Mind/Body Medicine

"The mind steadfastly refuses to behave locally, as contemporary scientific evidence is beginning to show. We now know, for example, that brainlike tissue is found throughout the body... So, even from the conservative perspective of modern neurochemistry, it is difficult if not impossible to follow a strictly local view of the brain." C Larry Dossey, M.D.^[1]

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

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

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

In the decades of the seventies and eighties, researchers trained their sites more directly onto these mechanisms. Herbert Benson, M.D. and his colleagues at Harvard Medical School led the way with the discovery of "the relaxation response." This work has led to a cascade of findings about how mind/body mechanisms can be used for medically significant impact on hypertension, heart disease, cancer and other conditions.

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

In Benson's perspective, "We are part of mainstream medicine, we are not alternative. You might say that this was considered alternative years ago, but it is now mainstream."^[2]

Taking Center Stage

Indeed he may be right. In early 1993, a widely reported study documented the surprising popularity of alternative medicine in this country. Published in the New England Journal of Medicine and led by Harvard researcher David Eisenberg, M.D., the study found that one in three adults had used some form of unconventional medicine. Of the varieties reported, mind/body techniques were the most frequently used.^[3] This followed by just a few months the creation of the Office of Alternative Medicine in the National Institutes of Health. And shortly thereafter, mind/body medicine was brought into the living rooms of millions of Americans by a television series called "Healing and the Mind," hosted by the popular journalist Bill Moyers on PBS.

The PBS series symbolized a highly visible milestone in the mainstreaming of what critics had previously considered a form of "fringe" medicine. Mind/body medicine (also known as behavioral medicine) is, of course, nothing new. The influence of the mind in healing is addressed in virtually every medical tradition, from the ancient teachings of ayurveda to modern allopathy. What is new is the legitimization of research in this field to the point of government funding, and the incorporation of mind/body programs into the offerings of major medical institutions C many of which are noted for their conservatism and scientific bent.

What is the emerging role of this work? Benson regards it as an integral part of comprehensive health care. He offers the metaphor of a three legged stool: "One leg is pharmaceuticals, another is surgery, and the third is what you can do for yourself. Mind/body medicine is strengthening the third leg, integrated with the other two legs."^[4]

KEY PRINCIPLES

The Biopsychosocial Perspective

In the late 1970's the eminent medical researcher George Engel of the University of Rochester made the bold statement that modern medicine needed a new way of thinking about health and illness.^[5] He proposed what he called the "bio-psycho-social" model, in which health is the outcome of many factors interacting together. This provides the theoretical framework underpinning mind/body medicine.

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

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

Mind/Body Communication

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

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

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

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

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

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

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

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

The Power of the Mind/Body Connection. One of the most stirring stories about the power of the mind/body connection concerns a man who was diagnosed with terminal cancer. It was reported by Dr. Bruno Klopfer in a medical journal in the late 1950's. It involves a man with metastatic cancer and tumors which had spread throughout his body. The patient had tried every available form of medicine, and his condition had hopelessly deteriorated to the point where he was bedridden and gasping for air.

His doctors agreed that he had only a few days to live. Then the man heard about an experimental drug called Krebiozen which was in the process of being tested. He insisted on being included in the experimental trials. His doctors, feeling he had nothing to lose and would soon be dead anyway, agreed out of compassion to give him the experimental drug. To their amazement, the man's tumors soon began to shrink dramatically, and he was discharged from the hospital.

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

The Stress Response

The stress response is a set of changes in the body that result when the person experiences what they perceive to be a challenging or threatening situation. This matter of "perceived threat" is important because the effects of the stress response on the body are the same, whether the threat is real or just imagined in the mind.

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

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

! Increased blood pressure

! Increased respiratory rate

! Increased heart rate

! Increased oxygen consumption (burning of fuel)

! Increased blood flow to skeletal muscles

! Increased perspiration

! Increased muscle tone

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

The Relaxation Response

Another key principle is the relaxation response which was discovered and named by Herbert Benson, M.D. and his colleagues in 1974.^[7],[8] They were studying a pattern of physiological changes that occurs in people practicing Transcendental Meditation (TM).

This pattern of changes has been found to represent a very beneficial state, one that is virtually a mirror image of the stress response. The relaxation response includes the following changes:

! Reduced blood pressure

! Reduced respiratory rate

! Reduced heart rate

! Reduced oxygen consumption (burning of fuel)

! Reduced blood flow to skeletal muscles

! Reduced perspiration

! Reduced muscle tension

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

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

Coping, Emotions, and Health

Researchers have identified how the ways we cope with emotions and stressful situations C our "coping styles" C can influence our physical health. Most firmly established are the links between coronary heart disease and the Type A behavior pattern. Type A is a way of coping characterized by constant hurriedness, intense competitiveness, and free-floating hostility.

