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©1983

CHRISTINE ADELE MINNING

All Rights Reserved

AN INVESTIGATION OF RELATIONSHIPS BETWEEN BLOOD NEUTROPHIL
FUNCTION AND IMAGERY, TRAINING, IMAGERY RATINGS,
AND INDIVIDUAL DIFFERENCES

by

Christine Adele Minning

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Personnel Services, and
Educational Psychology

1982

ABSTRACT
AN INVESTIGATION OF RELATIONSHIPS BETWEEN BLOOD
NEUTROPHIL FUNCTION AND IMAGERY, TRAINING,

IMAGERY RATINGS, AND INDIVIDUAL
DIFFERENCES

By

Christine Adele Minning

This investigation concerned relationships between imagery,
training, imagery ratings, and changes in the functions of neutro-
phils. A neutrophil is a particular type of white blood cell which
is associated with the body's immune system. A secondary question
of interest was whether specific personality factors would correlate
with the blood changes.

Data was collected on eight male and eight female volunteers.
All but two of the subjects were Michigan State University students
in medicine and psychology. The other two subjects were Lansing
businessmen with college degrees. The subjects' ages ranged from 21
to 38 with a mean age of 29.4. All subjects were screened for any
health or diet irregularities which might affect their blood results.
In addition, any persons who did not believe in the possibility that
they might be able to influence their blood cells were excluded fran
the study.

The study took place over an eight-week time period, and

each subject made a commitment to attend six sessions. During the

Christine Adele Minning

first session each subject had blood drawn, signed a consent fonn,
filled out a demographic data fonn and three personality inventories,
and had blood drawn again 20 minutes after the first sample was taken.

The second visit was a group session during which white
blood cell function was explained and slides of neutrophils were
shown which could later be used as a basis for imagery representations.

During the third session, subjects listened to a relaxation/
general imagery tape. The fourth and fifth sessions were group
training sessions. Subjects were divided into two groups of eight
each. Training consisted of the following: explaining the rationale
and purpose of the study, explaining the relaxation/specific imagery
procedure and giving suggestions for effective imagery, practicing
the imagery procedure as a group, asking subjects to draw pictures
of their imagery and rate the pictures according to specified
criteria, and answering any questions that arose.

The specific imagery procedure was adapted from imagery
instructions given to cancer patients in a comprehensive cancer
treatment program. The imagery procedure used in this study was
designed to help subjects relax and visualize their white blood cells.
They were asked to imagine their white blood cells changing shape,
sticking to the blood vessel wall, passing through the vessel wall,
and going to places in the body where "garbage" had collected. The
entire procedure lasted approximately 20 minutes. Subjects were
encouraged to experiment and be playful with their images and adapt
the procedure in any way that made sense for them. Articles

clarifying both imagery studies and white blood cell function were

Christine Adele Minning

distributed, and they were encouraged to read the articles and to
practice the technique at home.

Subjects came individually for the sixth session. Blood was
drawn, the relaxation/specific imagery procedure was repeated, blood
was drawn a fourth and final time, and they drew a picture of their
imagery. Subjects were then asked a series of questions about their
imagery by the investigator. This recall session was tape recorded,
and subjects were later scored independently by three raters for the
adequacy of their imagery process.

Blood was obtained on the four separate occasions by vena-
puncture. The blood samples were examined for changes associated
with motility--i.e., white blood cell count, adherence, and cellular
shape change. White blood cell count reflects the availability of
white blood cells for migration in the blood stream. Changes in
white blood cell count indicate whether the cells are free-floating
in the blood stream or the extent to which they have attached to the
blood vessel wall or have left the blood stream. Only those cells
that are circulating are measured by venapuncture. A 25 microlitre
sample of blood was diluted in white blood cell diluting fluid. The
white blood cells were then counted in triplicate on a Coulter
counter. The number of cells were multiplied by 1000 which gives
the number of white blood cells per milimeter of blood.

Adherence was determined by the ability of cells to stick to
protein-coated surfaces. Percent unstimulated adherence represents
the percent of isolated neutrophils that remain attached to a glass

cover. The procedure was repeated for neutrophils that were

Christine Adele Minning

stimulated by N-formyl-L-methionyl-L—phenylalanine (fMP), a
synthetic substance and a chemotactic factor produced by Sigma
Chemical Company. F-M-P activates shape change and adherence in the
cell. If neutrophils are dysfunctional, their percent adherence will
not increase when treated with fMP. Percent stimulated adherence
represents the percent of neutrophils treated with fMP that remain
attached to the glass cover.

The third measure of immune responsiveness was the capacity
of neutrophils to change shape. There are five classifications of
cell shapes: round, ruffled, bipolar, uropod, and pseudopod. 0ne
measure of chemotactic response is the ability of cells to assume a
bipolar configuration upon exposure to a chemotactic factor. The
percentage of cells with a bipolar configuration was detennined by
scoring 100 cells per slide. Shape index scores were detennined by
multiplying the shape change categories by a factor and adding them.
Scores were reported for unstimulated and stimulated shape change.

The instrument chosen to assess imagery was an adaptation of
the IMAGE-CA developed by Achterberg and Lawlis (1978) to evaluate
the imagery of cancer patients. The present study adapted the follow-
ing variables from the IMAGE-CA: vividness, leaving the blood
stream, strength, general feeling, symbolism, and clinical judgment.
In addition, three summary variables were rated: decrease in white
blood cell count, shape change, and adherence. The tape-recorded
sessions and the drawings of the images were used to detennine the

ratings. Imagery ratings were correlated with the blood results.

Christine Adele Minning

Three psychological inventories were used to measure correla-
tions between personality characteristics and ability to influence
neutrophil function. The International Opinion Survey, also known
as the Internal versus External Control of Reinforcement Scale
(Rotter, 1966), measures an individual's beliefs about who controls
his/her behavior and life events. The Type A Inventory was developed
by Friedman and Rosenman (1974) to identify personality character-
istics which may predispose individuals to coronary heart disease.
The Wellness Inventory (Travis, 1977) is a questionnaire which
measures degrees of wellness by quantifying wellness behaviors. It
was expected that scores on the three inventories would correlate
with blood changes.

Hypotheses that neutrophil function would change following a
20 minute relaxation/imagery session were tested. Findings revealed
that significant changes occurred for two of the three blood functions.
The total white blood cell count dropped significantly (p < .0001)
as predicted. This finding is particularly significant when
restricted to neutrophils. There was a 38 percent drop in neutrophil
count, as compared with a 20 percent drop in total white blood cell
count. The second blood measure, adherence, also dropped signifi-
cantly (p < .05). Subjects were instructed to visualize an increase
in adherence, therefore this finding was in the opposite of the
expected direction. There was no significant change in cellular
shape following the imagery condition.

The hypothesis that subjects who received higher ratings on

the adequacy of their imagery process would have greater changes in

Christine Adele Minning

blood function was also tested. Significant correlations were found
between imagery ratings for symbolism and white blood cell count
and changes in white blood cell count. Significant negative corre-
lations were found between imagery ratings and adherence functions
indicating that imagery effectiveness was related to a decrease in
neutrophil adherence.

Finally, the three personality variables were correlated with
changes in white blood cell function. Some significant correlations
were found between Wellness scores and blood changes, however, very
few significant correlations were found between Type A and Locus of
Control scores and the blood measures.

The results of this study suggest that healthy, motivated
subjects can be trained to lower their neutrophil count. It is also
possible that the decrease in adherence was due to the drop in
neutrophil count--i.e., the adhesive cells were part of the 38 per-
cent that marginated or left the blood stream. Likewise, lack of
neutrophil shape change might be explained by a similar possibility,
i.e., the cells that had changed shape had marginated or left the
blood stream and were unavailable for sampling by venapuncture.

The results also suggest that three independent raters can
predict blood function changes, and that effective imagery is related
to changes in neutrophil function, particularly adherence function.
It would appear that the more individuals are able to visualize
their white blood cells symbolically, the more they are able to

achieve a physiological effect. The correlations between control

Christine Adele Minning

blood samples and imagery ratings suggest that some persons may be
more capable of effective imagery than others.

The low number of significant correlations between person-
ality measures and blood changes might be due to the small size and
homogeneity of the sample, and/or the low reliability and validity
of the measures.

It is unclear what role the placebo effect played in relation
to blood function changes. Further investigations which control for
the placebo effect might clarify its contribution. Finally, the
question of generalizability beyond a highly motivated, healthy,
educated sample remains unanswered, and replications of this study

using larger and more heterogeneous samples was suggested.

DEDICATION

To my father, whose courage as he struggled to
live his life to the fullest inspired me to pursue this

study.

To my daughter, Laurie, who often surprised me
with her maturity and love by putting her own young

needs aside so that I could undertake this endeavor.

To my friends, whose patience, support, and

caring make it all worthwhile.

ii

ACKNOWLEDGMENTS

I wish to express my gratitude to my committee members:

John Schneider, Wayne Smith, Verda Scheifley, and Bob Winborn.
John's warm and sensitive manner impressed me many years ago when I
first heard him speak on loss and grief. He provided practical help
along the way and invaluable ("right brain") support on many
occasions when everything looked bleak.

Wayne's intelligent, gentle, and reasonable approach to
problems that arose was very helpful, and made my research fun. He
has come to be an inspiration to me by serving as an example of what
a true scientist really is.

Verda provided expertise on design and statistical issues
in a way that made working with her enjoyable. She was encouraging,
supportive, and understanding during many trying times.

I am grateful for the considerable time and effort Bob spent
proofreading my manuscript. His attention to detail and ability to
provide concrete (“left brain") feedback was exactly what I needed
to finish the project.

I owe a great deal to these fine people, and feel privileged
to have had an opportunity to work with them.

I would also like to thank Tim Boyd, my computer consultant,
as well as Maxine Thome, Ralph Kron, John Fredricks, and Grace
Niroumand for providing assistance and support when it was needed.

111'

Finally, I wish to express my gratitude to my subjects who
generously donated their time and their blood, and without whom

this study would not have been possible.

iv

TABLE OF CONTENTS

Page

LIST OF TABLES ............................................... vii

LIST OF FIGURES .............................................. viii
Chapter

I. INTRODUCTION .......................................... 1

Purpose ............................................... 1

Rationale ............................................. 2

Review of the Literature .............................. 11

Psychosomatic Disorders ........................... 11

Personality Factors ............................... 15

Type A Behavior ............................... 15

Life-style Habits ............................. 18

Locus of Control .............................. 19

The Placebo Effect ............................ 20

Imagery ........................................... 22

Other Altered States of Consciousness ......... 23

Applications of Imagery ....................... 24

Physiological Correlates of Related Techniques. 34

What Type of Imagery is Most Effective? ....... 35

How Can Imagery Be Measured? .................. 36

Immunology ........................................ 39

Hypotheses ............................................ 43

Summary ............................................... 44

II. RESEARCH DESIGN AND PROCEDURES ........................ 45

Pilot Study ........................................... 45

Subjects .............................................. 49

Procedures ............................................ 50

Measures .............................................. 54

Neutrophil Function Measures ...................... 54

White Blood Cell Count ........................ 54

Adherence ..................................... 55

Shape Change .................................. 56

Psychological Measures ............................ 57

Imagery Ratings ................................... 61

Design and Statistical Analysis ....................... 64

Summary ............................................... 66

V

Chapter

III. ANALYSIS OF DATA .......................................

Hypothesis 1: Relaxation/Specific Imagery and Changes
in Neutrophil Function ...............................
Hypothesis 2: Imagery Ratings and Changes in
Neutrophil Function ..................................
Hypothesis 3: Personality Factors and Changes in
Neutrophil Function ..................................
Summary ................................................

IV. SUMMARY AND CONCLUSIONS ................................

Summary ................................................
Conclusions ............................................
Discussion .............................................
Blood Measures .....................................
Imagery Ratings ....................................
Personality Measures ...............................
Implications for Future Research .......................

