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Mind-Body Healing and the Placebo Effect
By Sarah Tewhey

The integration between physical well being and mental peace has a long established history in healing therapies. Even today the most ardent skeptic of mind-body techniques will admit that a vacation to a beautiful location away from the stresses of daily life makes one feel peaceful, at ease and refreshed. Through recent advances in neuroscience and the field of psychoneuroimmunology scientists and the medical community are beginning to discover the physiological connections between mental life and the physical body.

Over the past thirty years, mind-body interactions are seeing a renewal in interest for the first time in over a century. However, the concept has been embedded within the medical research community as a phenomena known as the placebo effect. Once thought to be an unexplainable human reaction to inert substances, the placebo response is now being reexamined as a fascinating and mysterious aspect of the human experience and in some circles as a potential tool for healing. When examined side by side the placebo effect and the field of mind-body medicine appear to be meeting at a crossroads. The implications of research in both areas may lend insight into the future of human well-being, therapeutic intervention and health care reform.

The History of the Bodymind
For thousands of years, all around the world cultures have understood the important integration of the mind and the body. Mothers, fathers nurses and nuns have long used caring and a loving touch to heal and soothe the sick. In North American Navaho tribes, entire families and villages are involved in healing rituals and ceremonies to cure illness (Powell, 1891). In Central America a visit to the curendera means a cure from ailments such as envy and soul loss (Avila, 2000). In India and the far East living spaces are cleared of long-gone spirits said to cause trouble and disease. And, in ancient Greece the ill would often be sent to healing temples devoted to Asclepius the Greek god of healing with a protocol of rest, sleep, long walks and baths in the spring waters (Sternberg, 2001). Therapies of this nature can be found all over the world and up until only a hundred years ago were some of the best remedies that local medicine men, shamen, healers and early physicians had to offer. For thousands of years these therapies, while not complete in their ability to cure, were effective, trusted and considered highly therapeutic.

With the advent of modern medicine all of that changed. Medicine swung one hundred and eighty degrees and separated completely the mind from the body and the actual human being from its physical form. Based on the shape that modern medicine has taken and the frank skepticism that some physicians greet mind-body integration with, it is surprising to learn that Hippocrates, the Greek physician who lived in 400 B.C. both understood and put into practice the power of the mind to heal the body (Sternberg, 2001). Hippocrates understood both this vital integration and the importance of the doctor-patient relationship. It seems that he also understood the impact of belief on healing, or what would later be called the placebo effect. "For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician" (Siegel, 1989, p.121).

Today, modern physicians still take an oath in Hippocrates name when they finish their training. Although Hippocrates is heralded as one of the great fathers of medicine, some of his philosophies and perceptions appear to have been temporarily lost in the shuffle as we slowly separated mind and body.

Like other historical shifts in attitude this separation was slow, occurring over the course of several hundred years. One pointed mark in this history takes place in the seventeenth-century between Rene Descartes and the Pope. Rene Descartes was eager to use human bodies for dissection, a practice that was at the time banned by the church. Eventually however, a solution was found. Descartes would study the physical body exclusively and agreed not to speculate on the presence and inner workings of the soul, the emotions or the mind as these areas "belonged" solely to the interests of the church (Pert, 1997). Certainly, Descartes did a great justice to the advancement of science and medicine through this deal, but the repercussions of this separation of the mind from the body has effected modern western medicine ever since.

As time passed, and the physicianss ability to heal with drugs, surgery and other procedures became more successful, focus shifted even further away from mind-body interactions. Scientific methodology became more solidified, breakthroughs such as antibiotics and vaccinations gave medicine a real advantage over deadly diseases (Brody, 2000), and incredible steps were made to both discover and understand the intricate processes of the human body. The ability of the mind to heal the body became an old fashioned outlook as modern science sped full forward (Benson, 1996).

Medicine after World War II made enormous advances and new research methodologies were developed. Despite the inherent distaste for mind-body integration scientists and physicians came to use the mind as the standard for scientific research. The advent of the double-blind randomized trial meant that new drugs and procedures would be tested against the innate healing power of the human mind, also known as the placebo effect (Brody, 2000).

The Power of the Placebo
Howard Brody describes the placebo as a,
Change in a patient's condition that results from the symbolic aspects of the encounter with a healer or with a healing setting, and not from the pharmacological or physiological properties of any remedy used(1995).
Scientists use placebo in double-blind clinical trials to test new drugs or procedures. One group of individuals is generally given the actual drug being tested, while a second group receives a "dummy pill" known as a placebo. This placebo pill is often made of sugar and does not have any physiological effects, as t is pharmacologically intert. In this type of trial the actual drug has to produce significantly better results than the placebo in order to be considered effective (Enserink, 1999).

