[Senate Hearing 105-875]
[From the U.S. Government Publishing Office]
S. Hrg. 105-875
MIND/BODY MEDICINE
=======================================================================
HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED FIFTH CONGRESS
SECOND SESSION
__________
SPECIAL HEARING
__________
Printed for the use of the Committee on Appropriations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
______
U.S. GOVERNMENT PRINTING OFFICE
54-619 cc WASHINGTON : 1999
_______________________________________________________________________
For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC
20402
ISBN 0-16-058160-5
COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire HARRY REID, Nevada
ROBERT F. BENNETT, Utah HERB KOHL, Wisconsin
BEN NIGHTHORSE CAMPBELL, Colorado PATTY MURRAY, Washington
LARRY CRAIG, Idaho BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina BARBARA BOXER, California
KAY BAILEY HUTCHISON, Texas
Steven J. Cortese, Staff Director
Lisa Sutherland, Deputy Staff Director
James H. English, Minority Staff Director
------
Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
SLADE GORTON, Washington ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri DANIEL K. INOUYE, Hawaii
JUDD GREGG, New Hampshire DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina HARRY REID, Nevada
LARRY E. CRAIG, Idaho HERB KOHL, Wisconsin
KAY BAILEY HUTCHISON, Texas PATTY MURRAY, Washington
TED STEVENS, Alaska ROBERT C. BYRD, West Virginia
(Ex officio) (Ex officio)
Majority Professional Staff
Bettilou Taylor
Mary Dietrich
Minority Professional Staff
Marsha Simon
Administrative Support
Jim Sourwine and Jennifer Stiefel
C O N T E N T S
----------
Page
Opening remarks of Senator Arlen Specter......................... 1
Prepared statement of Hon. Tom Harkin, U.S. Senator from Iowa.... 2
Statement of Norman B. Anderson, Ph.D., director, Office of
Behavioral Sciences Research................................... 3
Prepared statement........................................... 4
National Institutes of Health for Behavioral and Social Sciences
Research....................................................... 7
Statement of Herbert Benson, M.D., president, Mind/Body Medical
Institute...................................................... 7
Prepared statement........................................... 9
Statement of Harold G. Koenig, M.D., director, Center for the
Study of Religion/Spirituality and Health, Duke University
Medical Center................................................. 16
Psychological and social stress.................................. 16
Prepared statement of Harold G. Koenig........................... 17
Stress and relaxation............................................ 26
Immune function.................................................. 27
Heart disease--stress and high blood pressure.................... 28
Self-care and relaxation......................................... 28
Susceptibility to breast cancer.................................. 29
Stress and immune system functioning............................. 31
Religious beliefs and practice--better immune functioning........ 31
Healing power of belief.......................................... 32
Science and religion............................................. 34
Research......................................................... 36
Health and behavior.............................................. 36
Alternative medicine and mind/body............................... 38
Changing people and their behavior............................... 39
Prepared statement of Caesar A. Giolito, executive director,
National Interfaith Coalition for Spiritual Healthcare and
Counseling..................................................... 40
MIND/BODY MEDICINE
----------
TUESDAY, SEPTEMBER 22, 1998
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
Washington, DC.
The subcommittee met at 11:01 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Arlen Specter (chairman)
presiding.
Present: Senator Specter.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
STATEMENT OF NORMAN B. ANDERSON, Ph.D., DIRECTOR,
OFFICE OF BEHAVIORAL SCIENCES RESEARCH
opening statement of senator arlen specter
Senator Specter. Good morning, ladies and gentlemen. The
Subcommittee on Labor, Health and Human Services, and Education
will now proceed.
This morning we will focus on mind/body treatment which has
come to be recognized as a very important part of medical
treatment, emphasizing stress related illnesses and the
elimination of stress contributing to a number of medical
conditions that can be treated by so-called mind/body
procedures contrasted with pharmaceutical or surgical
approaches. The mind/body approach, such as relaxation response
and those related to utilizing beliefs of the patients, have
been utilized to successfully treat disorders and illnesses.
In the fiscal year 1999 Labor, HHS bill, we have included
provisions to establish mind/body centers to explore the
benefits of mind/body medicine and to address issues of
application and research including the cost effectiveness of
mind/body interventions.
We have a distinguished panel of experts today. We will
begin with Dr. Norman Anderson who is Director of the Office of
Behavioral and Social Sciences Research for the National
Institutes of Health, a unit which was created in 1993. Dr.
Anderson, we welcome you here.
We would like to have a 5-minute rule generally, so we will
turn the green light on at 5 and the yellow at 1 and a red at
0. But we have some flexibility today on the timing, so we will
not be rigidly bound by the lights.
We may be joined by other Senators. Today is a very busy
day here. Yesterday was Rosh Hashanah and some are celebrating
it today. I do not have to specify the activities that are
underway in Washington, DC. So, it is a busy time. Whether we
will be joined or not by our colleagues will remain to be seen.
prepared statement
At this point I would like to submit Senator Tom Harkins
statement for the record.
[The statement follows:]
Prepared Statement of Senator Tom Harkin
Thank you, Mr. Chairman, for providing this forum to discuss the
promising field of mind-body medicine. As many of you know, I have
taken a great interest over the years in complementary and alternative
medicine (CAM). I believe strongly in the need for improved and
expanded research in this field. It is this belief that led me to
create the Office of Alternative Medicine at NIH in 1991 and more
recently, to propose giving the Office Center status and grant making
authority. I want to thank the Chairman for working with me on this
issue, and including my Center proposal in the LHHS bill this year.
Millions of Americans are turning to complementary and alternative
medicine (CAM) and practices. Currently, patient visits to CAM
practitioners outpace visits to conventional primary care physicians.
According to a recent study by Harvard University researchers, 80
million Americans regularly use complementary and alternative medicine,
usually in conjunction with more conventional care.
Harvard University reported that the public's out-of-pocket
expenses for these CAM products and services is equal to that paid out-
of-pocket for traditional physician services and is three times that
paid out-of-pocket for hospital expenses. In 1990, those costs equaled
more than $14 billion, of which at least $10 billion were not
reimbursed to patients by health insurance.
These practices, which range from acupuncture to chiropractic care,
to relaxation techniques, naturopathic, herbal and homeopathic
remedies, are not simply complementary and alternative, but are
integral to how millions of Americans are managing their health and
treating their illnesses.
Today, I am pleased to have the opportunity to hear from the
distinguished scientist, Dr. Herbert Benson, about his work in the
field of Mind/Body Medicine. The relaxation techniques espoused by Dr.
Benson have been shown to significantly improve patients' recovery from
a wide range of illnesses.
The groundswell of public demand for CAM therapies, including the
Mind/Body techniques described by Dr. Benson, has fueled the interest
of conventional medical practitioners. Eighty percent of medical
students in the U.S. have reported a desire for more structured
training in complementary and alternative medicine and practices,
including Mind/Body medicine. Indeed, the National Institutes of Health
reports that more than 50 percent of conventional physicians in the
U.S. now use or refer patients for alternative treatments.
Yet the federal government lags behind providers and the public.
The Federal agencies responsible for protecting and promoting public
health remain ill-equipped to deal with the public's demand for
information and answers regarding alternative and complementary health
care. Additionally, we are in an era when we must take a closer look at
ways to provide cost-effective, preventive health care. The movement
toward integrated medicine promises a more comprehensive, more
effective, and more responsive health care system. And evidence
suggests that this approach may be far more cost-effective as well.
As policymakers, we must act to promote quality research, provide
useful information to patients about CAM therapies, and ensure adequate
oversight of this burgeoning field. This hearing is an important step
in that process. I look forward to the testimonies to be presented here
today and urge the continued commitment of this Subcommittee in this
important public health issue. Thank you.
summary statement of norman anderson
Senator Specter. Dr. Anderson, all statements will be made
a part of the record in full, and now the floor is yours.
Dr. Anderson. Thank you, Mr. Chairman. It is really a
pleasure for me to participate in the hearing today on mind/
body approaches to health. This area of research is
particularly relevant to the mission of the Office of
Behavioral and Social Sciences Research or OBSSR at the
National Institutes of Health. Thank you for the opportunity to
discuss the commitment of NIH to conducting and disseminating
this vital research.
I am a clinical psychologist with training in behavioral
medicine, and I have served as the first Associate Director of
NIH for Behavioral and Social Sciences Research for the past 3
years. I am also an associate professor, currently on leave, at
Duke University and president of the Society of Behavioral
Medicine. In my role as Director of the OBSSR, I work with all
of the institutes and centers of the NIH on issues related to
basic behavioral and social sciences research and to research
on behavioral treatment and prevention approaches. These areas
of research have produced some of the strongest evidence for
the role of the mind in healing and health.
I would like to direct your attention to the picture on the
easel. The figure illustrates how the seemingly independent
factors affecting health are, in fact, integrated and
dependent. Please note the three large boxes on the poster. NIH
has a long and revered research tradition in the physiological
realm and more recently there has been tremendous excitement in
the realm of genetics research, but equally important is the
recognition of the role that behavioral psychological,
sociocultural, and environmental factors play in health. Our
beliefs, our emotions, our behavior, our thoughts, our family
and cultural systems, as well as the environmental context in
which we live, all are as relevant to our health as genetic
inheritance and our physiology.
Some might say that there is nothing really new in this
model, that we have long known that the mind, the body, and the
context in which we live influence health. But this model
brings a new oneness to our vision of the determinants of
health. This oneness is captured not so much by the boxes in
the poster, but by the arrows between the boxes which denote a
unity of the factors that affect health. The arrows make
salient the interaction and interdependence of the various
influences on health. Health science has now reached a point
where it is no longer accurate to talk about psychology versus
biology, the mind versus the body, or nature versus nature.
These processes are inextricably linked. When I talk about
mind/body medicine, I am referring to these linkages, that is,
the connections between psychological, behavioral, and
sociocultural processes with all levels of biological
functioning and with health.
The figure not only illustrates the factors affecting
health, but it also makes salient a number of scientific
questions. For example, we know that social, psychological, and
behavioral variables are important risk factors for illness,
but the question now is, how do they affect health? That is,
how do psychosocial and behavioral variables affect endocrine
activity, the immune system, or even gene expression? How can
we capitalize on discoveries in these areas to improve the
treatment and prevention of disease? These are some of the key
questions facing mind/body research today.
Research supported by the NIH continues to make progress in
addressing these questions. Here are just a few recent
discoveries.
Stress management training can reduce the fear and anxiety
associated with the experience of asthma in children, resulting
in more effective management of asthma attacks and fewer visits
to the emergency room, and as a consequence, decreasing costs.
Stress management training has also been shown to reduce the
likelihood of cardiovascular morbidity.
Breast and skin cancer patients who participate in
supportive groups show improved mood, adjustment, and decreased
pain and may actually experience a decrease in mortality.
Finally, a variety of behavioral interventions such as
relaxation training, which you will hear more about today,
cognitive therapy, and biofeedback have now been demonstrated
to reduce the chronic pain associated with a number of medical
conditions.
prepared statement
These and other findings reinforce the commitment to and
enthusiasm for research at the intersection of sociobehavioral
and biological science at the NIH.
Thank you again for your interest in mind/body approaches
to healing and health and for convening this hearing. I look
forward to any questions you might have. Thank you.
[The statement follows:]
Prepared Statement of Norman B. Anderson
Mr. Chairman, it is my pleasure to participate in the hearing today
on mind/body approaches to health. This area of research is
particularly relevant to the mission of the Office of Behavioral and
Social Sciences Research (OBSSR) at the National Institutes of Health
(NIH). Thank you for the opportunity to discuss the commitment of NIH
to conducting and disseminating this vital research.
I am a clinical psychologist with training in behavioral medicine,
and I have served as the first Associate Director of NIH for Behavioral
and Social Sciences Research for the past three years. I am also an
Associate Professor (on leave) at Duke University, and President of the
Society of Behavioral Medicine. In my role as Director of the OBSSR, I
work with all the Institutes and Centers of NIH on issues related to
basic behavioral and social science research, and to research on
behavioral treatment and prevention approaches. These areas of research
have produced some of the strongest evidence for the role of the mind
in healing and health.
I will focus my remarks on two questions: What are some recent
developments in research on the role of the mind in healing and health?
And what are the implications of this research for treatment and
prevention?
To address the first question, I direct your attention to the
picture on the easel (see Figure 1, attached). The figure illustrates
how the seemingly independent factors affecting health outcomes are, in
fact, integrated and dependent. Please note the three large boxes on
the poster. NIH has a long and revered tradition of funding research in
the physiological realm, and more recently, there is tremendous
excitement in the realm of genetics research. But equally important is
the recognition of the role that behavioral, psychological,
sociocultural and environmental factors play in health. Our beliefs,
our emotions, our behavior, our thoughts, our family and cultural
systems, as well as the environmental context in which we live, all are
as relevant to our health as our genetic inheritance and our
physiology.
Some might say that there is nothing really new in this model--that
we have long known that the mind, the body, and the context in which we
live influence health. But this model brings a new oneness to our
vision of the determinants of health. This oneness is captured not so
much by the boxes in the poster, but by the arrows between the boxes,
which denote unity of the factors that affect health. These arrows make
salient the interaction and interdependence of the various influences
on health. Health science has reached a point where it is no longer
accurate to talk about psychology versus biology; the mind versus the
body; or nature versus nuture. These processes are inextricably linked.
When I talk about mind/body medicine, I am referring to these linkages.
That is, the connections between psychological, behavioral, and
sociocultural processes with all levels of biological functioning--from
the organ systems, to the cellular, to the molecular--and with health.
The figure not only illustrates the factors affecting health, but
it also makes salient a number of scientific questions. For example, we
know that social, psychological, and behavioral variables are risk
factors for illness, but the question now is: How do they affect
health? That is, how do psychosocial and behavioral variables affect
neuroendocrine activity, the immune system, or gene expression? How can
we capitalize on discoveries in these areas to improve the treatment
and prevention of disease? These are some of the key questions facing
mind/body research today.
interdisciplinary research
Our next challenge is to seek a deeper understanding of mind/body
interactions, and to do this we need research that cuts across
disciplinary boundaries. That is, research that combines expertise from
such social and behavioral science fields as psychology, sociology,
demography, and anthropology, with expertise from the various fields of
biomedicine. The OBSSR has made advancing this type of cross-
disciplinary research one of its three primary goals. In cooperation
with the NIH Institutes and Centers, we have recently issued a Request
for Applications (RFA) to fund educational workshops designed to create
a larger contingent of scientists who are broadly trained in the
methods, procedures, and theoretical perspectives of disciplines
outside their own. The goal is not to turn, say, geneticists into
psychologists or vice versa, but to provide researchers with sufficient
understanding of other fields in order to better foster collaboration
across disciplines. We believe this collaborative research will
transcend the contributions of single disciplines, and produce entirely
new ways of thinking about health.
In recent years, we have made significant advances in the field of
mind/body medicine. Let me provide some examples of studies that
exemplify the influence of psychological, behavioral, and social
processes on all levels of biological functioning and health.
Asthma.--For persons suffering from asthma, especially children,
the experience of breathlessness is a very traumatic symptom that can
lead to panic which may aggravate the symptoms or make the person
unable to assess symptoms to determine appropriate treatment, such as
whether to use an inhaler or go to the emergency room. Studies funded
by the National Heart, Lung, and Blood Institute have shown that stress
management training can reduce the fear and anxiety associated with the
asthma experience. This has been shown to result in more effective
management of asthma attacks and more appropriate use of health
services, e.g., fewer visits to the emergency room.
Breast Cancer.--Many studies supported by the National Cancer
Institute have demonstrated the positive effects of psychosocial group
therapy for cancer patients, including improvements in mood,
adjustment, and pain. It is also possible that psychotherapy can
actually extend one's life, as well as improve its quality. In one
study, patients with metastatic breast cancer who received weekly
supportive group therapy actually lived an average of 18 months longer
than did those who did not participate in the group treatment.
Coronary Disease.--Although smoking and hypertension have long been
documented as very important risk factors for the development of
coronary disease, they do not fully account for the timing and
triggering of heart attacks and sudden death. Recent research has shown
that the onset of acute coronary syndromes does not occur at random.
For example, between 17 percent and 30 percent of heart attacks appear
to be triggered by external and behavioral factors. These include
emotional stress, strenuous physical exercise, cold weather, cocaine
abuse, sexual activity, and anger. Reducing trigger activities can
provide protection against heart attack and coronary deaths.
Preliminary studies funded by the National Heart, Lung, and Blood
Institute suggest that certain cardioprotective interventions, such as
those utilizing stress management and aerobic exercise training, show
promise in reducing cardiovascular morbidity.
Touch and Preterm Infant Survival.--Research funded by the National
Institute of Mental Health and the National Institute of Child Health
and Human Development has demonstrated the beneficial effects of touch
in both animals and humans. When newborn rats are separated from their
mothers, they are deprived of tactile stimulation. That deprivation of
touch results in a decrease of hormones that are critical for growth
and development. When the newborn is returned to its mother and
touching resumes, these hormones return to normal levels. Animal
research of this type has led to the development of behavioral
interventions for human pre-term infants, resulting in improved growth
and earlier hospital discharge.