BIBLIOGRAPHY ................................................

APPENDICES ..................................................

A. Consent Form, Demographid Cata Form, and Personality
Inventories ..........................................
Neutrophil Slides ......................................
Imagery Instructions ...................................
Imagery and Leukocyte Articles .........................
Questions Used for Imagery Ratings .....................
Correlations Between Imagery Ratings, Personality
Factors, and Blood Measures ..........................

WINDOW
o o o o 0

vi

Page

68

68
72

78
81

83
83

93

105

106
130
135
143

226
228

LIST OF TABLES

Table Page
1. Imagery and Cancer Status .............................. 34
2. Neutrophil Function Changes for One Subject ............ 42

3. Probability Levels for Analysis of Variance of Blood
Function Measures ...................................... 68

4. Means of Blood Function Measures for Control and
Imagery Conditions ..................................... 70

5. Means and Range of Scores for Imagery Ratings .......... 74

6. Significant Correlations Between Imagery Ratings and
Pre to Post Changes in Blood Function .................. 75

7. Significant Correlations Between Control Blood Function
Measures and Imagery Ratings ........................... 76

8. Significant Correlations Between Imagery Blood Function
Measures and Imagery Ratings ........................... 77

9. Significant Correlations Between Wellness Scores and
Pre to Post Changes in Blood Function .................. 79

10. Significant Correlations Between Wellness Scores and
Blood Function Measures ................................ 80

11. Neutrophil Function Test Means Before and After a 20
Minute Relaxation/Imagery Session ..................... 82

vii

LIST OF FIGURES

Figure Page

1. Pre and Post WBC Means for Control and Imagery
Conditions ............................................ 71

2. Pre and Post Adherence Means for Control and Imagery
Conditions ............................................ 71

3. Pre and Post Shape Change Means for Control and Imagery
Conditions ............................................ 73

viii

CHAPTER I

INTRODUCTION

PURPOSE

The purpose of the present study is to investigate the rela-
tionship between imagery and white blood cell function. More spe-
cifically, will a 20 minute relaxation/imagery session affect the
following characteristics of blood neutrophils: white blood cell
count, adherence, and shape change?

A study by Achterberg and Lawlis (1978) suggests that persons
can be rated according to certain specified criteria as to the
adequacy of their imagery, and these ratings will correspond with
the progress of their disease. A second purpose of the study is to
determine whether three independent raters of an imagery experience
can predict the following changes in neutrophil function: white
blood cell count, adherence, and shape change.

Personality and life-style factors have also been related to
health and illness (Friedman, Meyer & Rosenman, 1974; Rotter, 1954;
Strickland, 1977; Pelletier, 1977; Shealy, 1977; Travis, 1977). In
addition to testing the primary questions of interest, the study will
correlate three personality variables thought to be associated with
health with the three neutrophil function measures. The three per-
sonality variables which will be correlated with neutrophil changes
are Type A personality, locus of control, and wellness habits.

1

RATIONALE

New definitions of health have been emerging during the past
several decades. One reason for this expansion is that while medicine
is effective in certain areas--i.e., the treatment of infections,
fractures, etc.--some believe medicine to be relatively ineffective
in the treatment of stress-related disorders such as ulcers,
migraines, allergies, and cardiovascular and respiratory disorders
(O'Regan and Carlson, 1979) which are prevalent in society today.
Therefore, some investigators have been attempting to define health
from a broader perspective. The World Health Organization, for
example, has defined health as "physical, mental, and social well-
being, not merely the absence of disease or infirmity" (WHO, 1958).
The term "holistic health" is representative of this new trend to
view health from a broader perspective by considering the well-being
of the total individual. A high level of health would consist of an
optimal relationship between the physical, emotional, intellectual,
social, and spiritual parts of an individual.

In examining the recent concepts of holistic health, three
broad categories emerge: biological health, psychological health,
and behavioral health. Biological health refers to an individual's
ability to adapt to internal and external events in order to maintain
an optimal state of balance. Seyle (1976) talks about biological
health as an optimal state of balance between outside events and
internal adaptation to those events. Top (1964) asserts that the
body's immune system is always fluctuating, and germs invade and

multiply only when host resistance is low. Smith (1979) has found

during the past few years that sudden stress caused changes, such as
an elevation in white blood cell count, in the immune function of
three blood donors. Other investigators have also cited evidence
indicating that there are relationships between stress and responses
of the immune system (Riley, 1981; Engel, 1967; Pelletier, 1977).
Stress is a general term which has been defined a number of different
ways. Seyle (1974) defined stress as "the nonspecific response of
the body to any demand made upon it" (p. 14). This broad definition
will be used in this study.

Psychoneuroimmunology, an emerging discipline within the field
of behavioral medicine, examines the relationships between stress and
immune competence (Riley, 1981). Animal research has shown that
stress produces increased plasma concentrations of adrenal corticoids
and other hormones which can cause injury to elements of the immune
system, such as white blood cells (Roger, Dubey & Reich, 1979).

Stress may also be related to hypothalamic activity, and there is some
evidence that hypothalamic lesions modify cell-mediated immune
response (Schiavi & Camerino, 1976). Since the immune system is a
major defense against various pathological processes, stress "may
leave the subject ‘vulnerable to the action of latent oncogenic
viruses, newly transformed cancer cells, or other incipient pathologi-
cal processes that are normally held in check by an intact immunologi-
cal apparatus" (Riley, 1981, p. 1101). Other clinical studies have
linked stressful occurrences such as losses or traumatic events to

the onset of disease (Holmes & Rahe, 1967; Engel, 1967). In one study,

26 bereaved spouses showed depressed lymphocyte function six weeks

after bereavement (Barthrop, Lazarus, Luckhurst, Kiloh & Penny,
1977).

Thus, biological health is viewed as a dynamic state of being
related to the body's continual adjustment to stress. Audy (1973)
defines health as a person's ability to recover after a challenge to
adapt. However, since the elimination of stress is not a possibility
(or desirable state) for most individuals, biological health may be
partly a function of how a person deals with stress.

Psychological factors are important in detennining how indi-
viduals react to stress. Friedman and Rosenman (1974) have identified
certain personality factors, such as impatience, ambitiousness, and
time urgency, which they believe predispose persons to coronary heart
disease. They have labeled an individual possessing a number of these
traits as a "Type A personality." Another personality factor thought
to be related to health is an individual's beliefs about who controls
behavior and life events (Strickland, 1977). This personality con-
struct has been labeled "locus of control" (Rotter, 1954). Beliefs
range from "internal," which is a belief that positive and negative
events are a result of one's actions and efforts, to "external,"
which is a belief that events are controlled by outside forces such
as chance, fate, luck, and powerful persons.

In addition to personality characteristics, health is also
associated with behavioral or life-style factors. Health has been
defined, for example, as the maintenance of an optimal capacity
necessary for the perfonnance of valued tasks (Parsons, 1972), and a

number of researchers have defined health as a function of life-style

habits (Pelletier, 1977; Shealy, 1977; Ardell, 1979). An outgrowth
of this perspective has been the development of inventories which
measure degrees of health. One example of such an inventory is the
Wellness Inventory which is contained in the Wellness Workbook
(Travis, 1977). It consists of 100 questions measuring behavioral
characteristics such as sleep, safety, nutrition, exercise, and
creative activity. Footnotes are also included which explain the
health implications of selected items. The Wellness Inventory is
based on the belief that self-responsibility is the key to good
health.

Health, then, is perceived from a holistic perspective as a
complex and dynamic state of being which is affected by many inter-
related factors. If stress, psychological characteristics, and life-
style factors can adversely affect one's health, then perhaps these
factors can also enhance health. What are the natural regenerative
responses, for example, that account for some populations living
longer than others? Why do some persons get well while others do
not? The phenomenon of spontaneous remission raises some interesting
questions about what mechanisms are responsible for activating the
natural healing processes in the body (Everson, 1964; Simonton, 1978).

One mechanism that has been used by clinicians and practi-
tioners for centuries as an aid to mental and physical healing is
imagery (Samuels & Samuels, 1975; Achterberg & Lawlis, 1980).

Imagery is thought to be related to healing because it involves right
brain processes (Bry, 1979). The right hemisphere of the brain is

related to intuitive, creative, imagining functions, and the left

henisphere is thought to be responsible for logical, thinking func-
tions (Ornstein, 1977). The right hemisphere also seems to play a
predominant role in emotional processing and therefore is believed

to have a more direct connection with autonomic bodily functions
(Achterberg & Lawlis, 1980). It appears that left brain verbal
messages must be translated into non-verbal or imaginal messages by
the right brain before physiological changes can occur. For example,
patients who persist in verbally telling themselves to relax may
experience difficulty doing so, but if they imagine a pleasant scene,
they are more likely to evoke physiological changes consistent with
relaxation (Achterberg & Lawlis, 1980; Jaffe, 1980; Simonton, Simonton
& Creighton, 1978). Imagery has been used for healing purposes,
therefore, because it allows for a shift to right brain functions
which are more directly related to autonomic functions.

There are many different definitions of imagery. Visualiza-
tion and fantasy are often used synonomously with imagery to mean
"the internal experience of a perceptual event in the absence of the
actual external stimuli" (Achterberg, 1980, p. 27). This definition,
which differentiates imagery from simple memory retrieval, will be
used in this study.

Visual imagery has been used recently as part of a comprehen-
sive medical treatment program for cancer patients (Simonton,
Simonton & Creighton, 1978). Over 300 patients in this program were
taught relaxation and imagery procedures. Ninety-eight percent of
those who practiced three times per day for fifteen minutes experi-

enced a shrinkage of their cancers. Conversely, those who did not

practice the procedures regularly did not experience a shrinkage of
cancer growth.

Based on the results of the Simontons' work, an instrument
known as the IMAGE-CA was developed to assess imagery effectiveness
(Achterberg & Lawlis, 1978). The IMAGE-CA operationalizes and
measures imagery dimensions. These dimensions can, then, be corre-
lated with disease status. There appears to be a correlation between
effective imagery, as measured by the IMAGE-CA, and remission of
cancer growth. A study by Achterberg and Lawlis (1978) found a .78
correlation between ratings of visual imagery and change in cancer
growth two months later. There is a need for further research in
this area in order to detennineunore precisely the effect of imagery
on the body's immune system.

White blood cells are associated with the body's immune system.
There are five types of white blood cells: lymphocytes, monocytes,
eosinophils, basophils, and neutrophils. Neutrophils are the largest
and most numerous of the white blood cells, and they are also the
most important cells that offer defense against acute infections,
especially bacterial infections. They are the first cells to be
activated or mobilized in response to a challenge, i.e., inflamma-
tion. If neutrophils are absent or dysfunctional in an individual,
that person is more susceptible to infection. The degree of dys-
function has been correlated positively with the degree of suscepti-
bility to infection (Smith & Hollers, 1980; Jadwin, Smith & Meadows,
1980). There is some evidence, for example, that children whose
neutrophils are dysfunctional die at young ages (Anderson & Smith,

1981).

The principal function of neutrophils is phagocytosis--the
eating and digesting of foreign material. In order for neutrophils
to perfonn this function, they must be capable of motility so that
they can emigrate into sites in the body where the foreign substances
are located. This motility depends on the ability of these cells to
crawl and to attach to places in the body nearest to the site of
infection. They do this by becoming sticky (or adherent) and changing
from a circular to an elongated shape. The inability of these cells
to migrate has been linked with a predisposition to infection (Smith,
Hollers, Dupree, Goldman & Lord, 1972; Quie & Cates, 1978).

