Jeanne Achterberg, Ph.D.--Cochair
Larry Dossey, M.D.--Cochair
James S. Gordon, M.D.--Cochair
Carol Hegedus, M.S., M.A.
Marian W. Herrmann, M.A.
Roger Nelson, Ph.D.
Most traditional medical systems appreciate and
make use of the extraordinary interconnectedness of the mind and
the body and power of each to affect the other. In contrast,
modern Western medicine has regarded these connections as of
The separation between mind and body was
established during the 17th century. Originally it permitted
medical science the freedom to explore and experiment on the body
while preserving for the church the domain of the mind. In the
succeeding three centuries, the medicine that evolved from this
focus on the body and its processes has yielded extraordinary
discoveries about the nature and treatment of disease states.
However, this narrow focus has also tended to
obscure the importance of the interactions between mind and body
and to overshadow the possible importance of the mind in
producing and alleviating disease. The focus of medical research
has been on the biology of the body and of the brain, which is
part of the body. Concern with the mind has been left to
non-biologically oriented psychiatrists, other mental health
professionals, philosophers, and theologians. Psychosomatic
medicine, the discipline that has addressed mind-body
connections, is a subspecialty within the specialty of
During the past 30 years, there has been a
powerful scientific movement to explore the mind's capacity to
affect the body and to rediscover the ways in which it permeates
and is affected by all of the body's functions. This movement has
received its impetus from several sources. It has been spurred by
the rise in incidence of chronic illnesses--including heart
disease, cancer, depression, arthritis, and asthma--which appear
to be related to environmental and emotional stresses. The
prevalence, destructiveness, and cost of these illnesses have set
the stage for the exploration of therapies that can help
individuals appreciate the sources of their stress and reduce
that stress by quieting the mind and using it to mobilize the
body to heal itself.
During the same time, medical researchers have
discovered other cultures' healing systems, such as meditation,
yoga, and tai chi, which are grounded in an understanding of the
power of mind and body to affect one another; developed
techniques such as biofeedback and visual imagery, which are
capable of facilitating the mind's capacity to affect the body;
and examined some of the specific links between mental processes
and autonomic, immune, and nervous system functioning--most
dramatically illustrated by the growth of a new discipline,
The clinical aspect of the enterprise that
explores, appreciates, and makes use of mind-body interactions
has come to be called mind-body medicine. The techniques that its
practitioners use are mind-body interventions. The chapter
discusses the evidence that supports the mind-body approach,
describes some of these techniques, and summarizes the results of
some of the most effective interventions.
This approach is not only producing dramatic
results in specific arenas, it is forming the basis for a new
perspective on medicine and healing. From this perspective it is
becoming clear that every interaction between doctors and
patients--between those who give help and those who receive
it--may affect the mind and in turn the body of the patient. From
this perspective all of medicine, indeed all of health care, is
grounded in the mind-body approach. And all interventions,
alternative or conventional, can be enhanced by it.
Any discussion of mind-body interventions
brings the old questions back to life: What are mind and
consciousness?_ How and where do they originate? How are they
related to the physical body? In approaching the field of
mind-body interventions, it is important that the mind not be
viewed as if it were dualistically isolated from the body, as if
it were doing something to the body. Mind-body relations are
always mutual and bidirectional--the body affects the mind and is
affected by it. Mind and body are so integrally related that, in
practice, it makes little sense to refer to therapies as solely
"mental" or "physical." For example,
activities that appear overwhelmingly "physical," such
as aerobic exercise, yoga, and dance, can have healthful effects
not only on the body but also on such "mental" problems
as depression and anxiety; and "mental" approaches such
as imagery and meditation can benefit physical problems such as
hypertension and hypercholesterolemia as well as have salutary
psychological effects. Even the use of drugs and surgery has its
psychological side. The use of these methods often requires
placebo-controlled, double-blind studies to estimate and factor
out the physical effects of patients' beliefs and expectations.
When the term mind-body is used in this report,
therefore, there is no implication that an object or thing--the
mind--is somehow acting on a separate entity--the body. Rather,
"mind-body" could perhaps best be regarded as an
overall process that is not easily dissected into separate and
distinct components or parts. This point of view, which was put
forward a century ago by William James, the father of American
psychology, has recently been reaffirmed by brain researchers
Francis Crick and Christof Koch (1992).
Throughout history the value of
"human" factors in healing has been recognized. These
factors include closeness, caring, compassion, and empathy
between therapist and patient. Though these factors are
theoretically acknowledged by contemporary medicine, they are
largely ignored in current practice, partly because they are hard
to define and measure and cannot be easily taught. In many
mind-body interventions, however, their relevance is obvious. A
research agenda for the future should include an investigation of
the impact of these qualities on healing--not only on
alternative, mind-body interventions but on orthodox therapies as
Mind-body interventions frequently lead
patients to new ways of experiencing and expressing their
illness. For example, although healing usually denotes an
objective improvement in health, patients commonly state that
they feel "healed" but not "cured"--that is,
they experience a profound sense of psychological or spiritual
well-being and wholeness although the actual disease remains.
Distinctions between curing (the actual eradication of a disease)
and healing (a sense of wholeness and completeness) have little
place in contemporary medical practice but are important to
patients. A place should be made for these distinctions.
Acknowledging that "healing without curing" is both
permissible and honorable requires the recognition of spiritual
elements in illness._ It also requires honoring the wishes of
individuals in deciding what is best in the course of their
disease process. Sometimes, zealous attempts to cure may have
disastrous effects on patients' quality of life for the years
they have left.
Biological scientists have long been aware of
the importance of social relationships on health. As the
evolutionary biologist George Gaylord Simpson observed, "No
animal or plant lives alone or is self-sustaining. All live in
communities including other members of their own species and also
a number, usually a large variety, of other sorts of animals and
plants. The quest to be alone is indeed a futile one, never
successfully followed in the history of life" (emphasis
added) (Simpson, 1953, p. 53).
This observation is nowhere truer than in the
human domain, where perceptions of social isolation and aloneness
may set in motion mind-body events of life-or-death importance.
This point has been demonstrated in research on many dimensions
of human experience, among them the following:
Bereavement. The idea that a person can die
from being separated suddenly from a loved one is rooted in
history and spans all cultures--the "broken heart"
syndrome. In the United States, 700,000 people aged 50 or older
lose their spouses annually. Of these, 35,000 die during the
first year after the spouse's death. Researcher Steven Schleifer
of Mount Sinai Hospital, New York, calculates that 20 percent, or
7,000, of these deaths are directly caused by the loss of the
spouse. The physiological processes responsible for increased
mortality during bereavement have been the subject of extensive
investigations and include profound alterations in cardiovascular
and immunological responses. In study after study, the mortality
of the surviving spouse during the first year of bereavement has
been found to be 2 to 12 times that of married people the same
age (Dimsdale, 1977; Engel, 1971; Holmes and Rahe, 1967; Lown et
al., 1980; Lynch, 1977; Schleifer et al., 1983; Stoddard and
Henry, 1985). These studies have far-reaching therapeutic
implications as well. Individual and group support can--and have
been shown to--help mitigate the devastating effects of loss.
Poor education and illiteracy. A more general
and pervasive form of isolation results from poor education and
illiteracy, which are in turn associated with increased incidence
of disease and death. As Thomas B. Graboys of Harvard Medical
School has stated, poor education is "an Orwellian recipe in
which the estranged worker, besieged from above and below, mixes
internal rage and incessant frustration into a fatal brew"
Many believe that the common factor in poor
education, poor health, and higher mortality is simply that the
poorly educated take worse care of themselves. However, research
shows that smoking, exercise, diet, and accessibility to health
care, while important, do not explain the poorer health and
earlier death of these people; the influence of social isolation
and poor education is more powerful. Moreover, poor education
appears to be only a stand-in or proxy for stress and
loneliness--that is, low education actually does its damage
through the stress and social isolation to which it leads
(Berkman and Syme, 1982; House et al., 1982, 1988; Ruberman et
al., 1984; Sagan, 1987).
The underlying pathophysiological processes by
which social isolation may bring about poor health have been
illuminated by studies of primates in the wild. Low-ranking
baboons, whose entire life is spent in constant danger with
little control, demonstrate high circulating levels of
hydrocortisone, which remain elevated even when the stressful
event has passed. In addition, chronic psychological stress and
isolation have been associated with decreased concentrations of
high-density lipoproteins, which protect against heart disease,
and weaker immune systems with fewer circulating disease-fighting
lymphocytes (Sapolsky, 1990).
Attitude toward work and work status may also
be intimately related to health and well-being. Several lines of
evidence point to these correlations:
* When researcher Peter L. Schnall and his
colleagues examined the relationship between "job
strain," blood pressure, and the mass of the heart's left
ventricle, they found--after adjusting for age, race, body-mass
index, type A behavior, alcohol intake, smoking, the nature of
the work site, sodium excretion, education, and the physical
demand level of the job--that job strain was significantly
related to hypertension. They concluded that "job strain may
be a risk factor for both hypertension and structural changes of
the heart in working men" (Schnall et al., 1990; Williams,
* Epidemiologist C. David Jenkins demonstrated
in 1971 that most people in the United States who experience
their first heart attack when they are under the age of 50 have
no major risk factors. Although Jenkins's findings must be
tempered by the more recent redefinition of what constitutes
"normal" cholesterol and blood pressure, the point
remains: a purely physical approach may be inadequate for
understanding the origins of coronary artery disease in our
culture (Jenkins, 1971).
* In a 1973 survey in Massachusetts, a special
Department of Health, Education, and Welfare task force reported
that the best predictor for heart attack was none of the classic
risk factors, but the level of one's job dissatisfaction (Work in
America: Report of a Special Task Force to the Secretary of
Health, Education, and Welfare, 1973). It is possible that this
finding may be related to the observation that heart attacks in
the United States, as well as in other Western industrialized
nations, cluster on Monday mornings from 8 to 9 a.m., the
beginning of the work week (Kolata, 1986; Muller et al., 1987;
Rabkin et al., 1980; Thompson et al., 1992).
* Robert A. Karasek and colleagues have shown
that the job characteristics of high demand and low decision
latitude have predictive value for myocardial infarction.
Occupational groups embodying these personality traits--waiters
in busy restaurants, assembly line workers, and gas station
attendants, for example--are at increased risk for heart attack.
Their hypothesis is that increasing job demands are harmful when
environmental constraints prevent optimal coping or when coping
does not increase possibilities for personal and professional
growth and development (Bergrugge, 1982; Bruhn et al., 1974;
Karasek et al., 1982, 1988; Palmore, 1969; Sales and House, 1971;
* Psychologist Suzanne C. Kobasa and colleagues
have identified job qualities that offer protection against
cardiovascular morbidity and mortality, even in psychologically
stressful job settings. They refer to the "three Cs":
(1) control--a sense of personal decisionmaking; (2)
challenge--the sense of personal growth and wisdom; becoming a
better person; and (3) commitment to life on and off the job--to
work, community, family, and self. Persons experiencing these
qualities are said to possess "hardiness" and are
relatively immune to job-induced illness or death (Kobasa et al.,
Perceived meaning--how one perceives an event
or issue, what something symbolizes or represents in one's
mind--has direct consequences to health._ The annals of medicine
are replete with anecdotes illustrating the power of perceived
meaning--for example, accounts of sudden death after receiving
bad news. Moreover, perceived meanings affect not just health,
they also influence the types of therapies that are chosen. For
example, if "body" means "machine," as it has
tended to for people since the Industrial Revolution, illness is
likely to be seen as a breakdown or malfunction, and the tendency
is to prefer mechanically oriented approaches to treating
Therapies, therefore, are likely to be designed
to repair the machine when it malfunctions--surgery, drugs,
irradiation, and so on. Or, if illness symbolizes an attack from
the outside by "invading" pathogens or foreign
substances, as it does to many people, people are apt to look for
magic bullets in the form of antibiotics or other substances to
protect them from these threats. Society may even declare
counterattacks, such as the "wars" on acquired
immunodeficiency syndrome (AIDS), heart disease, cancer, high
blood pressure, or cholesterol. Perceived meanings, therefore,
can be translated into the body as potent influences, and they
can strongly influence the design of medical interventions.
More recently, careful studies have indicated
the pivotal role of perceived meaning in health. Sociologists
Ellen Idler of Rutgers University and Stanislav Kasl of the
Department of Epidemiology and Public Health at Yale Medical
School studied the impact of people's opinions on their
health--what their health meant to them. The study involved more
than 2,800 men and women, and the findings were consistent with
the results of five other large studies involving more than
23,000 people. All these studies lead to the same conclusion:
One's own opinion about his or her state of health is a better
predictor than objective factors, such as physical symptoms,
extensive exams, and laboratory tests, or behaviors such as
cigarette smoking. For instance, people who smoked were twice as
likely to die during the next 12 years as people who did not,
whereas those who said their health was "poor" were
seven times more likely to die than those who said their health
was "excellent" (Idler and Kasl, 1991).
Dorland's Illustrated Medical Dictionary,
twenty-fifth edition, defines the word placebo (in Latin, "I
will please") as an inactive substance or preparation given
to satisfy the patient's symbolic need for drug therapy and used
in controlled studies to determine the efficacy of medicinal
substances. It is also a procedure with no intrinsic therapeutic
value, performed for such purposes. Although the placebo response
is perhaps the most widely known example of mind-body interaction
in contemporary scientific medicine,_ it is at the same time one
of the most undervalued and neglected assets in today's medical
practice (Benson and Epstein, 1975). Even the definition from the
medical dictionary suggests the term's uselessness apart from its
narrow role in testing drugs. However, throughout most of medical
history--in the centuries before antibiotics and other
"wonder drugs"--the placebo effect was the central
treatment physicians offered their patients (Benson and Epstein,
1975). Doctors hoped that their reassuring attention and their
belief in their treatments would mobilize powers within their
patients to fight their illnesses.