Personality and Health.--A number of personality factors have been
linked to mortality in several studies. One characteristic, cynical
hostility or lack of trust, was found to predict increased rate of
death from all causes in several prospective epidemiological studies
including a 20-year study of corporate executives; a 25-year study of
physicians; and a 25-year study of attorneys. Recently, using data from
a 70-year longitudinal study of gifted and talented children,
scientists funded by the National Institute of Aging have discovered
that participants with childhood personality characteristics of high
social dependability or conscientiousness were, as adults, 30 percent
less likely to die in a given year than those low on these
characteristics. These findings on personality and health could not be
explained by differences in traditional disease risk factors among
participants.
Behavior, Experience, and the Brain.--Several NIH Institutes,
including The National Institute of Mental Health, the National
Institute of Neurological Diseases and Stroke, the National Institute
of Child Health and Human Development and others, have funded research
on how behavior and experience may alter brain structure and
intellectual functioning. Exposure to relatively enriched, complex, or
stimulating environments can produce substantial changes in cellular
functioning in the brain. Rats housed in environments with a variety of
toys and objects with which to interact have increased brain weight and
synapses (connections between brain cells). These findings have been
extended to human populations, where intensive preschool interventions
have led to demonstrable improvements in later intellectual functioning
and lower rates of mental retardation.
Chronic Pain.--Finally, because chronic pain afflicts so many in
our society, NIH recently held a consensus conference to evaluate the
use of behavioral medicine approaches in combating chronic pain and
insomnia. The conference yielded the following conclusions. First,
there is strong evidence for the efficacy of relaxation approaches in
reducing chronic pain associated with a variety of medical conditions.
Second, there is moderately strong evidence for the efficacy of
cognitive behavior therapy for chronic pain syndromes. Importantly, the
literature indicates that cognitive behavior therapy is superior to
placebo and to routine care for alleviating low back pain and pain
associated with rheumatoid arthritis and osteoarthritis. Finally, there
is strong evidence for the efficacy of combined behavioral medicine
treatments (e.g., cognitive therapy, relaxation, biofeedback, or
hypnosis) for several categories of pain, including back and neck pain,
dental or facial pain, joint pain, and migraine headache.
Other Advances.--Behavioral and social treatment and prevention
approaches have also been used successfully for problems such as
diabetes, arthritis, gastrointestinal problems, violence, depression,
and alcohol and drug abuse. I would be happy to answer any questions
you have about these areas.
My concluding remarks will briefly address the second question,
``What are the implications of mind/body research for both treatment
and prevention?'' The NIH, and my office in particular, take very
seriously the responsibility to ensure that our scientific findings
actually reach the people they are intended to benefit. For example, I
have organized a special task force to develop a plan for working with
health care providers and managed care companies to incorporate
scientifically validated behavioral treatment approaches into medical
care. As you know, many proven behavioral treatments are not reimbursed
by insurance companies. This must change--and I believe it will, as
companies become more aware of the cost savings they will accrue by
covering behavioral treatments and therapies for conditions ranging
from arthritis, diabetes, depression, and recovery from surgery.
Furthermore, approximately half of the nation's annual premature deaths
can be directly attributed to modifiable risk factors such as tobacco
use, unhealthy diet, lack of exercise, alcohol and drug abuse, and
risky sexual behavior. These and other behavioral and psychosocial risk
factors have been linked to higher ambulatory care and hospitalization
costs, with preventable illness accounting for as much as 70 percent of
all medical care spending.
Thank you again for your interest in mind/body approaches to health
and healing, and for convening this hearing. I look forward to any
additional questions you might have.
[GRAPHIC] [TIFF OMITTED] T07SE22.001
national institutes of health for behavioral and social sciences
research
Senator Specter. Thank you very much, Dr. Anderson.
I note that you are the first Associate Director of the
National Institutes of Health for Behavioral and Social
Sciences Research?
Dr. Anderson. Yes.
Senator Specter. Did this unit come into existence in 1993?
Dr. Anderson. No; the legislation was passed in 1993. The
office officially opened in 1995.
Senator Specter. I see. What took so long?
Dr. Anderson. I am not really sure. I was at Duke at the
time and was recruited to this position by the NIH.
Senator Specter. And you are an associate professor in the
Departments of Psychiatry, Psychology, Social and Health
Sciences at Duke University?
Dr. Anderson. Yes.
Senator Specter. And you have done extensive work on the
issue of high blood pressure in African-Americans.
Dr. Anderson. Yes.
Senator Specter. Well, thank you very much. I am going to
reserve the questions until we have heard from our full panel
of witnesses.
STATEMENT OF HERBERT BENSON, M.D., PRESIDENT, MIND/BODY
MEDICAL INSTITUTE
Senator Specter. We turn now to Dr. Herbert Benson who is a
foremost expert in this field, founding president of the Mind/
Body Medical Institute, and associate professor of medicine at
Harvard Medical School, and chief of the division of behavioral
medicine at the Beth Israel Deaconess Medical Center. Dr.
Benson is a pioneer in the field of behavioral medicine and
mind/body studies, as well as spiritual healing, a graduate of
Wesleyan, University of Harvard Medical School, author or
coauthor of over 150 scientific publications and 6 books. We
welcome you here, Dr. Benson, and look forward to your
testimony.
Dr. Benson. Thank you, Senator. Mr. Chairman, I am
delighted to have this opportunity to testify before this
committee today.
A study, published this month, predicted that spending on
health care is likely to double to $2.1 trillion by the year
2007. Imaginative and responsible approaches to health care are
needed. I propose that mind/body medicine with its self-care
approaches holds great promise for the Nation's health and
costs of health care.
My testimony will be evidence-based. The data I will
present will be scientific findings that have been published in
peer-reviewed journals. Some of these data were evaluated and
supported at a 1995 NIH technology assessment conference.
Consider for a moment that I were here today discussing a
new drug and the scientific evidence indicated that this new
drug could successfully treat a very wide variety of prevalent
medical disorders, conditions that lead to 60 to 90 percent of
visits to doctors. Furthermore, consider that this new drug was
safe and without dangerous side effects. It could also prevent
these conditions from occurring and recurring. And, consider
this new drug was demonstrated to decrease visits to doctors by
as much as 50 percent and that this decrease could lead to
annual cost savings of more than $54 billion. The discovery of
such a drug would be front-page news and immediately embraced.
Such scientifically validated mind/body therapies have been
shown to produce such clinical and economic benefits, but as
yet have not been so received.
Why, given results such as these, have mind/body self-care
therapies, such as the relaxation response, and those related
to beliefs of patients not been more effectively integrated
into mainstream medicine? Barriers to integration include: one,
the lack of knowledge of the existing scientific data among
health care providers, researchers in other fields, among
patients, and among policymakers in Government and private
industry; two, a bias against mind/body interventions in
medical care as being soft science; three, inadequate insurance
payments for these treatments; and four, a bias against
shifting away from the overwhelming use of pharmaceuticals and
surgeries and procedures.
One way to overcome these barriers is the establishment of
mind/body medical centers. They will make the benefits of mind/
body medicine, specifically those of the relaxation response,
and those related to utilizing the beliefs of patients more
visible. Mind/body medical centers would also markedly expand
the hard science of mind/body interventions. It could be argued
that NIH already has mechanisms in place to review mind/body
proposals and some might ask, why the need for the new centers?
NIH study sections do, indeed, skillfully assess and perform
reviews of quite circumscribed research. Unfortunately, a
striking paucity of study sections are equipped to adequately
review proposals that investigate the simultaneously occurring,
multiple mind/body linkages that involve human
physicochemistry, biology, psychology, social behavior, and
belief-related phenomena such as spirituality. Mind/body
centers, under the aegis of the Office of Behavioral and Social
Sciences Research at NIH, would be a meaningful step toward
overcoming narrowly focused, exclusively reductionistic
research. Understanding the interrelatedness of different
systems should be carried out in already existing organizations
that are experienced in mind/body research and treatments. It
might be advisable to encourage the centers to work
collaboratively together. The centers would also teach and
train health care professionals in mind/body approaches and
treatments. Finally, these NIH supported centers could markedly
expand the cost effectiveness of mind/body interventions and
provide data for new reimbursement strategies for Medicare and
Medicaid, as well as for private insurers.
prepared statement
The full integration of mind/body, self-care medicine is
completely compatible with existing health care approaches. The
integration is important not only for better health and well-
being, but also for a more economically feasible health care
system. Mind/body medicine responsibly fulfills the needs of
our people who want therapies that enhance and complement
traditional medicine and that do so in a scientifically
established safe and cost savings fashion. Mind/body medicine
holds such promise that it should be further researched,
advocated, and utilized for the health and well-being of the
people of our Nation.
Thank you.
Senator Specter. Thank you very much, Dr. Benson. As I say,
we will defer the questions until we have heard from Dr. Koenig
as well.
[The statement follows:]
Prepared Statement of Herbert Benson
I'm delighted to be called to testify on mind/body medical
interactions and their potential clinical applications.
Before I start my testimony, let me say a few words about the Mind/
Body Medical Institute and the work I have been doing at the Harvard
Medical School and its affiliated hospitals for the last thirty years.
The Mind/Body Medical Institute is dedicated to performing research and
to conducting teaching and training of health care professionals in
mind/body and behavioral medicine approaches and transmitting this
information to the general public. It is now just finishing its first
ten years of existence. I myself occupy the Mind/Body Medical Institute
Chair at the Harvard Medical School as an associate professor of
medicine.
A study, published this month, projected that spending on
healthcare is likely to double to $2.1 trillion by the year 2007 (Smith
et al., 1998). That's a trillion dollars more than we are spending now.
According to this report, managed care savings have about run their
course. What's driving this surge in costs? According to the report, it
is expensive prescription drugs, enthusiasm for new medical technology
and greater freedom to visit medical specialists whenever patients
desire to do so. Imaginative and responsible approaches to healthcare
are needed. I propose that mind/body medicine with its self-care
approaches holds great promise for the nation's health and cost of
healthcare (Friedman, et al., 1995).
My testimony will be evidence-based; the data I will present will
be scientific findings that have been published in peer-reviewed
journals. Some of these data were evaluated and supported at a 1995 NIH
Technology Assessment Conference.
I will cover the following categories: stress and the fight-or-
flight response; the relaxation response; the placebo effect and the
importance of belief in healing; the three-legged stool and the
importance of self-care; and the proper use of mind/body therapies and
the creation of mind/body medical centers.
Stress contributes to many of the medical conditions confronted by
healthcare practitioners. In fact, when the reasons for patients'
visits to physicians are examined, between 60 to 90 percent of visits
to physicians are related to stress and other psychosocial factors
(Cummings, VandenBos, 1981; Kroenke, Mangelsdorff, 1989). Current
pharmaceutical and surgical approaches cannot adequately treat stress-
related illness. Mind/body approaches including the relaxation
response, nutrition and exercise, and the beliefs of patients have been
demonstrated to successfully treat stress-related disorders. To better
understand mind/body treatments it is best to first understand the
physiology of the stress and the fight-or-flight response.
stress and the fight-or-flight response
Stress is defined as the perception of threat or danger that
requires behavioral change. It results in increased metabolism,
increased heart rate, increased blood pressure, increased rate of
breathing and increased blood flow to the muscles. These internal
physiologic changes prepare us to fight or run away and thus the stress
reaction has been named the ``fight-or-flight'' response. The fight-or-
flight response was first described by the Harvard physiologist, Dr.
Walter B. Cannon (1941) earlier in this century. It is mediated by
increased release of catecholamines--epinephrine and norepinephrine
(adrenalin and noradrenalin)--into the blood stream.
the relaxation response
Building on the work of Swiss Nobel laureate Dr. Walter R. Hess, my
colleagues and I more than 25 years ago described a physiological
response that is the opposite of the fight-or-flight response. It
results in decreased metabolism, decreased heart rate, decreased blood
pressure, and decreased rate of breathing, as well as slower brain
waves (Wallace, Benson, Wilson, 1971). We labeled this reaction the
``relaxation response'' (Benson, Beary, Carol, 1974).
The fight-or-flight response occurs automatically when one
experiences stress, without requiring the use of a technique. In
contrast, two steps are usually required to elicit the relaxation
response. They are: (1) the repetition of a word, sound, prayer, phrase
or muscular activity and (2) when other, everyday thoughts intrude,
there is a passive return to the repetition (Benson, 1975; Hoffman, et
al, 1982). Many different methods can be used to bring forth the
relaxation response including: progressive muscle relaxation,
meditation, autogenic training, yoga, and repetitive physical exercise.
In addition, many forms of prayer can also be used. These include
repetitive prayers such as the rosary as in the Catholic tradition,
centering prayers in Protestant religions and pre-davening prayers in
Judaism. The specific method used usually reflects the beliefs of the
person eliciting the relaxation response (Benson, 1984). The method may
be secular or religious, and performed either at rest or during
exercise.
Our research conducted at the Harvard Medical School and that of
others has documented that relaxation-response based approaches
generally used in combination with nutrition, exercise, and stress
management interventions result in alleviation of many stress-related
medical disorders. In fact, to the extent that stress causes or
exacerbates any condition, mind/body approaches that invariably include
the relaxation response have proven to be effective. Because of this
scientifically-documented efficacy, a physiological basis for many
millennia-old mind/body approaches has been established and has
overcome a great deal of initial professional skepticism.
It is essential to understand that regular elicitation of the
relaxation response results in long-term physiologic changes that
counteract the harmful effects of stress throughout the day, not only
when the relaxation response is being brought forth (Hoffman, et al,
1982). These mind/body approaches have been reported to be effective in
the treatment of hypertension (Stuart, et al, 1987), cardiac
arrhythmias (Benson, Alexander, Feldman, 1975), chronic pain (Caudill,
et al., 1991), insomnia (Jacobs, et al, 1993; Jacobs et al, 1996),
anxiety and mild and moderate depression (Benson et al., 1978),
premenstrual syndrome (Goodale, Domar, Benson, 1990), and infertility
(Domar, Seibel, Benson, 1990).
As a result of the evidence-based data, the relaxation response is
becoming a part of mainstream medicine. Approximately 60 percent of
U.S. medical schools now teach the therapeutic use of relaxation-
response techniques (Friedman, Zuttermeister, Benson, 1993). They are
recommended therapy in standard medical textbooks and a majority of
family practitioners now use them in their practices.
the placebo effect and the importance of belief in healing
The importance of mind/body interactions in healing is also
profoundly evidenced by the placebo effect. Throughout history,
medicine and healing has relied heavily on non-specific factors such as
the placebo effect (Benson, Friedman, 1996). In other words, what
patients believe, think and feel has profound effects on the body.
Physicians and other healers have historically appreciated the effects
of both positive and negative emotions. However, modern medicine has
largely disregarded and ridiculed the importance of mind/body
interactions such as the placebo effect by using such statements as,
``It's all in your head,'' ``It's just the placebo effect,'' or ``It's
a dummy pill.'' These pejorative terms arose gradually over a period of
decades as specific remedies for specific illnesses were developed and
the reliance on what is now called non-specific healing factors--the
placebo effect--diminished. Because the specific therapies were and
are, so dramatically effective, they became the sole treatments
utilized. Specific treatments such as insulin, antibiotics and cataract
surgery are truly awe-inspiring. The result was that mind/body
approaches were largely forgotten and pushed aside as the wondrous
modern pharmaceuticals and surgeries and procedures advanced. Rather
than using a combination of specific and belief-related therapies to
promote healing, modern medicine has come to value and to rely
exclusively on the specific effects of pharmacological and procedural
interventions. It ignores the healing powers of beliefs.
The pioneering work of Beecher (1955), established that in patients
with conditions of pain, cough, drug-induced mood changes, headaches,
seasickness, and the common cold, the placebo effect was effective in
35 percent of the cases. Since these early findings, the placebo effect
has been documented to be effective in 50 to 90 percent of diseases
that include bronchial asthma, duodenal ulcer, angina pectoris, and
herpes simplex (Benson, Friedman, 1996; Benson, 1996).
The placebo effect is dependent on three sets of beliefs: (1) the
beliefs of the patient; (2) the beliefs of the healthcare provider (the
healer); and (3) the beliefs that ensue from the relationship between
the healthcare provider and the patient.
A study of Japanese students who were allergic to the wax of a
lacquer tree, which produces a rash similar to that of poison ivy,
provides one demonstration of the power of the belief of patient
(Ikemi, Nakagawa, 1962). The students were first blindfolded and then
told that one of their arms would be stroked with lacquer tree leaves,
and that their other arm would be stroked with chestnut tree leaves, to
which they were not allergic. However, the researchers switched the
leaves. The skin that the subjects believed to have been brushed with
the lacquer leaves, but that was actually stroked with chestnut tree
leaves, developed a rash. The skin that had actual contact with the
leaves of the lacquer tree, but that was believed to have been stroked
with the chestnut tree leaves, did not react.