It has become a well-known phenomena in the field of medical science that as a general rule 30%-40% of the individuals in the placebo group generally experience significant positive effects from this inert pill. In some trials placebo response can be as high as 90%. (Benson, 1996). To the health care provider interested in the beneficial effects of the interaction between mind and body this phenomenon provides an incredible place to begin research. For the traditional researcher, or for drug companies trying to prove the effectiveness of a new medication the placebo has become a "problem" (Enserink, 1999), a "curse" (Enserick, 1999) and an "occupational hazard" (Enserick, 1999). The placebo in the west has become widely viewed as a hindrance to research and a roadblock in the the path of progress. The wide-spread opinion of the placebo effect is deep-seated and when investigated evokes a complicated history.

Historical Aspects of the Placebo
The word "placebo", coming from Latin and meaning "I shall please" , first appears in the Middle Ages in songs sung for the dead. The world also came to refer to a flatterer or an individual who told you only what you wished to hear and evaded the truth (Brody, 2000). The concept of the placebo effect was only introduced to the scientific world around 1785 and the term itself, already plagued with negative connotations came into medical terminology in the early nineteenth century. The placebo was defined as a treatment or medicine given to "please" patients rather than to actually help them (Brown & Severs, 1999). In 1898 Dr. Elmer Lee writes:
The principal influence or relation (of drugs) to the cure of bodily disease lies in the fact that the drugs supply material on which to rest the mind while other agencies are at work eliminating the disease from the system, and so the drug is frequently given the credit (Brody, 2000, p.23)

During Dr. Lee's time, a placebo pill or procedure was one of a physician's more valuable tools in healing. Dr. Lee's comment implies an understanding that the body does in fact harbor some innate and unexplainable power to heal. Physicians up to 50 years ago regularly gave inert pills to patients with a startling record of effectiveness (Benson, 1996). Time passed however, medical science became more exacting, medical ethics and informed consent took a center stage and the power of the placebo fell out of favor with many physicians. It became an obstacle in research and a discredited treatment. This negative view has persisted to the present day and continues to shape the way that the biomedical paradigm views the healing powers of the mind (Brown & Severs, 1999).

An Argument Against the Placebo Effect
There are plenty of individuals who are skeptical of mind-body therapeutics and a few who argue that the placebo response does not even exist. While there is accumulating evidence that the mind and the body do interact, the argument against the placebo should still be considered.

Most recently in May of 2001 two Danish researchers from the University of Copenhagen published a paper in the New England Journal of Medicine that made a case to disprove the existence of the placebo response. The research was a review and analysis of 114 different studies. The analysts determined that patients do not recover because of the placebo effect, but because of the natural uneven course of the disease process. Analysts also found that subjects in third-arm control groups given neither a drug or a placebo improve at roughly the same rate as those subjects given a placebo. The study states that these individuals are showing improvement because of the natural ups and downs of illness, not because of a mind-body interaction (Kolata, 2001).

Another analysis of research done by Kienle and Kiene in 1997 raises similar questions and examines specifically Henry Beecher's landmark paper in 1955 entitled "The Powerful Placebo". This team again sites unpredictable disease pathology as a reason for the seeming placebo effect as well as psychosomatic phenomena and the subject's desire to help researchers and doctors by answering questions in a fashion that they feel are polite and pleasing. Kienle and Kiene conclude that a variety of factors among the research subjects as well as inherent flaws in experiment design and implementation results in an effect that appears to indicate a mind-body interaction (Kienle & Kiene, 1997).

When in persuit of the truth it is vitally important to have every area of a subject scrutinized and examined. The result of each of these studies was to renew interest in the placebo, and has led the scientific community closer discovering what the placebo response is and how it works. While there is still some remaining controversy over the existence of the placebo effect, there are an abundance of recent articles that address this controversy. The skepticism surrounding the placebo effect has served to propel biochemical research into the discovery of how the placebo operates (de la Fuente-Fernandez & Stoessl, 2004). It has also led to discussions regarding the therapeutic effects of the placebo response.

Physiological Pathways
The actual physiological processes of the placebo effect are still largely unknown. Several exciting advances have been made however, most notably a recent study conducted at the University of Texas that lends insight into the way that the mind-body connection is operating within the realm of the placebo.

This study has uncovered some of the reasons why placebo works, and opened a wide range of questions and new information about the human ability to heal. An inert topical cream that subjects in the study were told would decrease the pain of a subsequent electrical shock was applied to the arm before a shock was given. Later on, an identical cream that subjects were told was inert was applied and a second shock was given. Many of the subjects reported afterward that they had felt less pain when the "analgesic" cream was applied.

Brain activity from functional magnetic imaging (fMRI) scans taken from each subject during the study show that the subjective experience of feeling less pain has real merit. When subjects reported feeling less pain, fMRI scans showed that there was reduced blood flow to pain sensitive areas of the brain leading to a reduction of activity in this area. Most interesting however, is that in addition to this reduction of activity in the pain center of the brain, subjects also had increased pre-frontal cortex activity. This area plays a large role in planning and expectation. It seems that the subject's expectation to feel less pain because of the application of the "analgesic" cream actually reduced activity in pain sensitive areas. (Placebo effect found in brain scans, 2004)

Because the brain has control over so many systems of the body, the implications of this study not only supports the science behind mind-body healing, but opens up entirely new questions for the medical community regarding patient beliefs, expectations and psychological roles in the healing process. Individuals who expect to get better, who believe in their doctor, their treatment and in themselves may be able to better regulate the healing process within their bodies.

