Part I: Fields of Practice

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.

Introduction

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 secondary importance.

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 psychiatry.

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, psychoneuroimmunology.

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.

Meaning of Mind-Body

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).

Timeless Factors in Healing

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 well.

Healing and Curing

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.

Evidence of Mind-Body Effects in Contemporary Medical Science

Social Isolation

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" (Graboys, 1984).

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).

Work Status

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, 1990).

* 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; Syme, 1991).

* 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., 1982).

Perceived Meaning and Health

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 illness.

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).

Placebo Response

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, Religion, and Health

"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, 1987).

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 factor._

Spontaneous Remission of Cancer

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 follows:

* 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 illness.

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.

Specific Therapies

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.

Psychotherapy

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 nature.

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 speaking.

3. Cognitive therapy facilitates changing specific behaviors but focuses on habitual thoughts that affect behavior.

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 therapy.

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 recovery.

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 psychiatric symptoms.

Clinical applications. Studies have shown that psychotherapy has had beneficial effects with medical crises and somatic illness.

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 patient.

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 this approach.)

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 illnesses.

* 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 "spirit."_

* 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 simultaneously.

Meditation

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 meditation.

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 beneficial results.

While many individuals and groups have examined the effects of meditation, two major meditation programs have extensive bodies of research: transcendental meditation and the relaxation response.

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., 1986);

* reduced anxiety;

* reduction of high blood pressure (Cooper and Aygen, 1978);

* reduction of serum cholesterol level (Cooper and Aygen, 1978);

* reduction of substance abuse (Sharma et al., 1991);

* 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 resources.

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.

Meditation and healing.

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 relaxation response.

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, 1992).

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 meditation:

* 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 benefits.

* 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 resources.

Imagery

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 cells.

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, 1987).

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, 1977).

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 investigation.

Clinical applications. Procedures for imagery fall into at least three major categories: (1) evaluation or diagnostic imagery, (2) mental rehearsal, and (3) therapeutic intervention.

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 education._

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, 1984).

* 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 imaging.

* 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 successful.

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 considered.

* 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

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 senses.

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; Platonov, 1959).

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 indeed.

* 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.

Biofeedback

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 therapy.

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 more.

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, 1989).

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.

Cost-effectiveness. Biofeedback-assisted 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 training.

Research needs and opportunities. The following are some of the research questions about biofeedback that need answering:

* 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 more effective?

* 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 approaches?

* 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 individual instruction?

* 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 single-group studies.

2. Controlled comparisons with the best available other techniques or with placebo treatments, using larger groups of patients, double-blind procedures, and adequate followup.

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 becomes available.

Yoga

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 relaxation.

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, 1978).

* 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, 1968).

* 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 Fitzgerald, 1986).

* 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 Coudron, 1987).

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.

Dance Therapy

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 skills.

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 quantified?

* 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.

Music Therapy

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 illnesses.

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 private practice.

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 al., 1989).

* 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 Cappella, 1989).

* 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, 1983).

* 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 following:

* 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 pain.

* 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 Parkinson's disease.

* 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 (Renner, 1986).

* 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, 1987).

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 following areas:

* 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 disorders.

* Disease prevention and health promotion of persons with disabilities.

Art Therapy

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 mental health.

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 (Bowker, 1990).

* 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; Levick, 1983).

* Childhood bereavement (Zambelli et al., 1989).

* As a modifier of locus of control in behavior-disordered students.

* Sexual abuse in adolescents.

* Deafness, aphasia, autism, emotional disturbance, physical handicap, and brain injury in children (Silver, 1966).

Research needs and opportunities.

Among the areas for further research are the following:

* 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.
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