A study of treatments for angina pectoris provides an example of
how beliefs of the healthcare practitioner can effect disease (Benson,
McCallie, 1979). A number of therapies for angina pectoris have been
used throughout the decades that are now known to have no therapeutic
value. These include cobra venom, vitamin E and bizarre internal
mammary artery surgeries. When they were used and believed in by
physicians, they had a dramatic effect. They were found to be 70 to 90
percent effective in relieving the pain of angina pectoris. Not only
would the pain disappear, but the patients' electrocardiograms and
exercise tolerance would improve. However, when these therapies were
later invalidated and no longer believed in by physicians, their
effectiveness dropped to 30 percent or lower.
The beliefs that ensue from the relationship between physicians and
patients are the third component of the placebo effect. A study by
researchers at the Massachusetts General Hospital (Egbert, et al, 1964)
compared two matched groups of patients who were to undergo similar
operations. The doctors responsible for their anesthesia visited both
groups of patients, but interacted with them quite differently. They
made only cursory remarks to patients in one group, but treated the
other group with warm and sympathetic attention, detailing the steps of
the operation and describing the pain they would experience. The
patients who received the friendlier more supportive visits were
discharged from the hospital an average of 2.7 days sooner and asked
for half the amount of pain-alleviating medication than patients in the
other group.
Some insight into the possible brain mechanisms for the placebo
effect is provided in a study conducted by Dr. Steven Kosslyn (Kosslyn,
et al., 1993). He and his colleagues examined how the brain processes
information, both real and imagined. Subjects were asked to look at a
grid with a letter printed on it. As they did so, a PET Scan was used
to determine what areas of the brain were active in seeing the grid and
the letter. The subjects were then asked to look at the same grid
without the letter on it, but asked to visualize the letter in their
mind's eye. The PET scan was then repeated. The same area of the brain
was stimulated in both situations. In other words, from the brain's
perspective the visualization of a scene is similar to actually seeing
the scene. This process helps to explain the placebo effect. All of our
thoughts, actions, and memories, represent the activation of specific
brain connections. Pain in an arm or leg is represented as activation
of specific brain areas. There are memories in our brains of pain.
There are also memories of being without pains. There are also brain
connections for having a skin rash and of being without a skin rash.
Thus, belief in a sugar pill or an inactive therapy can result in
activating the brain connections to ``remember'' what it is to be
without the pain or the rash. The pain or rash can be thus alleviated.
In other words, thoughts can activate brain connections that can result
in physical healing.
The biased words ``placebo effect'' probably should be discarded
and changed to ``remembered wellness.'' Remembered wellness is what
explains this powerful mind/body reaction and the words, remembered
wellness, have a positive connotation.
Placebos are not the only way to evoke remembered wellness.
Consider the most profound belief Americans share. Ninety five percent
of the U.S. population believe in God (Gallup, 1990). Research by
different investigators working in different locations throughout the
United States have repeatedly demonstrated a connection amongst
religious beliefs and greater well-being, better quality of life, and
lower rates of depression, anxiety and substance abuse (Koenig, 1998).
Religious beliefs and practices have been associated with enhanced
physical health (Koenig et al, 1997; 1998). They are also associated
with a lower use of expensive health services (Koenig, Larson, in
press). Recently, such research has appeared in respected medical
journals and has begun to influence both the education of physicians
and the practice of medicine (Marwick, 1995; Levin et al., 1997).
The effects of the relaxation response should not be confused with
remembered wellness (the placebo effect). The relaxation response is a
proven, specific mind/body intervention. The measurable, predictable,
and reproducible changes of the relaxation response will occur when you
follow the two specific steps--belief is not essential. It is like
penicillin--it will work whether or not you believe in it.
the three-legged stool and the importance of self-care
Health and well being and the incorporation of mind/body therapies
in medical care are best conceptualized in terms of an analogy of a
three-legged stool (Benson, Friedman, 1996; Benson, 1996). One leg is
pharmaceuticals, the second is surgery and procedures, and the third
leg is self-care. Self-care consists of health habits and behaviors for
which patients themselves can be responsible. Specifically, self-care
includes the relaxation response, beliefs that promote health, stress
management, nutrition and exercise. Health and well-being are balanced
and optimal when all three legs of the stool are in place. Of course,
attention to nutrition and exercise have been recognized for centuries.
In contrast, the scientific documentation of mind/body interactions has
only recently been presented.
For more than a hundred years medicine has relied almost
exclusively on the first two legs of the stool: pharmaceuticals and
surgery. Without the support of the third leg through mind/body and
behavioral approaches, the treatment of many medical conditions is
imbalanced and inadequate. Patients receive less than optimal clinical
care and the care they receive is more costly.
As I noted earlier, if medical care continues to be based only on
two legs, it is estimated that the costs for this care will double in
the next decade (Smith et al, 1998). Mind/body therapies are
scientifically-proven strategies that can be thoroughly integrated with
pharmaceuticals and surgery and procedures and they offer cost savings.
I've also noted that 60 to 90 percent of physician office visits are
related to stress-related conditions. To estimate the monies that could
be saved per year by the application of mind/body therapies, I used 75
percent as an average. I estimated that half of these doctor office
visits--or 37.5 percent--could be eliminated with a greater emphasis on
mind/body health. Using 1994 statistics, there were approximately
670,000 practicing physicians in the United States who reported an
average of 74.2 patient visits per doctor per week, for a total of
3,858.4 office visits per doctor that year. Each visit for an
established patient cost an average of $56.2. Thus, the average cost
per year was 670,000 3,858.4 $56.2 = $145.3
billion. By reducing these visits by 37.5 percent, the cost savings
would be $54.5 billion dollars, for one year alone (Benson, 1996).
One example of how mind/body, behavioral interventions can reduce
costs was shown through a study conducted at the Harvard Community
Health Plan (Hellman, et al, 1990). Two group mind/body interventions
were compared among high-utilizing primary care patients who
experienced physical symptoms which had psychosocial components. The
symptoms included: palpitations, shortness of breath, gastrointestinal
complaints, headaches, and sleeplessness. Both interventions offered
patients educational materials, relaxation-response training, and
awareness training, and both included cognitive restructuring. These
groups were compared with a randomized control group that received only
information about stress management. Six months after treatment only
the patients in the mind/body groups reported less physical and
psychological discomfort and averaged about 50 percent fewer visits to
the health plan than the patients in the control group. The estimated
net savings to the HMO above the cost of the intervention for the
behavioral medicine patients was $85 per participant in the first 6
months.
Chronic pain and insomnia are two other examples of the successful
integration into mainstream medicine of mind/body interventions (NIH
Technology Assessment Panel on Integration of Behavioral and Relaxation
Approaches Into the Treatment of Chronic Pain and Insomnia, 1996).
Millions of Americans are in chronic pain, which by definition, is
pain that cannot be eliminated, but must be managed. Chronic pain
sufferers, motivated both by medical and emotional factors, often
become frequent users of the medical system. The treatment of chronic
pain becomes extremely costly and frustrating for patients and
healthcare providers. In one study, clinic usage was assessed among
chronic pain patients at an HMO who participated in an outpatient
behavioral medicine program, of which the relaxation response is an
integral part (Caudill, et al., 1991). In addition to decreases in the
severity of pain as well as in anxiety, depression and anger, there was
a 36 percent reduction in clinic visits for over two years in the
patients who participated in the behavioral medicine program as
compared to their clinic usage prior to the intervention. In the 109
patients studied, the decreased visits projected to an estimated net
savings of $12,000 for the first year following treatment and $24,000
for the second year.
Another example of how these same mind/body interventions can
result in better medical care and reduce medical costs is in the
treatment of another extremely common disorder, insomnia (NIH
Technology Assessment Panel on Integration of Behavioral and Relaxation
Approaches Into the Treatment of chronic Pain and Insomnia, 1996).
Approximately 35 percent of the adult population experiences insomnia.
Half of these insomniacs consider it a serious problem. Billions of
dollars are spent each year on sleeping medications, making insomnia an
extremely expensive condition. In fact, the direct costs to the nation
are approximately $15.4 billion yearly and the actual costs in terms of
reduced quality of life, lowered productivity and increased morbidity
are astronomical. Although frequently employed, sleeping pills are not
effective in the long term.
The shortcomings of such drug therapy, along with recognition of
the role of behavioral features of insomnia, prompted the development
of mind/body behavioral interventions for this condition. Researchers
at our laboratories at the Mind/Body Medical Institute studied the
efficacy of a multifactor behavioral intervention for insomnia that
included relaxation-response training. Compared to controls, those
subjects who received behavioral and relaxation-response treatment
showed significantly more improvement in sleep patterns. On average,
before treatment it took patients 78 minutes to fall asleep. After
treatment, it took 19 minutes. Patients who received behavioral and
relaxation response treatment became indistinguishable from normal
sleepers. In fact, the 75 percent reduction in sleep-onset latency
observed in the treated group is the highest ever reported in the
literature (Jacobs, G.D. et al, 1993; Jacobs, Benson, Friedman, 1996).
It is also important to remember that the research on mind/body,
behavioral therapies in the treatment of both chronic pain and insomnia
were reviewed in 1995 at a NIH Technology and Assessment Conference.
The planning committee chairman was my late friend and colleague Dr.
Richard Friedman. Dr. Julius Richmond, former Surgeon General of the
United States Public Health Service and Assistant Secretary for Health
of the Department of Health and Human Services under President Carter,
was the chair of the independent panel (before he became a trustee of
the Mind/Body Medical Institute) that reviewed the evidence. Dr.
Richmond stated in a press conference that it was ``imperative'' that
these interventions be integrated into routine medical care.
the proper use of mind/body therapies and the creation of mind/body
medical centers
Consider for a moment that I were here today discussing a new drug
and the scientific evidence indicated that this new drug could
successfully treat a very wide variety of prevalent medical
conditions--conditions that lead to 60 to 90 percent of visits to
physicians. Furthermore, consider that this new drug was safe and
without dangerous side effects. It could also prevent these conditions
from occurring and recurring. And, consider that the new drug was
demonstrated to decrease visits to doctors by as much as 50 percent and
that this decrease could lead to annual cost savings of more than $54
billion (Benson, 1996). The discovery of such a drug would be front
page news and immediately embraced. Such scientifically-validated mind/
body therapies have been shown to produce such clinical and economic
benefits, but as yet have not been so received.
Why, given results such as these, have mind/body therapies such as
the relaxation response and those related to the beliefs of patients
not been more effectively integrated into mainstream medicine? Barriers
to integration include: (1) the lack of knowledge of the existing
scientific data among healthcare providers, researchers in other
fields, among patients and among policy makers in government and
private industry; (2) a bias against mind/body interventions in medical
care as being ``soft'' science; (3) inadequate insurance payments for
these treatments; and (4) a bias against shifting away from the
overwhelming use of pharmaceuticals as well as surgeries and
procedures.
One way to overcome these barriers is the establishment of mind/
body medical centers. They will make the benefits of mind/body
medicine, specifically those of the relaxation response and those
related to utilizing the beliefs of patients more visible. Mind/body
medical centers would also markedly expand the ``hard'' science base of
mind/body interventions. It could be argued that NIH already has
mechanisms in place to review mind/body proposals and some might ask,
Why then the need for new centers? NIH study sections do skillfully
assess and perform reviews of quite circumscribed research.
Unfortunately, a striking paucity of study sections are equipped to
adequately review proposals that investigate the simultaneously
occurring multiple, mind/body linkages that involve human
physicochemistry, biology, psychology, social behavior, and belief-
related phenomena such as spirituality. Mind/body medical centers under
the aegis of the Office of Behavioral of Social Sciences Research of
NIH would be a meaningful step toward overcoming narrowly-focused,
exclusively reductionistic research. Understanding the inter-
relatedness of different systems should be carried out in already
existing organizations that are experienced in mind/body research and
treatments. It might be advisable to encourage the new centers to work
collaboratively on joint projects. The centers would also teach and
train healthcare professionals in mind/body approaches and promote
responsible education to the public about mind/body mechanisms and
treatments. Finally, these NIH supported centers could markedly expand
studies of the cost effectiveness of mind/body interventions and
provide data for new reimbursement strategies for Medicare and Medicaid
as well as for private insurers.
The full integration of mind/body, self-care medicine is completely
compatible with existing healthcare approaches. The integration is
important not only for better health and well-being, but also for a
more economically-feasible healthcare system. Mind/body medicine
responsibly fulfills the needs of our people who want therapies that
enhance and complement traditional medicine and that do so in a
scientifically-established, safe, and cost-savings fashion. Mind/body
medicine holds such promise that it should be further researched,
advocated and utilized for the health and well-being of the people of
our nation.
references
Beecher, H. (1955). The powerful placebo. ``Journal of the American
Medical Association,'' 159, 1602-1606.
Benson, H. The Relaxation Response. New York: William Morrow, 1975.
Benson, H. Beyond the Relaxation Response. New York; Times Books,
1984.
Benson, H. Timeless Healing: The Power and Biology of Belief. New
York: Scribner, 1996.
Benson, H., Alexander, S., Feldman, C.L. (1975) Decreased premature
ventricular contractions through use of the relaxation response in
patients with stable ischemic heart-disease. (1975). ``Lancet,'' 2,
380-382.
Benson, H., Beary, J.F., Carol, M.P. (1974). The relaxation
response. ``Psychiatry,'' 37, 37-45.
Benson, H., Frankel, F.H., Apfel, R., Daniels, M.D., Schniewind,
H.E., Nemiah, J.C., Sifneos, P.E., Crassweller, K.D., Greenwood, M.M.,
Kotch, JB., Arns, P.A., Rosner, B. (1978). Treatment of anxiety: A
comparison of the usefulness of self-hypnosis and a meditational
relaxation technique. ``Psychotherapy and Psychosomatics,'' 30, 229-
242.
Benson, H., Friedman, R. (1996). Harnessing the power of the
placebo effect and renaming it Remembered Wellness. ``Annual Review of
Medicine,'' 47,193-199.
Benson, H., McCallie, Jr., D.P. (1979). Angina pectoris and the
placebo effect. ``New England Journal of Medicine,'' 300, 1424-29.
Cannon, W.B. (1941). The emergency function of the adrenal medulla
in pain and the major emotions. ``American Journal of Physiology,'' 33,
356.
Caudill, M., Schnable, R., Zuttermeister, P., Benson, H., Friedman,
R. (1991). Decreased clinic use by chronic pain patients: Response to
behavioral medicine interventions. ``Clinical Journal of Pain,'' 7,
305-310.
Cummings N.A., VandenBos, G.R. (1981). The twenty years Kaiser-
Permanente experience with psychotherapy and medical utilization;
implications for national health policy and national insurance.
``Health Policy Quarterly.'' 1, 59-75.
Domar, A.D., Seibel, M.M., Benson, H. (1990). The mind/body program
for infertility: A new behavioral treatment approach for women with
infertility. ``Fertility and Sterility,'' 53, 246- 249.
Egbert, L.D., Battit, G.E., Welch, C.E., Bartlett, M.K. (1964)
Reduction of postoperative pain by encouragement and instruction of
patients. ``The New England Journal of Medicine,'' 270, 824- 827.
Friedman, R., Sobel, D., Myers, P., Caudill, M., Benson, H. (1995).
Behavioral medicine, clinical health psychology, and cost offset.
``Health Psychology,'' 14, 509-518.
Friedman, R., Zuttermeister, P., Benson, H. (1993). Letter to the
Editor. ``The New England Journal of Medicine,'' 329,1201.
Gallup, G.H., Jr. ``Religion in America: 1990.'' Princeton:
Princeton Religion Research Center, 1990.
Goodale, I.L., Domar, A.D., Benson H. (1990) Alleviation of
premenstrual syndrome symptoms with the relaxation response.
``Obstetrics and Gynecology,'' 75, 649-655.
Hellman, C.J.C., Budd, M., Borysenko, J., McClelland, D.C., Benson,
H. (1990) A study of the effectiveness of two group behavioral medicine
interventions for patients with psychosomatic complaints. ``Behavioral
Medicine,'' 16, 165-175.
Hoffman, J.W., Benson, H., Arns, P.A., Stainbrook, G.L. Landsberg,
G.L., Young, J.B., Gill, A. (1982). Reduced sympathetic nervous system
responsivity associated with the relaxation response. ``Science,'' 215,
190-192.
Ikemi, Y., Nakagawa, S. (1962). A psychosomatic study of contagious
dermatitis. ``Kyoshu Journal of Medical Science,'' 13, 335-350.
Jacobs, G.D., Benson, H., Friedman, R. (1996). Perceived benefits
in a behavioral-medicine insomnia program: A clinical report. ``The
American Journal of Medicine,'' 100, 212-216.
Jacobs, G.D., Rosenberg, P.A., Friedman, R., Matheson, J., Peavy,
G.M., Domar, A.D., Benson, H. (1993). Multifactor behavioral treatment
of chronic sleep-onset insomnia using stimulus control and the
relaxation response: A preliminary study. ``Behavior Modification,''
17, 498-509.
Koenig, H.G. (1998). Handbook of Religion and Mental Health. San
Diego: Academic Press.
Koenig, H.G., Cohen, H.J., George, L.K, Hays, J.C., Larson, D.B.,
Blazer, D.G. (1997). Attendance at religious services, interleukin-6,
and other biological indicators of immune function in older adults.