Today the placebo response is considered
primarily a way of testing new drugs: if patients who have been
given a placebo improve as much as those who took the new
medication, the drug is dismissed as ineffective and with it the
placebo. "Since a beneficial effect is the desired
result," say cardiologist Herbert Benson and psychiatrist
Mark Epstein, "should not the placebo effect be further
investigated so that we might better explain its worthwhile
consequences?" (Benson and Epstein, 1975).
The placebo response relies heavily on the
interrelationship between doctor and patient. Patients bring with
them to the doctor's office their attitudes, expectations, hopes,
and fears. Doctors, in turn, have their own biases, attitudes,
expectations, and methods of communication, which have a profound
effect on patients. Doctors who believe in the efficacy of their
treatment communicate that enthusiasm to their patients; those
who have strong expectations of specific effects and are
self-confident and attentive are the most successful at eliciting
a positive placebo response (Wheatley, 1967). It is the
interrelationship between the doctor and patient and the
congruence of their expectations that bring about a positive
placebo response. If the congruence is lacking, a favorable
response rarely occurs (Hankoff et al., 1960).
The placebo response says a great deal about
the importance of the doctor-patient relationship and the need to
pay greater attention to it--and to provide further medical
training on how that relationship can be heightened. It is
particularly important in this highly technological era of
medicine, when doctor-patient contacts are diminishing.
Although the literature of mind-body
interaction documenting the placebo response is too vast to be
reviewed here, several additional mind-body issues raised by this
research deserve emphasis:
* The placebo response is almost ubiquitous.
Studies show that in virtually any disease, roughly one-third of
all symptoms improve when patients are given a placebo treatment
without drugs (Goleman and Gurin, 1993).
* Placebo responses can be extraordinarily
dramatic and offer valuable insights into the extent of the
"powers of the mind" (Levoy, 1989).
* The nocebo response, a toxic or negative
placebo event, raises serious questions about what is meant by
"the natural course" or "the inherent
biology" of any particular disease and suggests the great
degree to which attitudes and expectations can affect one's state
of health and the course of an illness.
* Nocebo effects can also be dramatic, are very
common, and should be more widely acknowledged. Even
anaphylactoid reactions (Wolf and Pinsky, 1954) and addictions to
placebos (Rhein, 1980)--reactions not commonly thought to be
"mental" in origin--have been reported, along with a
variety of other noxious reactions. In one controlled study by
the British Stomach Cancer Group, 30 percent of the control
(placebo-treated) group lost their hair, and 56 percent of the
same group had "drug-related" nausea or vomiting
(Fielding et al., 1983).
"Spirituality" is, generally
speaking, one's inward sense of something greater than the
individual self or the meaning one perceives that transcends the
immediate circumstances. "Religion" may be described as
the outward, concrete expression of such feelings.
The therapeutic potential of spirituality and
religion have generally been neglected in the teaching and
practice of medicine. However, epidemiologists Jeffrey S. Levin
and Harold Y. Vanderpool have assembled what they term an
"epidemiology of religion"--a large body of empirical
findings "lying forgotten at the margins of medical research
. . . specifically . . . nearly 250 published studies dating back
over 150 years which [present] the results of epidemiologic,
sociomedical, and biomedical investigations into the effects of
religion. Nearly all of these investigations were large-scale
studies" (Levin, 1989; Levin and Schiller, 1987; Levin and
Vanderpool, 1991; Vanderpool and Levin, 1990).
Reviewing this immense database, Schiller and
Levin found significant associations with variables such as
religious attendance and subjective religiosity for a wide
assortment of health outcomes, including cardiovascular disease,
hypertension and stroke, uterine and other cancers, colitis and
enteritis, general mortality, and overall health status (Schiller
and Levin, 1988). These data are so consistent that Levin and
Vanderpool suggest that infrequent religious attendance or
observance should be regarded as a consistent risk factor for
morbidity and mortality of various types (Levin and Vanderpool,
These findings are consistent with those of
David B. Larson and Susan S. Larson, who surveyed 12 years of
issues of the American Journal of Psychiatry and the Archives of
General Psychiatry. They found that 92 percent of the studies
that measured participation in religious ceremony, social
support, prayer, and relationship with God showed benefit for
mental health, whereas 4 percent were neutral, and 4 percent
showed harm (Larson and Larson, 1991). Craigie and colleagues, in
a 1990 review of 10 years of issues of the Journal of Family
Practice, reported similar findings: 83 percent of studies showed
benefit for physical health, 17 percent were neutral, and 0
percent showed harm (Craigie et al., 1990).
Matthews, Larson, and Barry made a major
contribution in bringing together the research in this field--a
two-volume report that compiles hundreds of studies, titled The
Faith Factor: An Annotated Bibliography of Clinical Research on
Spiritual Subjects (Matthews et al., 1993). Because research
indicates that religious and spiritual meanings are correlated
with increased physical and mental health and a lower incidence
of a variety of diseases, and because religious and spiritual
issues also affect profoundly how physicians regard death and
treat the elderly, the quarantine against bringing up these
matters in the doctor-patient relationship must be lifted.
Becoming sensitive to these delicate issues does not require
physicians to advocate any particular religious point of view. It
does imply, however, that they should honor the salutary effects
of spiritual meanings in their patients' lives, and inquire about
spiritual and religious issues as assiduously as any physical
The belief that life-threatening diseases such
as cancer may disappear suddenly and completely is universal.
This idea is usually coupled with the conviction that radical
healing is somehow connected with one's state of mind.
Opinions vary as to how often cancer regresses
spontaneously, leaving the person healthy. In their 1966 book on
spontaneous regression of cancer, Everson and Cole collected 176
case reports from various countries around the world and
concluded that spontaneous regression occurs in one of 100,000
cases of cancer. Other authorities believe the incidence may be
much higher. Everson and Cole found that almost any therapy to
induce remission seems to work some of the time. Regression of
cancer follows such diverse measures as intercessory prayer,
conversion to Christian Science, mud packs, vitamin therapy, and
force-feeding. They found that spontaneous regression occurs
after both insulin and electroshock treatments. Since almost any
treatment seems to work occasionally but not consistently, many
have concluded that these measures are equally worthless and that
spontaneous regression of cancer is purely a random event
(Everson and Cole, 1966).
This point of view is a historical oddity.
Prior to the 20th century, both physicians and patients believed
the mind was a major factor in the development and course of
cancer. In the years since Everson and Cole's review, this
perspective has been recovered and reexamined. Many
investigators--including psychologist Lawrence LeShan (1977) of
New York and psychiatrist Steven Greer (1985) of King's College
Hospital, London--have produced studies that suggest that
emotions, attitudes, and personality traits may affect the onset
of cancer as well as its course and outcome.
The Institute of Noetic Sciences has just
published the most comprehensive investigation of spontaneous
remission ever done--Spontaneous Remission: An Annotated
Bibliography (O'Regan and Hirshberg, 1993)._ This 15-year project
was the work of biochemist Caryle Hirshberg and researcher
Brendan O'Regan, who combed 3,500 references from more than 800
journals in 20 languages. The report deals not only with cancer
but also with the spontaneous remission of a wide spectrum of
diseases. It is the largest database of medically reported cases
of spontaneous remission in the world. Key findings are as
* Remission is a widely documented phenomenon,
almost certainly more common than generally believed.
* Remission is an extremely promising area of
research. Studying the psychobiological processes involved may
provide important clues to understanding the body's
self-regulatory processes and the breakdowns that precede the
onset of many diseases.
* Data on remissions can have an important
influence on how patients are treated and handled when diagnosed
with a terminal illness. Restoring hope may help instill a
"fighting spirit," an important factor in recovery from
This interest in the possible role of the mind
in the causation and course of cancer has been significantly
stimulated by the discovery of the complex interactions among the
mind and the neurological and immune systems, the subject of the
rapidly expanding discipline of psychoneuroimmunology.
The relationship between psychological
strategies and the regression of cancer is immensely complex and
cannot be fully reviewed here. Two salient points should be made,
however, that contradict popular belief and illustrate the
complexity of these events: (1) Although an aggressive, fighting
stance is generally advocated in stimulating spontaneous
regression of cancer, University of California-Los Angeles
psychologist Shelley E. Taylor has shown that (a) psychological
denial following the diagnosis of breast cancer and (b) openly
facing the disease and its implications are associated with
near-equal survival statistics (Taylor, 1989). (2) Sometimes a
mode of psychological acceptance, not aggressiveness, toward the
diagnosis seems to set the stage for spontaneous remission. This
point is particularly obvious in a series of spontaneous cancer
remissions reported from Japan by Y. Ikemi and colleagues (Ikemi
et al., 1975).
The profound differences in the psychological
stances taken by people who survive cancer suggest that not only
is there extreme variation between cultures, there are profound
differences in the psychology of cancer survivors within cultures
as well. Because the causal mechanisms involved are not known,
and in view of the sheer variety of the psychological states that
are apparently involved in spontaneous regression of cancer,
physicians are currently unjustified in recommending uniformly
that patients with cancer adopt a specific psychological stance
in hopes of getting well. Still, spontaneous remission of cancer
is a fact. Far more knowledge is needed about when and why it
happens and what can be done to promote it.
The Panel on Mind-Body Interventions has
selected the following therapies in an attempt to illustrate the
diversity of this field and to illustrate some of the scientific
work that has been done. The panel has not attempted to be
exhaustive in this review, nor does it believe an exhaustive
approach is possible in this document. Space does not allow
discussion of many alternative therapies in which mind-body
interactions are obviously prominent, such as anthroposophically
extended medicine (see the "Alternative Systems of Medical
Practice" chapter), Christian Science, and many others. Even
though the sampling of specific therapies is necessarily
restricted, the panel hopes this limited discussion will
contribute to the development of a larger dialog in which all
perspective mind-body interventions can eventually be considered.
It may be an error to focus on psychotherapy as
an adjunctive therapy. Only from a perspective that views doctors
as mechanics does psychotherapy become simply a technique. In
fact, psychotherapy is the medium and basis of all care. It
influences to some degree the efficacy of all health
interventions, even those thought to be purely physical in
Derived from Greek words meaning "healing
of the soul," psychotherapy means treatment of emotional and
mental health, which is in turn closely 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 emotive approaches. It also should be understood
more generally as the matrix of interaction in which all the
helping professions operate.
The number of health care professionals in the
United States with some level of training in psychiatric and
psychological counseling is immense. Currently, the American
Psychiatric Association registers approximately 37,000 members;
the American Psychological Association, 54,562 (approximately 60
percent clinical and 40 percent research and academic). The
Department of Labor estimates that there are between 380,000 and
400,000 social workers; the American Medical Association lists
615,000 physicians, and the American Nurses Association lists
2,000,000 nurses. All of these people, as well as alternative
health care practitioners, make conscious or unconscious use of
psychotherapeutic interventions in their contacts with patients.
Conventional psychotherapy is conducted
primarily by means of psychological methods such as suggestion,
persuasion, psychoanalysis, and reeducation. It can be divided
into the following six general categories. All of the following
therapies can be undertaken either individually or in groups.
1. Psychodynamic therapy is derived from
psychoanalysis. Current emotional reactions are related to past
experiences, usually those of early childhood. It is generally
directed toward changing fundamental personality patterns.
2. Behavior therapy emphasizes making specific
behavior changes, such as learning not to be afraid of public
3. Cognitive therapy facilitates changing
specific behaviors but focuses on habitual thoughts that affect
4. Systems therapy emphasizes relationship
patterns and may involve all family members in therapy sessions.
5. Supportive therapy concentrates on helping
people in major emotional crises, and treatment may include drug
6. Body-oriented therapy hypothesizes that
emotions are encoded in and may be expressed as tension and
restriction in any part of the physical body. Therapy uses
breathing techniques, movement, and manual pressure and probing
to help people release emotions that are believed to have been
located in their tissues.
Any and all of these approaches may be used,
but if a patient has a physical illness, the therapist focuses on
short-term treatment dealing with any emotional state directly
related to the physical condition. For example, depression and
anxiety are common effects of any serious illness and may make it
worse. Psychotherapy helps patients acknowledge the presence of
these emotions and diminish their effects, thus enhancing
According to a study by James J. Strain (1993),
an average of "one of every five people in the United States
has a psychological disorder every six months--most commonly
anxiety, depression, substance abuse, or acute confusion."
At present, approximately three-fifths of patients with
psychological problems are seen only by primary care physicians,
many of whom are not well trained in psychotherapy and do not
have adequate time to spend with each patient. Thus, despite the
enormous need for psychological care, most people with medical
illnesses do not receive screening or treatment for their
Clinical applications. Studies have shown that
psychotherapy has had beneficial effects with medical crises and
Medical crises. Research indicates that
psychotherapeutic treatment can hasten a recovery from a medical
crisis and is in some cases the best treatment for it. According
to Strain, brief psychotherapy reduced the hospital stay of
elderly patients with broken hips by an average of 2 days. These
patients had fewer rehospitalizations 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. Currently, however, most psychological
problems associated with physical illnesses remain undiagnosed or
are not identified until near the end of a hospital stay.
In-hospital psychotherapy helps people cope
with fears about their medical state by providing them with a
supportive atmosphere in which to verbalize feelings. This
atmosphere may give them a sense that their concerns are
understood. It may also, by altering mood and attitude, be a
significant factor in improving outcome. At the University of
Minnesota, 100 patients preparing to go through bone marrow
transplant for leukemia were examined for depression. Of the 13
patients diagnosed with major depression, all but one died in the
following year; but all of the other 87 patients were still alive
2 years later.
