Introduction

M

ost 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 inci

dence of chronic illnesses—including heart disease, cancer, depression, arthritis, and asthmawhich 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 functioningmost 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 mindbody 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?1 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. Mindbody 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.

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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 mindbody 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 asso

ciated 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 decisionmak

3For a review of the impact of perceived meaning on health, see Dossey, 1991.

ing; (2) challenge-the sense of personal growth and wisdom; becoming a better person; and (3) commitment to life on and off the jobto work, community, family, and self. Persons experiencing these qualities are said to possess "hardiness" and are relatively immune to jobinduced 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 healthwhat 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