``International Journal of Psychiatry in Medicine,'' 27, 233-250.
Koenig, H.G., George, L.K., Cohen, H.J., Hays, J.C., Blazer, D.G.,
Larson, D.B. (1998). The relationship between religious activities and
blood pressure in older adults. ``International Journal of Psychiatry
in Medicine,'' 28, 189-213.
Koenig, H.G., Larson, D.B. (1998). Use of hospital services, church
attendance, and religious affiliation. ``Southern Medical Journal,'' in
press (October issue).
Kosslyn, S., Alpert, N.M., Thompson, W.L. Maljkovic, V., Weise,
S.B., Chabris, C.F., Hamilton, S.E., Rauch, S.L., Buonanno, F.S. (1993)
Visual mental imagery activates topographically organized visual
cortex: PET investigations. ``Journal of Cognitive Neuroscience,'' 5,
263-267.
Kroenke, K., Mangelsdorff, A.D. (1989). Common symptoms in
ambulatory care: Incidence, evaluation, therapy, and outcome.
``American Journal of Medicine,'' 86, 262-266.
Levin, J.S., Larson, D.B., Puchalski C.M. (1997). Religion and
spirituality in medicine: research and education. ``Journal of the
American Medical Association,'' 278, 792-793.
Marwick, C. (1995). Should physicians prescribe prayer for health?
Spiritual aspects of well-being considered. ``Journal of the American
Medical Association,'' 273, 1561-1562.
NIH Technology Assessment Panel on Integration of Behavioral and
Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia
(1996). Integration of Behavioral and Relaxation Approaches Into the
Treatment of Chronic Pain and Insomnia. ``JAMA,'' 276, 313-318.
Smith, S., Freeland, M., Heffler, S., McKusick, D. and the Health
Expenditures Projection Team (1998). The next ten years of health
spending: What does the future hold? ``Health Affairs,'' 17, 128-140.
Stuart, E., Caudill, M., Leserman, J., Dorrington, C., Friedman R.,
Benson, H. (1987) Nonpharmacologic treatment of hypertension: A
multiple-risk-factor approach. ``Journal of Cardiovascular Nursing,''
1, 1-14.
Wallace, R.K., Benson, H., Wilson, A.F. (1971). A wakeful
hypometabolic physiologic state. ``American Journal of Physiology,''
221, 795-799.
STATEMENT OF HAROLD G. KOENIG, M.D., DIRECTOR, CENTER
FOR THE STUDY OF RELIGION/SPIRITUALITY AND
HEALTH, DUKE UNIVERSITY MEDICAL CENTER
Senator Specter. Dr. Harold Koenig is the director and
founder of the Center for the Study of Religion, Spirituality
and Health at Duke Medical Center. His areas of research
include depression in the medically ill elderly, religion,
aging and health, ethical issues, and geriatric psychiatry. Dr.
Koenig received his undergraduate degree from Stanford,
continued his education at the University of California at San
Francisco, and furthered his medical education in geriatric
medicine, psychiatry, and biostatistics at Duke University
Medical Center. Welcome, Dr. Koenig, and the floor is yours.
psychological and social stress
Dr. Koenig. Thank you, Senator.
As Dr. Anderson and Dr. Benson have already spoken to,
there is an increasing amount of scientific evidence that is
establishing the link between psychological and social stress
and a host of disabling and serious medical illnesses,
particularly heart disease and cancer which are the major
killers of Americans today. Traditional medical and surgical
treatments typically do not include mind/body medicine
approaches that could empower and motivate patients toward
self-care, prevent illness, speed recovery, and reduce the
costs of health care that are quickly spiraling out of control.
Patients have become accustomed to relying on medical and
surgical approaches to their illnesses rather than focusing on
things that they can do to improve their health or prevent
health conditions from occurring, and physicians have become
accustomed to treating sick people like broken down cars,
simply fix them and then send them out. Patients and physicians
need to be educated about and encouraged to participate in
self-care activities that help to maintain their wellness,
speed recovery, and prevent disease.
Now, the relaxation response and ways of eliciting it, like
repetitive prayer, is easily taught and widely acceptable to
Americans throughout the country. These techniques have been
shown to enhance well-being by alleviating and reducing
anxiety, pain, stress, and preventing substance abuse and
alcoholism and drug use. Consequently, given the relationship
between psychological stress and physical illness, we would
expect that these techniques would reduce blood pressure,
enhance coronary functioning, reduce coronary artery ischemia,
lower the risk of cancer, and perhaps even increase immune
system functioning.
Likewise, certain beliefs have been associated with greater
well-being and better physical health. Let us just take for an
example religious or spiritual beliefs. Now, they could be
beliefs really in anything, beliefs in your doctor or beliefs
in a pill, but as an example we will take religious and
spiritual beliefs because they are so prevalent in society.
These have been associated with reduction of acute stress,
prevention of depression, faster recovery from depression,
faster adaptation to chronic stress, and prevention and
treatment of drug and alcohol addiction. This has been shown by
multiple different research groups located in many different
areas of the country.
Likewise, because of this mind/body connection, we would
expect that perhaps religious beliefs and practices might be
associated with better health, and indeed they have been found
to be connected with a lower risk of coronary heart disease,
lower blood pressure, enhanced recovery from open heart
surgery, prevention of cancer, promotion of positive health
behaviors, and enhancement of immune system functioning, and
actually extension of overall survival.
Finally, religious beliefs and practices are associated
with quicker recovery from disabling illnesses like hip
fracture and stroke, and they can also help to prevent costly
disability in people that is causing a great increase naturally
in the costs of health care.
Now, again these religious beliefs and practices appear to
also directly reduce the amount of acute hospital use which is
the most costly form of health care. Indeed, we have found that
again these beliefs seem to actually shorten the hospital stay
of significantly ill older patients.
prepared statement
Now, mind/body centers will be equipped with sufficient
expertise to develop this new area in a way that NIH's typical
programs simply cannot do. Only centers with a critical mass of
investigators and core infrastructure can launch the ambitious
and multi-disciplinary projects that are necessary to advance
this field. Centers are also the best way of disseminating the
research findings to the public and to clinicians and to
rapidly moving these research findings into practical
applications.
Thank you.
[The statement follows:]
Prepared Statement of Harold G. Koenig
the effects of stress, relaxation, and belief on health and healthcare
costs
Thank you for inviting me to speak on this fascinating topic of
mind-body medicine and the usefulness of establishing mind-body
medicine centers to focus research and training in this area. I am a
physician boarded in geriatric medicine and geriatric psychiatry, serve
on the Duke University Medical Center faculty as an associate professor
of psychiatry, and direct Duke's Center for the Study of Religion/
Spirituality and Health. For the past 15 years, our center scientists
(now 8 in number) have investigated the effects of religious belief and
practice on health, conducting over 50 research projects and publishing
several hundred scientific papers. In my talk, I hope to accomplish
four goals: (1) Provide further evidence for a link between Stress and
physical health; (2) Examine the effects of the Relaxation Response on
specific health problems; (3) Explore the effects of Belief on health
and well-being; and (4) Demonstrate how mind-body practices may,
through Relaxation Response related therapies and Belief, reduce health
care Costs.
a link between stress and physical health
Mounting research is demonstrating that psychological stress
negatively impacts physical health, and that mind-body medicine
approaches are effective in relieving stress and counteracting its
negative health effects. Below, Bruce McEwen reviews this research and
Janice Kiecolt-Glaser provides a fascinating example that illustrates
the effects of stress on wound healing.
McEwen, B.S., and Stellar, E. (1993). Stress and the individual
mechanisms leading to disease. Archives of Internal Medicine, 153,
2093-2101. Examines diseases associated with stress, including asthma,
diabetes, gastrointestinal disorders, myocardial infarction,
hypertension, cancer, viral infections, and autoimmunity; discusses
mechanisms, including neurochemistry (serotonin) and immunology
(natural killer cell activity and cancer). See recent update in:
McEwen, B.S. (1998). Protective and damaging effects of stress
mediators. New England Journal of Medicine, 338, 171-179.
Kiecolt-Glaser, J.K., Marucha, P.T., Malarkey, W.B., Mercado, A.M.,
and Glaser, R. (1996). Slowing of wound healing by psychological
stress. Lancet, 346(8984): 1194-1196. Thirteen women (mean age 62)
caring for demented relatives (high stress) were compared with 13
controls matched for age (60 yo) and family income. Ball subjects
underwent a 3.5 mm punch biopsy. Healing was assessed by photography of
wound and response to hydrogen peroxide (healing defined as no
foaming). Wounds in stressed caregivers took significantly longer to
heal (48.7 vs 39.3 days, p<.05). Furthermore, peripheral blood
leukocytes (white blood cells) of caregivers produced significantly
less interleukin-1 beta mRNA in response to lipopolysaccharide
stimulation (suggesting impaired functioning).
If psychological stress adversely affects the cardiovascular and
immune systems, then perhaps cognitive (beliefs and attitudes) and
behavioral interventions may help decrease this effect.
the relaxation response
Below I review studies of the relaxation response (and methods of
eliciting it) on well-being and physical health.
Well-being
Studies have shown that the Relaxation Response, and the many
methods of eliciting it (such as repetitive prayer), help to relieve
stress, chronic pain, and negative mental health states like anxiety
disorder and drug and alcohol abuse. What are the nature of these
studies?
Reducing Anxiety
Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G.,
Fletcher, K.E., Pbert, L., Lenderking, W.R., and Santorelli, S.F.
(1992). Effectiveness of a meditation-based stress reduction program in
the treatment of anxiety disorders. American Journal of Psychiatry,
149, 936-943. Study of 22 patients referred for meditation and
relaxation program who had generalized anxiety disorder or panic
disorder (ages 26-65, 17 women). The intervention consisted of a 8-week
long course involving weekly 2-hour classes and a 7.5 hour intensive
meditation retreat session in week six. Subjects were assessed at the
start and end of intervention and at monthly intervals for 3 months
after treatment. A. significant reduction in symptoms of anxiety and
depression was identified during treatment and maintained for at least
3 months after treatment ended. The authors indicated that a 3-year
follow-up showed that 18/22 subjects maintained these beneficial
effects.
Azhar, M.Z., Varma, S.L., and Dharap, A.S. (1994). Religious
psychotherapy in anxiety disorder patients. Acta Psychiatrica
Scandinavica, 90, 1-3. Investigators randomized 62 Muslim patients with
generalized anxiety disorder to either traditional treatment
(supportive psychotherapy and anxiolytic drugs) or traditional
treatment plus religious psychotherapy. Religious psychotherapy
involved use of prayer and reading verses of the Holy Koran specific to
the person's situation. Patients receiving religious psychotherapy
experienced more rapid improvement in anxiety symptoms than those
receiving traditional therapy.
Reducing Chronic Pain
Kabat-Zinn, J., Lipworth, L., and Burney, R. (1985). The clinical
use of mindfulness meditation for the self-regulation of chronic pain.
Journal of Behavioral Medicine, 8, 163-190. Investigators compared
patients in two hospital clinics involving. One hospital clinic treated
patients using ``mindfulness meditation''; 90 chronic pain patients
received 10 weeks of a Stress-Reduction and Relaxation Program (SSRP).
In these patients, investigators found statistically significant
reductions in pain symptoms, mood disturbance, and psychological
symptoms. Pain-related drug utilization also decreased and self-esteem
increased. Improvement was independent of sex, source of referral or
type of pain. A comparison group of patients in the other hospital pain
clinic (n=21) and referrals to the SRRP from the pain clinic (n=21) did
not show similar improvement after traditional treatment protocols. At
follow-up, improvements were maintained for 15 months for all measures
except one measure of pain; the majority of subjects reported high
compliance with daily meditation.
Preventing and Treating Substance Abuse
Gelderloos, P., Walton, K.G., Orme-Johnson, D.W., and Alexander,
C.N. (1991). Effectiveness of the transcendental meditation program in
preventing and treating substance misuse: A Review. International
Journal of the Addictions, 26, 293-325. These investigators reviewed 24
studies on the benefits of Transcendental Meditation in treating and
preventing substance abuse. They concluded from this review that ``all
studies showed positive effects of the TM program.'' Only two studies,
however, used longitudinal experimental designs with random assignment
of subjects. Myers and Eisner (1974) randomly assigned young male
students from a community college (selected from a large pool of
volunteers). Sixty were assigned to TM, 60 to karate, and 60 to a no-
treatment control group. After 4 months, investigators compared groups
on use of marijuana, psychedelics, uppers, downers, and hard drugs.
There was a significant drop in one or more categories of substance
abuse in TM participants relative to controls. The second study
(Bounouar 1989), examined 925 TM participants and 6,145 controls who
attended an introductory lecture on TM. Subjects were followed for 20
months, examining tobacco consumption levels. Over 80 percent of those
who meditated twice a day quit or decreased smoking after 20 months vs.
55 percent of irregular meditators and 33 percent of controls
(p<.0001). Also see Alexander, C.N., et al (1994). Treating and
preventing alcohol, nicotine, and drug abuse through transcendental
meditation: A review and meta-analysis. Alcoholism Treatment Quarterly,
11(\1/2\), 13-87.
Physical Health
Because mind body-medicine techniques help to reduce stress and
anxiety, they also have a direct impact on stress-related physical
illnesses like cardiovascular disease and cancer, the No. 1 and No. 2
killers of Americans.
Reducing Blood Pressure
Benson, H. (1977). Systemic hypertension and the relaxation
response. New England Journal of Medicine, 296, 1152-1156. This article
reviews research on the relaxation response and blood pressure (BP). In
one of the studies reviewed, subjects were taught to elicit the
relaxation response by meditating for 20 minutes twice/day. After two
weeks, BPs were measured every two weeks for 6 months (BP's never
measured after meditation). Among meditating subjects, there was and
average drop in systolic BP (SBP) during 6 months of 7 mmHG lower than
at baseline and diastolic BP (DBP) was 4 mmHG lower than at baseline.
Subjects served as their own controls, with a 6-week run-in period when
no BP changes were observed before start of study. For subjects who
``chose to stop meditation,'' both SBP and DBP returned to initial high
levels within 4 weeks of the end of the study. This review also
discusses one study (published in 1973 in Lancet) that showed Yoga
combined with biofeedback reduced SBP by 20 mmHG and DBP by 14 mmHG in
hypertensive patients treated with antihypertensive medication,
compared with no statistically significant change in a matched control
group. A third study using a control group and Buddhist meditation
reported reductions of 15 mm SBP and 10 mm DBP in patients with
hypertension (NEJM, 1976). Other studies have also shown significant
decreases in both SBP and DBP with the relaxation response in
normotensive working populations.
Chesney, M.A., Agras, s., Benson, H., Blumenthal, J.A., Engel,
B.T., Foreyt, J.P., Kaufmann, P.G., Levenson, R.M., Pickering, T.G.,
Randall, W.C., Schwartz, P.J. (1987). Task Force 5: Nonpharmacologic
approaches to the treatment of hypertension. Circulation, 76 (Suppl I),
104-109. This is a more recent review of the literature. Authors
conclude that since 20 million people in the U.S. alone have mild
hypertension (HTN) and drug treatments for HTN have many potential
negative side-effects, non-pharmacological treatments ``must be
explored vigorously'' (p 104). Suggests that for the standard care of
hypertensive individuals that ``Relaxation-based treatments should also
be given early consideration in light of the evidence of their
efficacy'' (p 105).
Linden, W., and Chambers, L. (1994). Clinical effectiveness of non-
drug treatment for hypertension: A meta-analysis. Annals of Behavioral
Medicine, 16, 35-45. Perhaps one of the best reviews ever performed of
mind-body medicine strategies for reducing blood pressure. This review
is unique in that the authors control for initial blood pressure
levels. In previous reviews, persons with normal blood pressure were
included (in such populations it is difficult to demonstrate an effect
for mind-body strategies on blood pressure because the blood pressure
cannot be reduced much further). The authors concluded that these
approaches were equivalent to single drug therapy for hypertension.
Schneider, R.H., Staggers, F., Alexander, C., Sheppard, W.,
Rainforth, M. Kondwani, K., Smith, S., and King, C.G. (1995). A
randomized controlled trial of stress reduction for hypertension in
older African Americans. Hypertension, 26, 820-829. Study involved 111
African Americans in Oakland, CA, ages 55-85 with baseline blood
pressures <=179/104 mmHg (mild hypertension). Subjects were enrolled in
a randomized, controlled single-blind trial of Transcendental
Meditation (TM) compared with progressive muscle relaxation (PMR) and a
life-style modification education control program. TM and PMR sessions
lasted 1.5 hours initially and 1.5 hours/month for 3 months; data
collected every month. Investigators found that TM had significantly
greater effects on systolic blood pressure (p=.02) and diastolic blood
pressure (p=.03) than PMR; SBP was reduced by 10.7 mmHG (p<.003) and
DBP reduced by 6.4 mm (P<,.0001) for TM. The investigators concluded
that TM was twice as effective as PMR in reducing systolic and
diastolic blood pressures.