Somatic illness. Somatic illnesses, in which
physical symptoms appear to have no medical cause, are often
improved markedly with psychotherapy. The emotional mechanism
triggering somatic illness is presumed to be a problem that is
not acceptable to the person and is transformed into a physical
ailment. Studies measuring rates of return visits to a health
maintenance organization after receiving a brief interval of
psychotherapy are very positive. Another study demonstrated a
reduction in visits following group support and psychotherapeutic
treatment. A physician who recognizes this condition can save
time and money and alleviate the physical suffering of the
Cost-effectiveness. Psychotherapy has been
shown to speed patients' recovery time from illness. Faster
recovery in turn leads to smaller medical bills and fewer return
visits to medical practitioners. In a study by Nicholas Cummings
(Cummings and Bragman, 1988), patients who frequently visited
medical clinics were offered short-term psychotherapy, and
"these patients showed significant declines in their visits
to doctors, days spent in the hospital, emergency room visits,
diagnostic procedures, and drug prescriptions." The overall
health care costs decreased by 10 to 20 percent in the years
following brief psychotherapy.
A more specific example of cost-effectiveness
was demonstrated in a study by Margaret Caudill and colleagues
(1991), in which 10 group sessions of 90 minutes of psychotherapy
and relaxation techniques significantly reduced the severity of
pain. In a study of clinic use by chronic pain patients, patients
who participated in the outpatient behavioral medicine program
used 36 percent fewer clinic visits than those who did not. Cost
savings were estimated at more than $100 per patient per year
(Caudill et al., 1991).
Support groups. Social, cultural, and
environmental contexts, which have a powerful impact on bringing
about both psychological and physiological change, should be more
fully investigated. The literature on support groups demonstrates
that in a wide variety of physical illnesses, such as heart
disease, cancer, asthma, and strokes, a support group can have a
powerful positive effect.
Consider the potential role of group support
and psychological counseling in cancer and heart disease, the two
major causes of death in the United States. One recent,
well-publicized example of this ubiquitous effect is David
Spiegel's study on women with metastatic breast cancer. Women who
took part in a support group lived an average of 18 months longer
(a doubling of the survival time following diagnosis) than those
who did not participate. In addition, all the long-term survivors
belonged to the therapy group (Spiegel et al., 1989).
In a well-known 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 altogether, and after 1 year the coronary artery
obstructions were demonstrated to be smaller. This strongly
suggests that coronary artery disease, the Nation's most deadly
and expensive health care problem, is reversible through a
complementary, noninvasive, diet and behavioral modification
approach that emphasizes group psychotherapy (Ornish, 1990). (See
the "Diet and Nutrition" chapter for more details on
Support groups have two other major benefits:
(1) they help members form bonds with one another, an experience
that may empower members for the rest of their lives; and (2)
they are inexpensive or even free (e.g., Alcoholics Anonymous).
Research needs and opportunities. Future
opportunities for research on the interconnectedness of mind and
body include the following:
* Studies should be directed toward devising
methods for integrating psychotherapy into all aspects of health
care and evaluating its efficacy in all treatments.
* Researchers should try to understand better
how small shifts in behavior, thoughts, and attitudes can help
change a person's entire physical and psychological state.
* Whether behavioral intervention can delay or
prevent the onset of illness should be assessed.
* How support groups work should be explored.
What types of groups are best? Leaderless or directed groups?
Participants with single or mixed diagnoses? With time-limited or
open-ended sessions? What type of personality is most likely to
find them useful? Are they harmful to certain types of
individuals? If so, what types?
* The role of psychotherapy in treating serious
illness should be emphasized. Unfortunately, many people,
including health care professionals and academicians, consider
psychotherapeutic intervention in physical illness a luxury or
frill. However, the studies cited above suggest that
psychological intervention works best when used early and may
actually make the difference between life and death in certain
* Research should be undertaken on just how the
body records and expresses emotions and on the possible
effectiveness of body-oriented therapies in releasing physical
tensions and resolving emotional problems.
* Mental health researchers should direct more
attention to certain anomalous and unexplained mind-body events
that have long existed on the periphery of medicine and that are
generally ignored. Examples include the falling off of warts with
suggestion; psychological profiles of extremely long-lived
people; and the spontaneous and unanticipated remission of
"fatal" cancer. If explained, these events could yield
major gains in understanding the mind and its relationship to the
body and could yield valuable new approaches to health.
* Mental health departments in teaching
institutions should be bolder in entertaining novel explanations
of mind and consciousness and the relationship between mind and
brain. Currently, almost all academic institutions teach models
of consciousness that largely equate mind and consciousness with
the physical brain. This perspective is incomplete; it entirely
ignores the considerable data implying that a nonlocal concept of
consciousness may be a more encompassing explanation for the
manifestations of consciousness. (See Dossey, 1989, 1992; Jahn,
1981; and Josephson and Ramachandran, 1980.) For patients, a
physically based view of illness is restrictive, expensive, and
often harmful. As long as mind is equated with brain, the routine
tendency to employ physical interventions such as drugs for
mental disturbances will continue to overshadow other methods
that conceivably might be safer, more effective, and less costly.
* Mental health professionals should explore
other areas of science--areas usually considered "off
base" and "irrelevant"--for perspectives that
might be enriching. Quantum mechanics, dissipative structure
theory, chaos theory, and nonlinear dynamics are only a few areas
of science that have great potential relevance for understanding
the mind and consciousness._
* The concept of what constitutes appropriate
areas for psychiatric intervention should be enlarged. Impressive
evidence exists that "disorders of meaning" (a person's
sense that his or her life lacks meaning) are epidemic in society
and that these disorders can have life-and-death consequences.
Mental health professionals should deal more effectively with
issues involving meanings and values, which are usually shunted
aside by medical professionals. Some of these problems are
spiritual and require a reexamination of the traditional
distinctions psychiatrists have made between psychiatry and
religion, and between "science" and
* The cost-effectiveness of psychiatric
intervention in physical illness deserves to be better known and
should be more widely publicized. In an era of continued
escalation of health care costs, these interventions offer a very
real opportunity to improve health and limit costs
Meditation is a self-directed practice for
relaxing the body and calming the mind. The meditator makes a
concentrated effort to focus on a single thought--peace, for
instance; or a physical experience, such as breathing; or a sound
(repeating a word or mantra, such as "one" or a
Sanskrit word such as "kirim"). The aim is to still the
mind's "busyness"--its inclination to mull over the
thousand demands and details of daily life.
Most meditative techniques have come to the
West from Eastern religious practices--particularly those of
India, China, and Japan--but they can be found in all cultures of
the world. Christian contemplation--saying the rosary or
repeating the "Hail Mary"--brings similar effects and
can be said to be akin to meditation. Michael Murphy, the
cofounder of Esalen Institute, claims that the concentration used
in Western sports is itself a form of meditation. While most
meditators in the United States practice sedentary meditation,
there are also many moving meditations, such as the Chinese
martial art tai chi, the Japanese martial art aikido, and walking
meditation in Zen Buddhism. Yoga can also be said to be a
Until recently, the primary purpose of
meditation has been religious, although its health benefits have
long been recognized. During the past 15 years, it has been
explored as a way of reducing stress on both mind and body.
Cardiologists, in particular, often recommend it as a way of
reducing high blood pressure.
There are many forms of meditation--with many
different names--ranging in complexity from strict, regulated
practices to general recommendations, but all appear to produce
similar physical and psychological changes (Benson, 1975; Chopra,
1991; Goleman, 1977; Mahesh Yogi, 1963).
If practiced regularly, meditation develops
habitual, unconscious microbehaviors that produce widespread
positive effects on physical and psychological functioning.
Meditating even for 15 minutes twice a day seems to bring
While many individuals and groups have examined
the effects of meditation, two major meditation programs have
extensive bodies of research: transcendental meditation and the
Transcendental meditation. Transcendental
meditation (TM) was developed by the Indian leader Maharishi
Mahesh Yogi, who eliminated from yoga certain elements he
considered nonessential. In the 1960s he left India and came to
the United States, bringing with him this reformed yoga, which he
felt could be grasped and practiced more easily by westerners.
His new method did not require the often difficult physical or
mental exercises required by yoga and could be easily taught in
one training session. TM was soon embraced by some celebrities of
that day, such as the Beatles, and can now probably claim well
over 2 million practitioners.
TM is simple. To prevent distracting thoughts a
student is given a mantra (a word or sound) to repeat silently
over and over again while sitting in a comfortable position.
Students are instructed to be passive and, if thoughts other than
the mantra come to mind, to notice them and return to the mantra.
A TM student is asked to practice for 20 minutes in the morning
and again in the evening.
In 1968, Harvard cardiologist Herbert Benson
was asked by TM practitioners to test them on their ability to
lower their own blood pressures. At first, Benson refused this
suggestion as "too far out" but later was persuaded to
do so. Benson's studies and an independent investigation at the
University of California at Los Angeles were followed by much
additional research on TM at Maharishi International University
in Fairfield, IA, and at other research centers. Published
results from these studies report that the use of TM is
discretely associated with
* reduced health care use;
* increased longevity and quality of life;
* reduction of chronic pain (Kabat-Zinn et al.,
* reduced anxiety;
* reduction of high blood pressure (Cooper and
* reduction of serum cholesterol level (Cooper
and Aygen, 1978);
* reduction of substance abuse (Sharma et al.,
* longitudinal increase in intelligence-related
measures (Cranson et al., 1991);
* treatment of posttraumatic stress syndrome in
Vietnam veterans (Brooks and Scarano, 1985);
* blood pressure reduction in African-American
persons (Schneider et al., 1992); and
* lowered blood cortisol levels initially
brought on by stress (MacLean et al., 1992).
Relaxation response. Convinced that meditation
was a possible treatment for high blood pressure, Benson later
pursued his investigation at the Mind-Body Medical Institute at
Harvard Medical School. He identified what he calls "the
relaxation response," a constellation of psychological and
physiological effects that appear common to many practices:
meditation, prayer, progressive relaxation, autogenic training,
and the presuggestion phase of hypnosis and yoga (Benson, 1975).
He published his method in a book of the same name.
Over a period of 25 years, Benson and
colleagues have developed a large body of research. During this
time, meditation in general and the relaxation response
specifically have slowly moved from alternative to mainstream
medicine, although they are still overlooked by many conventional
doctors. Benson's research has demonstrated a wide range of
effects from meditation (or the relaxation response) on bodily
functions: oxygen consumption and carbon dioxide and lactate
production, adrenocorticotropic hormone excretion, blood elements
such as platelets and lymphocytes, cell membranes, norepinephrine
receptors, brain wave activity, and utilization of medical
In addition, one study by Benson's group
indicated that chronic pain patients who meditated had a net
reduction in general health care costs, suggesting that this
approach is cost-effective (Caudill et al., 1991)._
Although the positive effects of meditation
clearly outnumber and outweigh the negative effects, the latter
have also been studied (Blackmore, 1991). Potential adverse
effects include adverse psychological feelings (e.g., feelings of
negativity, disorientation) in a small percentage of meditators
after meditation retreats; and elicitation of acute episodes of
psychosis by intensive meditation in schizophrenics.
Despite the breadth and clarity of the
research_ indicating that meditation is a useful, low-cost
intervention, it continues to be regarded as unconventional and
is still ignored by most medical professionals. The report of the
National Research Council (NRC) on meditation, which drew heavily
on a negative review by Holmes (1984), emphasized concerns about
weak experimental designs, failure to discriminate meditation
from other sources of effects, and conceptual issues such as the
lack of an underlying mechanism. A critique of the NRC report by
Orme-Johnson and Alexander responded to these criticisms using
quantitative reviews which they claimed provided strong arguments
for taking a deeper look at meditation (Orme-Johnson and
Alexander, 1992). The Mind-Body panel's critique of the NRC
report is in appendix B of this report.
Current clinical use. In September 1987,
science writer Daniel Goleman reported in the New York Times
Magazine that some 400 universities offered some level of
training in behavioral medicine, including meditation, and
"thousands of hospitals, clinics, and individual
practitioners offer the treatments." Harvard Medical
School's Mind-Body Medical Institute has several thousand patient
visits per year in its clinical arm and maintains an active
research program as well as training programs for doctors,
nurses, social workers, and psychologists, in conjunction with
the school's continuing education program (Benson and Stuart,
1992). Other hospitals want clinics of this kind, and
dissemination is proceeding. The first affiliate is at Mercy
Hospital in Chicago. Others sites being negotiated are
Morristown, NJ; Columbus, OH; Charlottesville, VA; and Houston,
TX. Many other independent clinics employ meditation techniques,
such as the Cambridge Hospital behavioral medicine program and
the University of Massachusetts Medical School program.
In addition to being used by individuals,
meditation is also an important part of the unconventional
healing approaches used by mental, spiritual, and psychic
healers. Almost all healers consider some form of meditation or
quiet prayer fundamental to their practice. (Mental healing is
discussed in the "Prayer and Mental Healing" section.)
Indeed, the state of focused attention and exclusive concern that
some doctors demonstrate in orthodox medicine can be thought of
as a form of meditation. In addition, meditation is often
practiced by some physicians for their own benefit, even though
they do not use it in treating their patients.
Cost-effectiveness and potential economic
impact. Insurance statistics for a group of 2,000 meditators
compared with 600,000 nonmeditators show that the use of medical
care was 30 percent to 87 percent less for meditators in all but
one of 18 categories (childbirth) (McSherry, 1990; Orme-Johnson,
1987). In another study at the Harvard Community Health Plan,
patients who attended a 6-week behavioral medicine group that
included meditation made significantly fewer visits to physicians
during the 6 months that followed; the savings were estimated at
$171 per patient.
If the definition of meditation is expanded to
include more or less formal religious practices that emphasize
quiet prayer, the number of people using some form of meditation
becomes enormous and the potential health benefits
correspondingly large. In the United States, TM has been taught
to well over a million people, and it is estimated that most
continue the practice regularly. Benson's Mind-Body Medical
Institute currently has 7,000 patient visits per year and has
trained thousands of health professionals in applying the
Theory and rationale. How and why does
meditation work? There are several related theories about the
underlying mechanism. Ken Walton, director of the Neurochemistry
Laboratory, Maharishi International University, states:
The frequently striking results of [studies of
TM] have not been widely discussed in the medical literature,
purportedly because "there is no reasonable mechanism"
which could explain such a spectrum of health effects from a
simple mental technology. . . . Only in the last year has the
stress connection emerged with the degree of clarity it now has.