A more recent concept is the Type C pattern, which in many ways is the polar opposite of Type A. It involves the non-expression of anger and other unpleasant emotions, such as fear and sadness; unassertive and overly-appeasing behavior in relationships with others; and a preoccupation with meeting the needs of others, often to the point of extreme self-sacrifice. The theory of the Type C pattern was put forward by Lydia Temoshok, Ph.D., a leading health psychologist and PNI researcher with The Henry Jackson Foundation in Rockville, Maryland. She has found compelling evidence for a link between emotional expressiveness and the progression of cancer.^[9]

The middle ground, or Type B, is considered a more balanced way of coping that involves appropriate expression of all emotions, and the ability to meet one's own needs while responding to those of others. People who cope in this more balanced way tend to be less at risk for serious illness. The cultivation of these behaviors is often a goal in mind/body medicine programs, especially for heart disease and cancer.

Lifestyle Change

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

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

VARIATIONS: THE MANY CONTEXTS OF MIND/BODY MEDICINE

This field is uniquely cross-disciplinary. This accounts for its wide availability, helping make it the most commonly used form of alternative healing.

Its variety of techniques may be used by medical doctors, nurses, physician's assistants, naturopaths, osteopaths, practitioners of Chinese medicine and ayurveda, bodyworkers, homeopaths, and chiropractors. Other human service providers such as psychologists, clinical social workers, marriage and family counselors, ministers, and hypnotherapists also use these tools. And of course there are very specialized applications for midwives, physical therapists, exercise physiologists, respiratory therapists and others.

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

These methods are often taught to patients who are preparing to undergo surgery or other difficult treatments. Such preparation has been found in research to speed healing, reduce bleeding and complications, and result in earlier discharge from the hospital.

PROCEDURES AND TECHNIQUES

The repertoire of mind/body medicine includes all psychological strategies which directly influence physiological states. Following are the most commonly used methods.

Meditation

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

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

Mindfulness

This is actually another approach to meditation, which involves the ability to focus completely on only one thing at a time. In other words, in mindfulness the mind is full of whatever is happening right now. This can include walking, cooking, sweeping the floor, dancing, watching a bird, hearing the sound of a river, or any other focus you may choose. Whenever thoughts intrude, you simply return your attention back to the focus. This is a traditional Buddhist approach, and has been widely popularized by Jon Kabat-Zinn, Ph.D. in the Stress Reduction Clinic at the University of Massachusetts Medical Center in Worcester.

Progressive Relaxation

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

The remaining techniques described below, while they also can lead to induction of the relaxation response, are also used for other purposes.

Mental Imagery

This involves using symbols to imagine that the changes you desire in your body are actually happening. For example, you might imagine that pain is melting away and dripping like a warm liquid out of your finger tips. Or you might develop an image of your immune cells actively subduing and preying on cancer cells or viruses, like birds of prey swooping down to engulf field mice in a meadow. This is a highly personalized technique, and you would use images that are uniquely exciting and meaningful to you.

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

Autogenic Training

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

Breath Therapy

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

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

Hypnosis

A simple description of hypnosis is offered by Karen Olness, M.D., of Case Western Reserve University who calls it "a form of self-induced, focused attention that can make it easier for you to relax or learn to control your body's functions."^[10] It is this experience of extraordinary focus of attention that makes it possible to influence bodily states.

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

Hypnosis is especially useful for relief from pain, reducing the distress from other symptoms or the side effects of treatment, and establishing a greater sense of control. Hypnotic states can be self-induced or can be facilitated by a hypnotist or hypnotherapist. Finally, it can help in overcoming one's resistance to healthful behavior change, such as reducing smoking or changing one's eating habits.

Biofeedback

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

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

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

Biofeedback has many applications, including headache and migraines, anxiety, chronic pain, teeth grinding and clenching, Raynaud's disease (cold hands), incontinence, asthma, and muscle disorders including helping people learn to re-use arms or legs that have been traumatized. Essentially any bodily process that can be measured can potentially be controlled or influenced through the help of these techniques.