Koenig HG, George LK, Cohen HJ, Hays, JC, Blazer DG, Larson DB,
Larson, DB (1998). The relationship between religious activities and
blood pressure in older adults. International Journal of Psychiatry in
Medicine 28, 189-213. Epidemiological study of 4,000 randomly selected
older adults in North Carolina (NIA-supported Establishment of
Populations for Epidemiologic Studies of the Elderly (EPESE). Persons
who both attended religious services regularly and who prayed/meditated
regularly were 40 percent less likely to have diastolic hypertension
then those who did not (p<.0001, after controlling for age, sex, race,
education, smoking, physical functioning, and body mass index). Among
Black persons in the sample (54 percent of subjects), the effects on
blood pressure were even greater. Religious activities (especially
regular prayer and scripture reading) at one wave predicted lower blood
pressure levels three years later, after controlling for baseline blood
pressure and other compounding variables.
Heart Disease and Other Cardiovascular Risk Factors
Zamarra, J.W., Schneider, R.H., Besseghini, I., Robinson, D.K., and
Salerno, J.W. (1996). Usefulness of the transcendental meditation
program in the treatment of patients with coronary artery disease.
American Journal of Cardiology, 77, 867-870. A clinical trial that
tested the hypothesis that stress reduction intervention with TM could
reduce exercise-induced myocardial ischemia in patients with known CAD
(coronary are to read disease). 21 pts with known CAD were recruited
from the Buffalo, NY VA Hospital and prospectively studied. Subjects
were randomly assigned to TM (n=12) or waitlist control group (n=9). TM
group received 10 hrs of basic instruction and follow-up, including
personal instruction for 60 minutes initially and 30 min twice/week for
1st month and monthly thereafter. Subject were instructed to practice
TM 20 min twice/day for 6-8 months. After 8 months, the TM group had a
14.7 percent increase in exercise duration (p=.01), an 11.7 percent
increase in maximal workload (p=.004), and an 18.1 percent delay of
onset of ST depression (p=0.029), whereas control subjects showed no
substantial changes in these outcomes. Furthermore, the TM group showed
significantly greater reduction in rate-pressure products after 3 and 6
minutes of exercise (p=.02), compared to controls.
Leserman, J., Stuart, E.M., Mamish, M.E., and Benson, H. (1989).
The efficacy of the relaxation response in preparing for cardiac
surgery. Behavioral Medicine, Fall, 111-117. In this study, 27 cardiac
surgery patients (mean age 68) were randomly assigned to either
educational information + Relaxation Response vs. educational
information only. On the Profile of Mood States scale, the relaxation
response group experienced significantly greater reductions in tension
and anger than the education only group. More importantly, the
experimental group had lower incidence of supraventricular tachycardia
(SVT) (p=.04), a dangerous heart rhythm often complicating cardiac
surgery.
Sudsuang, R., Chentanez, V., and Veluvan, K. (1991). Effect of
Buddhist meditation on serum cortisol and total protein levels, blood
pressure, pulse rate, lung volume and reaction time. Physiology and
Behavior, 50, 543-548. This was a clinical trial involving 52 males
ages 20-25 years practicing Dhammakaya Buddhist meditation (similar to
Zen or transcendental meditation). Control group was 30 males of the
same age group not meditating. Serum cortisol levels were significantly
reduced in treatment group (combined A and B), and was different from
controls (p<.01, all comparisons). Serum protein levels increased after
6 weeks for combined group (p<.01) and different from controls (p<.05).
Systolic and diastolic blood pressures both significantly different in
combined treatment group (p<.01) and significantly different from
controls (p<.01). Heart rate significantly different at 3 and 6 weeks
(p<.01) and from controls (p<.01 at 3 wks, p<.05 at 6 wks). Pulmonary
function (vital capacity, tidal volume, and maximum voluntary
ventilation) significantly different at 3 and 6 weeks (p<.05) before
and after in treatment group.
Alexander, C.N., Robinson, P., Orme-Johnson, D.W., Schneider, R.H.,
and Walton, K.G. (1994). Effects of transcendental meditation compared
to other methods of relaxation and meditation in reducing risk factors,
morbidity and mortality. Homeostasis, 35, 243-264. Review of research
showing that TM is associated with reduced cardiovascular risk factors
such as hypertension, smoking, cholesterol.
Preventing Cancer and Limiting Cancer Spread
Koenig HG, George LK, Cohen HJ, Hays JC, Blazer DG, Larson DB
(1998). The relationship between religious activities and cigarette
smoking in older adults. Journal of Gerontology (medical sciences), in
press (November). Cigarette smoking and religious activities were
assessed in a probability sample of 3,968 persons age 65 years or older
participating in the Duke EPESE survey. Data were available for Waves
I-III of the survey (1986, 1989, and 1992). Analyses were controlled
for age, race, sex, education, alcohol use, physical health, and in the
longitudinal analyses, smoking status at prior waves. Participants who
frequently attended religious services were significantly less likely
to smoke cigarettes at all three waves. Likewise, elders frequently
involved in private prayer and meditation were less likely to smoke
(Waves II and III). Total number of pack-years smoked was also
inversely related to both attendance at religious services and private
prayer/meditation. Among those who smoked, number of cigarettes smoked
was inversely related to frequency of attendance at religious services
and private prayer/meditation. Retrospective and prospective analyses
revealed that religiously active persons were less likely to ever start
smoking, not more likely to quit smoking. Those who both attended
religious services at least once/week and prayed/meditated at least
daily were almost 90 percent more likely not to smoke than persons less
involved in these religious activities. The likely impact of religious
beliefs and activities like prayer on smoking-related diseases--like
lung cancer and chronic lung disease--is considerable.
Spiegel, D., Bloom, J.R., Kraemer, H.C., and Gottheil, E. (1989).
Effect of psychosocial treatment on survival of patients with
metastatic breast cancer. The Lancet, 2(8668), 888-891. This clinical
trial examined the effects of a psychosocial intervention on survival
among 86 women with metastatic breast cancer. The 1-year intervention
consisted of weekly supportive group therapy with self-hypnosis and
relaxation for pain. At 10-year followup, only 3 patients were alive
and death records obtained for the other 83 deceased patients. Among
those receiving the intervention, average survival was 36.6 months
compared to 18.9 months in the control group (p<.0001, Cox model).
Interestingly, differences in survival began 8 months after the
intervention ended.
Enhancing Immune Function (indirectly affecting cancer risk)
Carson, V.B. (1993). Prayer, meditation, exercise, and special
diets: Behaviors of the hardy person with HIV/AIDS. Journal of the
Association of Nurses in AIDS Care, 4(3), 18-28. Investigators studied
100 subjects who were either HIV positive or had AIDS. A Personal Views
Survey developed by Kobasa was used to determine ``hardiness'' (related
to longer survival in this population). Level of spirituality was
measured by responses to questions concerning participation in prayer,
meditation, use of imagery or visualization, reading religious
literature, spiritual retreats, and church services. A single item
examined the frequency of prayer. Spirituality (total score) was
significantly related to greater hardiness (r=0.18, p=.04), although
only prayer (r=0.233, p=.01) and meditation (r=0.262) were related to
hardiness when individual items were examined. Hardiness is seen as an
indirect measure of immune system functioning.
Woods, T.E., Antoni, M.H., Ironson, G.H., and Kling, D.W. (1998).
Religiosity is associated with affective and immune status in
symptomatic HIV-infected gay men. Journal of Psychosomatic Research, in
press. These investigators examined in the association between
religious beliefs and behaviors and immune functioning in 106 HIV
seropositive gay men. Religious activities--prayer or meditation,
religious attendance, spiritual discussions, reading religious/
spiritual literature--were associated with significantly higher CD4+
counts and CD4+ percentages (T-helper-inducer cells) (controlling for
self-efficacy and active coping with health situation, using regression
modeling). The effects of religious behaviors on immune function was
not confounded by disease progression (i.e., as disease worsened and
immune function decreased, persons unable to participate in religious
activity).
utilization of beliefs in health and well-being
Below I review studies that link beliefs with mental and physical
health. Religious belief is used here as an example of a common belief
that Americans possess. Other beliefs, however, might likewise serve as
examples of the power that beliefs have in affecting health outcomes
(i.e., belief in a drug or medical treatment, belief in a surgical
treatment, belief in one's physician, etc.).
Beliefs and Well-being
Beliefs have been shown to affect mental health by preventing or
relieving psychological stress and thereby influencing a wide variety
of psychiatric disorders.
Reducing Stress and Preventing Depression
Koenig, H.G., Cohen, H.J., Blazer, D.G., Pieper, C., and Meador,
K.G., Shelp, F., Goli, V., and DiPasquale, R. (1992). Religious coping
and depression in elderly hospitalized medically ill men. American
Journal of Psychiatry, 149, 1693-1700. In a consecutive sample of 850
elderly men acutely admitted to the hospital, investigators found that
patients who used prayer and religious belief to help them cope were
significantly less depressed; among a subgroup of 201 subjects, extent
of prayer and belief predicted lower depression scores 6 months later.
There are over 100 other studies showing that those who are more
religiously active experience lower rates of depression, commit suicide
less often, and have greater well-being (Koenig et al 2000).
Speeding Recovery from Depression or Adaptation to Stress
Koenig HG, George LK, Peterson BL (1998). Religiosity and remission
from depression in medically ill older patients. American Journal of
Psychiatry, 155, 536-542. One year prospective study of 87 medical
inpatients with depressive disorder to determine predictors of being to
remission. Twenty-eight physical health, mental health, social, and
treatment factors were examined. Investigators found that depressed
patients who had strong intrinsic religious belief recovered over 70
percent faster from depression than did those with weaker religious
commitment. In a subgroup of patients whose physical illness was not
improving (not responding to medical treatments), intrinsically
religious patients recovered over 100 percent faster. Other
investigators have reported similar findings in children (Miller et al
1997) and elderly persons in Europe (Braam et al 1997).
Propst, L.R., Ostrom, R., Watkins, P., Dean, T., and Mashburn, D.
(1992). Comparative efficacy of religious and nonreligious cognitive-
behavior therapy for the treatment of clinical depression in religious
individuals. Journal of Consulting and Clinical Psychology, 60, 94-103.
Examined the effectiveness of using religion-based psychotherapy in the
treatment of 59 depressed religious patients. The religious therapy
involved use of religious beliefs to counter irrational thoughts
associated with depression. Religious belief therapy resulted in
significantly faster recovery from depression compared to standard
secular cognitive-behavioral therapy. What was surprising was that the
benefits from religious-based therapy were most evident among patients
who received religious therapy from non-religious therapists.
Rabins, P.V., Fitting, M.D., Eastham, J., and Zabora, J. (1990).
Emotional adaptation over time in caregivers for chronically ill
elderly people. Age and Ageing, 19, 185-190. Followed 62 caregivers of
persons with either Alzheimer's disease or recurrent metastatic cancer,
examining factors that predicted adaptation two years later. Strong
religious belief (p<.0001) and frequent social contacts were the two
major predictors of adaptation in this group.
Preventing Substance Abuse
Cochran, J.K., Beeghley, L., and Bock, E.W. (1988). Religiosity and
alcohol behavior: an exploration of reference group theory.
Sociological Forum, 3, 256-276. These investigators used survey data
from General Social Surveys conducted between 1972-1984. During this
time, 7,581 adults ages 18 or older were surveyed. Results indicated
that four measures of religiousness (attendance at services, belief in
life after death, strength of religious belief, and religious group
memberships) were all inversely related to alcohol use or misuse, after
controlling for age, race, sex, urbanity, region, education, income,
and prestige. This study involved a large random national sample of
Americans of all ages.
Amey, C.H., Albrecht, S.L., and Miller, M.K. (1996). Racial
differences in adolescent drug use: The impact of religion. Substance
Use and Misuse, 31, 1311-1332. These investigators surveyed a random
sample of 11,728 senior high school students. The dependent variable
was substance use (LSD, cocaine, amphetamines, barbiturates,
tranquilizers, heroin, other narcotics, and inhalants). Religious
involvement was inversely related with all substances. Frequent church
attendance was associated with 29 percent less cigarette smoking, 45
percent less alcohol use, 33 percent less marijuana use, 21 percent
less other drug use. Importance of religious beliefs was associated
with 25 percent less cigarette smoking, 55 percent less alcohol use, 22
percent less marijuana use, and 12 percent less other drug use.
beliefs and physical health
Because beliefs impact mental health, they also have effects on
physical health because of the link between psychological stress and
physical disorders.
Preventing Cardiovascular Disease
Goldbourt, U., Yaari, S., and Medalie, J.H. (1993). Factors
predictive of long-term coronary heart disease mortality among 10,059
male Israeli civil servants and municipal employees. Cardiology, 82,
100-121. This was a prospective study of 10,059 Jewish males aged 40 or
over working as civil servants or municipal employees in Israel.
Subjects were first assessed in 1963 and mortality from heart disease
(coronary artery disease) (CAD) was assessed in 1986 (23-year follow-
up). Religious orthodoxy was measured by 3 items (religious vs. secular
education; self-definition as orthodox believers, traditional
believers, or secular believers; and frequency of synagogue attendance)
summed to create an orthodoxy of belief index. The most orthodox group
had lowest rate of mortality from CAD (38 vs. 61 per 10,000) and other
causes (135 vs. 168 per 10,000) than did non-believers. The risk of
death from CAD among most orthodox believers during the 23-year follow-
up was at least 20 percent less than among non-orthodox Jews or non-
believers. These results remained significant after controlling for
age, blood pressure, cholesterol, smoking, diabetes, body mass index,
and baseline coronary heart disease.
Koenig HG, George LK, Cohen HJ, Hays JC, Blazer DG, Larson DB,
Larson DB (1998). The relationship between religious activities and
blood pressure in older adults. International Journal of Psychiatry in
Medicine 28, 189-213. (noted earlier) This was a study of 4,000
randomly selected older adults in North Carolina participating in the
NIA-sponsored EPESE study. Persons who both attended religious services
regularly (reflecting belief) and who prayed/meditated regularly were
40 percent less likely to have diastolic hypertension then those who
did not (p<.0001, after controlling for age, sex, race, education,
smoking, physical functioning, and body mass index). Among Black
persons in the sample (54 percent of subjects) and younger elderly
(ages 65-74), the effects on blood pressure were even greater. In these
groups, religious activities at one wave predicted blood pressure
levels three years later, after controlling for baseline blood pressure
and other compounding variables.
Enhancing Recovery from Cardiac Surgery
Oxman, T.E., Freeman, D.H., and Manheimer, E.D. (1995). Lack of
social participation or religious strength and comfort as risk factors
for death after cardiac surgery in the elderly. Psychosomatic Medicine,
57, 5-15. These investigators at Dartmouth followed 232 adults for six
months after open-heart surgery, examining predictors of mortality. The
mortality rate in persons with low social support who did not depend on
their religious beliefs for strength was 14 times that of persons with
a strong support network who relied heavily on religion, after other
covariates were controlled. Even when social factors were accounted
for, persons who depended on religious beliefs were only about one-
third as likely to die as those who did not.
Preventing Cancer
Dwyer, J.W., Clarke, L.L., and Miller, M.K. (1990). The effect of
religious concentration and affiliation on county cancer mortality
rates. Journal of Health and Social Behavior, 31, 185-202. These
investigators used county-level cancer mortality data from the National
Center for Health Statistics (3,063 counties) for 1968-1970, 1971-1974,
and 1975-1980 to examine the relationship between religious affiliation
and death from cancer. Investigators found that religion (defined as
percent of population with full membership or as degree of religious
conservativeness) had a significant impact on mortality rates from
cancer, even after controlling for 15 factors known to affect cancer
mortality. Conservative Protestants and Mormons had the lowest
mortality rates and counties with higher concentrations of Jews or
liberal Protestants had the highest cancer mortality. Investigators
concluded that the general population in areas with high concentrations
of religious participants may experience health benefits resulting from
diminished exposure to or increased social disapproval of behaviors
related to cancer mortality.
Enhancing Immune System Functioning
Koenig HG, Cohen HJ, George LK, Hays JC, Larson DB, Blazer DG
(1997). Attendance at religious services, interleukin-6, and other
biological indicators of immune function in older adults. International
Journal of Psychiatry in Medicine 27:233-250. First study to examine
the relationship between religious activities and immune system
functioning. Investigators found that frequent religious attendance
(reflecting religious belief) in 1986, 1989, and 1992 predicted lower
plasma interleukin-6 (IL-6) levels in a sample of 1,718 older adults
followed over six years. IL-6 levels are elevated in patients with
AIDS, osteoporosis, Alzheimer's disease, diabetes, lymphoma and other
cancers. High levels of IL-6 indicate a weakened immune system.
Findings suggest that persons who attend church frequently have
stronger immune systems (lower levels of IL-6) than less frequent
attenders, and may help explain why better physical health is
characteristic of frequent church attenders.
Woods, T.E., Antoni, M.H., Ironson, G.H., and Kling, D.W. (1998).