Procedures to examine the adherence and the mechanisms of
chemotactic responsiveness of neutrophils have been developed to a
high level of reliability (Smith, 1979). Chemotactic factors are
agents known to attract cells to sites of infection. Inflammation
is thought to cause a production of chemotactic factors which produces
a gradient in the body. In chemotactic migration, cells migrate or
crawl toward increasing concentrations of chemotactic factors while
in a concentration gradient of that factor. One theory holds that
neutrophils migrate toward higher concentrations of the chemotactic
factor and thus toward the site of infection (Wilkinson, 1974).
Change in cellular shape and adherence are necessary for migration to
occur. Thus, the following three measures of effectiveness of
immune response can be postulated:

1. NBC refers to white blood cell count. The body has

approximately five litres of blood. There are 6800

cells per microlitre (ml) or cubicmilimeter (mm3) of
blood, and there are approximately 6,800,000 cells

per milimeter (ml) of blood. Mls. of blood will be
used for the purpose of discussion in this study.

WBC reflects the availability of white blood cells for
migration. Changes in WBC in a short period of time
generally reflect whether the cells are free-floating
in the blood stream, or the extent to which they have
attached to the blood vessel wall or have left the
blood stream.

2. Adherence or adhesiveness (Ad) refers to the percent
of isolated neutrophils that remain attached to a
glass cover. If neutrophils are dysfunctional, their
percent adherence will not increase when treated
with FMP.

FMP, an abbreviation for N-formyl-L-methionyl-L-
phenylalanine, is a synthetic substance and a
chemotactic factor produced by Sigma Chemical Company.
FMP activates shape change and adherence in the cell.
Stimulated adherence refers to the adherence of neutro-
phils that have been treated with FMP.

As noted previously, the adherent capacity of the cell
reflects its readiness for motility and its capacity to
leave the blood vessel and migrate to the inflammatory
site. Decreased adherence indicates a lower level of
readiness or that the adherent cells are no longer
accessible to venapuncture, i.e., the most responsive
cells have already attached or left the blood stream.

3. Cellular shape change (SC) refers to the shape of
neutrophils. There are five classifications of
neutrophil cell shapes: round, ruffled, bipolar,
uropod, and pseudopod.

A third measure of immune responsiveness is associated
with the capacity of neutrophils to change shape. A
neutrophil changes from a round to a bipolar shape by
becoming ruffled at the edges, sending out a pseudopod
(or front projection), elongating, and eventually send-
ing out a uropod (or tail). An average cell takes
approximately two minutes to change from a round to a
uropod shape. This process enables the cell to crawl
and migrate through the blood vessel by fonming a hole
in the vessel wall and passing through.

The greater the flexibility of the cells, the more mobile

they are. Mobility is associated with ability to respond,

lO

capability of reaching the site of inflammation, and performing the
phagocytic function.

Some preliminary experiments suggest that neutrophil function
can be influenced in different directions by varying the conditions
and context under which the samples are obtained (Schneider & Smith,
1981). In one experiment, a subject's WBC increased and neutrophil
adherence remained unchanged after running for 20 minutes. The same
subject's WBC dropped and adherence increased following a 20 minute
self-induced relaxation/imagery experience. Other preliminary
experiments have yielded similar results. Specifically, WBC tends
to increase under conditions of stress and exercise (Schneider &
Smith, 1981; Murphy, Shade & Vanepps, 1979). Adherence tends to
decrease under conditions of stress, but can increase following a
relaxation/imagery experience (Schneider & Smith, 1981). These pre-
liminary investigations serve as a basis for this study. They sug-
gest that neutrophil function can be influenced by factors such as
stress, exercise, relaxation, and imagery. The use of these
techniques have been employed in studies of peripheral and central
nervous system function, but there have been no investigations of
their effect on the immune system, specifically, neutrophil function
(McMahon & Hastrup, 1980). Also, the Achterberg and Lawlis studies
(1978) show that cancer patients who practice effective imagery three
times per day may experience a shrinkage of their tumors. There have
been no known controlled studies, however, investigating the influence
of an imagery experience on neutrophil function or correlating

effectiveness of imagery with specific neutrophil functions.

11

REVIEW OF THE LITERATURE
The literature relevant to the research topic spans several
separate but interrelated areas. A review of the related literature
in these areas is organized under the following major headings:

psychosomatic disorders, personality factors, imagery and immunology.

Psychosomatic Disorders

 

Much of the research on psychosomatic disorders during the
past 50 years has been concerned with the question of what factors
predispose a person to disease(s). Alexander (1950) has provided
one of the most comprehensive attempts to answer this question,
although some critics discount his contribution because of his
"specificity theory." Alexander suggested that specific psychologi-
cal conflicts might predispose a certain type of personality to a
specific type of disease, i.e., an ulcerative-colitis prone person-
ality is placed in a situation where s/he is expected to succeed but
is unable to do so. Over a period of time in this situation, this
person would probably develop an ulcer.

In contrast to Alexander's "specificity theory," Engel
(1967), Greene (1958), Schmale (1958), Schmale and Iker (1966) have
emphasized the nonspecific nature of disease onset. They point to
the importance of a generalized sense of loss and helplessness]
hopelessness which causes a person to "give up." It is this "giving
up" which they believe renders a person unable to effectively cope
with his/her environment, and creates a biological susceptibility to

illness.

12

Holmes and Rahe (1967) also support the idea that nonspecific
life events can predispose one to disease. They found that a high
frequency of life changes, i.e., moving to a different home, changing
jobs, divorce, etc., correlated with an increased risk to disease.

If an individual tallied a score of 300 points or higher on their
Social Adjustment Rating Scale, there was an 80 percent chance that
an accident or illness would occur within two years of the life
changes. They also found a correlation between the severity of
illness and the number of changes in the two year time period.

Selye (1974), notable for his research on stress, also sup-
ports the contention that a generalized response to stress occurs.

He writes of a "generalized adaptation syndrome" which is the body's
general reaction to any perceived threat (p. 26). Selye asserts that
the body does not differentiate between types of stressors and
responds in a similar fashion to each. Mason (1975) critiques
Selye's concept of stress by distinguishing "between a view of non-
specificity as a concept applied to higher level psychological
integrative mechanisms rather than to the lower level physiological
or biochemical mechanisms . . ." (p. 26). Although Selye's research
was based on physiological stress, the general response that he
observed is thought to be caused by the response of the pituitary-
adrenal cortical system to emotional stimuli, rather than physiologi-
cal stimuli. According to Mason, there is a growing body of data
which suggests that physical stimuli may not stimulate the pituitary-
adrenal cortical system unless emotional factors are also present,

and that physiological stimuli alone probably trigger complex and

13

multiple lower level physiological reactions. In essence, Selye's
"general adaptation syndrome" is thought to be primarily due to
behavioral or emotional stimuli rather than physiological stimuli,
i.e., there is a generalized response to emotional stress, but not
to physiological stress.

Although there is now considerable evidence that social and
psychological factors play a role in the predisposition and inception
of disease, there is some disagreement as to whether there are
specific personality types who are predisposed to specific diseases.
The bulk of current research suggests, however, that there are some
correlations between stress, personality factors, and specific
diseases.

A number of investigators have found correlations between
personality characteristics and progression of cancer. Gay (1970)
found that personality differences exist between rapidly and slowly
progressing cancer patients as measured by the Minnesota Multiphasic
Personality Inventory. The Simontons (1975) found that a recent
loss of a significant loved one was the single largest predisposing
factor for onset of cancer, and that a patient's belief system played
a major role in the course of the disease. In another study (Schmale
& Iker, 1966), a group of women who were being seen for regular
routine Pap smears were given a battery of psychological tests. The
researchers were able to predict with a high degree of accuracy which
women would contract cervical cancer. The single most important

predictor was a "hopelessness-prone personality.“

14

Achterberg (1980) studied the incidence of cancer among
retarded and mentally disturbed individuals. She found that only
four percent of this population had died of cancer compared to 18
percent of the general population. Within the retarded subgroup,
incidence of death due to cancer rose from three to ten percent as
10 rose. Within the mentally disturbed group, catatonic schizo-
phrenics had almost no incidence of cancer while paranoids had an
incidence similar to the general population. Achterberg concluded
that "tuning out" stress (or shutting out the environment), character-
istic of catatonics and severely retarded individuals, might account
for the reduced susceptibility to cancer.

Locke (1978) found that stress caused damage to cell immunity
in those who coped poorly with stress while those who coped well with
stress did not appear to suffer deficits in cell-mediated immunity.
His findings, which suggest that certain "susceptible" persons may
have decreased immunity to disease during times of high stress, have
implications for diseases such as cancer which appear to be linked
to a breakdown in cell-mediated immunity.

A study by Achterberg, Lawlis, Simonton, and Simonton (1977)
examined the relationships between psychological variables, blood
chemistries, and course of disease. They found that: "(1) Blood
chemistries tend to reflect ongoing or concurrent disease state,

(2) There is a statistical relationship between psychological vari-
ables and blood chemistries, and (3) Psychological factors are pre—

dictive of subsequent disease state." Among the psychological factors

 

15

studied, type of imagery was found to be the most important predictor
of subsequent disease state (p. 119).

Although the literature supports the contention that there
are correlations between stress, personality variables, and diseases,
it is difficult to determine how much of the total predisposing
variance is due to stress and psychological factors. The ”choice"
of disease appears to be an extremely complex phenomena. Weiner
(1977) aptly summarizes this point: "Multiple and interrelated pre—
disposing factors operate at the biochemical, immunological, physio—
logical, psychological, and social levels of organization. These
factors determine what disease or diseases a person may be predisposed
to, but they do not tell us when a person may fall ill or what addi-
tional mechanisms, if any, are implicated when the disease is
initiated" (p. 8).

In summary, a review of the literature on psychosomatic dis-
orders seems to indicate that certain key personality factors appear
to be related to various forms of health and illness. This study
will consider the effect of the following personality variables:

Type A behavior, life-style habits, and locus of control. These

personality variables will be briefly discussed in the next section.

Personality Factors

 

Type A Behavior
More Americans die of coronary heart disease (CHD) than of
any other single cause (Glass, 1977). Coronary heart disease is a

disorder of the coronary arteries which often destroys the heart

16

muscle itself. Atherosclerosis, or hardening of the arteries, is
usually the cause of CHD.

Stress has been linked with CHD because stress can cause
increased levels of cholesterol in the bloodstream, increased blood
pressure, and release of honnones (adrenaline and noradrenaline)
which speed up blood clotting and elevate blood pressure. These
physiological reactions may be linked to other factors, however, and
researchers have been indicated that an association exists between
stress, certain behaviors, and an increased incidence of CHD.

Osler (1892) was the first to postulate a link between spe-
cific behaviors and CHO. More recently, Friedman and Rosenman (1974)
have defined a personality type, referred to as Type A, who is at
risk for CHD. A Type A personality is characterized by a constella-
tion of behaviors or traits which include time urgency, impatience,
ambitiousness, enhanced competitiveness, hostility, and a high need
to control one's environment. A Type B behavior pattern is
characterized by little sense of time urgency, noncompetitiveness,
lack of aggressive drive, and a more patient and relaxed style.

Although there are no known studies correlating Type A per-
sonality traits with mental imagery, it would seem that certain
traits--i.e., impatience, polyphasic thinking, time pressure--would
interfere with effective mental imagery. These personality factors
would appear to hinder relaxed attention and focusing which are
thought to be important for forming and holding mental images.

There have been several studies which have provided empirical

support for a link between Type A personality traits and CH0. One

17

study (Rosenman, Jenkins, Brand, Friedman, Straus & Wurm, 1975)
examined 3154 males aged 39-59 over an eight-and-a-half year time
period and found that Type A men had 2.37 times the incidence of
cardiovascular heart disease as Type 8 men. In addition, Type A
subjects with CHD were five times more likely to have a second heart
attack as Type 8 individuals with CHO. Caffrey (1968, 1969) found
that among 1500 monks in twenty-six monasteries, those groups having
a larger number of Type A individuals also had a higher incidence of
CHD.