This study also puts to rest an old myth about the effectiveness of the placebo. Physicians skeptical of the placebo response often assumed that it was effective only when the patient's pain or illness was imaginary from the outset. Thus, if an illness was "all in the head" of a patient, then a cure by placebo would mean that in fact, there had never been illness present at all (Brody, 2000). In essence some physicians believed, and still believe today that a placebo is highly effective in curing only non-existent disorders, a view that the research team at the University of Texas has put to rest.

Stress, Healing and Placebo
Stress response has recently become a key focus in the field of mind-body interactions and may help to explain not only why we become ill, but how we heal as well. Through the discoveries of the connections between the hypothalamic-pituitary-adrenal axis, the immune system and the nervous system a completely new and innovative picture of the human body is emerging. It appears that a prolonged stress response from the body can in fact decrease the function of the immune system and severely alter the chemical balance of the body (Sternberg, 2001). This information is something that many of us understand intuitively, but has only recently been explored by the scientific community. Many mind-body therapeutics have a direct effect on stress response, which in turn alters a variety of other processes.

If the stress response is at least partially responsible for human maladies such as high blood pressure (Benson, 1975) and a general reduction in the function of the immune system, then to Dr. Herbert Benson in the late 1960's it only made sense that the body would have built in an opposite response to promote health, relaxation and well-being. At Harvard in the late 60's Herbert Benson was a professor of medicine and the Director of the Hypertension Section at Beth Israel Hospital in Boston. Over time he came to an understanding that stress was playing a large role in the high blood pressure he saw in his patients (Benson, 1975).

He devised and carried out a series of fascinating experiments on practitioners of transcendental meditation. He arrived at a conclusion that has been written about in esoteric texts for thousands of years, but was for the first time proven in a western laboratory. He found that practitioners of meditation seem to create a physiological state within the body that is exactly opposite to that of the stress response. He called this state the relaxation response and proceeded to devise a simple technique that could be used by anyone to achieve results (Benson, 1975).

The technique includes a single focus of the mind, a relaxed and comfortable posture for the body and voluntary respiratory control to slow breathing. Aside from altering the electrical activity of the brain this technique lowered the blood pressure, oxygen consumption and rate of respiration in patients who practiced regularly. The technique also produced a decrease in blood lactate levels. Blood lactate is associated with the activation of the sympathetic nervous system and is present in situations of high anxiety (Benson, 1975). Benson's early research implies that the mind has a profound impact on human physiology and that relief of stress via the relaxation response has a positive impact on overall health. This piece of information is instrumental for understanding the mechanism of the placebo response in the following example.

Research trials generally include subjects with a particular disorder or illness who have not had great success with pharmaceuticals already available. The placebo may work on these individuals via a reduction in stress. In research trials, the effects of stress on the body may be lowered though a sense of caring by medical professionals and hope for relief by means of an unexplored treatment. An individual suffering from years of depression who participates in a clinical trial for a new anti-depressant medication may experience a significant change in mood simply by feeling cared for by the researchers, spending time in a clinical setting and taking a pill that may be helping their illness.

Each of these components can relieve the anxiety the individual feels toward their illness and creates the possibility that the depression may be controllable (Kinser, n.d.) It has been shown that the more stress and anxiety a research subject has at the beginning of the experiment, the more responsive they will be to a placebo (Brody, 2000). The higher the initial stress of the research subject, the more opportunity the subject has to relax. The more the subject relaxes, the better the body is able to elicit some of the physiological effects of Benson's relaxation response. This makes the placebo response even more obvious and dramatic.

This scenario involves a number of factors that may reduce stress. Individuals who are involved in a research setting often participate in extensive questioning about lifestyle, diet and medical history, a procedure rarely undertaken in the fast paced climate of a hospital. This combined with the sense of possibility regarding the strength of the new drug can create a feeling that the subject is truly receiving help and a possible cure. An individual with high anxiety is likely to become more relaxed about the illness by participation in a research trial. This lowers the stress response, altering the chemical balance of the body and increasing the body's ability to recreate balance.

The Survivor Personality
Studies have been attempted over the years to determine who is more susceptible to the placebo effect. Some of these studies began in the early seventies in the hope that these individuals could be labeled and effectively removed from research trials. In the end, researchers found that no one is completely immune from the power of the mind to alter the processes within the body. Although questions still remain, in the years since there has been almost no conclusive evidence of there being a definitive "placebo personality" (Brody, 2000). While a placebo responder may not fit into a particular category it does appear that a combination of specific conditions and characteristics may make an individual more inclined to elicit mind-body interactions and maintain health in the face of illness and stress.