The . . . bottom line is the proposed vicious circle linking
chronic stress, serotonin metabolism, and hippocampal regulation
of the hypothalamic-pituitary-adrenocortical (HPA) axis (Nelson,
Similarly, Everly and Benson have proposed that
meditation is effective in a wide variety of disorders that may
be called "disorders of arousal," in which the limbic
system of the brain has become overstimulated. Relaxation and
meditation training serve to "retune" the nervous
system by damping the production of adrenergic catecholamines,
which stimulate limbic activity. Everly and Benson (1989) suggest
also that excessive limbic activity may inhibit immune
function--a possibility that may account for the association of
chronic stress and increased susceptibility to infection.
Research needs and opportunities. The following
points may be made about research needs in the area of
* More than 30 years of research, as well as
the experiences of a large and growing number of individuals and
health care providers, suggest that meditation and similar forms
of relaxation can lead to better health, higher quality of life,
and lowered health care costs. This research should be collected
and critically evaluated, and its results should be widely
disseminated to health professionals.
* Some of the research needs to be replicated
and the physiological and biochemical dimensions more fully
investigated to facilitate education, application, and acceptance
into mainstream medicine.
* Research is needed into the commonalities and
differences of meditation and other forms of self-regulation such
as hypnosis, relaxation, and guided imagery.
* The nature and purpose of meditation need to
be made more explicit by its advocates. In most traditions,
meditation was originally considered primarily a technique for
changing consciousness and achieving spiritual understanding;
improvements in health were considered only byproducts. Today,
meditation seems to be popularly regarded as utilitarian, as
simply as a tool for improving physical health. Future research
should compare the health benefits that result when meditation is
undertaken for explicit health reasons versus for its own sake.
* Most meditation research has involved young
or middle-aged Americans who have practiced meditation for
several months to several years. Understanding would be enhanced
by more studies of advanced, expert meditators who have spent a
lifetime of meditation in a variety of traditions and cultures.
This approach would be more likely to shed light on the maximal
health benefits possible from meditation.
* Many different schools of meditation exist,
advocating a variety of techniques. Prospective studies should
investigate whether any particular school offers special health
* To ameliorate the objections of many
Christian religious groups to meditation, cross-disciplinary
dialog and communication should be encouraged that would examine
(1) the commonalities between Christian prayer and contemplation
and Eastern meditation, and (2) the extraordinary similarities in
the esoteric mystical traditions of East and West.
Most important, meditation techniques offer the
potential of learning how to live in an increasingly complex and
stressful society while helping to preserve health in the
process. Given their low cost and demonstrated health benefits,
these simple mental technologies may be some of the best
candidates among the alternative therapies for widespread
inclusion in medical practice and for investment of medical
Imagery is both a mental process (as in
imagining) and a wide variety of procedures used in therapy to
encourage changes in attitudes, behavior, or physiological
reactions. As a mental process, it is often defined as "any
thought representing a sensory quality" (Horowitz, 1983). It
includes, as well as the visual, all the senses--aural, tactile,
olfactory, proprioceptive, and kinesthetic. Imagery is often used
synonymously with visualization; this use is misleading, because
the latter refers only to seeing something in the mind's eye,
whereas imagery can mean imagining through any sense, as through
hearing or smell.
Imagery is a common ingredient in many
behavioral therapies not specifically labeled imagery. Since it
often involves directed concentration, it can also be thought of
as a form of meditation (see the "Meditation" section).
Imagery can be taught either individually or in groups, and the
therapist often uses it to affect a particular result, such as
quitting smoking or bolstering the immune system to attack cancer
Practices that have a component of imagery are
almost ubiquitous. They include, among many others, biofeedback,
desensitization and counterconditioning, psychosynthesis,
neurolinguistic programming, gestalt therapy, rational emotive
therapy, and hypnosis (see the "Hypnosis" section). Any
therapy that relies on imagery or fantasy to motivate,
communicate, solve problems, or evoke heightened awareness and
sensitivity could be described as a form of imagery. Forms of
meditation that involve repeating a sound or mantra (e.g., TM) or
focusing attention on an object that has no concurrent external
referent (such as a whale in the ocean) could also be developed
as aspects of imagery. Likewise, relaxation techniques that
involve instruction (e.g., "Your hands are heavy"),
such as autogenic training, have an imagery component.
Whether imagery differs from hypnosis in terms
of purpose and state of consciousness is currently debated.
Hypnotherapists, particularly those who train clients in methods
of self-hypnosis, are often indistinguishable from practitioners
of imagery. What has been agreed on is that there is a
correlation between the ability to image and the capacity to
enter into an altered state of consciousness, including the
hypnotic state (Barber, 1984; Hilgard, 1974; Lynn and Rhue,
Numerous studies indicate that mental imagery
can bring about significant physiological and biochemical
changes. These findings, which have encouraged the development of
imagery as a health care tool, include its capacity to affect the
following: oxygen supply in tissues (Olness and Conroy, 1985);
cardiovascular changes (Barber, 1969); vascular or thermal change
(Green and Green, 1977); the pupil and the cochlear reflex
(Luria, 1968); heart rate and galvanic skin response (Jordan and
Lenington, 1979); salivation (Barber et al., 1964; White, 1978);
gastrointestinal activity (Barber, 1978); increase in breast size
(Barber, 1984); the Mantoux reaction (Black et al., 1963); and
blood glucose levels (Stevens, 1983). Several hundred studies
using biofeedback, which Green and Green (1977) refer to as an
"imagery trainer," expand the list considerably,
running the gamut from effects on the firing of single
motorneurons (Basmajian, 1963) to brain wave alterations (Brown,
Some of these findings are from well-controlled
studies, but the vast majority represent reports of single cases
or small studies that have not been replicated. Nevertheless, the
overriding conclusion is that there is a relationship between
imagery of bodily change and actual bodily change. Without
question, imagery calls for further and more precise
Clinical applications. Procedures for imagery
fall into at least three major categories: (1) evaluation or
diagnostic imagery, (2) mental rehearsal, and (3) therapeutic
Techniques used in evaluation or diagnostic
imagery involve asking the person to describe his or her
condition in sensory terms. The therapist gathers information
regarding the disease, the effect of treatment, and any natural
inner healing resources the person might be sensing. The patient
is asked, literally, "How do you feel?" In
psychotherapy settings, dreams or fantasies might be used in this
way, as a means to gaining insight or control over a situation.
Evaluation imagery is usually done early in a
therapy session and serves as a format for designing both mental
rehearsal and therapeutic intervention strategies. It also is an
indicator of the person's understanding of the mechanisms of
health and disease and provides opportunity for patient
Mental rehearsal is an imagery technique used
before medical techniques, usually in an attempt to relieve
anxiety, pain, and side effects, which are exacerbated by
heightened emotional reactions. Surgery or a difficult treatment
is rehearsed before the event so that the patient is prepared and
is rid of any unrealistic fantasies.
Typically, a relaxation strategy is taught,
then the treatment and recovery period are described in sensory
terms as the patient is taken on a guided imagery
"trip." Care is taken to be factual without using
emotion-laden or fear-provoking words, and the medical procedure
is reframed in a positive way whenever possible. The patient is
taught coping techniques such as distraction, mental
dissociation, muscle relaxation, and abdominal breathing.
Published results with mental rehearsals (or
sensory education) are almost uniformly positive and often
dramatic. Effects include reduced pain and anxiety; decreased
length of hospital stay; the use of fewer pain medicines,
barbiturates, tranquilizers, and other medications; and reduced
treatment side effects. Mental rehearsal is a cornerstone of
certain natural childbirth practices. It has also been tested in
burn debridement (Kenner and Achterberg, 1983) and as a
preparation for spinal surgery (Lawlis et al., 1985),
cholecystectomy, pelvic examination, cast removal, and endoscopy
(Johnson et al., 1978). In each of these instances, rehearsal
through imagery has been found to diminish pain and discomfort
and to reduce side effects.
Imagery as a therapeutic intervention is based
on the idea that the images have either a direct or an indirect
effect on health. Therefore, either the patients are shown how to
use their own flow of images about the healing process or,
alternatively, they are guided through a series of images that
are intended to soothe and distract them, reduce any sympathetic
nervous system arousal, or generally enhance their relaxation.
The practitioner may also use "end state" types of
imagery, having patients imaging themselves in a state of perfect
health, well-being, or successfully achieved goals.
A major and serious criticism of imagery
literature (as well as hypnosis literature) is that clinic
protocols are seldom provided. Therefore, it is impossible to
know what type of therapeutic strategy was used, and of course it
cannot be replicated. Some practitioners even regard their
protocols as trade secrets and refuse to divulge them.
Whether imagery is merely an antidote to
feelings of helplessness or whether the image itself has the
capacity to induce the desired physical effect is still unclear.
Existing research suggests both conclusions are justified,
depending on the situation in question.
Imagery has been successfully tested as a
strategy for alleviating nausea and vomiting associated with
chemotherapy in cancer patients (Frank, 1985; Scott et al.,
1986), to relieve stress (Donovan, 1980), and to facilitate
weight gain in cancer patients (Dixon, 1984). It has been
successfully used and tested for pain control in a variety of
settings; as adjunctive therapy for several diseases, including
diabetes (Stevens, 1983); and with geriatric patients to enhance
immunity (Kiecolt-Glaser et al., 1985).
Imagery is usually combined with other
behavioral approaches. It is best known in the treatment of
cancer as a means to help patients mobilize their immune systems
(Borysenko, 1987; Siegel, 1986; Simonton et al., 1978), but it
also is used as part of a multidisciplinary approach to cardiac
rehabilitation (Ornish, 1990; Ornish et al., 1983) and in many
settings that specialize in treating chronic pain.
In a survey of alternative techniques used by
cancer patients (Cassileth et al., 1984), imagery was cited as
the fourth most frequently used. And 46 percent of the
respondents listed "self" as practitioner, indicating
that imagery is often used as a self-help tool.
Imagery assessment tools. The measurement of
imagery as a mental process is fraught with the same problems
faced in measuring any other so-called hypothetical construct,
including learning, motivation, and perception. So far,
psychology has risen to the occasion and developed reliable and
meaningful measurement strategies.
A number of instruments with varying purposes,
degrees of validity, and reliability are currently in use for
measuring imagery. Sheikh and Jordan (1983) have reviewed the
imagery test used for psychological diagnosis. Imagery of cancer,
diabetes, and spinal pain have been specifically analyzed by
Achterberg and Lawlis, using a protocol to elicit sensory
information on healing mechanisms, treatment, and the disease
itself (Achterberg and Lawlis, 1984). These tests have been found
to be accurate predictors of treatment outcome in a number of
clinics and rehabilitation facilities.
Research accomplishments. Recent studies
suggest a direct impact or correlation between imagery (both as a
mental process and a set of procedures) and immunology. These
findings include the following:
* Correlations between various types of
leukocytes and components of cancer patients' images of their
disease, treatment, and immune system (Achterberg and Lawlis,
* Increased phagocytic activity following
biofeedback-assisted relaxation (Peavey et al., 1985).
* Enhanced natural killer cell function
following a relaxation and imagery training procedure with
geriatric patients (Kiecolt-Glaser et al., 1985) and in adult
cancer patients with metastatic disease (Gruber et al., 1988).
* Changes in lymphocyte reactivity following
hypnotic procedures (Hall, 1982-83) and instruction in relaxation
and imagery in adult cancer patients with metastatic disease.
* Altered neutrophil adherence or margination,
as well as white blood cell count, following an imagery procedure
(Schneider et al., 1983).
* Increased secretory immunoglobulin A (IgA)
(significantly higher than control group) following training in
location, activity, and morphology of IgA and 6 weeks of daily
* The specificity of imagery training was
suggested by a study on training patients in cell-specific
imagery of either T lymphocytes or neutrophils. The effects of
training, which were assessed after 6 weeks, were statistically
associated with the type of imagery procedure employed
(Achterberg and Rider, 1989).
Research issues. Although this early research
is very promising, further investigations are badly needed.
Longitudinal studies are virtually nonexistent. Consequently, the
major question remains: Will the physiological-biochemical
changes noted in imagery studies have an ultimate impact on
health or on the course of the disease?
Distinguishing clinical from statistical
significance is critical. Relying on statistical significance
alone may obscure much valuable information, such as the few
outstanding cases in which the methods were remarkably
For complex clinical research, innovative
research paradigms and statistical treatments are needed.
Traditional research methodology is based on the idea of a
univariate, linear model, which is rare (if not completely
absent) in the real world. The spirit of discovery is not served
by clinging to models that obscure much of the richness of the
human condition. Furthermore, there are a number of complex
variables that need to be accounted for in developing a research
design. The following are examples:
* The randomized control group design is often
impossible, impractical, and unnecessary. Its general efficacy
and the ethics of its application are now being seriously
challenged (Rider et al., 1990). Other designs should be
* Participant and therapist-researcher
motivation and belief are critical and significant variables to
consider in this type of behavioral research and should serve as
factors in group selection and measurement.
* Studies should be designed to maximize the
possibility of good outcome on health and well-being.
* Research into the relationship between
imagery and biological parameters--particularly those related to
immunology--is hindered by the state of the art in that area. For
instance, normative data are often absent, and reliability of
assay procedures is questionable. Clinical significance of any
changes may or may not be known. The specific impact of diet,
season, environment, age, mood, or even the time of day on many
of the immune assays is not well studied.
Research needs and opportunities. Existing data
suggest at least two major research directions:
1. The impact of imagery as part of a
multimodal treatment with conditions such as cancer, AIDS, or
autoimmune disorders. The research should include repeat
immunologic testing and followup. Specific studies could be
embedded within the overall design; for example, studies on the
effect of imagery specifically designed to enhance medical
treatment, the relationship between imagery and outcome of
disease, types of patients who respond to imagery, and so on.
2. Replication and expansion of earlier
intriguing--but small or poorly controlled--studies that
indicated a direct effect of imagery on biologic function.
