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Mind-Body Medicine in health promotion: Science, practice and philosophy

Craig Hassed, MBBS

Publication Date: 6  November 1998

Abstract

Over recent times there has been an explosion of knowledge in the physical sciences. In medicine the emphasis has tended to focus on the human body but often ignored a holistic perspective, that is the body's interaction with mind, emotion, social environment, and spirit. This more mechanistic and materialistic way of viewing the human being and illness has oftentimes been at the expense of more traditional holistic models which placed great emphasis on these more subtle elements of human experience. Possibly each approach, the mechanistic and holistic, view knowledge differently with former being more information based and the latter being more conceptual.

More lately, however, there has been a revival of interest in the scientific evaluation of this holistic view. This paper has three main aims: firstly to review some of the vast area of medical literature which already exists in mind-body medicine: secondly to discuss the practical application of one mind-body intervention, namely mindfulness meditation: thirdly to relate some of the key philosophical concepts of the holistic view. Mind-body medicine and its kindred fields of study, such as psychoneuroimmunology and psycho-oncology, are opening our awareness and requiring more communication and cooperation across the scientific community than ever before. Much of this work, because of its holistic nature, demands the collaboration of scientists from diverse fields of endeavour such as psychologists with immunologists, psychiatrists with oncologists, behavioural scientists with cardiologists. This research seems to be making a case for integrating mind-body medicine into conventional medical treatment. More research is required to allow more rigorous evaluation of these approaches. Thus far we can say that the potential of mind-body medicine for promoting health both physically and psychologically seems to be great. Its costs are relatively low, and the 'side-effects' seem to be generally good. It may well be that the next major breakthroughs in clinical medicine will involve the reintegration of contemporary physical sciences with traditional wisdom.

Introduction

The father of Western medicine, Hippocrates, said that the "human being can only be understood as a whole." The simplicity and wisdom of this concept is recognised today by the World Health Organisation.

"A state of dynamic harmony between the body, mind and spirit of a person and the social and cultural influences which make up his or her environment."

WHO definition of health

The ancient view was essentially a holistic one, ie an intimate interaction of body, mind, environment and spirit. The human being, and the whole of society and nature for that matter, was viewed as being intelligent, conscious and ordered. Nature had laws and in order to stay well or to treat illness one had to work with those laws. The physical world was believed to be underpinned by the mental world, and the mental world by the spiritual. As these 'worlds' move 'inwards' they become more subtle and difficult to measure. A lot of work has nevertheless gone into developing measurement tools for physical and psychological parameters and through their combination we are starting to be able to test if such relationships exist. This field of study is called mind-body medicine, probably the most comprehensive and reliable scientific examination of holism.

The Philosophy

The holistic model:

"The body is the shadow of the soul."i

This simple statement implies much. Contained within it is a summary of what mind-body medicine is about. Consciousness, being primary, illuminates thoughts, desires and emotions in the mind and these in turn affect behaviour and physiology. Consciousness gives life to mind and body. Other analogies have been used to help explain the holistic relationship between body and mind, for example to think of a driver and a vehicle. Though they are different they are intimately related. The driver directly affects the way the vehicle drives, its efficiency, maintenance, or neglect of maintenance, and whether or not it has accidents. Careful drivers obviously get the best out of their cars, have the fewest accidents and need the help of the mechanic the least. Another analogy is like the relationship between the conductor and the orchestra. If all are connected then there is harmony, if not there is discord, which is none other than discrepancy between the various parts. This is all very well but does it have relevance for medical science? It seems it does because there are many scientific observations which are hard to explain without making a philosophical shift in our view of the human being. These observations, which will be discussed at length in following sections, are hard to explain within a purely materialistic view.

The human body has an amazing innate and natural tendency to spontaneously heal itself when disease or trauma strike. This 'vital force' preserving life works with such great intelligence, precision and coordination that it almost defies belief. The awe with which many great scientists hold natural intelligence is well expressed by Einstein.

"Every one who is seriously involved in the pursuit of science becomes convinced that a spirit is manifest in the laws of the universe - a spirit vastly superior to that of man, and one in the face of which we with out modest powers must feel humble. In this way the pursuit of science leads to a religious feeling of a special sort, which is indeed quite different from the religiosity of someone more naive."

Albert Einstein - The Human Side.

All ancient and traditional healing systems, whether they be the Australian Aboriginal, the Western tradition given expression by Hippocrates, Traditional Chinese Medicine (TCM), the Indian system of Ayurveda, North American Indian or any other, all take into account this 'vitalism'. In a way they all appreciated the principle though they knew little about the mechanism. Perhaps today we have learnt more about mechanisms but have forgotten the principle. In any case the principle was one of working with nature.

"Thus the physician strengthens nature, and employs food and medicine, of which nature makes use for the intended end."

Thomas Aquinas

Practical implications for medical science:

"You ought not to attempt to cure the body without the soul. ... For this is the great error of our day in the treatment of the human body, that physicians separate the soul from the body."