In George Solomon's work with HIV patients he has discovered what he calls the "survivor personality" (B. Siegel, personal interview, June 14, 2004). These individuals are more likely to grow personally and maintain health despite life threatening illness. Long-term survivors of HIV have demonstrated to be realistic about their diagnosis and the possibilities of survival, willing to alter their lifestyles, assertive in getting their needs met, able to talk about their illness, responsible for their own health and involved with other individuals who have HIV. (Solomon & Temoshok, n.d.)

In 1975 Suzanne Ouellette Kobasa began a study at Illinois Bell Telephone to determine the characteristics of what she would later call the "stress resistant personality" (Ouellette Kobasa, 1990). Individuals who are under high levels of work related stress, but maintain an optimal level of health exhibited three common characteristics; a sense of control over their lives, interest in their work and most importantly what Ouellette Kobasa calls a "commitment to the self",
Commitment to the self was the most important discriminator...Those executives who stayed healthy reported...knowing who they were. They were able to talk about their values and priorities. They were in touch with their feelings. They knew what was important to them (Ouellette Kobassa, 1990, p. 223-224).
Any of these characteristics may alter processes in the body that reduce stress and create highly optimized mind-body interactions. If the ability to respond to a placebo is indicative of a greater capacity for mind-body healing ,then the placebo characteristics may be something to cultivate rather than be viewed as a weakness. If characteristics of a placebo responder can be understood and developed, then perhaps questions regarding the ethics surrounding the use of placebo can be completely eradicated. An individual could knowingly develop these characteristics in order to improve the curative power of the treatments they are receiving without necessarily being lied to by their health care providers.

Reintegration of the Mind and Body
The therapeutic uses of the placebo effect are only beginning to be explored and studied. It is here that placebo intermingles and becomes indistinguishable from the field of mind-body therapeutics. In fact, when used to describe an endogenous healing response the term "placebo effect" probably needs an update altogether. In Dr. Howard Brody's book "The Placebo Response" (2000) there is an actual section called "Placebo Response without the Placebo" (p.85) in which Brody explores the healing properties of the patient/client relationship and the patient's sense of control over their illness and treatment. In this section Brody shows that eliciting a helpful and healthful response from patients does not require them to be misled or lied to and that a change in tactics by health care professionals can create a powerful healing response. (Brody, 2000). But is this placebo? Where is the line drawn between the placebo effect, mind body medicine and the innate healing capabilities of a human being?

It is in this area that the subject matter becomes blurred and it is here that the most interesting area of study sits, poised atop the pillars of the scientific community, the CAM movement and the healing possibilities of psychology. If the placebo response is something that every human is truly capable of, has true therapeutic merit, does not always require that an individual be given any medication either real or fake and does not require that an individual be mislead in order for it to work, what has it become? It would seem that what was once an inconvenience for medical researchers may have come full circle to be used again as a therapeutic tool. It is at this juncture that there is truly an opportunity to take a variety of previously ignored factors regarding the healing process into consideration and perhaps create a new model of medicine.

Dr. Herbert Benson (1996), Dr. Howard Brody (2000) and a number of other physicians have made tremendous contributions to western medicine by suggesting that we learn to use the placebo effect to our advantage in healing instead of viewing it as a complication. Benson recognizes the importance of the mind-body interaction and in his book Timeless Healing (1996) and suggests that we do away with the word placebo altogether in favor of the term "remembered wellness".

In every situation from a minor daily stress to a life-threatening illness we each have the ability to "remember" states of peace, health and well-being and to change the present workings of the body because of this memory. Imagine that you have been suffering for a week with a terrible cold and finally make an appointment to see you doctor for help. On the day of your appointment you are waiting in the doctors office and suddenly notice that your symptoms have subsided and that you are feeling much better (Benson, 1996).

This scenario does not seem completely far-fetched as many of us have had a similar experience. Skeptics would argue that your cold had run its course, you body has healed and that your timing with the visit to the doctor was a mere coincidence. Proponents of mind-body healing would say that the moment you made the phone call to your doctor your body had a "memory" of going to the doctor previously and becoming well (Benson, 1996). This remembering from a past experience and prior conditioning may set your mind at ease a bit, reduce your stress response through reassurance that help is available in the near future, and thereby by boost your immune system just enough to fight the remainder of the cold.

This is an example of only one of possibly thousands of healing pathway scenarios that exist in our bodies. It is possible that these pathways can be activated through our minds via the "placebo effect", Benson's "remebered wellness" (1996), or Howard Brody's "inner pharmacy" (2000). These and many others are all terms for the same miraculous process of mind-body integration from which the field of mind-body medicine has developed.

The Recipe for Healing
What is called the placebo response and many mind-body therapies may reduce stress and provide effective results through the psychological pathways of expectancy, conditioning, meaning (Brody, 2000) and relationship. In all of the examples so far at least one and often several these components has been present. These factors seem to contribute to the effectiveness of the placebo response and most likely hold true for mind-body therapies, complementary and alternative approaches and modern health care as a whole. In a wide-ranging number of studies with everything from drug trials, childbirth, CAM therapies and post-operative recovery (Benson, 1996), research has shown that the mind's ability to heal the body is filtered through a number of channels.