In addition to Type A characteristics, some studies suggest
that life-style factors also play a role in the incidence of CHD.
Caffrey (1968, 1969) found that a Type A monastery living situation
and a high-fat diet were also associated with a higher incidence of
CHD.

A study by Shekelle (1979) emphasized that learning to manage
stress may be a factor in preventing heart disease. Shekelle sug-
gests that certain life-style factors, i.e., cigarette smoking, lack
of exercise, obesity and poor nutrition, and alcohol abuse, con-
tribute to cardiovascular risk.

In summary, there is some evidence that certain personality
traits, e.g., Type A, predispose individuals to CH0. Jenkins,
Zyzanski, and Rosenman (1976) found that a test measuring these
traits (the Jenkins Activity Survey) was a better predictor of CHD
than other variables such as serum cholesterol and number of
cigarettes smoked daily. Other studies suggest, however, that

certain life-style factors may also contribute to the incidence of

18

CHD and other illnesses. Some of these life-style factors will be

considered next.

Life-style Habits

 

Individual diffences in susceptibility to illness have been
related to the absence or presence of certain life-style behaviors
(Pelletier, 1977; Benson, 1975; Ardell, 1979; Shealy, 1977). Some
of the behaviors thought to be associated with health are aerobic
exercise (Cooper, 1970), relaxation (Benson, 1975), nutrition, and
environmental sensitivity (Ardell, 1979).

Travis (1977) has developed a questionnaire, the Wellness
Inventory, which measures a large number of these life-style
behaviors. The Wellness Inventory consists of 100 questions which
are divided into the following ten categories: productivity, care
and safety, nutrition, environment, physical, emotions, community,
creativity, auto, and parenting. Subscores are computed for each
category and then summed for an overall wellness score. Generally,
the findings suggest that the more responsibility an individual is
willing to take for his/her own health, the greater is the likelihood
of good health (Pelletier, 1977; Ardell, 1979).

A personality trait which influences how much responsibility
one takes for health-related behaviors is a belief that one has
some control over one's own health. This personality trait, which

Rotter (1954) defined as locus of control, will be discussed next.

19

Locus of Control

 

Locus of control is a personality construct which reflects
one's belief about who controls behavior and life events. This
internal-external (I-E) dimension was derived from Rotter's social
learning theory (Lefcourt, 1976; Phares, 1976; Rotter, 1954; Rotter,
Chance & Phares, 1972; Strickland, 1977), and represents an indi-
vidual's beliefs or expectancies. Beliefs range from "internal,"
which is a belief that positive and negative events are a consequence
of one's actions and efforts, to "external," which is a belief that
events are controlled by outside forces such as chance, fate, luck,
and powerful persons.

Results of research indicate that one's I-E expectancies are
significantly related to health-related behaviors. Internals are
more likely to collect infonnation about diseases hazardous to their
health (Wallston, Maides & Wallston, 1976; Wallston, Wallston, Kaplan
& Maides, 1976). Internals are also more likely to take action to
improve their health, such as to quit smoking (Coan, 1973) or to
participate in an exercise program (Sonstroem & Walker, 1973). Other
studies have shown that externals smoke more and have a higher
incidence of coronary heart disease, hypertension and psychological
maladjustment.

I-E expectancies also seem to be related to control over
physiological responses. Several studies demonstrate that internals
are more sensitive to internal cues and are superior to externals in
changing specific physiological responses such as increased electro-

encephalogram alpha responding, lowered galvanic skin response, and

20

increased heart rate (Ray, 1974; Wagner, Boureois, Levenson & Denton,
1974; Gosling, May, Lavand, Barnes & Carreira, 1974; Johnson & Meyer,
1974).

If mental imagery is defined as a conditioned sensory
response, according to a classical conditioning paradigm, it would
follow that internals should be capable of experiencing more vivid
mental imagery than externals. A study by Gralton, Hayes and
Richardson (1979) supports this notion. In their study, "introverts
reported more mental imagery and produced superior performance in
verbal learning tasks than extraverts" (p. 9). In general, the bulk
of research seems to indicate that internals are more likely to
engage in health-related behaviors, and that a shift toward an
internal orientation could lead to the development of healthier life-

style practices (Strickland, 1978).

The Placebo Effect

 

Related to locus of control is the placebo effect which is
also based on what an individual believes. A placebo is "any therapy
or component of therapy that is deliberately used for its nonspecific
psychological or psychophysiological effect but is without specific
activity for the condition being treated" (Shapiro & Morris, 1978,

p. 371).

The power of patients' expectancies has been demonstrated
experimentally in numerous studies. In one study (Vogyesi, 1954),
patients with bleeding peptic ulcers were given water injections.

One group was told the injections would cure them. A second group

21

was told the injections were experimental and might help them.
Seventy percent of the first group improved significantly while only
25 percent of the second group showed an improvement. In another
study (Beecher, 1961), placebos were thought to produce abnormal
numbers of a type of white blood cell in the immune system and to
reduce the amount of fat and protein in the blood.

The fact that placebo-induced cures often involve real
physical changes has generated speculation about how such physical
changes occur. One theory asserts that there are naturally occurring
substances in the brain, called endorphins, which are similar to
morphine. The placebo effect may allow the brain to secrete endor-
phins which maximizes the body's ability to respond to a variety of
healing techniques (Jaffe, 1980).

Other research suggests that the placebo effect operates in
a manner similar to hypnosis. For example, placebo is Latin for "I
shall please," and the placebo effect may be partially due to an
individual's desire to please another person. Rosenthal (1968)
studied the effect of suggestibility and found that subjects had a
strong tendency to conform to the expectations of the experimentor
(the Pygmalion effect). Another study, however, compared placebo-
induced responses to responses to hypnotic suggestion and found that
hypnotic analgesia alleviated pain more than placebo pills
(McGlashan, Evan & Orne, 1969).

According to Achterberg and Lawlis (1980), imagery is the
basis for the placebo effect. Placebos are thought to be effective

because they are "products of the imagination." "It is enhanced by

22

all those factors that contribute to the peculiar contents of the
imagination. The hopes and fears, expectancies, the previous learn-
ing experiences, an archetypal and current belief systems-~all form
the basis for the quality and degree of the response" (p. 37).

In most scientific research, placebo effects are considered
a confounding variable, and are controlled for by the use of designs
where neither the researcher nor the patient knows who received the
placebo. The present study is primarily interested in the fact that
placebo effects do exist and should be taken into consideration when
planning a study and interpreting results. The link between imagery,
healing, and the placebo effect will be discussed more fully in the

next section.

Imagery
From 1880 to 1910, attempts were made to identify pure imagery

types (White, Sheehan & Ashton, 1977). During this period, it
became clear that individuals image in one or more distinct modali-
ties. Betts (1909) developed a "Questionnaire upon Mental Imagery”
which evaluated imagery in seven sensory modalities: visual,
auditory, kinesthetic, cutaneous, gustatory, olfactory, and organic.
Bandler and Grinder (1975) suggest that therapists who are very
effective tend to identify and utilize their patients' most fre-
quently employed representational systems bylistening to the predi-
cates used to describe an experience. Effective therapists join the

patient in their most typically used representational system and

23

then find a point of overlap between that system and a new one in
order to expand and enrich experiencing.

There have also been various attempts to categorize types of
images. Samuels and Samuels (1975) provide an overview of classifi-
cations which include memory images, eidetic images (sometimes
referred to as photographic memory), imagination images, daydreams,
fantasies, hypnagogic and hynopompic images (which occur before and
after sleep), dreams, hallucinations or visions, and after-images.
The relationship of these types of images to perceptual reality
varies. Most imagery experiences, however, contain an element(s) of
symbolism (with the exception of eidetic imagery). It has been
postulated that imagery is effective in conflict resolution and
problem solving because it allows one to suspend the constraints of
external reality and explore unknown territory which often leads to

discovery and creativity.

Other Altered States of Consciousness

 

Much of the research on the physiological correlates of
imagery can be found under other topic areas such as: hypnosis,
self-hypnosis, biofeedback, meditation, and altered states of con-
sciousness. There is a vast body of literature which discusses the
role of hypnosis (and other altered states of consciousness) in
controlling pain and producing marked physiological changes (Hilgard,
MacDonald, Marshall & Morgan, 1974; Graves & Barber, 1976). Imagery
is usually regarded as a key variable in effecting such changes.

Hypnosis, like guided imagery, provides executive and monitoring

24

functions which produces a readiness for a dissociative experience
(Hilgard, 1979).

A survey of experimental literature on physiological corre-
lates of hypnosis is provided by Sarbin and Slagle (1979). Their
survey offers evidence that hypnosis/imagery can produce profound
changes in physiological processes such as: respiratory, cardio-
vascular, vasomotor, genitourinary, gastrointenstinal, endocrine,
metabolism, cutaneous, and central nervous system functions. Their
review also indicates that the more the subject is able to enter into

the hypnotic role, the more extensive are the physiological changes.

Applications of Imagery

 

Psychotherapy. Imagery has been used for a number of differ-

 

ent purposes. Psychotherapists use imagery to help patients obtain
access to repressed, unconscious experiences, to clarify perceptions
of conscious experiences, and to create different realities or per-
ceptions of themselves and their environment. Gendlin (1978) has
developed a technique which he calls "focusing," to help clients
work through conflicts by using relaxation and imagery to produce a
"body shift" which is a physical sensation, release, and step toward
change. Gendlin coined the term "felt sense" to describe the body's
wisdom, which he believes to be the most important ingredient in
change. A number of other psychotherapists have developed techniques
based on the theory that imagery opens channels from the unconscious
to the conscious mind which are necessary to the healing process
(Hilgard, 1977; Jaffe, 1980; Bry, 1979; Samuels & Samuels, 1975;

Simonton, Simonton & Creighton, 1978).

25

Leuner (1969) developed a method called Guided Affective
Imagery (G.A.I.) which begins with relaxation exercises similar to
Jacobson's progressive relaxation (1938) or Schutz's Autogenic Train-
ing Method (1959) and proceeds to imagery. The patient enters an
altered state of consciousness similar to a meditative state. Leuner

also encourages the use of music with G.A.I.

Mysig, The first accounts of the healing power of music
surfaced during the Renaissance era when music was found to influence
physiological functions such as breathing, blood pressure, muscular
activity, and digestion. Music has been used in combination with
imagery at Royal Victoria Hospital's palliative care program, begun
in September of 1977. A pilot study (1978) found music to be useful
for decreasing anxiety and for helping patients cope with intractable
pain. Music is used to promote muscular relaxation and to break the
pain cycle by relieving anxiety and depression and altering patients'
perception of pain.

Bonny (1980) combined music with guided imagery to facilitate
the action of drugs in LSD psychotherapy. According to Yingling's
theory (1962), music affects people in four ways: emotional,
sensual, associational, and intellectual. “The therapist must be
able to detennine the psychological state of the subject and then
choose a musical selection to implement the treatment aims" (Bonny,
1980, p. 14). Bonny's research found that "high-expectation" groups
preferred unstructured listening where a guide gives a simple relaxa-

tion exercise followed by only one suggestion, i.e., "let the music

26

take you where you need to go." A more structured approach appears
to be more effective for persons with a short attention span or high
anxiety.

Bonny's research also suggests that the presence of another
person or guide is helpful. The guide becomes the contact with
reality, allowing the subject to expend less energy on reality and
to experience more deeply than would be possible if the subject is
alone. Studies of hypnosis effects have also supported the importance
of a guide who serves as a replacement for aspects of the subject's

reality orientation (Hilgard, 1979).