Plato - Charmides

To a significant extent holism, and the implied need to take great care of the psychological and spiritual well-being of patients, has become neglected at the expense of an increasingly technological and pharmacological approach to health care. Much of this is no doubt due to the degree of 'reductionism' and 'deconstructionism' in modern science. Plato, for example, would have us 'reconstruct' the human being.

Whether or not this is a reasonable view time will tell. If it is well founded then ignoring it potentially does patients a disservice and can waste ever more precious and scarce medical resources.

Exploring new areas of knowledge can be hindered by either blind acceptance or blind rejection of a point of view. It is important that anyone who wishes to form an informed and balanced understanding of mind-body medicine should not be too ready to accept any claims about the role of psychological factors on health unquestioningly. Of course, the apparent contradictions between the assumptions we make and what actually happens in nature are in our thinking, not in nature herself. The scientific and philosophic communities are not immune from dogmatism. Recent examinations of the medical literature seem to suggest that, when informing each other, philosophy and science complement each other very well. This paper is an attempt to help bridge the apparent gaps and inconsistencies between these two bodies of knowledge.

"Miracles do not happen in contradiction to nature but only in contradiction to that which is known to us in nature."

St Augustine

The Science

The cause and effects of stress:

Much research has gone into measuring the effects of stress in recent years and the level of interest in the general community is considerable. For example a recent study found that among a population of general practice patients stress was the most commonly ascribed cause for the patient's symptoms. It was noted in 36% of cases with other causes such as not looking after oneself (26%), moods and emotions (25%), being overworked (25%) and being run down (24%) being the next most common.1

A similar rise of interest in the medical literature is noted.2 Stress has been recognised as a contributor to, or direct cause of, many illnesses. On one level stress can be seen as a natural and appropriate physiological response to an exceptional situation. For example, if one nearly steps on a snake then one may need to respond quickly to get out of the way. This 'fight or flight' response is there to preserve life by allowing the body to react. Stress may also lift our behaviour out of procrastination and inertia, although peak performance cultivates restful alertness and minimises unnecessary tension.

Inappropriate stress, on the other hand, is common in modern life and is not healthy. Here the mind is often not well focussed on what is going on and the mind is full of imaginings which we increasingly take to be real. Examples of this might include projecting fears into the future, catastrophising, habitually recreating past anxieties, and imagining stressors that aren't even there. As far as the body is concerned it does not distinguish between what is a real stressor and what is a perceived or imagined one. If it gets the message from the mind to react in a stressful way then it will. To return to our previous example, if a person imagines a rope to be a snake the body will react to the perception, not the reality. Mind you, if a person imagines a snake to be a rope then that can also lead to a mistake which may be dangerous. So it is not difficult to see what a central role perception, interpretation, imagination and conditioning have in the inappropriate stress response we experience so often. It underlines how important the individual and their coping mechanisms are in the stress response and if the response is unhealthy, severe or prolonged enough it can have a very negative effect on the health, relationships and behaviour. While this places responsibility on the individual it also empowers them to take charge of their reactions.

Stress reduction through the relaxation response helps to undo the harmful effects of this inappropriate stress. The relaxation response, which can be elicited in a variety of ways, is quite different to just sitting in a chair. It incorporates a deeply relaxed physical condition and a focussed, clear and alert mental state, sometimes called 'restful alertness.' To summarise, some of the effects of stress reduction through relaxation and meditation are presented in the following tables.3 4

There are many other physiological and psychological responses which are not listed here, and there are others yet to be studied, but in general all homeostatic mechanisms measured are normalised or tend towards "healthy" levels; lowering that which is high, and elevating that which is low.

Psychoneuroimmunology:

"The mind in addition to medicine has powers to turn the immune system around."

Jonas Salkv

There is presently an enormous explosion of research in the areas of how stress affects the body. One such area is called Psychoneuroimmunology which, put simply, means that the mind (psycho-) is connected through the nervous system (neuro) to the immune system (-immunology). Put another way, what we think and the emotions we foster seem to have a profound effect upon the way our immune system functions via the nervous system. This has major implications for susceptibility to infections and cancer, has effects upon response to allergens and also looks to be an important factor in the modulation of autoimmune and inflammatory conditions. This communication takes place via 'hard-wiring' and through neurotransmitters. The nerves are like telephone wires and the neurotransmitters act like a postal system, and by these two means the nervous system communicates with every element of the immune defences. Both systems are two directional, that is, the white blood cells are sending messages back to the central nervous system (CNS).29 30 31 Important in the feedback loop is the limbic system, very concerned with emotion.

Interestingly although we might have intuitively felt that the two systems were connected it is only in recent years that we are piecing together the mechanisms of this communication. When the first neurotransmitter receptor was found on the surface of a white blood cell it was a revelation with significant implications, but now over 60 such receptors have been found and the number grows. The 'chemistry of thought' looks not to be localised to the brain. In fact the same neurotransmitter receptors are found in the gut and many other places. It is becoming explainable how emotional states like stress, anxiety, depression and the like can depress the function of the immune system, cause gut spasm and so on. Furthermore, drugs which have psycho-active properties, such as sedatives, are also found to effect the functioning of immune cells because these cells have the same receptors. Even the blood-brain barrier is made more porous by stress.