SCIENTIFIC SUPPORT

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

Mind/Body Interactions

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

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

With this understanding it is easy to see how individuals who experience stress on a chronic basis are at greater risk for heart diseases. This connection was dramatically illustrated in a study of air traffic controllers, considered to be in a very stressful occupation, who were found to have five times the incidence of hypertension as a comparison group of second class airmen.^[12]

Other research has been able to anticipate who will develop hypertension and heart disease. One study followed 1100 adults for 20 years. Those who had the highest levels of anxiety at the beginning of the study turned out to have the highest rates of hypertension two decades later.^[13]

An eight year study of over three thousand people found that those with the Type A behavior pattern were twice as likely as Type B's to develop coronary heart disease.^[14]

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

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

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

The Mind and Immunity. In addition to affecting the heart, the chemistry of the stress response has been found to lower immune functioning. This is illustrated by studies of the effects of exam stress on medical students which have found: significant drops in the activity natural killer (NK) cells^[18] as well as in the numbers^[19],[20] of NK cells (NK cells are a key in fighting cancer cells and viruses); and significantly lower percentage of T-helper cells in the blood^[21],[22] (the cells that arouse the immune response to fight off an infection).

In a study of recently divorced people, those who wanted the divorce, for whom it brought relief, were found to have better immunity than those who did not want the divorce.^[23]

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

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

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

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

Major findings of Temoshok's research include the following:

! Patients who were more emotionally expressive had thinner tumors and more slowly dividing cancer cells.

! The more emotionally expressive patients had a much higher number of lymphocytes (immune cells) invading the base of the tumor.

! Patients who were less emotionally expressive had thicker tumors and more rapidly dividing cancer cells.

! Patients who were less expressive had relatively fewer lymphocytes invading the base of the tumor.

These findings helped contribute to the formation of the concept of "type C" coping .

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

Techniques of Mind/Body Medicine

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

Relaxation Training. This is by far the most widely studied subject in this tradition with hundreds of studies documenting its benefits. A few examples:

Patients with ischemic heart disease who practiced the relaxation response daily for four weeks achieved significant reduction in the frequency of pre-ventricular contractions.^[30]

Patients with hypertension who took an 8 week (once a week) training program achieved significantly lower blood pressure, and the benefits were maintained three years later.^[31]

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

Also, a study of patients receiving angioplasty procedures showed significantly less anxiety, pain, and need for medication.^[33] In patients receiving heart surgery, those who received the training had significantly lower incidence of post-operative supraventricular tachycardia.^[34]

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

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

Finally, in a study of exam stress in medical students, the more they practiced the relaxation response, the higher was the percentage of T-helper cells circulating in their blood.^[37]

Meditation. Of many various forms of meditation, TM has led the way in mind/body research. Over 500 papers have been published in 108 scientific journals, authored by scientists at 211 research institutions and universities, in 23 countries worldwide. Studies of TM were instrumental in discovering the relaxation response and its benefits for hypertension. Other studies have found important benefits for such diverse populations as prison inmates, drug addicts, and Vietnam veterans suffering from post-traumatic stress disorders.

In one study, patients with hypertension who practiced TM twice daily for 5-6 months achieve significantly lower blood pressure.^[38] In another, the effects of TM were compared to those of progressive muscle relaxation and "usual care" in hypertension. For those using TM, the decreases in systolic and diastolic blood pressure were twice as great as those for the subjects in the other groups.^[39] As will be seen later, TM has also shown impressive effects in reducing the utilization rates of medical services.

Imagery. Imagery is often used in combination with relaxation and meditation. A controlled study of 55 women examined the effects of imagery and relaxation on breast milk production in mothers of infants in a neonatal intensive care unit. They received a 20 minute audio tape of progressive relaxation followed by guided imagery of pleasant surroundings, milk flowing in the breasts, and the baby's warm skin against theirs. They produced more than twice as much milk as those receiving only routine care.^[40]

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

At Michigan State University, researchers found that students could use guided imagery to improve the functioning of certain white cells called neutrophils. (Neutrophils are important immune cells in defense against bacterial and fungal infection.) They could also decrease, but not increase, white cell counts. At one point in the study, a form of imagery intended to increase neutrophil count unexpectedly caused a drop instead. Subsequently, students were taught imagery explicitly intended to keep the neutrophil count steady, while increasing their effectiveness. Both of these goals were achieved.^[42]

Breath Therapy. A study examined the effect of Evocative Breath Therapy (EBT) on salivary immunoglobulin A (S-Iga). EBT involves abdominal breathing accompanied by music and post?hypnotic suggestion to promote emotional arousal and release. Forty?five adults in a group therapy program for cancer showed an average 46% increase in S-IgA levels, after an hour-long EBT experience.^[43]

Biofeedback. A controlled study of patients with irritable bowel syndrome found that biofeedback training brought a significant reduction in symptoms. This change was still present six months later.^[44] Another controlled study found a 41% reduction in migraine headaches in patients using a thermal biofeedback procedure at home.^[45]

Multi-Strategy Group Programs

Most organized mind/body therapy programs use a regimen of several techniques. Below are described some findings of such "multi-strategy" programs for specific illnesses.

