiritual integration. At the end of the intervention, those in the mind, body, and spirit group showed higher satisfaction and the group had fewer dropouts than the standard group (Targ et al, 2002).

Kinney and Rodgers (2003) conducted a similar intervention for breast cancer survivors using a mind, body, and spirit self-empowerment program. Fifty-one women participated in a 12-week psychospiritual supportive program that included multiple strategies for creating a balance among spiritual, mental, emotional, and physical health. Components included meditation, visualization, guided imagery, affirmations, and dream work. Statistically significant improvements were seen in depression, perceived wellness, quality of life, and spiritual well-being.

Guided imagery and progressive relaxation techniques were the focus of a recent study at New Jersey Goryeb Children's Hospital. Eighteen children between the ages of 5 and 12 with chronic abdominal pain were taught guided imagery and progressive relaxation techniques over 9 months. Abdominal pain improved in 89% of the patients, weekly pain episodes decreased, pain intensity decreased, days missed from school decreased, and physician office contacts decreased. In addition, social activities increased and quality of life improved (Youssef et al, 2004).

A recent Korean study examined the effectiveness of a combination of guided imagery and progressive relaxation techniques in reducing the chemotherapy side effects of anticipatory nausea and vomiting and postchemotherapy nausea and vomiting in 30 patients with breast cancer; the effects on patients’ quality of life was also measured. Both therapies combined produced improvements on all measures (Yoo et al, 2005). Mind-body pathways and therapeutic modalities have been difficult to understand and interpret in Western biomedicine.

Chapter References can be found on the Evolve website at http://evolve.elsevier.com/Micozzi/complementary/ (Micozzi 106)

Micozzi, Marc. Fundamentals of Complementary and Alternative Medicine, 4th Edition. W.B. Saunders Company, 2011. Vital Book file.

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