The immune system can function poorly either because of too few or too inactive white blood cells. It is not just a matter of the size of the army but also the 'alertness and responsiveness' of the army. The number of cells can be affected by stress but more immediate is the effect on function of WBC's. Not just emotional states but also lifestyle factors look to be important in this regard. Table 4 shows some of the factors which influence the activity of natural killer cells (NK cells), a very important link in cellular immunity.32

It has also been well documented that an unhealthy life-style is promoted by stress33 and is helped by effective stress management.34 It would seem that meditation35, psychological interventions36, a positive attitude and humour37 are all powerful immune system stimulants, or perhaps more accurately, help to reverse the immuno-suppressive effect of stress mediated through the stress hormones such as the adreno-corticoids. The concept of mind effecting resistance is not new.

"There is no reason for any panic. Fear is cowardly and very injurious. Cheerfulness increases resistance and prevents complications."

Public Health Bulletin during the Influenza epidemic of 1919.

The question arises as to whether these fluctuations in immune cell function are actually significant factors in our susceptibility to infections. The answer would seem to be yes as illustrated by a study in 1991.38 In this study 394 people had their levels of stress measured and were then exposed directly to five different cold viruses. When controlled for other factors the likelihood of actually getting a cold seemed to be directly proportional to the level of stress which the host was experiencing at the time of exposure. The implications of such an observation are obvious and similar conclusions are suggested in other studies, for example, there is a strong link between stress and relapse for herpes viruses.39 Meta-analysis has consistently shown stress effecting interleukin 2 receptor expression on lymphocytes whereas relaxation can elevate antibody titres.40 There are many studies yet to be performed for other, and potentially more serious, viruses but the implications are significant.

Medical students are often the subject of medical investigation because of their availability and willingness to participate in such experiments. One such study41 looked at the immune function of medical students over the exam period and found profound immune suppressionvi. This, of course, corresponds with the general observation that students frequently succumb to illness during or just after exams. In another study42 34 students were randomised into two groups, one being taught relaxation techniques and the others not. Those who were not taught relaxation had the predicted poor immune function but among those who were taught there was a variable response. This is explainable because those who learned but did not practice showed little or no improvement, but those who learnt and practiced showed significantly better immune function. There are many other things which have been found to have an effect upon the immune system. In another controlled trial it was found that medical students who kept a journal about significant events in their lives showed improved immune function and fewer doctor visits for infectious disease compared to students who kept no journal or kept a journal about insignificant events. These observations are quite understandable when we consider the negative impact of psychological stress on the immune system and the positive effects of stress reduction.vii

Care-givers are also at risk. Carers of those with Alzheimers disease have been found to exhibit immune suppression proportional to the level of distress they feel43, and that the immune suppression observed in those going through marital separation is proportional to the amount of negative emotion or difficulty the person experiences in letting go. These are just two of many such observations that underline the point that the person's perception of a situation and their coping ability are a central determining factor in the physiological response. For this reasons making generalisations about the amount of stress people should or should not feel in given situations is risky.

Stress and immunisation:

Interesting research is also taking place in a variety of other fields. Everywhere one looks there are observations being made of how the mind effects the body. Even the efficacy of vaccination with the Hepatitis B or Influenza vaccines seems to be effected by stress. In a series of controlled studies it was shown that those who were stressed prior to vaccination had significantly worse results in terms of antibody and T-cell response.44 45 The same researchers also demonstrated that wound healing is also inhibited by stress.46

Personality and illness:

Another interesting part of the field of mind-body medicine is the role of personality factors. The concept of our nature or personality directly affecting our physical health has been around a long time. There was great wisdom in many of the sayings of the ancient teachers of medicine.

"I would rather know the person who has the disease than know the disease the person has."

Hippocrates

Strong relationships seem to exist between people's disease patterns and their personality type. We all have various aspects of our personalities which are helpful and others which are not so. For some the less helpful ones are more predominant and this seems to have a negative influence on health. One needs to be careful in discussing personality factors and illness so as to encourage objective self-examination and personal growth and avoid the tendency for self-blaming and fatalism. Personality is just one factor, albeit an important one, interplaying with a number of others, such as environment, life-style and genetic predisposition.

Eysenck is one researcher who has been prominent in this field. His work suggests that various types of personalities are predisposed to particular illnesses. These personality factors, of course, interact with other variables such as genes, environment and life-style. These personality traits which he identified are of four types with three being of particular note.

• Type 1: tend to hopelessness, helplessness and suppression of emotion. These people are prone to cancer
• Type 2: tend to anxiety, aggression, ambition and they express emotion inappropriately. These people are more prone to heart disease.
• Type 4: live more in harmony with themselves and others. They communicate better, tend to optimism, were more self-aware and remained calmer under stress. These people got far fewer illnesses, especially cancer and heart disease.