Hypertension. A group program for patients with hypertension included training in the relaxation response, nutrition, exercise, and stress management.^[46] Findings included significant reductions in blood pressure, cholesterol, triglycerides, weight, percent body fat, and psychological symptoms. Importantly, most of the benefits were intact when the patients were checked three- to five-years later.^[47]

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

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

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

Reducing Symptoms of AIDS. In a controlled study, patients received group training in biofeedback, guided imagery, and hypnosis. Results included significant decreases in fever, fatigue, pain, headache, nausea, and insomnia. There also were significantly increased vigor and hardiness.^[51]

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

Psychological Well-Being in Cancer. Fifty-nine patients took a ten-day, 60-hour group program that includes imagery, relaxation training, lifestyle evaluation, emotional release therapies, group support, breath therapy, and learning from the illness experience. Results included significant improvements in emotional expressiveness, fighting spirit, quality of life, sense of control over health, and optimism C including for patients with metastatic disease. These improvements were still present three months after completing the program.^[53]

Psychological Well-Being and Immunity in Cancer. Sixty-six patients with malignant melanoma took a six-week structured group program that included health education, stress management, training in problem-solving, and psychological support. Six months after the program, there were significantly lower levels of psychological distress, and higher levels of positive coping methods in comparison to patients who did not have the program. There were also significant increases in the percentage of NK cells and in their functional effectiveness (cytotoxic activity).^[54]

Increasing Survival Time in Malignant Melanoma. The patients who participated in the above study were followed for six years. A startling difference in death rates between the two groups was found. Of those who were in the control group (no group therapy), 13 of 34 had a recurrence of cancer during the six years and 10 died. For those who had the group program, only 7 of 34 had recurrences and only 3 died.^[55]

Increasing Survival Time in Breast Cancer. A ten-year controlled study was conducted with 86 women with metastatic breast cancer. Those who had a year of weekly group sessions had nearly double the survival time of those who did not have the group (averaging 36 months versus 18 months). The group provided self-hypnosis and a form of therapy called "supportive-expressive therapy."^[56]

Cost effectiveness

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

Dr. Elizabeth Devine of the University of Wisconsin School of Nursing in Milwaukee conducted an analysis of 191 different scientific studies in which surgery patients were taught simple mind/body techniques. She found an average reduction in the length of hospital stay of 1.5 days (12%). This of course translates into enormous savings considering the cost of a day of hospitalization. Results also included faster recovery from surgery, fewer complications, and reduced post-surgical pain.^[57]

Other studies have found reduced utilization rates for outpatient medical services. For example, in one study 109 chronic pain patients took a 10-session outpatient group mind/body program. A 36% reduction in total monthly clinic visits for pain management was found in the first year after the program.^[58]

Another study looked at the medical care utilization rates of 2000 regular practitioners of TM, comparing them with 600,000 other members of the same insurance carrier. For children and young adults the reductions for inpatient services were 50%, and for older adults it was 69%. The reductions for outpatient services were 47% for children, 55% for young adults, and 74% for older adults.

The same pool of TM practitioners were compared to five other health insurance pools, showing 55% fewer visits for benign or malignant tumors, 87% fewer visits for heart disease, 30% fewer visits for infectious diseases, 31% fewer visits for mental disorders, and 87% fewer visits for diseases of the nervous system.^[59]

STRENGTHS AND LIMITATIONS

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

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

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

The leading PNI researcher Alastair Cunningham, who holds Ph.D.'s in both psychology and immunology, articulates this point well: "Although epidemiological considerations suggest that the contribution of psychological factors to cancer onset is small... no upper limit to what can be achieved by psychotherapy is necessarily thereby set: the relative influence of the psyche on outcome may be greatly expanded by such therapy, overriding the usual progression of disease."^[60]

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

It should also be remembered that while there have been many studies documenting "significant" effects of mind/body techniques, there are different kinds of significance. "Statistical" significance means that there is a measurable effect happening, but this does not guarantee that the effect is strong enough to cause tangible medical benefits.

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

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

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