Present Expectancy
One ingredient in the recipe for healing appears to be expectancy. Treatment results have been shown to be at least partially determined by what the patient or research subject expects the outcome to be in the future based on what they have been told in the present. A drug's effectiveness is boosted if the subject knows the action that the substance is supposed to create. In some trials the same drug will create the opposite reaction in different subjects depending on what an individual has been told the effect of the drug will be. These differing actions occur despite the drug's proven effectiveness for a certain action and its inherent chemical properties (Brody 2000). There is now research from fMRI scans that support the expectancy factor, as it appears that portions of our brains used in expectancy are actually activated during the placebo response (Placebo effect found in brain scans, 2004). This activation may also occurs anytime that we are receiving medical treatment from a trusted professional.

Dr. Bernie Siegel, in a recent interview recounted a story that illustrates expectancy. A Russian man who spoke almost no English was admitted to a hospital with a variety of symptoms and was diagnosed with a serious form of cancer. The physician tried to explain the situation to the man, conveying to him that he had six months to live. The Russian man misunderstood and believed that his prognosis was to be cured in six months. The man in the story lived for fifteen years beyond the diagnosis (B. Siegel, personal interview, June 14, 2004).

While the power of expectancy is available to everyone, Dr. Siegel maintains that suggestive techniques and the placebo response are most effective in children. Children with cancer, he states, can sometimes be given highly effective placebo pills to prevent the hair loss that accompanies chemotherapy (B. Siegel, personal interview, June 14, 2004).

If what we expect to happen in the present has the potential to create physiological changes, then certainly our experiences from the past have an equally important role.

Prior Conditioning
Conditioning is another ingredient in the recipe for mind-body healing. Current treatment effectiveness is sometimes influenced by the individual's past experiences and associations. A famous and powerful example of conditioning comes from experiments done with rats at the University of Rochester by Dr. Rober Ader and Dr. Nicholas Cohen. In this experiment rats were injected with an immunosuppressant drug and simultaneously fed water sweetened with saccharin. Over time the rat's immune systems would depress while drinking the saccharin water alone, without the injection of the drug. (Borysenkyo, 1987). The outcome of this experiment shows how profoundly conditioning stimuli can effect actual physiological processes

The classic example of conditioning is the infamous Pavlov's dog. Ivan Pavlov was a Russian scientist in the late nineteenth and early twentieth century who studied psychological conditioning. Pavlov trained his dog to associate being fed with the sound of a bell. Over time, the dog became conditioned to the association and would begin to salivate at the sound of the bell even though no food was present (Sternberg, 2000). This experiment shows that an outside stimulus can create a very real and predictable physiological reaction that was completely unrelated to the stimulus prior to the conditioning.

The mechanism of the placebo and many mind-body therapies is now being discussed in terms of human behavior and evolution. An increasingly popular theory is the "top-down and bottom-up" (Benson, 1996) mechanisms by which an individual responds to incoming messages from the outside world. Processing from the "bottom-up" relies on actual sensory information from the body to determine what is happening. In this process higher brain centers take in information from the environment, analyzes it and respond appropriately. In this process every situation is handled as though it has never been encountered before, making an individual adaptable to many circumstances, but not very quick to respond.

The second process is known as a "top-down" reaction. In a given a set of circumstance the brain will process the information by looking for similarities between the present situation and past experiences. This link between past and present allows the body to react to a situation very quickly based on memories of previous behavior (Benson, 1996).

The placebo response and mind-body healing may operate through this "top-down" mechanism via conditioning. When we encounter illness, we immediately make associations between this sickness and illness in the past. Often times, we ignore and bypass the actual circumstances altogether in favor of an explanation that is familiar. If an individual associates their present state with a scary or unpleasant past situation , then worry and anxiety can develop and may worsen the prognosis or contribute to the creation of entirely new symptoms. If an individual remembers an experience of recovery and helpful treatment in the past, then the body relaxes and is better able to stimulate an endogenous healing response.

Relationship
The effect of the patient/practitioner relationship deserves a category of its own and has been recognized over and over again as an instrumental factor in healing. Hippocrates understood the importance of this relationship (Siegel, 1989) along with countless health care providers before and after him. In the modern world individuals are becoming increasingly discouraged with the health care they receive. If you step into doctor's office today, the average time that you will have to explain your situation to a doctor or resident is approximately twenty three seconds (Marvel, Epstein, Flowers & Beckman, 1999), hardly enough time to elicit the kind of response our minds require to feel cared for, listened to and understood. Individual relationships to health care professionals provide an important component to healing that should not be underestimated.

As complementary and alternative therapies continue to grow, the actual effectiveness of these types of therapeutics remains hotly debated. In clinical trials many alternative therapies have not successfully shown to be more effective than a placebo (Benson, 1996). Dr. Herbert Benson (1996) actually maintains that the effects of most CAM therapies including acupuncture and herbal remedies are an effect of "remembered wellness".