Hypnosis, derived from the Greek word hypnos
(sleep), and hypnotic suggestion have been a part of healing
since ancient times. 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.
Modern hypnosis began in the 18th 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. Since then, the fortunes
of hypnosis have ebbed and flowed. The famous Austrian
neurologist Sigmund Freud at first found hypnosis extremely
effective in treating hysteria and then, troubled by the sudden
emergence of powerful emotions in his patients and his own
difficulty with its use, abandoned it.
In the past 50 years, however, hypnosis has
experienced a resurgence, first with physicians and dentists and
more recently with psychologists and other mental health
professionals. Today it is widely used for addictions, such as
smoking and drug use, for pain control, and for phobias, such as
the fear of flying.
Hypnosis is a state of attentive and focused
concentration in which people can be relatively unaware of, but
not completely blind to, their surroundings. If something demands
attention--such as a fire in the wastebasket--hypnotized people
easily rouse themselves to react to the situation. In this state
of concentration, people are highly responsive to suggestion.
But, contrary to popular folklore, people cannot be hypnotized
involuntarily or follow suggestions against their wishes. They
must be willing to concentrate their thoughts and to follow the
suggestions offered. In the end, all hypnotherapy is
self-hypnosis. Some people--usually those with a vivid fantasy
life--are better hypnotic subjects than others.
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 a client through
relaxation, mental images, and suggestions or teaches clients to
do this for themselves. Many hypnotherapists provide guided
audiotapes for their clients so they can practice the therapy at
home. The images presented are specifically tailored to the
particular client's problems and may employ one or all of the
Physiologically, hypnosis resembles other forms
of deep relaxation: a generalized decrease in sympathetic nervous
system activity, a decrease in oxygen consumption and carbon
dioxide eliminations, a lowering of blood pressure and heart
rate, and an increase in certain kinds of brain wave activity
(Spiegel et al., 1989).
The most prominent organization of clinical
professionals in the field is the American Society for Clinical
Hypnosis, which numbers approximately 3,000 members (M.D.s and
Ph.D.s). In addition, there are probably thousands of others who
use hypnotherapy as part of their practice (e.g., R.N.s, M.S.W.s,
marriage and family counselors, and lay therapists).
Clinical applications. One of the most dramatic
uses of hypnosis is the treatment of congenital ichthyosis (fish
skin disease), a genetic skin disorder that covers the surface of
the skin with grotesque hard, wartlike, layered crust.
Dermatologists thought ichthyosis was incurable until an
anesthesiologist, Arthur Mason, in the mid-1950s used hypnosis by
chance to effectively treat a patient he thought had warts. After
Mason used hypnosis on the patient (a 16-year-old boy), the boy's
scales fell off, and within 10 days, normal pink skin replaced
it. Since that time, hypnosis has been used to treat
ichthyosis--not always resulting in complete cure but often
resulting in dramatic improvement (Goldberg, 1985).
Hypnosis is, however, most frequently used in
more common ailments, either independently or in concert with
other treatment. The following are a few examples:
* Pain management. Pain increases with
heightened fear and anxiety. Because hypnotherapy helps a person
gain control over fear and anxiety, pain is also reduced.
Hypnotic suggestion (one may suggest that a part of the body
become numb) can be used instead of or together with an
anesthetic. Twelve controlled studies have demonstrated that
hypnosis is a superior way to reduce migraine attacks in children
and teenagers. In one experiment, schoolchildren were randomly
assigned a placebo or propranolol, a blood-pressure lowering
agent, or taught self-hypnosis; only the children using
self-hypnosis had a significant drop in severity and frequency of
headaches (Olness et al., 1989). Another pain study of patients
who were chronically ill reports a 113-percent increase in pain
tolerance among highly hypnotizable subjects versus a control
group who did not receive hypnosis (Debenedittis et al., 1989).
* Dentistry. Some people have learned how to
tolerate dental work with hypnotherapy as the only anesthetic.
Even when an anesthetic is used, hypnotherapy can also be
employed to reduce fear and anxiety, control bleeding and
salivation, and reduce postoperative discomfort.
* Pregnancy and delivery. Women who have
hypnosis prior to delivery have shorter labors and more
comfortable deliveries. Women have also used self-hypnosis to
control pain during delivery (Rossi, 1986).
* Anxiety. Hypnosis can be used to establish a
new reaction to specific anxiety-causing activities such as stage
fright, plane flights, and other phobias.
* Immune system function. Hypnotherapy can have
a positive effect on the immune system. One study has shown that
hypnosis can raise immunoglobulin levels of healthy children
(Olness et al., 1989). Another study reported that self-hypnosis
led to an increase in white blood cell activity (Hall, 1982-83).
Other studies in the past 40 years have shown
that hypnosis can affect a wide variety of physical responses,
including reduction of bleeding in hemophiliacs (Lucas, 1965),
reduction in severity of attacks of hay fever and asthma (Mason
and Black, 1958), increased breast size (Honiotest, 1977; LeCron,
1969; Staib and Logan, 1977; Willard, 1977; Williams, 1973), the
cure of warts (Ahser, 1956; Sinclair-Geiben and Chalmers, 1959;
Surman et al., 1973; Ullman and Dudek, 1960), the production of
skin blisters and bruises (Bellis, 1966; Johnson and Barber,
1976), and control of reaction to allergens such as poison ivy
and certain foods (Ikemi, 1967; Ikemi and Nakagawa, 1962;
No one knows exactly how such bodily changes
are brought about by hypnosis, but they clearly occur because of
the connections between mind and body. It is also clear that
suggestions have the capacity to affect all systems and organs of
the body in a variety of ways.
To flow naturally in and out of hypnotic states
is common; it happens to people watching television, for
instance. We are also likely to move into a trance state in
situations of extreme stress. When a person in a position of
power yells, the yelling may have effects that become as strong
as posthypnotic suggestions. When physicians or other health care
providers make predictions about an illness, they may have a
similar effect. It is particularly important that physicians
understand this state and the potential power of the positive and
negative suggestions they use with their patients.
Research needs and opportunities. The following
needs exist in the area of hypnosis:
* Because of the profound influence of
hypnosis, an understanding of how to apply it in all therapeutic
settings is needed. Future study must be directed toward
influencing and maximizing the beneficial capacity of trance
states occurring in doctors' offices and on operating tables as
well as minimizing the destructive effects of negative or offhand
remarks made in these places. And of course, further research is
needed on explicit, hypnotic treatment for specific illnesses.
* The cases in which hypnosis has resulted in
dramatic improvements of severely disfiguring genetic diseases
such as ichthyosis deserves further scientific attention. They
raise fundamental questions about the extent and limits of the
mind's powers and suggest that such limits may be very wide
* Hypnosis is often reserved as a
"backup" therapy to be used when conventional
treatments fail. However, the examples above show the broad
spectrum of its usefulness and suggest that in some conditions
hypnosis may be appropriately considered as a first-line therapy
instead of a last resort.
Originating in the late 1960s, biofeedback is a
treatment method that uses monitoring instruments to feed back to
patients physiological information of which they are normally
unaware. By watching the monitoring device, patients can learn by
trial and error to adjust their thinking and other mental
processes in order to control bodily processes heretofore thought
to be involuntary, such as blood pressure, temperature,
gastrointestinal functioning, and brain wave activity.
Biofeedback can be used to treat a wide variety
of conditions and diseases ranging from stress, alcohol and other
addictions, sleep disorders, epilepsy, respiratory problems, and
fecal and urinary incontinence to muscle spasms, partial
paralysis or muscle dysfunction caused by injury, migraine
headaches, hypertension, and a variety of vascular disorders.
More applications are being developed yearly.
In a normal session, electrodes are attached to
the area being monitored (the involved muscles for muscle
therapy, the head for brain wave activity); these electrodes feed
the information to a small monitoring box that registers the
results by a sound tone that varies in pitch or on a visual meter
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
(e.g., muscle relaxation or contraction, or more alpha and theta
brain waves). Through trial and error, patients gradually train
themselves to control the inner mechanism involved. Training for
some disorders requires 8 to 10 sessions. Patients with long-term
or severe disorders may require longer therapy. Obviously, the
aim of the treatment is to teach patients to regulate their own
inner mental and bodily processes without help from the machine.
In its simplest form, biofeedback therapy always involves a
therapist, a patient, and a monitoring device capable of
providing accurate physiological information.
A major reason why many patients like
biofeedback training is that, like behavioral approaches in
general, it puts them in charge, giving them a sense of mastery
and self-reliance over their illnesses and health. Such an
attitude may play a crucial role in the lower health care costs
seen in patients after learning biofeedback skills.
Background. In 1961, experimental psychologist
Neal Miller proposed that the autonomic, or visceral, nervous
system was entirely trainable. Miller's suggestion ran contrary
to prevailing orthodoxy, which held that all autonomic
responses--heart rate, blood pressure, regional blood flow,
gastrointestinal activity, and so on--were beyond voluntary
control. In a remarkable series of experiments he showed that
instrumental learning and control of such processes were indeed
possible. One result of his work was the creation of biofeedback
In the succeeding three decades, Miller's work
has been expanded by scores of researchers. Approximately 3,000
articles and 100 books have been published to date describing
biofeedback and its applications. There are currently about
10,000 practitioners in the United States. Two organizations
certify biofeedback professionals and paraprofessionals, and more
than 2,000 individuals have received national certification.
Biofeedback does not belong to any particular
field of health care but is used in many disciplines, including
internal medicine, dentistry, physical therapy and
rehabilitation, psychology and psychiatry, pain management, and
The most common forms of biofeedback involve
the measurement of muscle tension (electromyographic, or EMG,
feedback), skin temperature (thermal feedback), electrical
conductance or resistance of the skin (electrodermal feedback),
brain waves (electroencephalographic, or EEG, feedback), and
respiration. More recently, increasingly sophisticated
measurement devices have expanded biofeedback possibilities.
Sensors can now measure and feed back the activity of the
internal and external rectal sphincters (for the treatment of
fecal incontinence), the activity of the detrusor muscle of the
urinary bladder (for the treatment of urinary incontinence),
esophageal motility, and stomach acidity (pH). Currently there
are approximately 150 applications for biofeedback. Medical
awareness of biofeedback is increasing, and referrals to
biofeedback clinics continue to climb. Some treatments are
already widely accepted. The American Medical Association, for
example, has endorsed EMG biofeedback training for treating
muscle contraction headaches.
Research accomplishments and clinical
applications. Substantial research exists demonstrating the
effectiveness of biofeedback in a number of conditions, including
bronchial asthma, drug and alcohol abuse, anxiety, tension and
migraine headaches, cardiac arrhythmias, essential hypertension,
Raynaud's disease/syndrome, fecal and urinary incontinence,
irritable bowel (spastic colon) syndrome, muscle reeducation
(strengthening weak muscles, relaxing overactive ones),
hyperactivity and attention deficit disorder, epilepsy,
menopausal hot flashes, chronic pain syndromes, and anticipatory
nausea and vomiting associated with chemotherapy (Basmajian,
Like all other forms of therapy, biofeedback is
more useful for some clinical problems than for others. For
example, biofeedback is the preferred treatment in Raynaud's
disease/syndrome (a painful and potentially dangerous spasm of
the small arteries) and certain types of fecal and urinary
incontinence. However, it is one of several preferred treatments
for muscle contraction (tension) headaches, migraine headaches,
irritable bowel (spastic colon) syndrome, hypertension, asthma,
and a variety of neuromuscular disorders, especially during
rehabilitation. EEG biofeedback therapy is one of several
preferred treatments for certain patients with epilepsy or
attention deficit disorder.
relaxation training has been shown to be associated with decrease
in medical care costs to patients, decrease in number of claims
and costs to insurers in claims payments, reduction of medication
and physician usage, reduction in hospital stays and
rehospitalization, reduction of mortality and morbidity, and
enhanced quality of life (Schneider, 1987).
Efforts are being made to further increase the
cost-effectiveness of biofeedback therapy through the use of
group and classroom instruction, reduced therapist contact, and
home-based training. No studies have yet been made that discuss
cost-benefit issues for the nonrelaxation-based biofeedback
therapies, such as neuromuscular education and seizure reduction
Research needs and opportunities. The following
are some of the research questions about biofeedback that need
* What is actually learned during biofeedback?
An awareness of some internal response or an awareness of
associations between stimuli and responses?
* What variables influence learning in the
biofeedback setting? How do they exert their effects? For
example, what are the effects of the quality and quantity of
reinforcements used to promote learning?
* What is the full range of bodily responses
that can be modified by instrumental training procedures? Are the
influences of biofeedback large enough to make a clinical
difference? Or, are they laboratory curiosities?
* Which physiological responses are best to
modify with respect to a specific disorder? For example, is
lowering of blood pressure best achieved by feedback of blood
pressure, or is feedback of muscle tension or skin temperature
* To what extent does transfer of training take
place from the laboratory to real life? Can an individual
self-regulate a physiological response at home as well as in a
clinic? How long does the learning last?
* How do motivation and expectancy relate to
the successful learning of biofeedback skills? What criteria
predict who will be a successful biofeedback subject?
* How does biofeedback compare with other
approaches (e.g. meditation, relaxation, suggestion, hypnosis) in
altering physiological processes?
* How can biofeedback's effects be separated
from other treatment variables such as the therapist's attention,
verbal exchanges, suggestion, patient expectation, the clinical
atmosphere, or participation in a self-help program?
* In which situations can biofeedback-assisted
learning be used in lieu of pharmacological or surgical
therapies, and in which situations as an adjunct to these
* For what conditions might group instruction
in biofeedback skills be as effective as individual teaching? How
can subjects be identified as more suitable for group teaching or
* How can biofeedback teaching procedures be
more widely applied to the medical problems of children? Might
the widespread teaching of biofeedback skills to children
emphasizing self-care and self-responsibility at a young age
counteract the widespread dependence and reliance on the medical
system demonstrated by adults?