Imagery and medicine. The use of imagery most relevant to

 

this study is medicine's use of imagery in healing. Philosophers,
physicians, and priests of many cultures have recognized the
importance of images (Samuels & Samuels, 1975). Ancient healing
practices in Egypt and Greece employed the use of imagery. Patients
were encouraged to sleep and find relief through dreaming and
visualizations, a practice referred to as incubation sleep.
Aristotle felt that images were causal factors in producing disease
or health. The idea of visualizing perfect health is carried on by
certain primitive cultures and vitalistic groups today. The Canadian
Eskimo and Navaho Indians use imagery to contact tribal spirits as
part of their healing rituals. Mary Baker Eddy, founder of the
Christian Science Church, tells her followers to mentally envision

harmony and health as a way to overcome disease (1934).

27

A holistic medical philosophy was replaced, during the
Cartesian period, by a mechanistic concept of dualism. The body and
the mind were treated separately, and the practice of medicine grew
increasingly specialized. Psychosomatic disorders were dissociated
from physical processes and viewed as purely psychological. Con-
version reactions were referred to as "physical hysteria" and
patients were often seen as "malingerers" (McMahon & Hastrup, 1980).

Although a mind/body dualism has persisted in current medical
practice, some physicians and clinicians have continued to be inter-
ested in the role of imagery in the process of healing. Hartley
(1966) was the first post-Cartesian to redirect thinking to the role
of imagination in physical disorders. He also advanced the notion
of "parallelism" which included both psychological and physiological
processes, and which has influenced medicine's approach to psycho-
somatic disorders during the past half-century (McMahon & Hastrup,
1980).

A more contemporary concept goes beyond parallelism and
includes a third phase of existence referred to as a "biotonic phase"
of existence (Weiner, 1976). The biotonic phase is believed to be a
deeper structure which underlies both mental and physical events.
Within this structure, imagery is viewed as a part of the total
system. This concept has been supported by a large body of psycho-
physiological research correlating imagery to central and peripheral
nervous system events. For example, research correlating imagery to
central nervous system events indicates that imagery and perception

evoke the same neurophysiological processes (Perky, 1910; Leuba,

28

1940; Hebb, 1968; Jacobson, 1931; Penfield, 1954; Davidson & Schwartz,
1977). There is also a considerable body of research demonstrating
the effects of imagery on the peripheral nervous system--i.e.,

changes in muscle tension, salivation, electrodennal activity, and
cardiovascular events (McGuigan, 1973; Schwartz, Fair, Salt, Mandel

& Klerman, 1976; White, 1978; Yaremko & Butler, 1975; Drummon, White
& Ashton, 1978; Furedy & Klajner, 1978). In fact, there is some
evidence that an image may have a greater physiological effect than

a visual or auditory stimulus (Primakoff & Goldberger, 1976;

Waters & McDonald, 1973).

Current uses of imagery in modern medicine. Imagery has

 

been used for healing in two ways: (1) in a general way as in the
relaxation response, and (2) in a specific way such as increasing
blood flow to one area of the body. Schwartz (1973) reviews examples
of how imagery has been used to increase self-control of bodily
processes, and suggests that imagery may be a more effective means

of self-control than biofeedback. Controlled research data is
lacking, however, on this issue (Schwartz, 1973).

One of the most thoroughly researched and widely used of all
the visualization techniques which utilizes both general and specific
effects is autogenic training. This system was developed in the
19305 by Schultz, a German psychiatrist and neurologist. Autogenic
therapy uses a series of six standard, 60-second visualization
exercises directed at different parts of the body. Luthe (1969)

cites 2400 studies on this approach which have found profound effects

29

on body physiology. Autogenic training is used in Europe as an
adjunct to standard medical procedures to assist with a variety of
disorders.

Samuels (1973) recommends the use of imagery in private
practice. He distinguishes between two types of imagery: receptive
and programmed. Receptive imagery is a "tuning into oneself”
process and is used for diagnostic purposes. Programmed visualiza-
tion involves creating images for the purpose of healing. Samuels
uses pictures from medical books, laboratory slides, etc., as sources
for images. Swearingen (1978), an orthopedic surgeon, shows pictures
of a four-stage healing process to his patients. He believes that
patients can understand their injury, and can use imagery to
influence the healing process.

Heidt (1978) has developed an "image disease/discomfort”
approach which uses imagery in combination with therapeutic touch.
In this approach, imagery is thought to serve three functions:

(1) to form a close relationship with patients in a short period of
time; (2) to facilitate the expression of patients' feelings; and
(3) to indicate patients' beliefs about their part in the healing
process. Patients listen to a tape in which they are instructed

to relax and take an imaginary journey through their body. They are
then asked to draw pictures of their disease, their treatment, and
how they are overcoming their disease.

A new area of nursing, referred to as "sensory information,"
tells how to take patients on a fantasy trip which teaches them what

their upcoming hospital experience will feel like (Johnson, Rice,

3O

Fuller & Endress, 1978). This new type of patient education goes
one step beyond merely describing what is wrong and what procedure(s)
will be used. It is based on the belief that recovery is aided by
delimiting patients' feelings of helplessness and loss of control

by teaching relaxation techniques and setting realistic expectations
about the duration of pain. Controlled experiments, using patients
undergoing various painful procedures, showed that the "sensory
information" group responded better to treatment and required fewer
postoperative days in the hospital. The group who received relaxa-
tion in addition to sensory information consistently responded
better than the other groups. These results suggest that relaxation
may also be an important factor in physiological change.

Esdaile (1957), a physician who practiced in India 100 years
ago, advanced the idea of hypnoanesthesia in surgery. He observed
that his patients manifested little or no shock and healed more
rapidly than patients who had been given chemoanesthesics. As a
result of his work, Esdaile concluded that hypnoanesthesia raised
the pain threshold, it raised patients' ability to withstand shock,
and when used in conjunction with chemoanesthesia, it produced
neuromuscular relaxation. The discovery of anaesthetics such as
nitrous oxide, chloroform, and ether, caused hypnoanesthesia to be
discarded. In addition, most physicians do not receive training in
hypnosis, and unfortunately for many, hypnosis became associated
with entertainment and the performance of theatrical feats

(Achterberg & Lawlis, 1980).

31

The use of imagery to relieve pain has received renewed
interest, however (Melzack & Casey, 1968). The three primary
physical techniques for relieving pain have been: (1) phannacological
agents which act on the nervous system, (2) anesthetic nerve blocks
performed by injection into nerve roots, and (3) surgery at sites
along pathways from peripheral receptors to the cortex. According
to Melzack and Casey (1968) in a review of pain treatment techniques,
none of these methods are totally satisfactory. They state that
"the surgical and pharmacological attacks on pain might well profit
by redirecting thinking toward the neglected and almost forgotten
contribution of motivational and cognitive processes. Pain can be
treated by not only trying to cut down sensory input by anesthetic
blocks, surgical intervention and the like, but also by influencing
the motivation-affective and cognitive factors as well” (p. 435).

Meichenbaum and Turk (1976) likewise recommend that
cognitive-motivational factors be considered in the treatment of
pain. These factors probably account for the efficacy of placebos
and hypnotic analgesia. Turk applied their "stress-inoculation
training" procedure to an ischemic (experimentally-induced) pain
situation. Imagery was one of three strategies taught to subjects
to help them reduce pain. Subjects in the training group reported
improved pain tolerance for 15 minutes compared to minimal change in
pain tolerance for the control group. Others have also successfully
used guided imagery as a treatment for chronic pain (Fuller, 1980;

Lane, 1981).

32

Most important to this study is the work of Simonton and
Simonton (1978). Their strong conviction that imagery plays a major
role in the causation and course of cancer has led them to develop a
comprehensive treatment program for cancer patients with imagery as
its cornerstone. At the Cancer and Counseling Research Center in
Fort Worth, Texas, the Simontons work with cancer patients who have
advanced malignancies. Their six-week program is based on a
holisitic approach to recovery. Since they believe that everyone
participates in his/her health or sickness, the first step in the
program is for patients to identify how they participated in their
disease process. Patients are asked to list and discuss the major
stresses that have occurred in their lives six to 18 months prior to
the onset of their disease. Next, patients are helped to identify
some of the ”benefits" of their illness. For some, illness may be
a way to be taken care of, or to slow down, or to express certain
feelings. Alternative ways of meeting these needs are explored.
Patients are encouraged to set three month, six month, and one year
goals, and these goals are discussed in terms of expectancy, realism,
and enjoyment. The Simontons have observed that those who seem to
recover dramatically from their illness are physically active,
therefore each patient develops a regular exercise program. A
healthy diet plan is also instituted. The family atmosphere is seen
as crucial to the patient's progress, and family members are helped
to understand their feelings about the disease. Counseling is pro-
vided so that communication can be more direct, open, and ultimately

caring.

33

In addition to these interventions, patients are taught to
relax and visualize recovery. Through relaxation, patients learn
how to reduce tension and stress and prepare for the imagery
process. The imagery experience helps patients in several ways:
to create a positive expectancy, to identify important beliefs that
might be hindering recovery, to release hostilities from the past,
to communicate with an "inner guide to health," to manage pain, and
to aid in self-discovery in other areas of their lives. Patients
are educated about how their immune system functions. They see
x-rays of their disease state as well as pictures of tumors healing,
and these pictures provide a basis for their visualizations. Patients
are taught to relax and to visualize their cancer cells. They are
asked to visualize their chemotherapy or radiation treatment destroy-
ing these cells. Then they are asked to visualize their white blood
cells mobilizing to obliterate and carry away the dead cancer cells.
Patients are encouraged to practice these visualization exercises
three times a day and to draw pictures of their images.

The Simontons noted that some terminal cancer patients have
improved against overwhelming odds, and a .78 correlation has been
reported between effective imagery and change in symptoms (Achterberg
& Lawlis, 1978). They found that 93 percent of those patients
scoring one standard deviation above the mean on effective imagery
showed no additional tumor growth two months later. Forty-three
percent of this group showed no evidence of the disease at all. By

contrast, 100 percent of those patients who scored at least one

34

standard deviation below the mean showed new cancer or had died in

the intervening two months.

TABLE 1.—-Imagery and Cancer Status.

 

 

Imagery Rating Cancer Status (two months later)
Score of 198 or more 93% showed regression of tumor
(2 = 169, 5.0. = 34) 43% showed no evidence of disease
Score of 150 or less 100% showed nevcancer growth or
had died

 

Physiological Correlates of
Related Techniques

 

 

There are numerous religious and secular techniques which
have elicited profound physiological changes. Perhaps the best known
technique today is the "relaxation response" developed by Benson
(1975). Subjects concentrate on a constant stimulus (an object,
sound, or phrase) which is repeated again and again. They are told
to disregard distracting thoughts and not to worry about how they
are doing. Benson found that after 12 minutes of relaxation, oxygen
consumption decreased by 13 percent, carbon dioxide production
decreased by 12 percent, and respirations decreased from 16 to 11
breaths per minute. Other general effects of relaxation on the body
were: decreased blood lactate, lowered blood pressure, slightly.
increased forearm blood flow, decreased heart rate, and intensifica-

tion of alpha brain waves.

35

In the late 19605, Miller and Dicara (1969) found that rats
could alter certain physiological responses--i.e., blood pressure,
blood flow, and stomach acidity--in response to reinforcement. They
were able to regulate blood flow to specific areas of their bodies.
This control has been applied to human beings and labeled biofeed-
back. Biofeedback research has often included the study of yogis
(Boyd, 1976). Green (1972) studied Swami Rama who was able to cause
two areas on the palm of his hand to change temperature 10°F in
opposite directions. Swami Rama also raised his heartbeat from 70
beats per minute to 300 beats per minute. When asked how such
control is achieved, subjects usually report detailed visualizations.

It appears, therefore, that imagery can produce profound
physiological changes. Two remaining questions are: (1) what type

of imagery is most effective? and (2) how can imagery be measured?

What Type of Imagery is Most Effective?