So why exactly are individuals being drawn to CAM therapies and why do the results seem so promising? Ted Kaptchuk who heads placebo research at Harvard University suggests that alternative medicine as a healing modality may be a system that intrinsically promotes the healer/patient relationship that is so important for health. He suggests that, "Therapeutic patterns that heighten placebo effects are especially prominent in unconventional healing, and it seems possible that the unique drama of this realm may have `enhanced' placebo effects in particular conditions" (Nelson, 2003).

In effect, the mind-set of the CAM practitioner, the practitioner/patient relationship in the CAM setting and the openness of the patient to try CAM therapies in the first place may be the right combination for an exceptional placebo response CAM practitioners are more likely to take detailed histories of their patients, spend time getting to know who they are and crafting highly individual treatment protocols (Nelson, 2003). This combination may make an individual feel more cared for and may cultivate a feeling that the treatment has been created just for them and their particular illness or ailment.

Prior to the advent of modern medicine doctors relied largely on the caring and attention that they were able to bring their patients. The waning physician/patient relationship has brought attention to the importance of the healing partnership. In the words of Dr. David Speigel who has published extensive research on the effects of psychosocial treatment on patients with breast cancer;
In our medical training we tend to focus exclusively on the technical aspects of what we do - surgery, chemotherapy, and so on. But I feel more strongly than ever that the doctor's role is to help the patient cope with all aspects of what it means to be sick and to face the limitations in life. The best medical care must always involve attention not only to the physical treatments, but also to the way the patient is coping with them (Moyers, 1979, p.160).

Meaning
Larry Dossey, author of Healing Beyond the Body (2001) and member of Hillary Rodham Clinton's Task Force on Health Care Reform also served as a battalion surgeon in the Vietnam War. It was there that he first began to learn about the connections between meaning and health, after attempting with only partial success to get his troops to take their malaria pills. Reality struck when one young man contracted malaria and gave Dossey a high five before being air lifted out of the camp. While malaria meant a life-threatening illness to Dossey, it meant a one way ticket out of combat for young soldiers (Dossey, 2001).

Similar anecdotes come from Dr. Henry Beecher in war-time field hospitals housing seriously injured soldiers. After their injuries, the soldiers reported feeling markedly less pain than his normal civilian patients during peacetime. The meaning behind this mysterious observation lies in the fact that an injured soldier has been removed from the battlefield and an incredibly stressful and life-threatening situation (Benson, 1996). While a serious injury for a civilian can mean a life-altering disaster, the same injury for a combat soldier means relief. The meaning that we attach to our health can have broad effects both in our psychological process and our physiology.

Meaning is the least well understood, most complex and perhaps the most profound mechanism for mind-body healing and the placebo response. Human beings have a build-in desire to create meaning from their experiences, especially those that severely alter or impact their lives such as injury or illness (Brody, 2000). Since the beginning of human existence we have found ways to explain and give meaning to our surroundings and our lives through stories. We each have a personal story that is imbued with our own interpretations, feelings, hopes, desires and seemingly unrelated connections to present events with situations of the past and expectation of the future. Creating stories about our lives allows human beings to bring a sense, order and control to a world that is often random and unfair (Brody, 2000).

An individual with an illness or injury, with physical pain or with a mental imbalance will create a new chapter to their life story around their sickness. This story will be full of hope and of suffering, and most importantly personal meaning. More than any other situation in life, illness and injury become the subjects of intense meaning. When we are sick we ask "Why me?", we wonder when or if we will get better, try to find reasons for the presence of the illness and try to discover therapies that make us well. We build an immense amount of meaning and emotion around the processes of sickness and healing and for this reason meaning as a factor in treatment becomes phenomenally important.

What is interesting is that people have a strong desire to share their stories, to be understood by their peers and health care providers and to work with meaning as part of the healing process. CAM practitioners generally work more with meaning in their evaluations of patients. It is only with a CAM practitioner that you will hear questions such as "What do you think your diagnosis is?", "Why do you think you got sick?", "What do you think you need in order to heal?". These questions dig into the personal stories and meanings that each person gives to their situation, and may help to explain why so many people are turning to CAM practitioners. The answers to these questions are generally surprising and insightful. When you ask a patient how they got sick and how they will get well and ask them to tell their story, they will usually know exactly how to treat themselves. As we will see next, the telling of the personal story, also known as disclosure is in itself a powerful healer.

James Pennebaker and colleagues from the Southern Methodist University created a number of studies in the late 1980's to measure the effect of emotional disclosure and health (Brown, 2002). What they found is fascinating and also reveals some of the importance that the personal story, and the ability to share that story has on our health.

In a 1988 study with undergraduate college students, individuals who wrote about emotionally traumatic experiences for twenty minutes on four consecutive days were found to have better immune function and a higher concentration of several mitogens during and after the experiment, with heightened immune responses lasting up to six weeks. It was also shown that over the following months the group asked to write about traumatic experience made fewer visits to the student health clinic than individuals in a second group asked only to write about trivial events (Brown, 2002).