* What innovations in chip and microprocessor
technology are needed to open up new areas of experimental and
clinical research in biofeedback? How might miniaturization
provide opportunities for patients to wear portable devices in
real-life situations, thus expanding biofeedback learning?
Progress in this field, as in many other
alternative and orthodox therapies, will entail three general
steps or phases:
1. Pilot studies to determine whether there are
any promising effects worthy of investigation and to detect any
negative side effects or practical difficulties. These may be
anecdotal case reports, systematic case studies, or uncontrolled
2. Controlled comparisons with the best
available other techniques or with placebo treatments, using
larger groups of patients, double-blind procedures, and adequate
3. Broad clinical trials on large patient
populations under ordinary conditions, to determine the
effectiveness of the treatment in conditions other than unusually
favorable ones with especially talented therapists.
Most clinical research in biofeedback has been
done in Phase I, although some studies have appeared in Phase II.
Phase III studies are needed and can be expected if funding
In India, where it has been practiced for
thousands of years, yoga is a way of life that includes ethical
precepts, dietary prescriptions, and physical exercise. Its
practitioners have long known that their discipline has the
capacity to alter mental and bodily responses normally thought to
be far beyond a person's ability to modulate. During the past 80
years, health professionals in India and the West have begun to
investigate the therapeutic potential of yoga. To date, thousands
of research studies have shown that with the practice of yoga a
person can indeed learn to control such physiological parameters
as blood pressure, heart rate, respiratory function, metabolic
rate, skin resistance, brain waves, body temperature, and many
other bodily functions (see also the "Ayurvedic
Medicine" section in the "Alternative Systems of
Medical Practice" chapter).
As the practice of yoga has gradually moved
into the West, it has been used most often as part of an integral
program of health enhancement as well as for the treatment of
chronic diseases. A prime example of the latter application is
Dr. Dean Ornish's use of yoga in conjunction with dietary
changes, moderate aerobic exercise, meditation, and group support
to reverse coronary artery disease (Ornish, 1990) (see the
"Diet and Nutrition" chapter).
For the most part, the West has adopted three
aspects of entirely different yoga practices: the postures (or
asanas) of hatha yoga, the breathing techniques of pranayama
yoga, and meditation. Studies of meditation were discussed
previously in this section. Here, the focus is on the therapeutic
utility of programs that combine hatha yoga and pranayama yoga.
A typical yoga session as practiced in the
United States lasts 20 minutes to an hour. Some people practice
daily at home, while others practice one to three times a week in
a class. A session usually begins with gentle postures to relax
tension in the muscles and joints, then moves to more difficult
postures. Every movement should be made gently and slowly, and
practitioners are urged not to stretch beyond what is comfortable
for them. Rather, practice should be "easeful."
Emphasis is placed on breathing slowly from deep in the abdomen.
Specific pranayama breathing exercises also are an important part
of the practice. Guided (or self-guided) relaxation, meditation,
and sometimes visualization follow the asanas. The session
frequently ends with chanting, such as a repeating Om shanti
("Let there be peace"), to bring the body and mind into
a deeper state of relaxation.
The physical and psychological benefits of yoga
reportedly include massage of muscles and internal organs;
increased blood circulation; rebalancing of the sympathetic and
parasympathetic nervous systems; increase in brain endorphins,
enkephalins, and serotonin; deeper breathing; increased lymph
circulation; countering of the effects of gravity on the body;
increasing nutrient supply to the tissues; and augmenting alpha
and theta brain wave activity, which reflects a greater degree of
Research. Since it began in the 1920s,
scientific research on yoga has been enormous. Some 1,600 studies
are listed by Monroe and colleagues (1989), and many more have
been undertaken since that bibliography was published in 1989.
Following are a few examples of those studies:
* Rats who were placed in headstands for an
hour a day and then subjected to a variety of shocks adapted more
rapidly to stressful situations than the control group (Udupa,
* Human beings doing postures such as the
shoulder stand daily became more "stress hardy"
(Gaertner et al., 1965).
* People practicing yogic meditation showed a
200-percent increase in skin resistance (less stress) within 10
minutes after beginning to meditate. The anxiety level remained
altered (reduced) for long periods after the meditation training
session ended (Benson, 1972).
* With the practice of yoga, the heart works
more efficiently (Ornish et al., 1983), and the respiratory rate
decreases (Bakker, 1976).
* Blood pressure is lowered, accumulated carbon
dioxide diminishes, and the brain waves reflect a more relaxed
state (Anand and Chhina, 1961; Blacknell et. al., 1975; Fenwick
et al., 1977).
* EEG synchronicity, a unique change in brain
waves found only in deep meditation, reflects improved
communication between the right and left brain with regular yoga
practice (Banquet, 1972).
* Physical fitness (as measured by the
Fleishman Battery of Physical Fitness) is improved (Therrien,
* With yoga training in conjunction with
dietary changes, cholesterol levels have been shown to drop an
average of 14 points in 3 weeks (Ornish et al., 1983).
* Yoga brings increased chest expansion, better
breath-holding abilities, and increased vital capacity and tidal
volume (Maris and Maris, 1979; Shivarpita, 1981).
* Blood sugar levels improve and diabetes is
better controlled after regular yoga practice (Monroe and
* Yoga, because of its psychological benefits,
has been used successfully for drug treatment among prisoners, to
help people stop smoking (Benson, 1969), and to improve job
satisfaction (Maris and Maris, 1979).
* Yoga can be used successfully as an
adjunctive therapy for asthma (Gore, 1982), high blood pressure
(Blacknell et al., 1975), drug addiction (Benson, 1969), heart
disease (Ornish et al., 1983), migraine headaches (Benson et al.,
1977), and cancer (Frank, 1975).
* Yoga has been used successfully with
arthritis and the arthritic symptoms of lupus (Coudron and
Research needs and opportunities. Although many
possibilities to further research can be considered, two areas
are of primary importance--surgery and cancer. Yoga should be
studied as a form of pain relief for surgical patients. Use of
yoga both before and after surgery should be studied and
evaluated in terms of the number of days of recuperation and the
level of pain experienced. Studies also should be done with
cancer patients who practice 1 hour of yoga a day for a year
together with specific, ongoing lifestyle changes: a low-fat,
high-fiber diet and weekly group support meetings.
Because dance is a direct expression of the
mind and body, it is an intimate and powerful medium for therapy.
Throughout the world, people have always danced to celebrate
major events, to bond communities, to share sentiments, and to
heal the sick and the alienated.
Applications. The use of dance as a medical
therapy in the United States began in 1942 through the pioneering
efforts of Marian Chace. Psychiatrists in Washington, DC, found
that their patients were deriving therapeutic benefits from
attending Chace's dance classes. As a result, Chace was asked to
work on the back wards of St. Elizabeth's Hospital with patients
who had been considered too disturbed to participate in group
activities. At about the same time, Trudi Schoop, a dancer and
mime, volunteered to work with patients at Camarillo State
Hospital in California. A group approach for nonverbal and
noncommunicative patients was needed, and dance/movement therapy
(DMT) met that need.
In 1956, dance therapists from across the
country founded the American Dance Therapy Association, which has
now grown to more than 1,100 members._ It publishes a journal,
the American Journal of Dance Therapy; fosters research; monitors
standards for professional practice; and develops guidelines for
graduate education. It also maintains a registry for therapists:
the certification registered dance therapist (D.T.R.) is granted
to individuals with a master's degree and 700 hours of supervised
clinical internship; the certification "Academy of Dance
Therapists Registered" (A.D.T.R.) is awarded after
therapists have completed 3,640 hours of supervised clinical
work, which qualifies an individual to teach, supervise, and
engage in private practice.
Dance/movement therapists are employed in a
wide range of facilities, work with diverse populations, and
address the needs of a broad spectrum of specific disorders and
disabilities. Typically, dance/movement therapists work with
individuals who have social, emotional, cognitive, or physical
problems. Evolving specializations include using DMT as a disease
prevention and health promotion service with healthy people and
as a method of reducing the stress of caregivers and of patients
with cancer, AIDS, and Alzheimer's disease.
Therapy goals vary according to the population
served: for the emotionally disturbed, goals are to express
feelings, gain insight, and develop attachments; for the
physically disabled, to increase movement and self-esteem, have
fun, and heighten creativity; for the elderly, to maintain a
healthy body, enhance vitality, develop relationships, and
express fear and grief; and for the mentally retarded, to
motivate learning, increase body awareness, and develop social
The underlying assumption in DMT is that
visible movement behavior is analogous to personality. Thus, the
process of changing how one moves (e.g., from fragmented to
integrated or graceful) can effect total functioning. Specific
aspects in DMT--such as music, rhythm, and synchronous
movement--promote the healing processes by altering mood states,
reawakening stored memories and feelings, organizing thoughts and
actions, reducing isolation, and establishing rapport. Dancing in
a group creates the emotional intensity necessary for behavioral
change, and physical activity increases the endorphin level,
inducing a state of well-being. Total body movement stimulates
functioning of body systems (circulatory, respiratory, skeletal,
and neuromuscular). Activating muscles and joints reduces body
tension and body armoring. Unspeakable events, expressed in
dance, can then be verbalized.
DMT has been demonstrated to be clinically
effective in developing body image, improving self-concept,
increasing self-esteem, facilitating attention, ameliorating
depression, decreasing fears and anxieties, expressing anger,
decreas-ing isolation, increasing communication skills, fostering
solidarity, decreasing bodily tension, reducing chronic pain,
enhancing circulatory and respiratory functions, reducing
suicidal ideas, increasing feelings of well-being, promoting
healing, and increasing verbalization (Fisher and Stark, 1992).
Research needs and opportunities. Although the
efficacy of DMT has been demonstrated since the 1940s through
extensive clinical practice, the following kinds of research
should be done:
* Experimental studies to establish
cause-effect relationships between specific approaches and
patient outcomes. For example, what is the effect of daily DMT on
depressed teenagers and drug abusers? What are the effects of
psychotropic drugs on the ability of patients to respond to DMT?
What are the effects of DMT on the ability of autistic children
to communicate (Holtz, 1990)?
* Regression studies to isolate the independent
and interactive effect of DMT. In many settings DMT is but one of
several treatment modalities. Studies addressing the question of
how much of the variation in patient change is accounted for by
DMT alone and by DMT in combination with other therapies would
yield useful information (Holtz, 1990).
* Studies about how specific elements of
dance--such as exuberance, vitality, social contact, and
bonding--promote healing, longevity, and health-enhancement. Can
the effects of these different components be dissected and
* If dance is engaged in for a specific
purpose, is its therapeutic effect diminished? That is, to what
extent does the effect of dance depend on spontaneity?
* Studies indicate that DMT is an aid to
recovery after illness. However, few studies exist on the use of
dance therapy for prevention of illness. Studies could be done to
evaluate the adjunctive use of dance in blood pressure control or
in reduction of blood lipids.
Throughout history, music has been used to
facilitate healing. Aristotle believed the flute in particular
was powerful. Pythagoras taught his students to change emotions
of worry, fear, sorrow, and anger through the daily practice of
singing and playing a musical instrument. The first accounts of
the influence of music on breathing, blood pressure, digestion,
and muscular activity were documented during the Renaissance
(Munro and Mount, 1978).
Music, more than the spoken word, "lends
itself as a therapy because it meets with little or no
intellectual resistance, and does not need to appeal to logic to
initiate its action . . . [and] is more subtle and primitive, and
therefore its appeal is wider and greater" (Altshuler,
1948). This wide appeal, as well as the considerable research
base, suggests music may be used more and more both by itself and
in conjunction with other treatments to ameliorate certain
Music therapy began as a profession in the
1940s, when the Veterans Administration Hospital incorporated
music into rehabilitation programs for disabled soldiers
returning from World War II. The National Association for Music
Therapy, Inc. (NAMT), was established in the United States in
1950. At the same time, degree programs were developing to
educate and train professional music therapists. Since then, the
organization has established curricular programs in music
therapy, which include both clinical practice and internships at
sites in a wide variety of medical and community settings;
organized an impressive scientific database for the profession;
developed standards of practice and a code of ethics; and
fostered the development of a theoretical rationale for music's
beneficial effect on the mind and body.
There are more than 5,000 registered music
therapists (R.M.T.s) in the United States, and more than 80
undergraduate and graduate degree programs. In addition, there
are 165 clinical internship training sites. A baccalaureate
degree in music therapy requires course work in music therapy;
psychology; music; biological, social, and behavioral sciences;
disabling conditions; and general studies. It includes field work
in community facilities or on-campus clinics serving individuals
with special needs. After graduation, a student must serve a
6-month internship in an approved facility to be eligible to take
the exams to become a board-certified therapist.
Two refereed journals are sponsored by NAMT:
the Journal of Music Therapy and Music Therapy Perspectives.
Three published indexes in music therapy exist with more than
6,000 citations of periodical articles published between 1960 and
1980 (Eagle, 1976, 1978; Eagle and Minter, 1984). An electronic
database of medical music therapy (Computer-Assisted Information
Retrieval Service System, CAIRSS) has been established with
citations from more than 1,000 journals including empirical
studies, case reports, and program reviews.
Music therapy is used in psychiatric hospitals,
rehabilitation facilities, general hospitals, outpatient clinics,
day care treatment centers, residences for people with
developmental disabilities, community mental health centers, drug
and alcohol programs, senior centers, nursing homes, hospice
programs, correctional facilities, halfway houses, schools, and
Music therapy is used to address physical,
psychological, cognitive, and social needs of individuals with
disabilities and illnesses. After assessing the strengths and
needs of each client, a qualified music therapist provides the
appropriate treatment, which can include creating music, singing,
moving to music, or just listening to it.
Music therapy can be used to meet medical goals
in many areas, including the following:
* Physical and emotional stimulation for those
with chronic pain or impaired movement. Music evokes a wide range
of emotional responses. It can be a sedative to promote
relaxation, or it can be a stimulant to promote movement to other
physical activity (Coyle, 1987; Kerkvliet, 1990; Zimmerman et
* Communication for those with autism or
communication disorders. Music is a unique form of communication.