 

Lang's (1979) "bio-infonnational theory of emotional imagery"
provides some answers for the first question. According to Lang,
imagery is a "conceptual network, controlling specific somatovisceral
patterns, and constituting a prototype for overt behavioral expres-
sion" (p. 495). Lang (1980) has found that certain types of imagery
evoke certain types of physiological responses, and subjects who
image more vividly and more actively have greater physiological
activity.

Of course, individuals vary in their capacity to image.

Hebb (1968) found large individual differences in the ability to

36

develop vivid visual imagery, and Wolpe (1969) indicated that about
10% of his American and South American clients were unable to obtain
sufficiently vivid images for successful desensitization. Psycho-
somatic patients are often characterized by alexithmyia, an inability
to describe feelings, which may include an absence of fantasies
regarding feelings, needs, and drives. However, many people can be
taught to image more effectively by simply imaginging more active
scenes (Lang, 1980). According to Lang, it is possible to evaluate
imagery content, and "to analyze the image for perceptual, semantic,
and affective response structure, and to explore the impact of train-
ing procedures which modify in predictable ways the emotional cogni-
tion of normal subjects" (1979, p. 508). Lang's analyses have led
him to emphasize active responding in the image script, i.e., to

have subjects imagine themselves as personally engaged in the
activity "as if" it were really happening. Rather than merely
describing a scene, imagery instructions would include active sug-

gestions such as: I ran away from . . . , etc.

How Can Imagery Be Measured?

 

White, Sheehan, and Ashton (1977) provide a survey of the
major imagery self-report measures. They discuss the reliability
and validity of the various instruments and the extent to which they
measure the same process. Some instruments measure vividness and/or
clarity of images while others measure preferred modality and control
of imagery. The Betts QMI (Sheehan, 1967), a shortened version of
the Betts Questionnaire upon Mental Imagery (1909), is the most

widely used measure of imagery vividness.

37

Ron Pekala (1980), who developed a questionnaire (the
Phenomenology of Consciousness Questionnaire) for the purpose of
detennining the reliability of altered states of consciousness,
found internal consistency coefficients of .74. Subjects who were
found to be reliabile within a specific state varied when retested,
therefore no test-retest reliability was found when measuring
states. (Apparently states are not as stable as traits.)

White, Sheehan, and Ashton (1977) report sex and age differ-
ences in imagery ability. Females appear to have more visualizing
ability than males, and this ability increases with age for both
sexes. There are no definitive explanations for these findings,
however, it is hypothesized that increased practice with age
improves imagery ability.

Few researchers have examined physiological correlates of
imagery scores. Two studies found that regular breathing is
associated with visual imagery (Chowdhury & Vernon, 1964; Richardson,
1977). The belief that imagery is accompanied by an increase in
alpha brain waves has not been supported by E.E.G. studies (Paivio,
1973). However, Achterberg and Lawlis (1978) confirm Brown's idea
(1974) that alpha suppression occurs for inexperienced imagers, but
sustained alpha occurs for experienced imagers.

Achterberg and Lawlis (1978) have developed an instrument to
assess imagery, the IMAGE-CA. The IMAGE-CA was developed to communi-
cate with cancer patients about their disease. The authors managed
to formalize imagery drawings and interview sessions in order to

make objective scoring procedures possible. (Pekala also found that

38

states of consciousness could be operationalized according to
dimensions.) The relationship between the IMAGE-CA dimensions and
disease status were verified in two follow-up validation studies.

In the first study, a correlation of .78 (n = 58) was found between
ratings of effectiveness of visual imagery and progress change in
cancer status as stated earlier. The clinical judgment dimension
(highest weight) was the strongest predictor. A second validation
study, using a sample of 21 cancer patients of a lower socioeconomic
level, substantiated the results of the first study. In the second
study, clinical judgment had only a moderate positive loading instead
of a high one.

Thus, it appears that imagery dimensions can be operational-
ized and measured. The success of the IMAGE-CA in predicting future
disease status makes this instrument of particular interest in tenns
of assessing other health conditions. Using this instrument,
patients were able to define their health status with more accuracy
than by measures of their blood chemistries (Achterberg, Lawlis,
Simonton & Simonton, 1977).

In summary, imagery has been used for healing purposes for
many centuries (Achterberg & Lawlis, 1980). More recently, the
Simontons (1978) have taught cancer patients to imagine that their
white blood cells are attacking and killing off their cancer cells.
Achterberg and Lawlis (1978) report correlations between effective
imagery, as measured by th IMAGE-CA, and remission of tumor growth

for these patients.

39

The present study supports Schwartz's idea (1973) that
effective imagers should be able to exercise control over physiologi-
cal functions. It attempts to provide data on one specific

physiological process--white blood cell function.

Immunology

 

The immunologic system has been divided into two broad
components: humoral or antibody-mediated reactions and cell-
mediated immunity. This study is interested in cellular immunology,
specifically neutrophils, a type of white blood cell. There are
five types of leukocytes or white blood cells: lymphocytes, mono-
cytes, and three granulocytes--basophils, eosinophils, and neutro-
phils. Neutrophils comprise 50 to 70 percent of all leukocytes.

The morphological characteristics of neutrophils are as follows:
they contain neutral-staining granules within which are enzymes that
break down bacteria; they have a polysegmented nucleus; and they

are eight to ten microns in diameter.

From a physiological viewpoint, neutrophils are produced in
the bone marrow. They circulate in the blood for approximately
eight to ten hours, and then leave the blood stream and go into the
body tissues where they live for a few more hours. Their principal
function is phagocytosis--the eating and digesting of foreign
material, especially bacteria and tissue debris that cause infections.
Neutrophils have specialized structures in their cytoplasm that con-
tain enzymes which digest the foreign material. They have the

ability to sense bacteria and migrate to where they are needed.

40

They accumulate in large numbers at sites of infection, i.e., pus is
made up mostly of neutrophils. In essence, neutrophils are a mobile
cell in that they crawl to sites of infection where they perform
their phagocytic function. They are capable, then, of directional
locomotion, or chemotaxis, and of phagocytosis (Wilkinson, 1974).

In order for neutrophils to perform their phagocytic function,
they must be capable of moving from the blood stream into the
inflammatory site. When these cells do not migrate, repeated
infections may occur (Smith, Hollers, Dupree, Goldman & Lord, 1972;
Smith, Dupree & Goldman, 1972; Anderson & Smith, 1981). For example,
children whose neutrophils do not migrate to sites of infection
often die at young ages (Smith, Hollers, Dupree, Goldman & Lord,
1972). In the process of responding to an infection, three events
typically occur: white blood cell count increases, neutrophils
become adherent or sticky, and neutrophils change from a round to
an elongated shape. They are then ready to squeeze through the blood
vessel wall and crawl to the site of the infection.

Procedures to examine these three neutrophil functions have
been developed (Smith, Hollers, Patrick & Hassett, 1979). Studies
on the mechanisms of the chemotactic responsiveness of neutrophils
suggest that their function can be influenced by stress, exercise,
and relaxation/imagery. For example, on three separate occasions,
three routine blood donors had marked decreases in the adhesiveness
of their neutrophils following episodes of emotional stress (Smith,
1979). Specifically, their white blood cell count increased and

adherence decreased from a mean of 45 percent to 15 percent.

41

In another experiment, a subject used two separate conditions
to measure pre to post changes in white blood cell function
(Schneider & Smith, 1979). In Condition 1, the subject had blood
samples taken immediately before and after running for 10 minutes
(a nonnal activity for the subject). In Condition II, blood samples
were taken before and after a 20 minute self-induced relaxation/
imagery session. The imagery focused on increasing time adherence
and responsiveness of neutrophils. A third sample was taken 24
hours later.

Results of this n = l study are shown in Table 2. Dramatic
differences may be seen in white blood cell count (WBC), adherence,
and stimulated adherence which are related to the conditions
defined. (Adherence refers to the proportion of neutrophils remain-
ing attached to a serum-coated surface; stimulated adherence refers
to the adherence of neutrophils that are treated with the chemotactic
factor, fMP.) After jogging, the subject's white blood cell count
increased from 5,400 to 6,900 cells, and adherence remained unchanged.
After the relaxation/imagery session, white blood cell count dropped
from 5,800 to 4,300 cells (the decrease in white blood cell count
was due primarily to a decrease in the number of neutrophils), and
adherence increased from 63 percent to 91 percent adherence.
Stimulated adherence increased from 89 percent to 100 percent.
Twenty-four hours later, adherence was still elevated to 85 percent
and stimulated adherence was still at 100 percent.

Other preliminary experiments have yielded results which

correspond to those found in the n - 1 study (Schneider & Smith,

42

TABLE 2.--Neutrophil Function Changes for One Subject.

 

 

Stimulated
Condition WBC Adherence Adherence
I: Jogging
Pre 5400 61% 81%
Post 6900 63% 86%
II: Relaxation/Imagery
Pre 5800 63% 89%
Post 4300 9l% 100%
24 Hour Post 4800 85% 100%

 

1981). After jogging for 20 minutes, five experienced joggers'
white blood cell count increased and adherence remained unchanged
(42% to 43%). Following a relaxation/imagery experience, three
subjects' white blood cell count showed no change, while adherence
increased to a mean of 81 percent. Thus, using pre and post blood
samples (20 minutes apart), changes were noted in subjects' white
blood cell count, adherence, and stimulated adherence which appeared
to correspond to reported images which occurred during the 20
minute session.

In summary, neutrophils were chosen for the present study
for three reasons. First, observations have indicated that neutro-
phils, like other white blood cells, are sensitive to stress factors
(Smith, 1979). Second, neutrophils play a critical role in the

immune system's responses to bacterial infections and inflammation

43

(Wilkinson, 1974). Finally, procedures have been developed to
reliably detennine the behavior of these cells while in the blood
stream in ways which can be related to immune system function (Smith,

Hollers, Patrick & Hassett, 1979).

HYPOTHESES

In view of the review of the literature, two primary
questions were investigated: (1) Will a 20 minute relaxation/
imagery experience affect the white blood cell count, adherence,
and shape change functions of blood neutrophils? and (2) Will
imagery ratings correspond with changes in white blood cell count,
adherence, and shape change of neutrophils?

In addition to testing the primary questions of interest,
the study will correlate three personality variables, thought to be
associated with "health," with changes in the white blood cells.
The three personality variables are Type A personality, locus of
control, and wellness behaviors.

To investigate these questions, the following primary
hypotheses were stated:

I. The total white blood cell count will drop following
a 20 minute relaxation/imagery experience.

2. The neutrophils will become more adhesive after a
20 minute relaxation/imagery experience.

3. The neutrophils will change from a circular to a
more elongated shape after a 20 minute relaxation/
imagery experience.

4. Higher imagery ratings will correspond with greater
neutrophil change scores.

44

To investigate the exploratory questions, the following
exploratory hypotheses were tested:

1. Lower Type A scores will correspond with greater
neutrophil change scores.

2. Higher Internal Locus of Control scores will
correspond with greater neutrophil change scores.

3. Higher Wellness scores will correspond with greater
change scores.
SUMMARY

The two primary purposes of the study were to determine the
effect of a relaxation/imagery experience on blood neutrophil
function, and detennine whether imagery ratings would correspond
with changes in neutrophil function. A secondary purpose of the
study was to see whether specific personality factors would correlate
with the blood changes.

The independent variable was a 20 minute relaxation/imagery
experience. The dependent variables were the neutrophil function
measures and the psychological measures. It was expected that
neutrophil functions would change following the 20 minute relaxation/
imagery session, and that imagery ratings and personality variables

would correspond with blood changes.

CHAPTER II

RESEARCH DESIGN AND PROCEDURES

This chapter is divided into the following sections: the
pilot study, the subjects, procedures, measures (neutrophil function
measures, psychological measures, and imagery ratings), and the

design and statistical analysis.