A second study in 1995 examined medical students who wrote about a personal traumatic experience and then received the Hepatitis B vaccination over the standard four month period. In four and six month follow ups, individuals in this "emotional expression" group showed several interesting differences as compared to the control group. In this group that had disclosed personal information prior to receiving the vaccination, the Hepatitis B antibodies circulating in the blood were higher and numbers of T helper lymphocytes and basophils were lower, both signs of health and strong immune function (Brown, 2002).

So what is happening is these situations? As of yet, researchers are not exactly sure. According to Pennebaker and Susman it seems that traumatic experiences that are not discussed, in particular those that occur in childhood or in the recent past, lead to a increase in a variety of health problems. Studies have shown that providing mental health facilities in the workplace or utilizing mind-body techniques in the doctor's office can significantly reduce the number of visits to the physician (Brown, 2002)

In the course of our lives we create stories and string them together. At times the events are sequential and at times the order of events slows down, speeds up or gets rearranged as we prescribe meaning. Based the research presented linking state of mind and health, a life story riddled with depression, fear, anger, anxiety and guilt create tremendous psychological suffering and perhaps impede the healing process altogether. It would seem that the solution for this problem would be to simply change the life story. While actual events in the past are static and can not be reversed, what can change is the meaning that is given to these events and the way that one chooses to perceive life both in the present and the future. This form of therapy can heal lives and perhaps even illness.

Bernie's Keys to Survival
As a renowned surgeon and innovator of modern western medicine, Dr. Bernie Siegel has many stories to share about the power of the mind. Dr. Siegel believes that eventually enough stories and examples will be compiled that the medical community will no long be able to deny the power of mind-body techniques. Like the physicians in the times before modern medicine he conducts his research through experience and displays his findings through example.

Dr. Siegel encourages individuals to take charge of their own healing process, to educate themselves, to take control of their health and most importantly to engage in the work needed to heal their own lives. Healing requires life changes to be made, and an individual needs to create these changes for themselves. In an interview in June of 2004 the conversation presented several important factors in healing. These keys are instructive skills on how to survive and are tools in the construction of a positive life story both in health and in sickness.

"Live your chocolate ice cream. "
"If you had fifteen minutes to live what would you do. I'd say get a pint of chocolate ice cream and eat it" - Bernie Siegel
Hence, the phrase "live your chocolate ice cream". Dr. Siegel asserts that many of the cancer patients he works with begin to live in this way. Often for the first time they begin to live their lives as they have always wanted to, and stop devoting so much time to things that they do not truly enjoy. This shift in life can bring a tremendous amount of healing. According to Dr. Siegel we are conditioned from the time we are children to reply, "good" or "fine" when we are asked how we are, even if that answer is a lie. This dishonesty with others and ourselves lays the groundwork for avoiding our "chocolate ice cream" which contributes to unhappiness, suffering and disease. Healing happens when we are honest with ourselves and acknowledge our true wishes for life. "Burn out" on the other hand comes from "living a life that we don't necessarily want to have."

The incredible meaning behind this phrase however becomes clear when we begin to think about personal story and personal meaning. Bernie Siegel has seen countless patients with cancer and other illnesses begin change the course of their lives, finally allowing themselves to do what they truly wish to do, and be who they truly are. And, Dr. Siegel has seen firsthand time and time again what profound healing this can bring into a life.

"Act and behave as the person you want to be."
If you can envision what kind of a person you truly are, or what kind of a person you would like to be, and then behave like this individual, then slowly over time you become that person. Dr. Siegel is adamant that this change should not come from a place of guilt or shame about not being good enough, as this is a trap that many individuals fall into. This change should be made as a way to find a life that is happy and fulfilling.

It is here that the tricky area of "opportunity vs. guilt" arrives and is a point of misunderstanding among many people when it comes to Dr. Siegel's work. Seeing illness as an opportunity for learning and growth, taking responsibility and taking action to heal are ways of using illness as a springboard for personal change and life-altering discovery. Taking that responsibility on as burden by asking "what did I do wrong" places blame on yourself for creating the illness and is not conducive for healing or for growth. There is a distinct difference between opportunity and guilt, but they lie on a fine line whose boundaries must be understood..

Conclusion
We each have a responsibility in life to be honest with ourselves and to work to create positive, helpful and healing connections between our life events and the meaning we attach to these events. Through the work of so many insightful researcher and physicians we have seen how certain qualities and factors can alter both state of physiological well-being and quality of life. As human beings we are in a unique position to use these findings to our advantage and take charge of our health from within.

An interesting paradox has occurred within modern health care that is now being recognized within progressive circles. The biomedical paradigm has largely shunned the healing power of the mind for over a century, and yet the double-blind study is the pillar upon which all good medical research stands (Brody, 2002). Despite trying removing the mind from the healing process, scientists test all new drugs and procedures against the placebo response, which is the ability of the mind to participate in the healing processes of the body.