Mind you, any emotional response could have its place if it is appropriate to the situation, is not 'over-expressed' or 'under-expressed' and is left in the past once the situation is over. Some of his findings are detailed below.

It is not a particularly helpful thing to tell people that they are pre-disposed to certain illnesses by their personality traits unless you were going to offer them a way to avert the problem. It would seem these traits were not fixed because therapy could help to minimise the unhelpful personality traits and communication patterns and help to enhance better coping mechanisms and as a result have a positive long term effect on the physical and psychological health. The differences were significant. For example, one study looked at 490 cancer and heart disease prone individuals but who had not succumbed to the illnesses they were predisposed to. They were randomised into an intervention group given autonomy training over six months and a control group who were not. When followed up over seven years the control group had a 76% death rate over compared to only 20% for the intervention group and the control group had six times the rate of death from cancer and three times the death rate from CHD, ie as these personality markers changed so too did the disease profiles.

A variety of factors could contribute to such an observation but the result is surprising nevertheless. One of the most encouraging things is that we often view our personality traits as largely fixed but they seem to be quite malleable. Perhaps it would be more true to look on them as habituated behavioural patterns, and like any habit it can be unlearnt. One of the positive things about illness and stress is that it can be a great motivator for constructive change if used intelligently.

Other studies performed by Hans Eysenck are also very interesting. The heart disease and cancer prone personalities he identified were looked at over a thirteen year period. Over that time they were monitored in respect to their tendency to develop the illnesses they were predisposed to when compared to similarly prone individuals who had had their personality factors modified through training. He demonstrated quite clearly that modifying personality and communication patterns 'for the better' significantly reduced the tendency to become ill independently of other risk factors. Important elements in the training were greater self-awareness, relaxation, improved communication, group support and finding new ways of dealing with stressful situations. The findings from one of these studies are tabled below.49

These are not to isolated findings. Considering the accumulating evidence there is little debate that personality factors have a powerful influence over health independent of life-style factors, but much of the debate is over how marked the influence is. There are other classifications of personality characteristics but however it is classified part of the difficulty in researching such a field is trying to be precise about intangible factors.

Nevertheless, further data seems to be accumulating that the personality and emotions have potent effects upon the recovery from many diseases such as heart disease. For example, one recent study looked at people with already established and severe CHD. It was shown that those with a 'type D' personality were 4.7 times more likely to have another AMI (acute myocardial infarction) over the next 6-10 years when controlled for other factors and compared to other personality types. Type D personality is made up of two main elements.

1. A high level of negative affect (anxiety, anger, worry etc).
2. A tendency to suppress these emotions.

The difference observed between these groups was not explainable by the usual risk factors for heart disease.50 For those with established CHD mental stress has once again been found to independently increase the number of ischaemic episodes by a factor of 2.2 times, even when controlled for other factors.51

Type D is one of another classification. Some of the original research on personality looked at personality types A and B. Type A were described as hurried, hostile and intensely competitive and are more prone to heart disease. Type B were largely the opposite of these attributes. Type C, a cancer prone personality, are more likely uncomplaining, cooperative and resistant to expressing emotions especially hostility and anger. Type D is as described above.

Much closer to home the largest study yet undertaken into the causes of bowel cancer also showed significant links to personality when controlled for all other known risk factors. Especially important was the role of anger and the tendency to suppress emotions. In this study it nearly doubled the risk of bowel cancer.52

One needs to remember that stress and personality are a factor among many; the genetic predisposition, diet, other life-style factors, environment etc. It is not useful to tell someone that their cancer or heart disease is all in their mind. A lot of the problem may relate to the mind, and so thoughts, behaviours and attitudes may need to be addressed, but the best approach will be a holistic one combining lifestyle and environment as well psychological and behavioural interventions.

The positive effects of laughter:

Another interesting area of study demonstrates the positive effects of humour on health. That humour effects the health in a positive way is nothing new, although our methods of scientific observation are.

"The arrival of a good clown exercises more beneficial influence upon the health of a town that of twenty asses laden with drugs."

Dr Thomas Sydenhamviii

"A merry heart doeth good like a medicine but a broken spirit drieth the bones."

Proverbs

One needs to be careful that in studying humour we don't kill it. As Mark Twain said, "Studying humour is like dissecting a frog - you may know a lot but end up with a dead frog." That said the beneficial effects of laughter which have been noted are summarised in table 5. These, of course, can be of great therapeutic benefit.

Moderate physical exercise is also another modality of treatment which tends to have good side effects. It is a potent therapy in the treatment of many conditions such as heart disease, lung disorders, insomnia, depression, anxiety and osteoporosis just to name a few.53

Mind-body interventions for CHD and cancer:

Employing a holistic mind-body approach as an adjunct to medical care for serious illness seems to be extremely beneficial. There are the already mentioned direct physiological benefits, ie cardiovascular and immunological, but there are also the life-style benefits. Each works together. Employing the mind and emotions includes learning to relax, to communicate, to resolve long held emotional and personal issues, to learn to open up to other as in group therapy, and looking for meaning and purpose in ones life situation. David Spiegel, well known for his work with support groups put it this way.