Religiosity is associated with affective and immune status in
symptomatic HIV-infected gay men. Journal of Psychosomatic Research, in
press. (noted earlier) Study of 106 HIV seropositive gay men; religious
activities--prayer or meditation, religious attendance, spiritual
discussions, reading religious/spiritual literature (indicators of
religious belief)--were associated with significantly higher CD4+
counts and CD4+ percentages (T-helper-inducer cells) (controlling for
self-efficacy and active coping with health situation, using regression
modeling).
Extending Overall Survival
Strawbridge, W.J., Cohen, R.D., Shema, S.J., and Kaplan, G.A.
(1997). Frequent attendance at religious services and mortality over 28
years. American Journal of Public Health 87:957-961. Major study by
researchers at the University of California at Berkeley reporting
results of a 28-year follow-up of 5,000 adults involved in the Berkeley
Human Population Laboratory. Mortality for persons attending religious
services once/week or more often (reflecting religious belief) was
almost 25 percent lower than for persons attending religious services
less frequently; for women, the mortality rate was reduced by 35
percent. Frequent attenders were more likely to stop smoking, increase
exercising, increase social contacts, and stay married; even after
these factors were controlled for, however, the mortality difference
persisted.
Multiple other studies (Duke, UC, and Michigan studies) soon to be
published. The effects of religious attendance (once per week or more
frequent) on survival are equivalent to 40-60 pack years of cigarette
smoking.
mind-body medicine and reduction of health care costs
A number of studies have now demonstrated that Beliefs may help
reduce health care costs. This may occur (1) by reducing physical
disability (which leads to lost productivity, high caregiver costs, and
expensive nursing home placement) and (2) by directly reducing the most
expensive form of health care, acute hospitalization.
Reducing Physical Disability
Pressman, P., Lyons, J.S., Larson, D.B., and Strain, J.J. (1990).
Religious belief, depression, and ambulation status in elderly women
with broken hips. American Journal of Psychiatry, 147, 758-759.
Investigators studied time to recovery in 33 elderly women hospitalized
with hip fracture. Women who expressed greater religious beliefs and
devotional practices experienced less depression and were able to walk
further at the time of hospital discharge (reflecting less disability
and faster recovery).
Idler, E.L., and Kasl, S.V. (1997). Religion among disabled and
nondisabled elderly persons, II: Attendance at religious services as a
predictor of the course of disability. Journal of Gerontology 52B,
s306-s316. A 12-year longitudinal study of 2,812 older adults in New
Haven, CT, conducted by Yale University researchers. Found that
frequent religious attendance (reflecting religious belief) in 1982 was
associated with significantly less disability during the 6-12 years of
follow-up. These findings persisted after controlling for baseline
physical functioning, health practices, social ties, and indicators of
well-being.
Reducing Use of Acute Hospital Services
McSherry E, Ciulla M, Salisbury S, Tsuang D (1987). Spiritual
resources in older hospitalized men. Social Compass 35(4):515-537.
Heart surgery patients with higher than average personal religious
beliefs on admission had post-op lengths of stay that were 20 percent
less than those with lower than average belief scores.
Bliss JR, McSherry E, Fassett J (1995). Chaplain intervention
reduces costs in major DRGs: An experimental study. In Heffernan H,
McSherry E, Fitzgerald R (eds), Proceedings NIH Clinical Center
Conference on Spirituality and Health Care Outcomes, March 21, 1995.
Investigators randomized 331 open-heart surgery patients to either a
chaplain intervention (supportive of religious belief) or usual care.
Patients in the intervention group had an average 2 days shorter post-
op hospitalization, resulting in an overall cost of $4,200 per patient.
Koenig HG, Larson DB (1998). Use of hospital services, church
attendance, and religious affiliation. Southern Medical Journal, in
press (October issue). Found an inverse relationship between frequency
of religious service attendance (reflecting religious belief) and
likelihood of hospital admission in a sample of 455 older patients.
Those who attended church weekly or oftener were significantly less
likely in the previous year to have been admitted to the hospital, had
fewer hospital admissions, and spent fewer days in the hospital than
those attending less often; these associations retained their
significance after controlling for covariates. Patients unaffiliated
with a religious community had significantly longer index hospital
stays than those affiliated. Unaffiliated patients (reflecting
religious belief) spent an average of 25 days in the hospital, compared
with 11 days for affiliated patients (p<.0001); this association
strengthened when physical health and other covariates were controlled.
Intrinsic religious belief was also associated with fewer days in the
hospital.
Something needs to be done about rising costs of health care,
particularly among persons aged 65 years or older. There will soon come
a time when we will not be able to afford expensive medical and
surgical treatments for all elderly people (Figure). For that reason,
it is essential that we focus on relatively low cost mind-body
therapies that patients can learn and practice themselves in order to
maintain wellness and speed recovery from illness when it occurs.
Supporting healthy belief systems may also help empower the self-care
process.
[GRAPHIC] [TIFF OMITTED] T07SE22.002
why are centers needed?
First, current study sections and programs are not equipped with
the sufficient expertise. This is a new area and in the case is being
made for centers precisely because it doesn't fit typical NIH programs.
Second, only centers can launch the ambitious, multi-disciplinary
research projects needed to advance this field. No single investigator
can do what must and needs to be done. A critical mass of investigators
is essential.
Third, centers help with dissemination, since they typically have a
``dissemination core.'' Dissemination means creating manuals, holding
workshops and symposia, communicating with media, and moving the
research into clinical practice. Developing practical applications
based on rigorous research are not typically a component of
conventional NIH grants. So there is often a temporal lag between
scientific findings and their use by clinicians and the public.
summary
There is highly credible scientific research that has established a
link between psychological and social stress and a host of debilitating
and costly medical illnesses, particularly cardiovascular disorders and
cancer, the major killers and disablers of Americans. Traditional
medical and surgical treatments typically do not include mind-body
approaches that may empower and motivate patients towards self-care,
prevent illness, speed recovery, and reduce the costs of health care
that are quickly spiraling out of control. Patients have become
accustomed to relying on medical and surgical approaches to their
illnesses (rather than focusing on things they can do to improve their
conditions), and physicians have become accustomed to treating sick
people like broken down cars (fix them when they're broke and send them
on their way). Patients and physicians need to be educated about and
encouraged to participate in self-care activities that help to maintain
wellness and speed recovery.
The Relaxation Response and ways of eliciting it (like prayer) is
easily taught and widely acceptable to the American populous. These
techniques have been shown to enhance well-being by alleviating or
reducing anxiety, chronic pain, and stress, and by preventing or
treating alcohol and drug abuse. Consequently, given the relationship
between psychological stress and physical illness, it is expected and
has been found that these techniques reduce blood pressure, coronary
artery ischemia, cardiovascular risk factors (like smoking and
cholesterol level), lower the risk of cancer or prevent its spread, and
enhance immune system functioning.
Likewise, certain Beliefs have been associated with greater well-
being and better physical health. Taking religious or spiritual beliefs
as an example, these have been associated with lower levels of acute
stress and prevention of depression, faster recovery from depression
and adaptation to chronic stress, and prevention or treatment of
alcohol and drug addiction. Likewise, religious beliefs and practices
have been associated with a lower risk of death from coronary heart
disease, with lower blood pressures, enhanced recovery from open-heart
surgery, prevention of cancer, promotion of positive health behaviors,
enhancement of immune system functioning, and the extension of overall
survival. Finally, religious beliefs and practices are associated with
quicker recovery from disabling illnesses and prevention of costly
disability in older persons, and (along with chaplain interventions)
are associated with reduced use of acute hospital services which are
the most expensive form of health care.
Mind-body medicine centers will be equipped with sufficient
expertise to develop this new area in a way that typical NIH programs
cannot do. Only centers with a critical mass of investigators and core
infrastructure can launch ambitious, multidisciplinary projects that
are necessary to advance this field. Centers are also the best way of
disseminating research findings to the public and to clinicians and of
rapidly moving the research findings into practical applications.
stress and relaxation
Senator Specter. Thank you very much, Dr. Koenig.
Dr. Benson, is the essence of mind/body the elimination of
stress and relaxation?
Dr. Benson. It is really much more than that, but stress
and relaxation are perhaps the two best areas. Modern
neurochemistry, neurobiology is showing us that the mind and
body are inseparable. What we think influences our bodies; our
bodies influence our mind. Frequently our minds have difficulty
in differentiating a reality from a thought. Let me give you
one example. I will cite the work of Dr. Harold Koenig--I am
sorry--Dr. Steven Kosslyn. Your speech was so nice, I cited
you. [Laughter.]
Dr. Kosslyn at Harvard Medical School had people stare at a
grid at Harvard University. There was a capital A within that
grid. He did a PET scan. A certain area of their brain lit up,
their occipital cortex. Then he had these same people stare at
the same grid without a letter A.
Senator Specter. Without a letter A?
Dr. Benson. Without the letter, without the capital letter
within it. But in their mind's eye visualized the letter A and
did another PET scan. Exactly the same.
The point is this.
Senator Specter. They said to the individuals to visualize
the same letter?
Dr. Benson. That you had been looking at previously within
the grid, but this time they are simply visualizing it without
actually seeing it. He did another PET scan, Senator, and the
same area of the brain lit up. In other words, whether you are
actually viewing something or think you are viewing it in your
mind's eye, from the brain's point of view it is a reality. So,
you see our thoughts are often interpreted as realities to our
bodies.
Senator Specter. Well, how would you specify the work that
you do with the mind as to how it impacts on the body? Dr.
Anderson, I am going to come to you next on this question. You
have all these dotted lines going back and forth between the
behavioral and the physiological factors and the genetic
factors.
But, Dr. Benson, in laymen's language what goes on in the
mind which then has a physiological impact on the body? Two
examples were given by Dr. Koenig. He talked about cancer and
about heart disease. Could you start with cancer as to how you
could specify that?
Dr. Benson. Yes; stress affects the immune system and
enhanced stress depresses many immune functions. By focusing on
a word, a sound, a prayer, a phrase and disregarding everyday
often stressful thoughts when they come to mind, what happens
is a set of physiologic changes within the body that are
opposite to those of stress. Instead of increased metabolism,
there is decreased metabolism. There is decreased blood
pressure, decreased heart rate, decreased rate of breathing,
and slower brain waves.
Senator Specter. When the stress is relieved.
immune function
Dr. Benson. No; when stress is relieved by focusing on
thoughts that break the train of everyday stressful thoughts.
These physiologic changes are opposite to those of stress
and counteract the harmful effects of stress and, for example,
have been shown to enhance immune function when regularly
practiced.
Senator Specter. Define the immune function please.
Dr. Benson. Immune function is the ability of the body to
counteract internal defense systems to foreign invaders. Cancer
could be viewed as such a foreign invader. If the immune system
is depressed, perhaps the growth of cancer would be enhanced by
stress because the immune function would no longer be fully
operant and controlling the cancer.
Senator Specter. Well, is that really a good example in
light of the fact that--or to what extent do we understand the
causes of cancer so that that would be a factor in inhibiting
the growth of cancer?
Dr. Benson. There is no evidence whatsoever that stress
causes cancer. There is evidence----
Senator Specter. Is there evidence of the absence of stress
stops the growth of cancer?
Dr. Benson. There is no evidence for that, as far as I
know, Senator.
However, it has been shown that immune function, the
protective aspects of the body, do influence perhaps the growth
of cancer, and there are several studies that have shown that
relaxation response based therapies do lead to longer survivals
in patients who regularly carry out these behaviors.
heart disease--stress and high blood pressure
A much clearer picture is possible in heart disease where
stress brings forth the hormones epinephrine and
norepinephrine, also called adrenalin and noradrenalin. These
can directly influence high blood pressure. They directly
influence the amount of blood flow through the coronary
arteries to the heart muscle, decreasing it, sometimes leading
to angina pectoris and sometimes, when quite severe, even
leading to or contributing to a myocardial infarction but
certainly contributing to atherosclerosis.
Senator Specter. Are there scientific tests which support
the conclusion that relief of stress has a direct impact on
heart disease?
Dr. Benson. There are considerable studies that Dr. Koenig
has, in fact, reviewed or at least alluded to that show that
stress is a direct contributor to high blood pressure and that
relief of stress can lower blood pressure which in turn lowers
the risk of heart disease.
Furthermore, stress has directly contributed to angina
pectoris, and it is shown that belief system, for example--
thoughts of a person can directly influence angina pectoris.
Let me be specific.
Therapies have been used for angina pectoris for over 200
years. The diagnosis has never been changed, but a number of
bizarre therapies have come along. These include cobra venom,
xanthines, aminophylline, vitamin E, bizarre surgeries such as
ligation of the internal mammary artery. Absurd. It should not
work and it does not. But at one time they were believed in by
physicians, and we did a study that was published in the New
England Journal of Medicine that showed when these therapies
were believed in, before they were shown to be bogus, they were
70 to 90 percent effective in alleviating angina pectoris. And
not only did the relief of the pain of angina occur, but also
the exercise tolerance of these patients improved and their
electrocardiograms normalized. When these therapies were no
longer believed in by patients, specifically by their
physicians, their effectiveness dropped to 20 to 30 percent. In
other words, belief here translated itself into a marked
healing capacity.
Senator Specter. So, you have relaxation and stress and you
have belief as two big factors. Any others?
Dr. Benson. Yes; health and well-being is best viewed as
being akin to a three-legged stool being held up by one leg of
pharmaceuticals, a second leg of surgery and procedures, but
there should be a third leg to that three-legged stool and that
third leg is self-care.
self-care and relaxation
Now, two components of self-care are relaxation procedures
and another is the belief system of patients. Several other
components are nutrition, exercise. The cognitive, behavioral
stress management approaches are also aspects of the third leg.
So, in addition to relaxation----
Senator Specter. Say that again. Cognitive what?
Dr. Benson. Cognitive restructuring, psychological
approaches, where your thinking is used to actively change your
thoughts themselves which in turn influence the physiology.
Senator Specter. Is that like belief?
Dr. Benson. It is akin to belief. Yes; in a sense because
it does restructure your belief system, but whereas belief
tends to involve not only secular but also religious/spiritual
approaches and cognitive/behavioral approaches are generally in
the secular/psychological realm.
Senator Specter. Cognitive is in the secular/psychological
realm, unlike belief which has a religious component.
Dr. Benson. As well, yes.
Senator Specter. Dr. Anderson, would you amplify that
dotted line between physiological factors and genetic factors?
Dr. Anderson. Yes.
Senator Specter. I always thought that the genes were
pretty much out of our control.
Dr. Anderson. Actually no. The genetic makeup that we are
born with certainly is out of our control, but really one of
the most exciting frontiers in genetics research is the
question of what turns genes on and what turns them off. I
think the area of gene expression now is showing very clearly
that things outside of our genetic structure actually determine
whether genes are activated.
Senator Specter. So, genes are not immutable? If you have
two parents who were 90, those genes are not going to carry you
to 90 by themselves. They have to be turned on?
Dr. Anderson. It depends on one's exposures across the life
course, whether one is exposed to certain types of diet,
perhaps even chronic stress. Other environmental factors will
determine exactly which genes are turned on and turned off.
You asked specifically about----
Senator Specter. I can understand that genes might not be
the sole determinant, but explain a little further, if you
would, the turn on or the turn off of genes.
Dr. Anderson. Well, I will go back to your original
question about the physiological factors and genetic factors
and that interaction. Research is now showing that
neuroendocrine factors, such as adrenalin, noradrenalin,
actually act on genes to cause the genes to produce proteins
which then go on to produce other factors that affect health
and illness. So, genes are not operating alone. They interact
with physiological factors and, as we are learning now,
behavioral factors.
susceptibility to breast cancer
Senator Specter. Dr. Anderson, when we talk about tests
which would examine the genes, say, of a young woman to make a
determination as to susceptibility to breast cancer and we face
all the difficult ethical questions about how to handle that
and whether to tell the insurance company, are you saying that
the analysis of the genes alone would not be determinative as
to her developing breast cancer but it would depend upon other
factors intervening to turn on or turn off the genes?
Dr. Anderson. Yes; again, I will qualify my comments by
stating that I am not a geneticist, but it is very clear that
genes are significant risk factors--and I underscore that term,
risk factors--for cancer. However, everyone who carries a
genetic risk for cancer does not go on to develop the disorder.
One of the areas of research that NIH is very interested in is
determining among those people who have a genetic risk which
ones then go on to develop cancer. The direction of this
research is looking in part at nongenetic factors.
Senator Specter. Are there scientific tests which have
shown some basis for concluding what would prevent somebody
with a gene, a predisposition to cancer, to avoid developing
cancer?
Dr. Anderson. I do not know of any specific test as yet.
This is one of these areas of scientific opportunity that NIH
is interested in, and we cannot say conclusively what factors,
among those people with a genetic risk, will prevent them from
going on to develop cancer.
Senator Specter. How long has medical science really
understood the genetic factor even to be able to conduct tests
as to whether that is the dominant or influenceable by other
considerations?
Dr. Anderson. Well, interest in genetics has gone on for
some time, but I think in the last decade or so with the
advances in molecular biology, there has been obviously an
increased interest as evidenced by the Genome Institute at NIH.
What we have not done as yet is linked these boxes in the
figure. We know a lot about genetic factors. We know a lot
about behavioral and physiological factors, but we have not
done as good a job as we could of linking these factors.