Using music with people who are nonverbal or who have difficulty
communicating facilitates their social interaction and may
increase their functioning (Grimm and Pefley, 1990; Street and
* Emotional expression for those with mental
health problems. Music can be used to express a wide variety of
emotions, ranging from anger and frustration to affection and
tenderness. These feelings often take the form of vocalizations
that may or may not employ words (Jochims, 1990; Schmettermayer,
* Associations with music for those with
Alzheimer's disease and other dementias. Selecting music from an
individual's past may evoke memories of times, places, and
persons. These memories can contribute additional information to
the treatment of the individual (Clair and Bernstein, 1990;
Gibbons, 1988; Hanser, 1990).
Research accomplishments. Thousands of specific
research studies have been undertaken in the clinical uses of
music in medical and dental treatment, and many others are
currently in process. Among those clinical uses are the
* As an analgesic. As early as 1914, Kane
investigated using a phonograph in the operating room for calming
patients prior to anesthesia. Music as an analgesic for dental
procedures was one of the earliest and most thoroughly
investigated areas. It also has been used successfully during
childbirth and with obstetric patients. A 1985 study using music
as an anxiolytic showed suppressed stress hormone levels in
orthopedic, gynecologic, and urologic surgery patients (Bonny and
McCarron, 1984; Frandsen, 1989).
* As a relaxant and anxiety reducer for infants
and children. Many studies have dealt with music's effect on
hospitalized infants and pediatric patients. Lullabies in the
neonatal nursery increased the weight gain and movements of
newborns; music activities reduced fear, distress, and anxiety in
hospitalized infants, toddlers, and their families and promoted
"wellness" attributes in very ill children (Aldridge,
1993; Armatas, 1964; Atterbury, 1974; Chetta, 1981; Crago, 1980;
Daub and Kirschner-Hermanns, 1988; Fagen, 1982; Kamin et al.,
1982; Locsin, 1981; MacClelland, 1979; Mullooly et al., 1988;
Oyama et al., 1983; Sanderson, 1986; Tanioka et al., 1985).
* With burn patients. Burn patients experienced
alleviation of aesthetic sterility and distraction from constant
* With terminally ill individuals. Cancer
patients, using music therapy, increased their ability to discuss
their feelings and talk about the trauma of the disease (Fagen,
1982; Frampton, 1986; Gilbert, 1977; Walter, 1983).
* With persons with cerebral palsy. As early as
1950, music therapy together with physical therapy was shown to
reduce the neurological problems of children with cerebral palsy.
* With individuals who have had strokes or have
Parkinson's disease. Federal funding from the Administration on
Aging is currently being used for research into the effects of
music therapy and physical therapy on people with strokes or
* With persons who have sensory impairments or
AIDS. Many studies have explored the applications of music
therapy to individuals who have sensory impairments (visual and
hearing), mental retardation, or AIDS.
* With elderly persons. In 1991 the U.S. Senate
Special Committee on Aging convened a hearing on the therapeutic
benefits of music for elderly persons, which included neurologist
Dr. Oliver Sacks, singer Theodore Bikel, rock musician Mickey
Hart, music therapists, and clients. The hearing record documents
in detail the benefits of music therapy to the elderly (Special
Committee on Aging, 1991). After the hearing, Senator Harry Reid
(D-NV) introduced the Music Therapy for Older Americans Act,
which was later folded into the Older Americans Act Amendments of
1992. This act lists music therapy as both a supportive and a
preventive health service. The new Title IV initiative creates
research and demonstration projects and education and training
initiatives, for which Congress appropriated nearly $1 million.
In 1993, six nationwide music therapy projects were funded
* With persons with brain injuries. In 1993,
the Office of Alternative Medicine awarded one of its first 30
grants "to investigate any beneficial effects of a specific
music therapy intervention on empirical measures of
self-perception, empathy, social perception, depression, and
emotional expression in persons with brain injuries." This
research is now under way (Lehmann and Kirchner, 1986; Lucia,
Research needs and opportunities. In areas
where it has not been done, systematic review and meta-analysis
should be performed to assess the quality and outcomes of the
research. In addition, further research is needed in the
* Neurological functioning, communication
skills, and physical rehabilitation.
* Perception of pain, need for medication, and
length of hospital stay.
* Cognitive, emotional, and social functioning
in those with cognitive impairments.
* Emotional and social well-being of caregivers
and families of those with disabilities.
* Clinical depression and other mental
* Disease prevention and health promotion of
persons with disabilities.
Art therapy is a means for patients to
reconcile emotional conflicts, foster self-awareness, and express
unspoken and frequently unconscious concerns about their disease.
In addition to its use in treatment, it can be used to assess
individuals, couples, families, and groups. It is particularly
valuable with children, who often cannot talk about their most
pressing and painful concerns.
The connection between art and mental health
began to be recognized with the advent of mental institutions in
the late 1800s and the early 1900s. Prinzhorn's book Artistry of
the Mentally Ill, published in 1922, with stunning art made by
institutionalized adults, helped ignite inquiries into the
spontaneous graphic outpouring of disturbed patients. In addition
to the interest in the artistic or diagnostic value of the
patients' productions, there was the realization that the
production of art was valuable in rehabilitating a patient's
In the 1940s, Margaret Naumberg blended ideas
about psychoanalytic interpretive techniques and art to develop
art as a tool to help release "the unconscious by means of
spontaneous art expression . . . and on the encouragement of free
association. . . . The images produced . . . constitute symbolic
speech" (Naumberg, 1958). A decade later, Edith Kramer began
her own exploration into the use of art. She focused her approach
on the artmaking process itself. In her brand of therapy, a
therapist is able to bring "unconscious material closer to
the surface by providing an area of symbolic experience wherein
changes may be tried out, gains deepened and cemented. The art
therapist must be at once artist, therapist, and teacher . .
." (Kramer, 1958). Then, in 1958, Hana Kwiatkowska
translated what she knew as an artist into the field of family
work and introduced specific evaluation and treatment techniques
at the National Institute of Mental Health.
Art therapy was formalized in the founding of
the American Art Therapy Association in 1969._ Along with the Art
Therapy Credentials Board, the 4,000-member organization sets
standards for the profession, strives to educate the public about
the field, has a code of ethics and a system of approving
educational programs and registering art therapists, and will
soon certify art therapists. Registered art therapists (A.T.R.s)
must have graduate degree training and a strong foundation in the
studio arts as well as in therapy techniques and must complete a
supervised internship with work experience. Currently, 2,250 art
therapists are registered by the association. They practice in
psychiatric centers, drug and alcohol rehabilitation programs,
prisons, day care treatment programs, schools for the mentally
retarded, residences for the developmentally delayed, geriatric
centers, and hospices. Two journals are available: Journal of Art
Therapy and Art Therapy Journal.
Art therapy differs from regular art classes
such as painting, sculpture, and drawing, in that the therapist
is trained both in diagnosis and in helping patients with
specific health problems. In their art, for instance, patients
may focus on parts of their bodies that unconsciously concern
them but which they have never mentioned to their physicians or
nurses. Such revelation can lead to further investigation and
additional diagnosis. In helping patients express their feelings
about a disease--such as cancer, for instance--therapists may
lead them to draw images of themselves with cancer. These images
may reveal a great deal about their feelings about their cancer,
its severity, and its effect on their health and well-being.
Research accomplishments. Research on art
therapy has been conducted in clinical, educational,
physiological, forensic, and sociological arenas. Studies on art
therapy have been conducted in many areas.
* Burn recovery in adolescent and young
patients (Appleton, 1990).
* Eating disorders.
* Emotional impairment in young children
* Reading performance (Catchings, 1981).
* Chemical addiction (Chickerneo, 1993).
* As a prognostic aid in childhood cancer.
* As an aid in assessing ego development and
psychological defensiveness in young children (Kaplan, 1986;
* Childhood bereavement (Zambelli et al.,
* As a modifier of locus of control in
* Sexual abuse in adolescents.
* Deafness, aphasia, autism, emotional
disturbance, physical handicap, and brain injury in children
Research needs and opportunities.
Among the areas for further research are the
* Test the effect of art therapy on anxiety
levels of patients subjected to invasive medical procedures.
* Determine whether art therapy enhances
recovery and diminishes hospital stays for hospitalized patients.
* Examine whether art enhances relaxation art
in guided imagery and relaxation training.
* Develop specific art interventions for
children with communication problems and test the impact on their
academic and social performance.
* Determine whether clients' choice of art
materials and quality of art affects their psychophysical state.
* Assess group therapy as a tool to improve
corporate working relationships.
* Assess self-portraits as a prognostic
indicator for clients with eating disorders.
* Examine use of art therapy with juvenile
offenders to assess moral development and modify impact of peer
* Investigate art therapy as an avenue to pain
* Test whether art therapy increases acceptance
of physical and psychological changes in the elderly.
* Assess the utility of art therapy as a coping
technique with survivors of natural disasters.
The use of prayer in healing began in human
prehistory and continues to this day. Contemporary surveys reveal
that most Americans pray and that they pray frequently, and
almost always when they or their loved ones are ill.
The terms mental healing and spiritual healing
are frequently used interchangeably. What does
"spiritual" mean in this context? For many healers,
spiritual healing is an integral part of their personal religion
(e.g., healing comes from Jesus, Mary, a particular saint, God,
and so on). Yet this cannot be the whole story, because spiritual
and prayer-based healing is universal. It cannot be attributed to
any particular religious point of view; it occurs in nontheistic
traditions such as Buddhism just as it does in the theistic
traditions of the West and in animistic societies as well. What
is the unifying principle in mental-spiritual healing that
seemingly transcends personal religious views? Is
mental-spiritual healing a direct effect of mind or
consciousness? Are personal religious interpretations irrelevant?
What is the most fundamental, basic requirement for
mental-spiritual healing, without which it cannot occur?
Techniques vary widely from culture to culture
and are too diverse to be reviewed here. Overall patterns can
nonetheless be discerned among mental-spiritual healers
practicing in the United States.
One of the most thorough and innovative
evaluations of this field is by psychologist Lawrence LeShan, a
pioneer in investigating the relationship between psychological
states and cancer (LeShan, 1966). LeShan found that
mental-spiritual healing methods are of two main types. In type 1
healing, which LeShan considered the most important and prevalent
kind, the healer enters a prayerful, altered state of
consciousness in which he views himself and the patient as a
single entity. There need be no physical contact and there is no
attempt to "do anything" or "give something"
to the person in need, only the desire to unite and "become
one" with him or her and with the Universe, God, or Cosmos.
Type 1 healers uniformly emphasize the
importance of empathy, love, and caring in this process. When
healing takes place, it does so in the context of an enveloping
sense of unity, compassion, and love. These healers state that
this type of healing is a natural process that does not violate
the laws of innate bodily function but rather speeds up ordinary
healing--a very rapid self-repair or self-recuperation.
LeShan's type 2 healers, on the other hand, do
touch the patient and describe some "flow of energy"
through their hands to the patient's area of pathology. Feelings
of heat are common in both healer and patient. In this mode,
unlike type 1, the healer tries to heal. Some type 2 healers see
themselves as originators of this healing power; others describe
themselves as transmitters of it.
Type 1 healers do not have to be close to the
patient to facilitate healing; for them, the degree of spatial
separation from the person in need is irrelevant. Type 2 healers
work on site in the presence of the patient.
These healing techniques are offered only as
generalities. Some healers use both methodologies, even in the
same healing session, and other healing methods could be
Rationale. How does this type of healing occur?
There is no explanation within contemporary medical science,
particularly for type 1, nonlocal healing.
The absence of an underlying
"mechanism" is the greatest impediment to progress in
this field, if such a word is even applicable. The lack of an
explanation for these events prompts many people to dismiss them
without investigating the evidence: since they cannot occur, they
do not occur. Proponents of this foregone conclusion regard any
"evidence" for mental healing as illusory, nothing more
than artifacts of poor experimentation or data processing, or
chance results of complex random processes.
The absence of a known mechanism, however, does
not necessarily mean that mental healing does not or cannot
occur, or that the research supporting it is necessarily flawed.
Until the turn of this century, scientists had no explanation for
a very common event: sunshine. An understanding of why the sun
shines had to await the development of modern nuclear physics. Of
course, the ignorance of scientists did not annul sunlight.
Likewise, although the evidence is not so immediate, mental
healing may be valid in the absence of a validating theory.
What might a future model of the mind that
permits mental-spiritual healing look like? Such a model will
almost certainly be nonlocal.
The idea prevalent in contemporary science is
that the mind and consciousness are entirely local
phenomena--that is, they are localized to the brain and body and
confined to the present moment. From this point of view, distant
healing cannot occur in principle, since the mind cannot stray
outside the "here and now" to cause a remote event.
Studies in distant mental influence and mental healing, however,
challenge these assumptions. Dozens of laboratory experiments
suggest that the mind can bring about changes in faraway physical
bodies, even when the distant person or organism is shielded from
all known sensory and electromagnetic influences. They imply that
mind and consciousness may not always be localized or confined to
points in space, such as brains or bodies, or in time, such as
the present moment (Braud, 1992; Braud and Schlitz, 1991; Jahn
and Dunne, 1987).
For medicine, the implications of a nonlocal
concept of the mind may be profound. Among them are the
* Nonlocal models of the mind may be helpful in
understanding the actual dynamics of healing. They may help
explain instances in which a cure appears suddenly, radically,
and unexpectedly; or when healing appears to be influenced by
events occurring at a distance from the patient and outside his
or her awareness.
* Nonlocal manifestations of consciousness may
complicate traditional experimental designs and require
innovative research methods because they suggest, among other
things, that the mental state or expectation of the experimenter
may influence the experiment's outcome, even under
"blind" conditions (Solfvin, 1984).