"Living better also seems to mean living longer."ix

Many people do take a constructive attitude, learning about themselves through their illness, and such people are consistently found to do far better than those who simply become despondent.

Controlled trials looking at the effects of a holistic approach to treating CHD and cancer have yielded remarkable results. It is sometimes baffling why more studies are not done. One such study, looking at the progression of CHD, demonstrated significant improvement in both CHD and quality of life.54 In this study patients were compared in two groups. The control group had conventional medical management only, and the intervention group who also had a comprehensive lifestyle program including:

1. group support
2. stress management including:
   • meditation and yoga
3. a low fat vegetarian diet
4. moderate exercise

Dr Ornish tries not to isolate any one intervention as this would preclude the holistic nature of the intervention. The results are shown in the following table.

Interestingly, three patients in the control group improved, a few held ground but most deteriorated. What was notable about those in the control group who improved was that they were the ones who made significant lifestyle changes of their own accord. In fact improvement was related to lifestyle change in a 'dose response' manner. Other important points to be drawn from the study were that the costs of the lifestyle program were vastly less than for bypass surgery despite the results being so much superior. In the US the comparative costs are around $3,900 for the Ornish program compared to $40,000 for bypass surgery.x Needless to say the insurance companies are very interested in promoting it but, unfortunately the medical profession has been a little slower in some quarters which raises some interesting potential medico-legal dilemmas if medically valid and effective treatment option are not offered.xi

An important question is whether such observations can they be applied to help produce beneficial health outcomes for patients. The Ornish study on heart disease had already shown significant improvements for people who included a lifestyle and mind-body approach to their illness when compared to controls. Are such results reproducible? It seems they are if judged by another comprehensive study.55 In this paper the researchers followed 107 people with established coronary heart disease and divided them randomly into three groups, which were matched for other factors. The treatment given to the three groups were:

1. Usual medical management
2. Usual medical management plus physical exercise
3. Usual medical management plus stress management

The patients were then followed up for a period of five years to see who had major cardiac events over that time; for example non-fatal AMI, fatal AMI, deterioration requiring bypass surgery etc. The findings were striking.

For the stress management group this is nearly a 75% reduction in the risk of having another major cardiac event over that 5 year period. Considerable discussion centred around trying to determine what factor led to the positive outcome for the stress management group. There were some things which distinguished the intervention groups from the usual care group and might go some way to explaining the observations. The exercise group showed better blood lipid profiles and aerobic fitness and an improvement in overall psychological well being with less distress and depression. The stress management group also showed improved lipid profiles (we know that stress management improves cholesterol and increases HDLs), but no increase in physical fitness and yet they had less ischaemic episodes. The factor, which really distinguished the stress management group from the other groups, was both the degree of reduction in overall distress and, more significantly, a reduction in hostility. The stress management group found better ways of adapting to stressful situations. The stress management intervention included:

• A 16-week program helping the patient to -
• Perceive stressful situations differently
• Monitor stressful thoughts
• Find new ways of responding to stressors
• Training in relaxation techniques and biofeedback
• Group support

The differences between the groups are quite striking. No single piece of information can tell the whole story about mind-body medicine but each piece, like the parts of a jigsaw, begins to paint a cohesive picture, albeit with many pieces still missing.

What is also interesting to note is that similar interventions produce beneficial outcomes for entirely different diseases. For example a similar picture to the one appearing for heart disease is also becoming evident in the management of cancer. Psychological and social factors, a simple balanced lifestyle and improved quality of life are essential ingredients in preventive strategies and successful medical management. It is important that assertions that such assertions be tested.

Controlled trials looking at survival of cancer patients who are given psychosocial support showed there was a significant improvement in both quality of life and survival time. A study by Dr David Spiegel looking at women with metastatic breast cancer showed a doubling of survival time from 18.9 months to 36.6 months from the time of entry into the study if women were given group support and taught simple relaxation and self-hypnosis techniques as a part of their management.56 In fact 10 years after the study three women in the intervention group were still alive but none in the control group who had the usual medical management alone.

A study looking at patients with early stage malignant melanoma57 showed that there was a halving of recurrence and much lower death rate when the usual surgical management was combined with only six weeks of stress management early after the diagnosis. These patients also had their immune function monitored and it was shown that although the two groups were originally comparable six months after the stress management intervention the intervention group had significantly better immune function. This translated into a major difference in survival rates at six years.

The physiological mechanisms which bring about this improvement are under consideration. PNI may hold at least some of the answers. A reduction of stress brings about a subsequent improvement in immune function and we know that immune cells aggressively attack cancer cells, such as malignant melanoma, but only if they can recognise them. Many tumours, however, wear their antigens intracellularly and therefore are not recognised by immune cells.58 There must be other mechanisms. It is known that inflammatory mediators are increased by stress. These mediators act like a 'fertiliser' for cancer cells which may be lying in a relatively dormant condition in the body. Perhaps stress reduction helps to reduce the output of such mediators helping to switch the balance back in favour of the body in terms of tumour cell replication and death (apoptosis). There may also be a variety of 'genetic switches' regulating tumour cell replication and death which are affected by stress mediators.