Ultimately the things that cause disease are interdependent and
linked.
Senator Specter. I am just inquiring of staff how long the
Genome Institute has been in high gear and I am told since
1990. Are they, to your knowledge, conducting tests to see what
would stop the path from predisposition, say, in the genes to
cancer to eventuating in cancer?
Dr. Anderson. I cannot answer that conclusively. I do not
know all of their portfolio in the area. I would be happy to
find out from Francis Collins about that.
Senator Specter. Do you know whether they are studying any
of the mind/body aspects as to what happens when there is a
genome predisposition?
Dr. Anderson. They do have a portfolio in their ethical,
legal, and social aspects of genetics research.
Senator Specter. Ethical, legal, and social.
Dr. Anderson. Yes.
Senator Specter. Would that cover mind/body?
Dr. Anderson. Mind/body would be a part of that, yes.
Senator Specter. So, you are saying the Genome Institute
does have some mind/body in it?
Dr. Anderson. Well, again, it depends on one's definition
of mind/body.
Senator Specter. Say Dr. Benson's definition of mind/body.
Dr. Anderson. Well, what I would like to do, if I could, is
go back to the figure. I am not sure that the Genome
Institute--and again, I can determine this conclusively--
whether they are looking at these interactions, the
interactions of physiological factors on genetics or behavioral
and social on genetics. I am just not that familiar enough with
their portfolio to say conclusively if they are doing that.
Senator Specter. Well, we will check that out. Staff will
do that. I would like to find that out.
Dr. Koenig, you had mentioned cancer as a disease which
would be influenced by mind/body studies. Would you amplify
that please?
stress and immune system functioning
Dr. Koenig. As Dr. Benson said, cancer has many different
types of causes, and there is again this connection between
stress and immune system functioning. Now, when people become
depressed or stressed out, their body starts pouring out what
is called cortisol. Cortisol comes from the adrenal glands, and
what that does is that directly then impacts on the functioning
of the blood cells that then attack cancer cells as they
develop. It is called the theory of immune surveillance where
the immune system actually guards and grabs hold of these
cancer cells as they are initiating in the body, which is
probably happening all the time.
Now, again if people are less depressed, if they are
experiencing less stress because of the mind/body techniques,
belief, repetitive prayer, the relaxation response, then those
negative health consequences, the cortisol being released, is
not going to happen as likely.
Furthermore, belief systems determine whether or not
someone will drink alcohol, smoke cigarettes, and do a whole
host of different activities that can lead to cancer.
Senator Specter. When you feature so prominently, as you
do, Dr. Koenig, the religion/spirituality aspect of mind/body,
are there any scientific studies that show that people who are
more religious have fewer diseases or fewer ailments?
Dr. Koenig. Yes; there are, Senator. In the psychological
health realm, there are probably well over 200 studies that
have shown this. We have done at least 10 at Duke.
We are also now looking again at physical health
consequences. We have been able to show that people who attend
religious services regularly and who frequently pray, read the
Bible, that those people have a 40-percent reduction in the
likelihood of having diastolic hypertension which is directly
the factor that causes stroke and heart attack. We have also
been able to show that people who are more religiously involved
do not smoke cigarettes as often, and so invariably you are
going to see lower rates of chronic pulmonary disease and lower
rates of cancer.
religious beliefs and practices--better immune functioning
We have also been able to show that religious beliefs and
practices are associated with better immune functioning. We can
measure interleukin-6 levels in the blood stream and show that
people who have a strong faith and are participating in
religious activities actually are less likely to have high
levels interleukin-6 in their blood stream which is an
indicator of a weakened immune system. People who have AIDS
have high levels of interleukin-6 in their blood stream. So,
people who have a strong faith seem to have lower levels of
this substance in their blood stream, suggesting that they have
stronger immune systems.
There have been at least six studies now that have shown
that people with strong beliefs simply live longer, and these
are studies performed at the University of California-Berkeley,
as well as at Duke and institutions in different areas of the
country. So, it is not simply one single research group that is
finding these positive health effects. It is multiple,
different, prominent investigators.
Senator Specter. So, the religious aspect impacts on a
number of areas related to this field. One is the belief in and
of itself. When people pray, they have faith that they will get
better because of divine intervention. So, they do get better?
Dr. Koenig. That certainly can be a mechanism by which it
occurs.
Senator Specter. Is there any scientific evidence to
support that in isolation?
Dr. Koenig. Well, there are certainly lots of case reports
that have shown that. For example, there is a case report
published in, I believe, Archives of Internal Medicine that
shows that an older woman who had atrial fibrillation, which is
a serious cardiac arrhythmia, was going to go in for
cardioversion.
Senator Specter. How serious is atrial fibrillation?
Dr. Koenig. Atrial fibrillation can increase the
ventricular rate so that people can develop congestive heart
failure and certainly, if they do not have cardiac reserve,
they can die from it.
Now, she was going to have a cardioversion where they put
the paddles on and kind of snap the rhythm back, but she and
her family got into a prayer group before the procedure and
they prayed for and she prayed and did some chanting and it
reversed completely.
Another example is----
Senator Specter. That can happen without prayer too, can it
not?
Dr. Koenig. Yes; it can.
Senator Specter. Dr. Benson, you had your hand up. We are
going to get back to you, Dr. Koenig. We are just beginning,
but go ahead, Dr. Benson.
healing power of belief
Dr. Benson. Thank you. Several points.
Supporting what Dr. Koenig says, I would like to point out
how we in medicine have dealt with belief system. We know in
medicine that belief can heal, but we have dealt with the
healing power of belief in a very pejorative fashion. We have
labeled it the placebo effect: It is all in your head. What has
evolved over these----
Senator Specter. What is wrong with that? I thought if it
was all in your head, it was good.
Dr. Benson. All in your head is terrific, but take the case
of a woman who was suffering from multiple symptoms of unclear
etiology, four to five doctors all saying it is in your head.
She was so upset because it was a pejorative that when she
received----
Senator Specter. Like gulf war syndrome.
Dr. Benson. Pardon?
Senator Specter. Like gulf war syndrome, told all the
veterans from the Gulf it was all in their head. They became
very distressed about that. It added a new level of distress to
the gulf war veterans.
Dr. Benson. Exactly.
Let me finish up, if I may, Senator, with this woman's
case. When she got the diagnosis of multiple sclerosis, which
in her case was life-threatening, she was thankful for that.
She was so put down by it is all in your head, that she would
rather have a life-threatening disease.
Now, we in medicine over this last 150 years have developed
marvelously, awesomely, spectacularly effective treatments, the
antibiotics, insulin, surgeries that by biblical standards are
producing miracles on an assembly line basis. The blind can see
again with cataract operations. We became in medicine depending
only on the first two legs of the three-legged stool,
pharmaceuticals, surgery and procedures, and said we do not
need that third leg. We can do it all by your simply taking the
drug or having this surgery.
It is not enough because beliefs are effective and we know
this in medicine when we test a new substance against, let us
say, a placebo tablet, as we often do. Placebos are effective
in 50 to 90 percent of cases that involve angina pectoris,
asthma, congestive heart failure, rheumatoid arthritis, all
forms of pain. In fact, death itself can be caused by belief.
If you believe in voodoo and you have a hex placed on you, you
could die.
But we in medicine, comparing the placebos against a new
drug, if both were 60 percent effective, we would drop them
both because we are looking that the drug was better than
belief. We have not focused enough on the power of belief and
asked the question what is it that makes belief and placebos
work? Now, that is the way we deal with belief in medicine and
that has been a problem.
Now, in America some 95 percent of people believe in God.
This, for them, is their most powerful belief. It is no
surprise then that such powerfully belief-related therapies,
such as belief in God, can result in healing. We must pay more
attention to it.
Now, that is a long introduction to answer what I believe
was your question, Senator, and that is, is religious belief
the only way? No; belief itself is what is important, but the
belief of the individual has to be honored. It could be
secular. It could be religious. And that is what we are in a
position to do now by paying attention to belief, by studying
the mind/body effects whereby beliefs do lead to the findings
that others have found, and I think mind/body centers would be
a way to emphasize that. That is why belief related therapies
will, of course, include religious beliefs but will include
other beliefs as well.
Senator Specter. What kind of beliefs other than religious
beliefs?
Dr. Benson. Belief in your doctor, belief in the healing
power of your body to heal, nature's power to heal, belief in
relationships. All of these are powerful beliefs.
Take one study, if I may, that was done by Dr. Ochsman----
Senator Specter. Because these beliefs will reduce stress
and anxiety?
Dr. Benson. Yes; and can have direct effects on disease.
Men undergoing bypass surgery at Dartmouth Medical School--
this was a study by Ochsman. These were all men over 54. Those
who believed in God had one-third the mortality. Those who
believed in God and also had a very strong social support
system, the very sort of aspects that the Office of Behavioral
and Social Sciences Research look at, those who also had a
strong support system, Senator, had one-tenth the mortality of
those who did not. Support system is vital. This is a
behavioral factor related to belief as well.
Senator Specter. Let me come back to you, Dr. Koenig. When
you were talking about the religious aspect, we started to talk
about the belief, the religious aspect would also impact on
stress and would also impact on items like smoking. So, there
are quite a number of factors on mind/body which the religious
beliefs would impact on.
Dr. Koenig. That is correct, Senator.
Senator Specter. To what extent is the issue of religious
belief, having this medical benefit which you describe here,
talked about and touted in the field of religion to induce
people to go to religious services and become more religious?
Dr. Koenig. Very little I think. I think that I have found
that the clergy has not been tremendously receptive to this
research, which is surprising to me because I would think that
this would be----
Senator Specter. A pretty good talking point.
science and religion
Dr. Koenig. Right, but they really have not been all that
receptive. I think that the barrier between science and
religion----
Senator Specter. They do not like to deal with doctors.
Dr. Koenig. That could also certainly be, or subjective
beliefs of the science.
Senator Specter. When you talked about belief in the
doctor, would that apply to lawyers, Dr. Benson?
Dr. Benson. Would that apply to?
Senator Specter. Lawyers?
Dr. Benson. Belief in lawyers, belief in your lawyer. Yes;
that is an interesting phenomenon and I am not totally
qualified----
Senator Specter. It is a question, Dr. Benson.
Dr. Benson. Would belief in your lawyer lead to better
health and well-being?
Senator Specter. Well, you talk about a social support
system. You mentioned doctors. It is just natural to ask a
question about whether belief in the lawyer would have a
similar beneficial effect.
Dr. Benson. In my 30 years of answering questions, that is
the first time I have faced that one, Senator. [Laughter.]
Senator Specter. You ought to do more town meetings. You
would find a lot of new questions. [Laughter.]
Well, it is only said slightly in jest, Dr. Benson. You are
talking about beliefs.
How do you account for the fact, Dr. Anderson, that at
least according to the information presented to me, these mind/
body studies are only at Harvard and Duke?
Dr. Anderson. I think that probably reflects the panel that
is assembled here, but in fact----
Senator Specter. No; are there any besides Harvard and
Duke?
Dr. Benson. Are there mind/body medical centers?
Senator Specter. Correct.
Dr. Anderson. I do not think there are very many things
called mind/body medical centers out there, no. But there are
research groups at a number of universities around the country
who are interested in and who study mind/body medicine, yes.
Senator Specter. Can you give me an illustration of where
such a study is undertaken and the parameters of it generally?
Dr. Anderson. Certainly. Let us start with the University
of Pittsburgh. They have a well-developed research program in
an area called psychoneuroimmunology.
Senator Specter. Psychoneuroimmunology.
Dr. Anderson. And it is a field that the very long word
suggests. It looks at the interaction of psychological,
neuroendocrine, and immune system factors, particularly how
stress affects the immune system. There are a number of groups
that are interested in that very topic at Pittsburgh, at Ohio
State, at UCLA, and the University of Miami in Florida, just to
name four.
Senator Specter. Well, stress is an important component of
what has been discussed here today, but only one component.
Dr. Anderson. It is only one component.
Senator Specter. Does the psychoneuroimmunology group at
Pittsburgh pick up the issue of beliefs?
Dr. Anderson. In the broadest sense. I do know of one
researcher there by the name of Mike Scheier who studies the
influence of an optimistic attitude on the immune system and
the cardiovascular system, that is, in a sense a belief in the
broadest sense of that term that one will experience positive
outcomes as opposed to negative outcomes.
Senator Specter. Dr. Anderson, what is your professional
opinion on the interest that the Senate, at least through the
full Appropriations Committee, has stated on mind/body and
allocating some $10 million? We are interested on the
subcommittee in the wide range of research activities. NIH has
a budget somewhat larger than $10 million. I do not know what
fraction $10 million would be of $13.6 billion. We ought to
figure that out. [Laughter.]
And then the second part of the question would be what
percentage it would be of $15.6 billion, if you get a $2
billion increase.
But do you think that this money would be well spent to try
to develop other centers which would focus on the subject
matter which your unit heads?
Dr. Anderson. Let me provide a multi-layered response to
that question. As a representative of the entire NIH and not
just my office today, as you know, NIH really prefers maximum
flexibility in creating funding initiatives and has----
Senator Specter. Do you think for this committee to say $10
million is too much direction on $13.6 billion?
Dr. Anderson. Well, let me just complete this thought, that
we do prefer maximum flexibility. However, if you are asking if
there are areas of scientific opportunity enough to warrant
funding supporting $10 million of research in this area, yes,
there are a number of areas of scientific opportunity, only
some of which were discussed today. If these funds are
earmarked for NIH, we would prefer flexibility in creating the
mechanism of funding, because for some research areas, centers
are not the way to go. In other research areas, they might be.
research
Senator Specter. What are other research possibilities are
you thinking of, Dr. Anderson?
Dr. Anderson. They could be research in--well, I will name
three areas. One has to do with biological, psychological, and
social interactions that we talked about earlier. There is a
great deal of scientific opportunity in the
psychoneuroimmunology area that I have already mentioned, the
effects of behavior and stress on the brain, behavioral
genetics, and behavioral cardiology. There is also----
Senator Specter. Are those items taken up by NIH at the
present time?
Dr. Anderson. Yes; they are taken up by NIH, but there are
also additional areas of scientific opportunity. These are
areas that my office is actively pushing because there are so
many questions that need to be addressed.
Senator Specter. These are in the behavioral and social
sciences research area.
Dr. Anderson. Yes; under which I would put research on
stress and research on belief.
Senator Specter. What is the total budget of your unit?
Dr. Anderson. My office? It is about $2.8 million.
Senator Specter. $2.8 million?
Dr. Anderson. Yes.
Senator Specter. That is not a very large share of the NIH
pie, is it?
Dr. Anderson. No; it literally is not, but our recent
estimate of how much the Institutes fund in the larger field of
behavioral and social sciences research is over a billion
dollars.
Senator Specter. You say the overall figure for behavioral
research is a billion dollars?
Dr. Anderson. Yes.
Senator Specter. Under whose office does that fall?
Dr. Anderson. Well, this is all investigator initiated
research. As you know, most of the research that NIH funds, NIH
does not ask for proposals or set aside money for specific
areas, but tells the investigators, send in your proposals,
send in your ideas, and they get peer reviewed once they come
into the NIH system.
Senator Specter. So, you say a billion dollars is now being
allocated on the behavioral subject?
Dr. Anderson. Behavioral science, yes.
Senator Specter. Behavioral science.
Dr. Anderson. Of which the fields we are talking about
today are a subset.
Senator Specter. How much is being allocated to mind/body
studies at the present time, if you know?
health and behavior
Dr. Anderson. That is very hard to determine because of a
lack of a clear definition. One definition that NIH has been
assessing their portfolio based on is called health and
behavior. The health and behavior number includes many of the
things that we talked about today, but some additional things
as well. The 1997 number was about $900 million, but that
includes things such as research on diet, research on smoking,
research on exercise, alcohol use, and drug abuse as well. So,
it is much broader than the topic today.
Senator Specter. Well, you say some items do not lend
themselves to centers. Would you say the center at Duke on
mind/body is a good organizational approach?
Dr. Anderson. It has worked well at Duke, based on my
understanding of the center, but when we talk about centers in
an NIH context, we are talking about something very specific,
that is, the center grant mechanism, which is a very specific
mechanism, actually a set of mechanisms. I think there are
about five or six. Most of these are fairly large research
grants that have a core facility that a number of investigators
use. And for some research areas, frankly they are not ready
for centers yet. Others might be. What we would like to do is
leave it to the investigators to determine whether the research
they are interested in is appropriate for a center or what we
call an RO1 or an investigator initiated grant, a program
project grant, or a training grant.
Senator Specter. What is your thinking on that, Dr. Benson?
We have taken the center approach. I am not sure the
nomenclature is necessarily the last word, but how do you
respond to what Dr. Anderson has said?
Dr. Benson. The progress that NIH has made with the
approaches that Dr. Anderson has just outlined are truly
spectacular. To be funded in a so-called RO1 grant, one has to
go through appropriate study sections, and the study section
approach tends to be quite narrow in its focus--has to be--
because the way that kind of science is defined is that it is
next-step research, namely that there is ample research that
brought you to this point, and the next logical question would
be to have a given intervention, something changing, and then
see what happens to the system under study.