At the same time, however, nonlocal
manifestations suggest unmistakable spiritual qualities of the
psyche, including the possibility that a nonlocal consciousness
might survive the death of the local brain. The temporal barrier
may also be violated: information apparently may be received by a
distant person, at global distances, before it is mentally
transmitted by the sender (Radin and Nelson, 1989). These events,
replicated by careful observers under laboratory conditions,
suggest that there is some aspect of the psyche that is
unconfinable to points in space or to points in time. In sum,
these events point toward a nonlocal model of consciousness,
which at the very least allows for the possibility of distant
healing information exchange and perhaps distant healing
A nonlocal model of consciousness implies that
at some level of the psyche there are no fundamental
spatiotemporal separations between individual minds. If so, at
some level and in some sense there may be unity and oneness of
all minds--what Nobel physicist Erwin Schroedinger called the One
In a nonlocal model of consciousness,
therefore, distance is not fundamental but is completely
overcome--in which case the mind of the healer and the patient
are not genuinely separate but in some sense united.
"Distant" healing thus becomes a misnomer, and because
of the unification of consciousness, the patient may be said to
be healing himself or herself.
Offering nonlocality as the bedrock of mental
healing merely shifts the question: instead of asking how mental
healing occurs, now one must ask how nonlocality happens.
Currently no one knows, not even the physicists whose many
experiments have established it as a solid part of modern
physics. The saying comes to mind, "Physicists never really
understand a new theory, they just get used to it." Perhaps
the same may be said of physicians and their attempts to
understand mental healing. Nonlocal mental models imply
"action at a distance," which has been an abhorrent
concept to most scientists since Galileo. But that situation may
be changing. Physicists have repeatedly documented that nonlocal
phenomena occur in the subatomic, quantum domain, wherein
information can seemingly be "transferred" between
distant sites by processes that are "immediate, unmitigated,
and unmediated."_ Whether quantum nonlocality is a possible
explanation or rationale for biological or mental nonlocality is
a question for future research. Nobel prize-winning physicist
Brian D. Josephson of Cambridge University has suggested that
nonlocal events occur in the biological world as well as the
quantum domain. He proposes that human ways of knowing,
particularly the human capacity to perceive patterns and meaning,
make possible "direct interconnections between spatially
separated objects." Josephson suggests that these
interconnections permit the operation of "psi
functioning" between humans, currently held by biomedical
science as impossible (Josephson and Pallikara-Viras, 1991). In
any case, the fact that nonlocal events are now studied by
physicists in the microworld suggests a greater permissiveness
and freedom to examine phenomena in the biological and mental
domains--such as mental healing--that may possibly be analogous.
Research accomplishments and major reviews.
Anecdotal accounts of the power of prayer in "mental,"
"spiritual," "psychic," "distant,"
or "absent" healing are both legendary and legion.
Countless books on these subjects are available, but this
literature contains little scientific value.
Scientific attempts to assess the effects of
prayer and spiritual practices on health began in the 19th
century with Sir Francis Galton's treatise entitled
"Statistical Inquiries into the Efficacy of Prayer"
(Galton, 1872). Galton assessed the longevity of people
frequently prayed for, such as clergy, monarchs, and heads of
state. He concluded that there was no demonstrable effect of
prayer on longevity. Judged by modern research standards,
Galton's study contains many flaws, but he succeeded in advancing
the idea that healing methods involving prayer and similar
spiritual practices could be subjected to empirical scrutiny.
Since Galton's time, a sizable body of
scientific evidence has accumulated in the field of spiritual
healing showing positive results. This information is little
known to the scientific community. Psychologist William G. Braud,
a leading researcher in this field, summarizes this research in a
There exist many published reports of
experiments in which persons were able to influence a variety of
cellular and other biological systems through mental means. The
target systems for these investigations have included bacteria,
yeast, fungi, mobile algae, plants, protozoa, larvae, insects,
chicks, mice, rats, gerbils, cats, and dogs, as well as cellular
preparations (blood cells, neurons, cancer cells) and enzyme
activities. In human "target persons," eye movements,
muscular movements, electrodermal activity, plethysmographic
activity, respiration, and brain rhythms have been affected
through direct mental influence (Braud, 1992; Braud and Schlitz,
These studies in general assess the ability of
humans to affect physiological functions of a variety of living
systems at a distance, including studies in which the
"receiver" or "target" is unaware that such
an effort is being made. The fact that these studies commonly
involve nonhuman targets is important; lower organisms are
presumably not subject to suggestion and placebo effects, a
frequent criticism when human subjects are involved.
Many of these studies do not describe the
psychological strategy of the influencer as actual
"prayer," in which one directs entreaties to a Supreme
Being, a Universal Power, or God. But almost all of them involve
a state of prayerfulness--a feeling of genuine caring,
compassion, love, or empathy with the target system, or a feeling
that the influencer is one with the target.
In addition to the review by Braud, two other
major reviews of this field have been published in the past
decade by researchers Jerry Solfvin and Daniel J. Benor (Benor,
1990, 1993; Solfvin, 1984). These reviews examine the results of
more than 130 controlled studies of distant mental effects,
approximately half of which show statistically significant
results. The Future of the Body: Explorations Into the Further
Evolution of Human Nature, a scholarly, encyclopedic work by
Michael Murphy, cofounder of the Esalen Institute, reviews the
major research accomplishments in the field of mental healing and
related fields and is a valuable guide (Murphy, 1992). The
potential relevance of this area for medical practice has been
examined by Larry Dossey (1993).
Experiments in distant hypnosis deserve intense
scientific scrutiny. In such studies a subject is hypnotized
remotely, is unaware when the hypnosis is taking place, and has
no sensory contact with the hypnotist. Several such experiments
were performed in France in the late 1800s by Janet and Gilbert
and were repeated with greater refinement in 260 laboratory
experiments in 1933 and 1934 by Vasiliev and colleagues in
Leningrad (Vasiliev, 1976). These studies offer tantalizing
suggestions that the human mind may display nonlocal
characteristics (see the next section). For reasons to be
discussed there, exploring this possibility scientifically should
be given high priority.
Extent of the nonlocal perspective. The
nonlocal manifestations of consciousness are not limited to
prayer. Consciousness appears to manifest nonlocally in secular
laboratory settings as freely as in a church, implying that
prayer is only one of the possible avenues for the expression of
these events. If nonlocal mental events are indeed ubiquitous,
they may pervade all healing endeavors to some degree, even those
that appear overwhelmingly mechanical, such as pharmacological
and surgical therapies. Therefore it is unclear whether any
therapy can be considered totally mechanical or
"objective" (Braud, 1992). Nonlocal mental events may
affect all therapies to some degree, and the nonlocal perspective
may have to be considered when any therapy is assessed.
Research needs and opportunities. In addition
to demonstrating whether there is a distant healing effect of the
mind, future research should examine the following questions:
* How robust, reliable, and dependable is the
mental healing effect?
* What qualities in the praying person and the
recipient facilitate and retard distant healing effects?
* How can talented or potential healers be
* Is healing a "gift," or can
individuals be trained to heal?_
* Do some prayers work better than others in
* Why does the ability to heal fluctuate? Why
is it not constant? Are mental healers like talented athletes,
who can be either "hot" or "cold"? Since
healing abilities seem to fluctuate, how can experimental
protocols allow for this variation? Is it justifiable to apply
the same experimental designs to healers as to penicillin, which
presumably does not have an "off" day?
* How can mental healing be integrated with
orthodox medical approaches, particularly in hospital
environments? Can medical and surgical approaches be used
simultaneously with mental healing, or are these methods
* Can mental healing be tested in the same way
as a new drug or surgical procedure? Is the randomized,
prospective, double-blind methodology equally appropriate for
physically and for mentally-spiritually based therapies?
* How can the public be protected from
fraudulent or misguided mental "healers"? Is it
possible to establish a requirement akin to board certification
for healers in an attempt to ensure efficacy and protect
consumers from worthless "healers" and predatory
* What about more general ethical
considerations? Is a mental healer justified in attempting to
heal people without their knowledge and consent?
* Is it possible to harm distant organisms and
aid them through distant mental influences?_
There are two related but separate directions
of research in the field of nonlocal therapy: (1) the need to
develop actual healing methods, and (2) the need to shed light on
the fundamental nature of human consciousness. The first goal
obviously requires the use of some type of living organisms as
the recipient, but the second need not. In fact, the effects of
consciousness can be studied in certain laboratory settings that
offer greater precision and control than is offered by the usual
experiments that involve living organisms as recipients. An
example is the sophisticated studies in remote human-machine
interactions that have been done for a decade at the Princeton
Engineering Anomalies Research laboratory by Robert G. Jahn,
former dean of engineering of Princeton University, and his
colleagues (Jahn and Dunne, 1987).
Conclusions. Appallingly little is known about
the origins of consciousness and how it relates to the physical
brain. Although hypotheses purporting to explain consciousness
abound, there simply is no consensus among expert
neuroscientists, psychologists, artificial intelligence
researchers, and philosophers as to its nature. Perhaps the lack
of knowledge is not surprising; in medical research, scientists
usually consign consciousness to last-place status and opt for
"practical" research areas--the development of new
drugs, surgical therapies, vaccines, and so forth.
Research in this area is analogous to basic
investigations in other exotic areas of science such as particle
physics, which have no immediate, bottom-line value. There is a
need to know more about the basic, fundamental nature of
consciousness--its spatial and temporal characteristics and its
precise relationship with matter, including the brain. Without
this basic understanding, progress in all forms of therapy,
alternative and traditional, will be hampered, because the
effects of consciousness are to some degree involved in all of
The mind-body interventions described in this
chapter are part of a neglected dimension in health care. They
offer what people are hungry for--a medicine that addresses more
than the body. In addition to preventing or curing illnesses,
these therapies by and large provide people with the chance to be
involved in their own care, to make vital decisions about their
own health, to be touched at deep emotional levels, and to be
changed psychologically in the process.
There is nothing inherent in many alternative
medical therapies that necessarily sets them apart from the way
contemporary drugs and surgery are used. Because they are, after
all, things, it is possible to use diets, herbs, homeopathic
remedies, and most other alternative treatments with the same
impersonal, remote objectivity that prompts people today to say,
"My doctor doesn't care about me!" It is possible to
convert any alternative technique into the "new
penicillin" or the "latest surgery"--something
given or done to a body without regard for the person involved.
The mind-body approach outlined here is potentially a corrective
to this tendency, a reminder of the importance of human
connection and the power of patients acting on their own behalf.
But caring and compassion are not enough, and
"putting the patient back into health care" is not
sufficient. Alternative therapies, including the mind-body
approaches that have been described, must be proved to work, must
be safe, and must be cost-effective. While more work needs to be
done, evidence also is already substantial that many of these
mind-body therapies, if appropriately selected and wisely
applied, meet these demands.
To further the development of alternative
medical practices and mind-body interventions, the Panel on
Mind-Body Interventions recommends the following:
* Development of educational materials, models,
and programs in each of the mind-body areas discussed in this
chapter, and dissemination to faculty and students in medical and
other schools of health education.
* Development of comprehensive reviews of the
literature in the various areas of the mind-body field. Such
reviews would document the enormous body of work already done and
specify directions for future research, thus facilitating the
most efficient use of resources. Five areas should receive focus
in a comprehensive review:
1. The theoretical foundations, research
accomplishments, and clinical applications of mind-body
interventions as well as the commonalities and differences among
various self-regulation strategies.
2. The dynamics of the therapeutic relationship
between providers and patients. What qualities, for example,
allow therapists and patients to work well together? What factors
distinguish "technicians" from "healers"? How
do beliefs and attitudes of both patients and physicians affect
health care and treatment outcomes?
3. The influence of social context on health
and illness, including the impact of family, work, education,
economic status, and culture.
4. The effects of belief, values, and meaning
on health and illness.
5. The influence of nonlocal phenomena on
health and illness.
* Development of a clearinghouse for
information dealing with mind-body approaches to health and
illness, including the publication of a journal on mind-body
* Evaluation of the legal, regulatory, and
economic barriers to the integration of the mind-body perspective
and techniques into the health care system.
* Institution of studies dealing with
integration of mind-body techniques already shown to be effective
(e.g., biofeedback plus hypnosis plus imagery), with attention to
possible increases in cost-effectiveness when these approaches
are used integrally rather than singly.
* Comparison of the long-and short-term effects
of various self-regulation strategies.
* Basic investigations of the nonlocal effects
of consciousness. These studies would involve human-machine as
well as human-human interactions and would employ degrees of
spatial separation of global or greater distances. Such research
is vital in laying a theoretical foundation for understanding the
role of consciousness in health in general and for progress in
the mind-body field.
* Research addressing mind-body factors in
chronic illness in poor and minority communities.
* Development of stress reduction techniques
and nonpharmacological health education programs in elementary
and secondary schools. Such programs would emphasize the role of
self-responsibility in young children as well as the impact of
attitudes, beliefs, and emotions in health.
* Development of drug rehabilitation and
recidivism-reduction programs that emphasize mind-body
* A project to investigate how patient
education affects the outcome of research studies. If the
findings so justify, research designs should be developed that
inform patients fully of the nature of the protocol in which they
are participating and that provide immediate feedback of results.
* Funding and support of small pilot programs
in the mind-body field.
* A study of the psychosocial characteristics
of people who experience spontaneous remissions of cancer and
* Development of research methods that include
subjective ways of knowing and "state-specific"
* The beginning of a systematic study of what
it means to be healthy.
* A task force on the nature of consciousness
to be formed within the Office of Alternative Medicine. This task
force would be composed of representatives from various
disciplines whose work deals with the nature of consciousness,
including psychologists, neurophysiologists, artificial
intelligence experts, physicists, physicians, and philosophers.
The mission of this group would be to formulate a model of
consciousness that, as completely as possible, would account for
the manifestations of consciousness that surface in mind-body
research. Such a model would be of significant value in
legitimizing the area of mind-body interventions and in
stimulating progress in this field.
Achterberg, J., and G.F. Lawlis. 1980. Bridges
of the Bodymind: Behavioral Approaches to Health Care. Institute
for Personality and Ability Testing, Champaign, Ill.
Achterberg, J., and G.F. Lawlis. 1984. Imagery
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