NIH Mind/Body Connections

Introduction
Meaning of Mind/Body
Evidence of Mind/Body Effects
Specific Therapies
Summary


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~ 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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.)

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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?

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~ • 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.

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• 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.7

• 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."8

• 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.

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~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.

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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.

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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).

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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).9

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.

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Despite the breadth and clarity of the research10 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.

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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.

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~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.

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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.

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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.

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