One particular immune mediator which is generating a lot of interest is melatonin. Melatonin has anti-tumour effects. It is anti-proliferative, an intranuclear down-regulator of gene expression, and an inhibitor of the release and activity of growth factors.59 Melatonin stimulated endogenously, ie at physiological levels, has many beneficial effects but at the much higher pharmacological doses that many people are taking it can actually have very negative effects, such as causing immuno-suppression. Hence the risk of people self-medicating with hormones such as this. When we look at the things which do stimulate melatonin endogenously we find many of the life-style interventions which form a part of holistic cancer support programs. On the other hand it is starting to be postulated that low melatonin levels, such as those associated with jet-lag, may be part of the reason that some occupational groups are at higher risk of cancer.60

On a number of fronts we can now begin to say with confidence that every investment in the quality of life of patients with life-threatenting illness is also an investment in beneficial therapeutic outcome.

Social factors and health:

There is a wealth of research data to confirm that a person's social integration and relationships have a profound effect upon their susceptibility to illness independent of the usual lifestyle risk-factors or participation in preventive health programs. For example a US task-force looking into predictors for CHD found that job dissatisfaction and unhappiness were the stronger predictors than the usually accepted risk factors.63 Some social factors are found to have protective effects on health, for example being marriedxv, having an extended network of friends and family, church membershipxvi and group affiliation.64 Social marginality has been shown to predispose to CHD, cancer, depression, hypertension, arthritis, schizophrenia, TB and overall mortality.65 66 The sociologist James House looking at epidemiological data from 2,754 adults demonstrated that socially isolated males were 2 to 3 times more likely to die over the following 9 to 12 years and that women were 1.5 times as likely to die.67 Whether a person subjectively feels socially isolated is of course much to do with the person's attitude as it is to do with the number of people they have in their environment. Many people lead very 'social' lives but can be socially isolated.

Even when a person has well established illness their social context may have a profound effect on recovery. For example looking at 2,320 adults there was a four times increased death rate following acute myocardial infarction (AMI) if the person was socially isolated and experienced high levels of stress.68 Similarly, in another study those over 65 years of age were three times more likely to die post AMI if they had poor social support as measured by the simple question, "Can you count on anyone to provide you with emotional support (talking over problems or helping you to make a difficult decision)?69 These observations were not explainable by physical risk factors or access to medical care. There is a lot more which could be said but what needs to be emphasised is that a patient's social context is more than an appendage to a good medical history, it is a central factor in their health and a powerful but often untapped tool in terms of its therapeutic potential. It goes a long way to explaining why support groups are so useful.

Meditation and Healing:

Mindfulness meditation is one which is very simple to learn, and of direct and obvious benefit in learning to deal with the demands of daily life, is little more than an exercise in learning to concentrate in a restful way. It is one of the best tested and validated and does not generally clash with cultural backgrounds as the principle of mindfulness and its practical application are of such immediate relevance. Professor John Kabat-Zinn has used it in a variety of settings such as for relief of anxiety and also the management of chronic pain.70 71

The general public are becoming increasingly interested in low cost, non-invasive and more natural methods of treatment such as meditation. It would seem that the insurance companies are also interested in approaches to promoting health such as meditation. Such conclusions are drawn from huge audits one comparing 600,000 thousand non-meditators to 2,000 meditators.72 The findings suggest that in every disease category there are significant reductions in illness, for example an 87% reduction in heart disease, a 55% reduction in tumours and an overall 50% reduction in health care costs. This was not a controlled trial though the groups were roughly matched for age. On the strength of this sort of evidence and the things mentioned in previous sections insurance companies in the US and Europe are starting to offer substantial reductions on life insurance premiums for people who practice meditation regularly. Such benefits are likely to be explained by a combination of factors; ie the direct physiological benefits which a more harmonious and conscious state of mind offers and the improvement in lifestyle which more conscious and autonomous behaviour offers.

Spirituality and health:

It is strange that despite consistent evidence that spirituality is protective for physical and mental health and also against substance abuse it is not generally seen to be relevant in the medical history or treatment. If a physical risk factor of similar significance was overlooked then it would be seen as irresponsible. One recent analysis of 77 references demonstrated consistently that religious commitment was protective against illness, helped recovery and improved coping.73 The relationship seems to hold whether the studies are retrospective or prospective and whether or not they control for other lifetyle and social variables. Just to illustrate, it was recently shown that religious commitment was associated with significantly quicker recovery from depressive illness. Just a 10 point increase on the scale of religiosity increased the speed of recovery by 70%.74 In terms of protection from bowel cancer religiousness was associated with a 30% reduction in risk even when controlled for every other known risk factor.75 Similar relationships hold for cardiac risk factors such as hypertension.