PILOT STUDY

The present study is based on a pilot study conducted by the
investigator at Michigan State University from June to August, 1980.
The pilot study involved 22 subjects, which included nine students
at Michigan State University, 12 persons from the Lansing community,
and one professor at Michigan State University. The sample was
comprised of 15 males and seven females, ranging in age from 19 to
48, with a mean age of 31 years. All subjects volunteered to
participate in the study in response to a notice posted at the
Lansing YMCA and/or direct verbal requests.

Each subject filled out three personality inventories (which
will be described in detail later), a consent form, and a demographic
data form immediately prior to their participation in an experimental
condition. Subjects were randomly assigned to one of four conditions:
specific imagery, general imagery, relaxation/biofeedback, and a
control condition. For the specific imagery condition, subjects

45

46

listened to a 20 minute tape which included instructions to relax
and imagine their white blood cells changing shape, getting sticky,
and leaving the blood stream. A background sound of a heartbeat
("Ultimate Heartbeat," Environment Records) accompanied the guided
imagery instructions. For the general imagery condition, subjects
listened to a 20 minute tape instructing them to relax and imagine
a pleasant scene on the beach. Sounds of waves rolling in onto the
seashore were dubbed in on this tape ("The Psychologically Ultimate
Seashore," Environment Records). For the biofeedback condition, the
subjects were familiarized with biofeedback technqiues by D. R. Vorro
(Associate Professor of Anatomy at Michigan State University), and
all questions were answered to ensure that they understood the
experimental procedure. Levels of relaxation were monitored using
standard biofeedback techniques. Specifically, subjects were seated
in an isolated room (516 East Fee Hall) and were allowed to view the
electrical activity on a CRT (cathode ray tube) and simultaneously
listen to the electrical activity from headphones for 20 minutes.
Dr. Vorro monitored electrical activity via surface electrodes
placed on the subjects' foreheads. The signals were processed by a
polygraph enabling Dr. Vorro to evaluate the level of relaxation.
For the control condition, subjects read for 20 minutes from one of
several books selected for their non-arousing content.

For each of the four conditions, blood samples were taken
via venapuncture immediately before and after the 20 minute experi-
mental procedures. No explanation or training about the study was

provided. Subjects came for one pre-post session only. No

47

significant differences were found pre to post in any of the groups.
Some subjects showed marked changes in total white blood cell count
(WBC) and adherence, but in varying directions. For example, in the
specific imagery condition, one subject's WBC dropped 3,000 cells
(per milimeter of blood) while another subject's WBC increased
10,000 cells. Several reasons for these findings were postulated,
and the present study is an outgrowth of changes that were made
based on observations from the pilot study.

To compensate for hypothesized sources of error in the pilot
study, the following six changes were made for the present study:

First, experiences known to affect neutrophil function
(Riley, 1981) were controlled for, i.e., exercise, caffeine and other
drugs, infections, and stress. In the present study, all subjects
were screened for any health or emotional irregularities which might
affect their blood results. They were informed as to the function
of neutrophils, and asked to delay their participation if anything
might be currently altering their neutrophil function.

Second, in the pilot study, subjects were randomly assigned
to one of four groups. In the present study, subjects were assigned
to one condition (specific imagery) which allowed for the use of a
smaller sample size. All subjects, then, were able to be tested
during one season of the year. The Fall season was chosen to control
for seasonal fluctuations in neutrophil function. Blood samples were
also taken at the same time of the day for all subjects. Control

data was obtained by drawing blood from the subjects twice (with a

48

20 minute interval) before the experiment began. Any persons who
were found to have "abnormal" neutrophil function were excluded from
the study.

Third, the pilot study consisted of one session only and did
not include a training/practice component. The present study
followed, as closely as possible, the steps outlined by Meichenbaum
and Turk (1976) in their cognitive/behavioral treatment program for
pain control which includes educational, rehearsal, and application
phases. Subjects were provided with information about the procedure
by the investigator and the functions of the involved bodily
mechanisms by Dr. Wayne Smith (Professor of Anatomy at Michigan
State University). Opportunities were provided for practicing the
relaxation/imagery procedure, and options were given to the subjects
as to the kinds of imagery they might choose to use by encouraging
them to be playful and creative with their images-~i.e., allowing
subjects to experiment with any images that came into their minds.

Fourth, in the pilot study, subjects listened to a tape
recording for the general and specific imagery conditions. In the
present study, the specific imagery instructions were read aloud by
the investigator. This change was based on observations made during
hypnosis and other altered states of consciousness (Hilgard, 1979;
Bonny, 1980) which suggest that the presence of a guide allows
subjects to suspend reality functions and enter into a deeper trance
state. In addition, the background heartbeat sound used during the
Specific imagery condition in the pilot study was replaced by sounds

0f ocean waves pounding on a seashore. Several pilot subjects had

49

commented that the heartbeats interfered somewhat with their ability
to relax, and since a background sound to reduce distractions seemed
desirable, a more neutral sound was chosen.

Fifth, pilot subjects were instructed to fill out three
personality measures, a demographic data sheet, and pennission to
participate in the study form. This was done in an office in the
Department of Psychiatry at Michigan State University immediately
prior to the experimental condition. Since many subjects were from
the community and not familiar with the Department or psychological
testing, the experience may have been stressful and interfered with
relaxation. In the present study, subjects were oriented to the
experimental room and procedures in advance.

Finally, in the present study, the placebo effect was not
controlled for, but was incorporated into the design of the investi-
gation. Subjects were given infonnation about how others had been
able to affect neutrophil function via imagery, and they were
encouraged to believe that they might cause changes in their neutro-

phils.

SUBJECTS
Data was collected on eight male and eight female subjects
for a total sample size of 16. Thirteen of the subjects were Michigan
State University students--nine were first year medical students, two
were counseling psychology students, one was a clinical psychology
student, and one was an undergraduate student. A college teacher

at Lansing Community College, a geologist, and a marketing manager

50

with a local paper company comprised the remaining three subjects.
The subjects' ages ranged from 2l to 38 with a mean age of 29.4.
All subjects were screened over the phone by the investigator who
asked them if they had any health or diet irregularities which might
affect their blood results, and all were classified as healthy. For
example, participation was delayed for any person who had an infec-
tion within the past week, had active allergies, or had used
certain drugs within three days of a blood sample--i.e., aspirin,
alcohol, marijuana, or other mind-altering substances.

Subjects were informed of the intent of the study in advance.
Any persons who did not believe in the possibility that they might
be able to influence their blood cells were excluded from the study.
The total sample, then, was not representative of the general
population in that they were believed to be highly motivated, in
college or college educated, healthy, and already had a belief in

their ability to influence their white blood cells.

PROCEDURES
This investigation took place over an eight-week time period,

and each subject attended six sessions. The study was designed to
control for daily and seasonal fluctuations in white blood cell
function by having blood samples drawn at the same time of the day
for all subjects, and having the same amount of time elapse between
Pre and post blood samples, i.e., seven weeks. This necessitated
diVViding the 16 subjects into two groups of eight each, labeled

Phase 1 and Phase 2, respectively. Phase 1 subjects attended sessions

51

from October 16, 1980 to November 25, 1980, and Phase 2 subjects
participated from October 27, 1980 to December 15, 1980.

During the first session, each subject had blood drawn
using a standard venapuncture procedure, signed a consent fonn
explaining the nature and purpose of the study, filled out a demo-
graphic data form and three personality inventories, and had blood
drawn again 20 minuts after the first sample was taken. (See
Appendix A for forms and personality measures.) The investigator
conducted all of the sessions except for session two, and Dr. Wayne
Smith drew all of the blood samples.

The second visit was a group session conducted by Dr. Smith
during which white blood cell function was explained and slides of
neutrophils were shown which could later be used as a basis for
imagery representations. (See Appendix B for pictures of the
slides.)

During the third session, subjects listened to a relaxation/
general imagery tape. (A transcript of the tape is given in Appendix
C.) The purpose of this session was to acquaint subjects with the
relaxation/imagery process, and to familiarize them with the private
office and surroundings in which they would do the final specific
imagery experience. Dr. John Schneider, Associate Professor of
Psychiatry at Michigan State University, donated his private office
which is located in the Department of Psychiatry in East Fee Hall.
Because the office afforded privacy and comfort, i.e., subjects were
seated in a reclining leather chair, it was well-suited for the

imagery experience. In addition to providing practice, this session

52

also served to attempt to desensitize anyone who might feel anxious
relaxing in a psychologist's private office.

The fourth and fifth sessions were group training sessions.
Training consisted of the following: explaining the rationale and
purpose of the study, describing results of the Simontons' work
(1978), explaining the relaxation/imagery procedure and giving sug—
gestions for effective imagery, practicing the imagery procedure as
a group, asking subjects to draw pictures of their imagery and rate
the pictures according to specified criteria, and answering any
questions that arose. Subjects were provided with blank paper and
were asked to draw a picture(s) of what their white blood cells had
looked like during their imagery experience. They then were asked
to evaluate their images, using their pictures, according to seven
variables which are described in the subsection entitled "Imagery
Ratings." A typical question would be, "How vivid were your white
blood cells?" They were also told that these seven variables were
thought to be related to changes in white blood cell function, i.e.,
the more vivid your images are, the more change will occur in your
white blood cell function.

The specific imagery procedure was adapted from the imagery
instructions given to cancer patients in the Simonton's treatment
program (1978). The adapted imagery procedure was designed to help
subjects relax and visualize their white blood cells. They were then
asked to imagine their white blood cells changing shape, sticking
to the vessel wall, passing through the vessel wall, and going to

places in the body where "garbage" had collected. The white blood

53

cells were to be seen as "garbage collectors," picking up ”garbage”
and dumping it outside the body. The entire procedure lasted
approximately 20 minutes. Subjects were encouraged to experiment
and be playful with their images and adapt the procedure in any way
that made sense for them. Articles clarifying both imagery studies
and leukocyte function were distributed, and they were encouraged
to read the articles and to practice the technique at home. (See
Appendix C for the imagery instructions and Appendix D for the
articles.)

Subjects came individually for the sixth session. They were
seated in the private office mentioned earlier, blood was drawn by
Dr. Smith, the relaxation/specific imagery experience was repeated
by the investigator, blood was drawn a fourth and final time, and
they drew a picture of their imagery. The procedure was the same as
the one used during the training sessions. All subjects were given
an opportunity to emerge from their relaxed state at their own rate
which took approximately one to five minutes.

Subjects were then asked a series of questions about their
imagery by the investigator. (The questions are listed in Appendix
E.) The investigator did not draw the blood and was not informed of
the blood results until the completion of the study. This recall
session was tape recorded. Based on the Achterberg and Lawlis pro-
cedure for quantification of anatomical imagery (which is explained
in detail in the next section), subjects were later scored inde-
pendently by three raters for the adequacy of their imagery process.

Each of the three raters had familiarized him/herself with the

54

Achterberg/Lawlis procedure by reading their book, Imagery of Cancer
(1978), which explained the procedure in detail. Each rater was
also familiar with the nature and purpose of the study. One of the
raters was an assistant professor in the Department of Psychiatry

at Michigan State University. The second rater was a first year
student in Human Medicine at Michigan State University, and the
third rater was the investigator. All three volunteered to be

raters.

MEASURES
The measures used in this study can be divided into three
categories: neutrophil function measures, psychological measures,

and imagery ratings.

Neutrophil Function Measures
Blood was obtained on four separate occasions by venapuncture.
Ten milimeters (ml) were anticoagulated with heparin, two ml were
anticoagulated with EDTA and three ml were allowed to clot in a
glass tube. A portion of the serum was stored at -70°C for possible
future use. Three neutrophil measures were observed: white blood

cell count (WBC), adherence (Ad), and shape change (SC).

hflfite Blood Cell Count

White blood cells are produced in the bone marrow and are
found circulating in the blood stream (circulating pool) or attached
tt) the blood vessel walls (marginal pool). Under ordinary circum-

stances, approximately 50 percent are circulating and 50 percent are

55

marginal. Changes in white blood cell count are caused by cells
shifting from the circulating to the marginal pool and vice versa.
Only those cells that are circulating are measured by venapuncture.
A 25 microlitre sample of blood was diluted in white blood
cell diluting fluid. The white blood cells were then counted on a
Coulter counter. They were counted in triplicate to account for
variability. The number of cells were multiplied by 1000 which

gives the number of white blood cells per milimeter of blood.