The public's opinion is changing, the opinion of the medical establishment is changing and the research studies conducted by scientists are beginning to reflect this. Each system of health care has its strengths and its weaknesses and it is only through combining the best parts of each modality that a true comprehensive system of healing will be developed. By including placebo groups within research studies modern Western medicine has already laid the ground work for a strong case in favor of mind-body healing. It is now up to health care providers and the public to employ what placebo studies have shown, so that medicine can end its history of mind-body segregation and move into a new era of healing.

Bibliography
Avila, E. (2000). Woman who glows in the dark. New York: Tarcher.

Benson, H. (1975). The relaxation response. New York: Avon Books.

Benson, H. (1996). Timeless healing: The power of biology and belief. New York: Fireside.

Borysenko, J. (1987). Minding the body, mending the mind. Toronto: Bantam Books.

Brown, W.A. & Severs, B. (1999). Placebos: Fooling the body to heal itself. USA today magazine, 128(2650), p. 32. Retrieved on May 19, 2004 from Expanded Academic ASAP.

Brody, H. (1995). Placebo. In Reich, W. (Ed.), Encyclopedia of Bioethics. New York: Simon & Schuster.

Brody, H. & Brody, D. (2000). The Placebo Response. New York: Cliff Street Books.

Brown, W. (2002). Psychoneuroimmunology and western religious traditions. In H.G. Koenig & H.J. Cohen (Eds.), The link between religion and health: Psychoneuroimmunology and the faith factor (pp. 262-274). New York: Oxford University Press.

de la Fuente-Fernandez, R. & Stoessl, A.J. (2004). The biochemical basis of the placebo effect. Sci Eng Ethics, 10(1), 143-150. Retrieved on June 10, 2004 from http://www.ncbi.nlm.nih. gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14986780 &itool=iconabstr

Dossey, L. (2001). Healing beyond the body. Boston: Shambhala.

Enserink, M. (1999). Can the placebo be the cure? Science, April 9, 1999, 284(5412), pp238- 239.

Kienle, G.S. & Kiene H. (1997). The powerful placebo: fact or fiction? Journal of Clinical Epidemiology, 50(12), 1311-1318. Retrieved on June 10, 2004 from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstr act&list_uids=9449934&itool=iconabstr

Kinser, P.A. (n.d.). Therapeutic placebo effect: A mind/body connection. Retrieved on May15, 2004 from http://students.haverford.edu/pkinser/neuro-placebo.htm.

Kolata, G. (2001). Study casts doubt on the placebo effect. The New York Times. May 24, 2004. Retrieved on June 10, 2004 from http://www.nytimes.com/2001/05/24/health/2 4PLAC.htm?ex=1089432000&en=eed82c65eb741105&ei=5070&ex=1089000000 &en=981fe235824ce89c&ei=5070

Marvel, M.K., Epstein, R.M., Flowers, K, & Beckman H.B., (1999). Soliciting the patient's agenda, have we improved? JAMA, 281(3), 283-287. Retrieved on June 25, 2004 from http://jama.ama-assn.org/cgi/content/abstract/281/3/283?maxtoshow=&HITS=10&hits =10&RESULTFORMAT=&fulltext=23+seconds&searchid=1089319700417_6197&stor ed_search=&FIRSTINDEX=0&journalcode=jama

Moyers, B. (1979). Therapeutic support groups. [Interview with David Speigel]. In Moyers, B., Healing and the mind (pp.157-170). New York: Doubleday.

Nelson, D. (2003). The placebo in alternative medicine: "Real" healing or "nuicense" noise? The Back Letter, 18(1), p.16. Retrieved on June 10, 2004 from Expanded Academic ASAP.

Ouellette Kobasa, S.C. (1990). Stress-resistant personality. In R. Ornstein & C. Swencionis (Eds.), The healing brain: A scientific reader (pp.219-230). New York: The Guilford Press.

Pert, C. (1997). Molecules of emotion. New York: Simon &Schuster.

Placebo effect found in brain scans. (2004, March 17). Biotech Week, 575-576. Retrieved on May 15, 2004 from Extended Academic ASAP

Powell, J.W. (1891). 8th Annual Report of the Bureau of Ethnology to the Secretary of the Smithsonian Institute 1886-87. Washington: Government Printing.

Siegel, B. (1989). Peace, love and healing. New York: HarperPerennnial.

Solomon G. & Temoshok, L. (n.d.). Characteristics of long-term survivors. Retrieved on June 20, 2004 from http://www.thebody.com/mb/longterm.html.

Sternberg, E. (2001). The balance within: The science connecting health and emotions. New York: W.H. Freeman and Company.

copyright 2003

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Sarah Tewhey is a student and teacher of Yoga, Ayurveda and the healing arts. She completed two years of study with Dr. Vasant Lad at The Ayurvedic Institute and a B.S. at Lesley University in Mind/Body Studies with a specialization in the female healing process and its relationship to modern medicine. Sarah is currently a student in the Masters program at Southwest Acupuncture College in Albuquerque.
Sarah can be contacted at:
sarah@ayurlight.com