When you start getting into mind/body areas, you are
looking at multiple simultaneously interacting systems. The
present mechanisms at NIH cannot really do adequate justice to
assessing such approaches because of their traditional narrow,
reductionistic approach. This is why centers are necessary to
be able to study simultaneously occurring phenomena at
different levels, physicochemical, biological, social, and look
at interventions that are not characteristically normally
looked at. We are not looking at a new drug or a new chemical
substance. We are looking at thought patterns.
Senator Specter. Dr. Koenig, what do you think about Dr.
Benson's approach?
Dr. Koenig. I agree that the current NIH programs do need
to focus in on specific kind of reductionistic areas, whereas
centers have the option of bringing together multiple different
disciplines together, the sociologist, psychologists, the
medical physicians, the anthropologist, bringing them all
together and working together. That is particularly important
for a field like this that is relatively new and needs kind of
initiation, and because it involves multiple different
disciplines and expertise in each of those disciplines as
opposed to just requiring, say, a single expertise such as in
psychiatry.
Senator Specter. Dr. Koenig, do you think that a $10
million allocation is realistic to look toward initial
financing of, say, half a dozen centers?
Dr. Koenig. What I think is that actually probably the
money would be better spent on only about three or four
centers, simply because there are only about that number of
centers that have the critical mass in place and the
infrastructure that can really get up and start doing something
because this is really----
Senator Specter. Would you include Duke as one? [Laughter.]
Dr. Koenig. Well, certainly we have the----
Senator Specter. I would ask you if you would include
Harvard as one and ask Dr. Benson if he would include Duke as
one.
Dr. Koenig. Yes; I think Duke has multiple, different
disciplines and we have established----
Senator Specter. What institutions beside Duke and Harvard,
or Harvard and Duke?
Dr. Koenig. Well, I think Dr. Anderson said Pittsburgh.
Pittsburgh and UCLA are probably the two highest runners. There
are multiple different investigators at each of those
institutions that are already studying it.
Senator Specter. Only one in Pennsylvania? [Laughter.]
Dr. Benson. Where does your support system come?
[Laughter.]
Senator Specter. It is a challenging matter for the
Congress to try to deal with these matters--the Senate, the
committee, the subcommittee. There is a fair amount of
resistance at NIH for congressional suggestions. There are some
markers laid down on the prostate cancer this year, last year
on Parkinson's, in the past on other lines. Generally there is
not too much tension between the Congress and NIH because the
Congress does not know very much and does not get very much
involved, so we do not give you much trouble, Dr. Anderson. We
pretty much leave you with billions of dollars to spend as you
see fit.
alternative medicine and mind/body
But my own sense is that on mind/body there is a different
line and a need to develop it. Precisely how is really up to
the experts. I have a sense that a center, as Dr. Koenig and
Dr. Benson outline it, would be a good approach. It is going to
have to be administered by NIH and there is going to have to be
cooperation by NIH to whatever line Congress says, but we have
given you a lot of money to work on other lines because we
think you are so successful and are doing such very important
work.
Before we conclude the hearing, I think we ought to have a
definition as to the distinction between mind/body which some
may confuse with alternative medicine. Let me turn to you, Dr.
Benson, to give a definitional distinction between alternative
medicine and mind/body.
Dr. Benson. Let us go back to the metaphor of the three-
legged stool, health and well-being being held by a three-
legged stool. One leg is pharmaceuticals. The second leg is
surgery and procedures, and the third leg is that self-care
leg. In that self-care leg, we have the relaxation response,
belief, nutrition, exercise, and stress management, cognitive
work.
Now, first of all, mind/body medicine has a great deal of
scientific evidence behind it. Mind/body medicine, therefore,
is largely scientifically proved. Alternative medicine is not
scientifically proved. If it were, it would no longer be
alternative.
Secondarily, alternative medicine is not in the self-care
realm. There is little difference between an herb and a
pharmaceutical. It is given to you.
Secondarily, with the second leg, there is little
difference between acupuncture, let us say, and a surgical
procedure. It is done to you, whereas self-care is something
you do for yourself.
Another element of mind/body medicine that has not been
adequately covered in this particular hearing, Senator, is the
cost savings. Preliminary data now show that these self-care
approaches decrease visits to doctors in HMO settings by
upwards of 50 percent, and in capitated HMO settings, this is
money in the bank.
In contrast, alternative medicine appears to be cost
additive. People do not give up their doctor. They do not give
up their surgery, their penicillin, but they take an herb or
they take a procedure with it. So, from a cost savings, long-
term point of view, these mind/body approaches will save money
where alternative medicine will probably add money.
Senator Specter. You say mind/body saves money for HMO's.
Do HMO's include mind/body in their coverage sheet?
Dr. Benson. The HMO scene to my assessment is a frightful
one. They are simply cutting costs and they are cutting down on
some--many of them are responding to anything new in a very
defensive way. For example, for a belief to be enhanced, the
doctor/patient relationship is vital. HMO's are cutting down on
the amount of time that a doctor can spend with his or her
patient. That is awful because that is undermining the----
Senator Specter. Do HMO's generally cover mind/body?
Dr. Benson. The HMO's are now beginning for the first time
to cover mind/body approaches because they are beginning to see
the cost savings aspect. In fact, the Mind/Body Medical
Institute, of which I am president, has as one of its major
programs teaching and training, and more and more HMO people
are coming to us to learn these approaches that are being
sponsored. For example, Kaiser in California is now learning
our approaches. It is a beginning. We need much help, though.
This is another thing the centers would do. They would enhance
teaching and training capabilities. For example, we are much
too small. If--and I hope--these approaches will catch on to
teach and train the health care professionals of our Nation,
and the centers would be one way to enhance such teaching and
training.
Senator Specter. Dr. Koenig, is there anything you would
care to add before we conclude the hearing?
changing people and their behavior
Dr. Koenig. Well, I would like to actually just continue to
respond to your first question. Ten million dollars is a lot of
money, and whether or not that should be appropriated. I think
truly that is a small investment when you consider the
potential benefits of these belief related and relaxation type
responses. These are behaviors that can oftentimes change--
changing a belief system can potentially help a person's health
for the rest of their life, and learning some of these very
simple relaxation techniques can be incorporated and it can
last again for years and years. The potential cost savings by
changing people and their behavior, particularly with regard to
smoking or drinking, could be potentially huge. We have to do
something about that, given the costs of the baby boomers that
are aging and just are overwhelming our health system.
Senator Specter. Dr. Anderson, is there anything you care
to add?
Dr. Anderson. Yes; if an earmark is given for OBSSR, we
would prefer to give investigators maximum flexibility in
determining the mechanism, that is, not limiting it to centers,
but including centers but also other mechanisms as well.
Senator Specter. Could you give me a written response as to
whether there are mechanisms you would like to see, how you
would like to see it structured?
Dr. Anderson. Yes.
Senator Specter. In light of your administration of the
program.
Dr. Benson, a final word?
Dr. Benson. We are very thankful. I am very thankful--we at
the Mind/Body Medical Institute are--for this opportunity to
present these data to the subcommittee.
I would like to end with a financial consideration, that as
I noted at the outset, we expect that data are now supporting
that $2.1 trillion will be spent by the year 2007 on health
care. This is a doubling. Yet, if we look at mind/body
approaches that are inherently cost saving, our calculations
show that conservatively they could save $54 billion per year
by people learning to take better care of themselves with self-
care approaches that include those we have defined today.
Senator Specter. $54 billion now or by 2007?
Dr. Benson. 2007. This was published just recently, in
fact, this month--these estimates of a doubling to $2.1
trillion.
prepared statement
Senator Specter. The following statement was received from
Caesar A. Giolito, executive director, National Interfaith
Coalition for Spiritual Healthcare and Counseling, Washington,
DC, by the subcommittee and I would like it to be made part of
the record at this time.
[The statement follows:]
Prepared Statement of Caesar A. Giolito, Executive Director, National
Interfaith Coalition for Spiritual Healthcare and Counseling
The National Interfaith Coalition for Spiritual Healthcare and
Counseling is composed of thirty-two national associations and faith
groups responsible for the nationwide delivery of certified pastoral
care and counseling services in a wide variety of settings such as
medical and mental health facilities, pastoral counseling centers,
churches, synagogues, diverse workplaces, military installations,
correctional facilities, rehabilitative centers, nursing and long-term
care facilities, addictive treatment centers, hospices, and through
solo practitioners.
These associations are composed of interfaith ministers and persons
endorsed by religious faith groups and trained, certified, and/or
licensed in pastoral care and counseling, including pastoral
counselors, chaplains, clinical pastoral care educators, mental health
clergy, parish ministers, and seminary professors. The associations
also include accredited pastoral counseling centers and clinical
pastoral education teaching institutions, as well as over 100
theological schools throughout the nation. These providers of service
and education have received specialized graduate training in both
religion and the behavioral sciences, and practice and/or teach the
integrated discipline of pastoral care and counseling.
The purpose of this coalition is to promote the role of qualified
pastoral care and counseling and make it accessible to the vast numbers
of people in our nation who have the need and desire to integrate the
spiritual dimension into their mental and physical healing.
A vast growing number of the general public, clergy, theologians,
physicians, clinical psychologists, clinical social workers, nurses,
mental health counselors, medical community professionals and other
practitioners, educators, and researchers agree that the underlying
principles of spiritual healing are universal; that healing of the
spirit promotes and accelerates healing of the mind and body, and that
the total healing of the individual and society itself cannot be
realized without the effective treatment of the whole person--mind,
body, and spirit.
It has been the usual case that spiritual healthcare providers have
been the energizing force in the area of belief-related therapy, and
continues to be so. Chaplains and pastoral counselors in many medical
institutions around the country are very much part of the healthcare
delivery team, and, for the most part, physicians, nurses, and other
medical personnel have been interested and supporting onlookers.
As studies in the area of the spiritual dimension and its effects
on health have proliferated, with mounting evidence that it has
positive impact in the healing process, the medical community has
become increasingly interested and involved.
Medical researchers such as Herbert Benson, M.D., Harold Koenig,
M.D., and numbers of other prominent researchers, from both the medical
and pastoral care communities, have uncovered compelling scientific
evidence of the efficacy of belief-related therapy in healthcare.
These studies have captured the imagination of physicians
throughout the country. Many of them wish to know more about belief-
related therapy and the spiritual dimension to consider including it in
their therapies, and to provide higher quality and more effective cures
for their patients.
Probably the greatest indicator of rising interest in the medical
community is the growing number of courses in spirituality, religion,
and ethics for medical students and residents. Many practicing
physicians, who were not given that opportunity when they attended
medical school, are now inquiring into this area.
On May 15, 1998, the National Interfaith Coalition, and the Greene
County, Missouri, Medical Society co-sponsored a day-long symposium for
the physicians of that area, and 200 physicians, on a weekday, packed
an auditorium at Southwest Missouri State University to hear
presentations on this subject by a group of expert pastoral care
researchers and physicians.
The Coalition and physicians of Greene County now plan to establish
a national model in Springfield, Missouri which integrates belief-
related therapy into the area's healthcare delivery system. This
seminal project, the first of its kind in the United States, will also
be sponsored by Springfield's medical institutions, including Columbia
Hospital South, Cox Health Systems, Lakeland Regional Hospital, the
Medical Center for Federal Prisoners, and St. John's Health System. The
Greene County Public Health Department will be a sponsor as well.
The project plans to provide spiritual assessments and belief-
related therapy for inpatient and outpatient services and to compare
patient outcomes with a twin city that does not provide the spiritual
dimension in its healthcare delivery.
General Colin L. Powell, USA (Ret.) stated in regard to the
project, ``I realize that you, the members of the National Interfaith
Coalition for Spiritual Healthcare and Counseling and the Physicians of
Greene County, Missouri, are attempting to break new ground. I thank
each of you for reinvesting your collective energy, beliefs and special
skills back into Main Street--back into America--and I look forward to
even greater successes as you enlist others in the cause.''
These initiatives must also be tested on ``Main Street,'' as
General Powell puts it, if we are to thoroughly and scientifically
study belief-related therapy as a component of healthcare in everyday
life.
Joni Scott, M.D., Clinical Director of the Breast Center in St.
John's Hospital in Springfield, Missouri, and a member of the
Physicians' Task Force for the project claims that this initiative to
include the spiritual dimension in healthcare has been driven by the
element of patient satisfaction, since 95 percent of Americans believe
in God and wish to utilize their faith and prayer in times of crisis.
As Dr. Herbert Benson has pointed out in his testimony, another
significant factor spearheading this dimension is the rapidly rising
cost of healthcare. He states that 60 to 90 percent of visits to
physicians are stress related, and that utilization of belief-related
therapy could lead to annual cost savings of more than $54 billion.
Pastoral Counselors and Chaplains are a valuable national resource
in delivering this care since they are professionally trained and
nationally certified to do so. The Pastoral Care field is interested in
making quality belief-related therapy accessible to those who desire
it, with a special emphasis on the poor, elderly, disabled, infirm,
addicted, incarcerated, and otherwise at risk persons.
The National Interfaith Coalition has a broad spectrum of citizen
support as shown by its National Advisory Committee. The members of the
Coalition and Advisory Committee are listed herein:
national interfaith coalition for spiritual healthcare and counseling
Adventist Chaplaincy Ministries
American Association for Ministry in the Workplace (AAMW)
American Association of Pastoral Counselors (AAPC)
American Association on Mental Retardation-Religion Division (AAMR)
American Baptist Churches USA
American Correctional Chaplains Association (ACCA)
Assemblies of God
Association for Clinical Pastoral Education (ACPE)
Association of Professional Chaplains (APC)
Catholic Health Association (CHA)
Christian Church, Disciples of Christ
Christian Reformed Church of North America (CRCNA)
Church of the Brethren
Episcopal Church: The Assembly of Episcopal Hospitals and
Chaplains; Office for Bishop of Armed Forces
Evangelical Covenant Church
Evangelical Lutheran Church of America
Independent Fundamental Church of America (IFCA)
Kansas COMISS
Lutheran Association for Maritime Ministry
Lutheran Church-Missouri Synod
National Association of Catholic Chaplains (NACC)
National Association of Jewish Chaplains (NAJC)
National Association of Veterans Affairs Chaplains (NAVAC)
National Conference on Ministry to the Armed Forces
National Conference of Veterans Affairs Catholic Chaplains (NCVACC)
National Institute of Business and Industrial Chaplains (NIBIC)
New York Board of Rabbis
Presbyterian Church (USA), PHEWA
Reformed Church of America
Southern Baptist Convention
United Church of Christ
United Methodist Church
national interfaith coalition for spiritual healthcare and counseling
national advisory committee
Herbert Benson, M.D., President, Harvard Medical School's Mind/Body
Institute
Beatrice S. Braun, M.D., AARP Board of Directors
Patricia A. Cahill, J.D., President and Chief Executive Officer,
Catholic Health Initiatives
Dr. Arthur Caliandro, Marble Collegiate Church
Dr. Elbert C. Cole, National Council on Aging
U.S. Senator Tom Harkin (D-IA)
Mrs. Virginia Harris, Chairman, Christian Science Board of
Directors
Dr. James Kok, Crystal Cathedral
David Larson, M.D., President, National Institute for Healthcare
Research
Bishop John Leibrecht, Springfield-Cape Gerardeau Catholic Diocese
Mrs. Norman Vincent Peale, Blanton/Peale Institute
Bishop Joe E. Pennel, Jr., United Methodist Church
Rabbi Joseph Potasnik, New York Board of Rabbis
Mr. Michael Quinlan, former Director of U.S. Bureau of Prisons
Dr. Robert Schuller, Crystal Cathedral
Dr. Martin E.P. Seligman, President, American Psychological Assn.
Harvey Sloane, M.D., former Commissioner of Public Health, District
of Columbia
Dr. Thomas Smith, Executive Director, National Institute for
Healthcare Research
Dr. Gordon L. Sommers, Past President, National Council of Churches
Sr. Teresa Stanley, General Superior, Incarnate Word Sisters, San
Antonio
Dr. Orlo Strunk, Jr., Journal of Pastoral Care
Bishop Joseph M. Sullivan, Auxiliary Bishop of Brooklyn, N.Y.
Catholic Diocese
John M. Templeton, Jr., M.D., President, John Templeton Foundation
U.S. Representative Edward Whitfield (R-KY)
Dr. Robert Wicks, Loyola College, Maryland
Bishop Roy Winbush, Chairman, Congress of National Black Churches
Admiral Frank Young, M.D., former FDA Commissioner
Mr. Raul Yzaguirre, President, National Council of La Raza
conclusion of hearing
Senator Specter. Well, thank you very much, Dr. Anderson,
Dr. Benson, and Dr. Koenig, and that concludes our hearing.
Thank you. The subcommittee will stand in recess subject to the
call of the Chair.
[Whereupon, at 12:13 p.m., Tuesday, September 22, the
hearing was concluded, and the subcommittee was recessed, to
reconvene subject to the call of the Chair.]
-