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to Menu PageIn 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.
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.11
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, 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.
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.