Perhaps ignoring spirituality represents a bias against what science can't measure or maybe it is a sign of an increasingly secular, dispirited, cynical and fractured community.

"Not everything that can be counted counts and not everything that counts can be counted."

Albert Einstein

Interesting questions are raised by the review of such findings. How far, clinically and ethically, should a medical practitioner become involved in the spiritual life of their patients especially when a doctor may not hold the same cultural or religious views as the patient? This issue obviously needs to gain more attention, but what one could reasonably say is that gauging a person's spiritual awareness, sense of meaning and direction in life should form an important part of a medical, social and psychological history especially for the young. Preferably the subject should be broached in a sensitive and non-dogmatic way. For suitably aware practitioners and motivated patients giving information to patients about the relevance of spirituality to health and encouraging them to consider these issues might form part of a holistic approach to their problems. Because of the potential for spirituality to help a person cope with stress and modify behaviour it may well help the medical condition by potentiating treatment, and secondly help a person to transcend the adversity associated with illness. More detailed questions of a spiritual and religious nature should probably be referred to culturally appropriate non-medical 'experts' in the field.

The Practice

Eliciting the 'relaxation response' in practice:

This can be done in a number of ways. Regular physical exercise is one way which a lot of people use and it has similar wide ranging beneficial effects for mind and body.76 Others use certain sorts of music to good effect. Gaining wider popularity are long tried techniques like Tai Chi and Yoga. In more recent times other techniques are used such as hypnosis and biofeedback. One should also acknowledge the benefits which many experience through prayer, self-expression and good communication.

Probably the most studied form of stress reduction are the variety of relaxation and meditation exercises. Most techniques will rely on the attention being focussed or rested on something and in the process learning to not struggle with, but let go of, unnecessary and distracting mental activity. Table 3 lists some of these practices.

Different forms of meditation suit different people. Which is the best form of meditation? The one you practice. As a practice there is little use in thinking in terms of success, criticism or failure, but just practice. With experience comes learning how to meditate more deeply; success will come of its own the less anxious one gets about results. Meditation should be simple and easy, and where it is becoming difficult or complicated then one should seek guidance as one is not meditating appropriately. Such simple techniques are finding increasing use in clinical practice for both groups and individuals. Courses are now being run on a regular basis for both the doctor's personal benefit as well as improving their clinical skills in managing stress.77 They are simple and, unlike many pharmacological and surgical treatments, the side-effects are beneficial. Outlined below is a mindfulness meditation technique.

Mindfulness meditation:

Preparation

It is important, wherever possible, to have a quiet place to practice the exercise without interruption. This is not to say that you cannot apply the technique anywhere, any time. It is recommended that it be practiced initially for 5 minutes twice daily (before breakfast and dinner are good times) and at other times during the day if needed, even if only for long enough to take a coupe of deep breaths, just to help break the build-up of tension and mental activity throughout the day. One can increase the amount of time if one wishes as one goes.

Position

A position where you are unlikely to go to sleep is best for meditation so sitting in an upright position, with the back and neck straight, is recommended. Lying down can also be useful but the ease of going to sleep may not always be desirable unless it is late at night. Make sure the position is balanced and relaxed, with no strain or undue muscle tension. Let the eyes gently close.

Progressive muscle relaxation

Become aware of your presence in the room, here and now, and just rest in that, free of thoughts of past and future. Be conscious of the body and let it fall still. Now, become aware of each part of the body and release muscle tension patiently, consciously and methodically. Start with the feet and if there is any muscle tension being held there let it go. Be conscious of the legs and if there is any tension there let it pass. Become aware of the stomach and let it relax. Now the back. Allow the body to hold it's upright posture with a minimum of strain. And so on with the hands, the arms, the shoulders, neck and face. If you become aware of any tension coming back into the body just practice letting it go again. The important thing to remember is that you do not have to make yourself relaxed, it is more a way of allowing yourself to relax. Trying to force things and 'get it right' sets us up for frustration, failure and strain and is counterproductive.

Breathing

Feel the breath as it passes in and out of the body, by simply letting the attention rest right where the air passes in and out. Again, no force required. If distracting thoughts and feelings come into the mind, carrying the attention away with them, just be aware of them but let them go. There is no need to try and stop these thoughts coming into mind, nor to try and force them out. You may well notice that trying to force them out just feeds them with attention making them stronger. Just let them pass allowing the attention to return to the breath. Practice standing back, observing, detaching and letting go. Even let go of the thought of 'getting the right result' from the meditation practice. To help one not get caught up with the thinking just see the thoughts as nothing but images and sound appearing in the mind like at a movie, whether they be they pleasant or unpleasant. Treat them with casual disinterest as distractions.

Listening

Now let the attention turn to the listening, by being conscious of all the sounds you can hear around you. Let them come and go. Listen to the sounds which are close and also as far out to the distance as you can. In so doing become aware of the space around you. There is no need to listen to a commentary in the mind about the sounds, or about anything else for that matter, just listen, and rest. Once again let go of distracting thoughts. These are disabling and prevent us from both resting and coming into the here and now. After you have practiced for your allotted time slowly go backwards through the steps, ie being aware of breathing then the body and then slowly allow the eyes to open. After a few moments move into the activities which need your attention.

An exercise such as the one above can be included as a part of a daily routine. Even a few minutes at least twice a day can be invaluable. The calmness and focus becomes, over time, increasingly available in more and more trying situations. It improves 'stress hardiness.' These practices can be well complemented by shorter practices at frequent intervals throughout the day, say at the completions of one activity and the commencement of another. These are like full stops and commas punctuating our day. Without the punctuation the text tends not to make sense. This is not a method of escaping life but rather a way of engaging in it in a more focused, efficient and reasonable manner.

Conclusion

Today we seem to be at the frontier of some challenging yet exciting developments in health care and health promotion. Research is reopening some recently neglected chapters focussing on the 'softer' medical sciences.

Traditional philosophical wisdom and modern science are integrating in a complementary way not previously thought possible. In our approach to western medicine we may well benefit by applying some of the simple principles, for example from our Greek forebears such as Plato and Hippocrates, to contemporary health problems. Scientifically valid ways of testing outcome measures for these approaches in practice need to be applied.

So far, what many clinicians have felt intuitively for millennia seems to be becoming validated the more we look into the research. The challenge presented to the researcher is to develop methodologies which can deal with factors that are inherently hard to define and measure such as 'personality factors', 'social connectedness' and 'religiosity'. Much research has also tended to work on an illness rather than a wellness model where wholeness and quality of life are of primary not secondary importance. Furthermore, holistic interventions lend themselves much better to outcome studies rather than mechanistic ones, and perhaps studies like Dean Ornish's can form a prototype for the treatment and investigation of many other chronic conditions.

What we ignore may well prove costly, whether that cost is measured in terms of a patient's quality of life, therapeutic outcome, or dollars. Unfortunately many studies looking at the prevention and treatment of heart disease, cancer and other serious illnesses include very little analysis of psychological, social and spiritual factors. Analysis has tended to focus mostly on what is easiest to measure, that is the physical factors, but if we do not look more closely at other factors we may be missing important relationships.

At present there is a need for greater general awareness of this field of medicine both in the general and medical communities. This has important implications for future directions in medical education and health care funding. If indeed mind-body medicine and holism are practical options as alternatives or adjuncts to other more technological and pharmaceutical medical treatments then hopefully this will culminate in helping to reunite the traditional 'wise and caring' doctor once again with the scientifically astute one.

Further reading:

• Mind-body Medicine: edited by Goleman and Gurin. Published by Choice Books, 1995.
• Mind-body Medicine: A Clinician's Guide to Psychoneuroimmunology: edited by Watkins. Published by Churchill Livingstone, 1997.
• The Neurophysiology of Enlightenment: by Robert Wallace. Published by Maharishi International University Press, 1989.
• Peace of Mind: by Ian Gawler. Published by Hill of Content, 1989.
• Full Catastrophe Living: by John Kabat-Zinn. Published by Delta, 1990.
• The Physical and Psychological Effects of Meditation: edited by Murphy and Donovan. Published by The Institute of Noetic Sciences, 1997.

Endnotes

1. This was a statement made by Marsilio Ficino, a great Platonic Philospher of the Folrentine Renaissance.
2. See the later section on Psychoneuroimmunology (PNI).
3. See the later section on the mind and heart disease.
4. See the later section on the mind and cancer.
5. Discoverer of the polio vaccine.
6. In particular lowered NK cell activity, a 90% reduction in gamma interferon and lowered response of T-lymphocytes.
7. There is much more information about the science of the area and enthusiasts would do well to refer to Ader's textbook called "Psychoneuroimmunology".
8. Thomas Sydenham was a very prominent 17th Century Physician.
9. From the book "Mind-body Medicine." Spiegel is a professor of psychiatry at Stanford University.
10. Figures from the insurance company, Mutual of Omaha.
11. Dr Steven Horowitz, a leading US cardiologist, was quoted as saying "It is almost medical malpractice not to offer it" in Business Week magazine in 1993.
12. Relative Risk.
13. Though this is a substantial reduction it was not statistically significant.
14. This result was so marked that despite the small numbers it was statistically significant.
15. Unhappy marriages and separation were also associated with poor health especially if the person was less able to let go.
16. It seems as though having a spiritual dimension in ones life is protective as the effect in noted across a number of denominations and religions. There no doubt could be a number of explanations for such an observation.
17. The first four are more aimed at finding a peacefulness and stillness 'beneath the mental activity' whereas the fifth is more directly aimed at 'reconditioning' the mind. One of the problems with the mind's tendency to visualise and imagine is that it is at the source of much of our stress and maladaptive coping strategies, such as when we 'catastrophise' or 'awfulise' or when we prejudge events. It can go on habitually and unconsciously and we frequently lose the ability to distinguish between reality and imagination.

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