Adherence

Adherence was determined by the ability of cells to stick to
protein-coated surfaces. After the neutrophils were isolated, they
were injected into a glass chamber and allowed to settle for 500
seconds. The apparatus for measuring adherence is two gaskets and
two cover glasses. The chamber is filled with Hanks balanced salt
solution (which contains all salts necessary for cell function and
approaches a balanced physiologic condition), and the cells are
injected into the chamber. Gravity causes the cells to settle. The
chamber is flipped over. After 500 seconds, some cells detach, and
some cells stick to the upper glass cover. Percent unstimulated
adherence represents the percent of isolated neutrophils that remain
attached to the glass cover.

adherent

total x 100 = percent adherence

The same procedure was repeated for neutrophils that were stimulated

by f-Met-Phe (fMP), a synthetic substance and a chemotactic factor

56

produced by Sigma Chemical Company. F—M-P, which binds to a fairly
specific receptor site on the cell, activates shape change and
adherence in the cell. If neutrophils are dysfunctional, their per-
cent adherence will not increase when treated with fMP. Percent
stimulated adherence represents the percent of neutrophils treated

with fMP that remain attached to the glass cover.

Shape Change

 

One measure of chemotactic response is the ability of cells
to assume a bipolar configuration upon exposure to a chemotactic
factor. There are five classifications of cell shapes: (1) round,
(2) ruffled, (3) bipolar, (4) uropod, and (5) pseudopod. The uropod
is the tail of the cell and the pseudopod is the front of the cell.
An average cell takes approximately two minutes to change from a
round to a uropod shape. Five minutes after chemotactic stimulation,
roughly 90 percent of the cells are in the last three classification
categories.

The neutrophils are suspended in a Hanks balanced salt solu-
tion and fixed with gluteraldehyde, which kills the cell but per-
serves its morphology. The fixed cells are examined with a "phase
contrast" microscope, which allows the examiner to see the cells
without staining them. The chemotactic factor, fMP, is added to the
sample in a concentration that gives the highest response (10'6
molar). In a second round, varied concentrations of fMP are used to
determine to what extent the imagery would affect the dose response.

The percentage of cells with a bipolar configuration is determined

by scoring 100 cells per slide. Shape Index scores are detennined

57

by multiplying the shape change categories by a factor and adding
them. The Shape Index, then, is a weighted summary that gives a
more sensitive indication of overall change. Scores are reported
for unstimulated and stimulated shape change.

All three techniques have been found to be highly reliable,
reproducible, and sensitive procedures through repeated samplings.
The procedure for adherence and shape change has been used for over
100 subjects, and has been found to be highly reliable. For
example, multiple samples taken from single subjects have yielded
less than a five percent variation in adherence and less than a two
percent variation in shape change (Smith, 1980).

Two other procedures were done as a check on the health of
the subjects. Hematocrit is an indication of anemia. Sedimentation
rate is an indication of infection. All 16 subjects fell within a

normal range.

Psychological Measures

 

Three psychological inventories were used to measure correla-
tions between personality characteristics and ability to influence
neutrophil function. All three measures were paper-and-pencil self-
administered questionnaires (see Appendix A).

One of the inventories was a test measuring Type A person-
ality characteristics. Two major approaches have been used to
assess Type A behavior. These are the Structured Interview
(Rosenman, Friedman, Straus, Wunn, Kositchek, Haan & Werthessen,

1964) and the Jenkins Activity Survey (Jenkins, Rosenman & Friedman,

58

1967). The present study used the Jenkins Activity Survey (JAS)
which is a questionnaire consisting of 44 items of which 16 are
scored. The JAS was developed from an item pool derived from the
structured interview questions and from clinical experience. Those
items that significantly discriminated individuals classified by
the interview as Type A were selected for the inventory.

An interjudge agreement of classification of 72 percent was
found between the JAS and the Structured Interview (Zyzanski &
Jenkins, 1970). The JAS was also found to be significantly related
to coronary heart disease in a study known as the Western Collabora-
tive Group Study (Jenkins, Rosenman, and Zyzanski, 1974). Test-
retest reliability was 65 percent for both one year and four year
intervals.

Most of the present validity data for the JAS has been
derived from laboratory studies which used college students as
subjects. A number of studies support the concurrent, predictive,
and construct validity of the Type A concept and the JAS (Dembrowski,
1978). For example, comparisons with other psychological tests--
i.e., the Minnesota Multiphasic Personality Inventory, Rotter's I-E,
Thurstone Temperament Scale--yielded significant correlations which
supported the validity of a Type A pattern.

Certain Type A behaviors--i.e., time urgency, impatience,
POlyphasic thinking, and the need to be in control of one's environ—
mentp—would appear to interfere with one's ability to relax and
image effectively, therefore it was postulated that higher Type A

SCOY‘es would be negatively correlated with blood changes.

59

The Wellness Inventory (Travis, 1977) is a questionnaire
which purports to measure degrees of wellness. It consists of 100
questions which are divided into the following ten categories:
productivity, care and safety, nutrition, environment, physical,
emotions, community, creativity, auto, and parenting. Subscores
are computed for each category and summed for an overall wellness
score.

There is no normative data for test-retest reliability or
validity, therefore interpretation relies primarily on clinical
judgment. The questionnaire simply categorizes behavior as opposed
to asking for opinions.

Travis reports scores ranging from 65 to 75 for persons
participating in his wellness program. In addition, locally, 34
undergraduates in the College of Agriculture participating in a
lecture series in Project LEAD at Michigan State University had a
mean score of 64.5 with a standard deviation of 8.41 (Schneider,
1980). Another group of 12 male and female white collar workers
participating in a stress workshop had a mean score of 71.2 with a
standard deviation of 6 (Schneider, 1980).

Since life-style habits have been related to one's physical
health and functioning, it was expected that higher wellness scores
would be associated with greater blood changes.

The International Opinion Survey, also known as the Internal
versus External Control of Reinforcement Scale (Rotter, 1966),
measures an individual's beliefs about who controls his/her behavior

and life events. The test demonstrates reasonable reliability

60

based on data obtained in a series of samples (Rotter, 1966). Item
analysis and factor anlaysis estimates are fairly high for an addi-
tive scale. Test-retest reliability estimates range from .49 to .83,
and the test correlates satisfactorily with other scales measuring
the same variable--i.e., the Likert scale. Although the test shows
reasonable internal consistency, it is limited in its ability to
discriminate between individuals. Thus, the test is thought to be
more suitable for investigations of group differences than individual
differences.

Construct validity of the I-E Scale has been determined by
correlations between scores and behavioral criteria, i.e., internals
take more steps to improve their environmental situations.

Several studies suggest that better results occur when the
type of treatment program is congruent with I-E expectancies
(Abramawitz, Abramawitz, Roback & Jackson, 1974). Internals seem to
do better in non-directive programs where they have more control,
while externals prefer more structured intervention. The present
study provided some structure, but attempted to allow for a great
deal of flexibility and subject-control, i.e., subjects were
encouraged to develop their own personal images. One would expect
that internals might respond more creatively to this situation, and
creativity is thought to contribute to imagery effectiveness. In
summary, internal-external expectancies appear to be related to
imagery ability (Gralton, Hayes & Richardson, 1979), therefore it

was expected that "internals" would experience more vivid imagery

61

than "externals," and, thus, manifest greater changes in neutrophil

function.

Imagery Ratings

 

The instrument chosen to assess imagery is an adaptation of
the IMAGE-CA (Achterberg & Lawlis, 1978). The IMAGE-CA consists of
14 dimensions which were derived from hundreds of interviews with
patients. These dimensions are: vividness, activity, and strength
of the cancer cell; vividness and activity of the white blood cell;
relative comparison of size and numbers of cancer and white blood
cells; strength of white blood cells; vividness and effectiveness
of medical treatment; degree of symbolism; overall strength of
imagery; regularity of imagery process; and clinical opinion related
to prognosis based on combined imagery factors (pp. 27, 28).

Scores for the 14 dimensions are derived from two sources:
(1) drawings by the patients, and (2) tape recordings of structured
interviews. The 14 dimensions can be divided into four categories:
the disease, white blood cell defense system, treatment, and general
imagery characteristics. Scoring was based on the following
criteria:

1. Vividness of cancer cells: High scores were given

for continuous and clear descriptions. This
dimension was not strongly related to progress of
disease.

2. Activity of cancer cells: This dimension attempted

to assess the patient's feeling about growth and
spread of malignancy.

10.

11.

12.

13.

62

Strength of cancer cells: High scores were given for
weak or fragile images. This dimension was the most
important of the three cancer cell dimensions in
predicting subsequent disease.

Vividness of white blood cells: High scores were
given for clear and continuous descriptions.

Activity of white blood cells: Higher ratings were
given for more detailed, active, complex and self-
generated images.

Numerosity of white blood cells: Higher scores were
given when the number of white blood cells relative
to cancer cells was high.

Size of white blood cells: Once again, the size of
white blood cells relative to cancer cells was of
interest. Relative sizes may tell something about a
patient's attitude toward sickness and health.

Strength of white blood cells: The nature of the
interaction of the white blood cells and cancer cells,
i.e., strength, was found to be one of the most
powerful predictors of short-term disease state.

High scores were given if the white blood cells

were often winners over the cancer cells.

Vividness of treatment: Low scores were given when
descriptions were fragmented and difficult to follow.

Effectiveness of treatment: High scores were given
when patients saw their treatment effectively combating
their disease.

Symbolism: Higher scores were given for more
symbolistic imagery. It is especially important
that the white blood cells appear symbolically. The
authors suggest that the content of the imagery is
important, because symbols often reflect personality
dynamics.

Overall strength of imagery: This dimension assesses
a patient's overall ability to image, and is derived
from specific details, emotional intensity, etc.

Estimated regularity of imagery: High scores were
given for frequent practice of imagery.

63

14. Clinical judgment: This dimension was found to be
the most complex, yet the best predictor of disease
status. The power of this dimension is determined
by the ability of the rater(s).

Scores ranged from 1 (low) to 5 (high), and raw scores were
weighted, summed, and transformed to standard scores (stens). A
sten score is descriptive of the normative sample population. A
sten score ranges from 1 to 10, with respect to a normal distribution,
with a mean of 5.5 and a standard deviation of 2.0. Reliability was
measured by interdimensional correlations and interrater correlations.
All of the correlations were statistically significant, but had a
wide range from .60 to .95. Validity was measured by correlating
the scores to objective medical criteria two months later. If a
patient scored 140 or above, his prognosis for remission of disease
was excellent. If the score was less than 100, the prognosis was
poor.

The present study adapted the following variables from the
Achterberg and Lawlis IMAGE-CA (1978): vividness, shape change,
adherence, leaving the blood stream, strength, general feeling,
symbolism, and clinical judgment. In addition, three summary
variables were rated: decrease in white blood cell count, shape
change, and adherence. At the end of the experimental condition,
subjects were asked to draw a picture of their imagery and were
asked a series of questions about their images by the investigator
(see Appendix E). This recall session was tape recorded.

After two training protocols, the three raters described

learlier (who had no knowledge of the blood results) independently

64

rated the subjects on the 11 variables. The tape recorded sessions
and the drawings of the images were used to detennine the ratings.
Scores ranged from 1 (low) to 5 (high). Each rater took the tape
recordings of the sessions home with him/her in order to arrive at
independent ratings. Then the three raters met together in Dr.
Schneider's office at Michigan State University to compare their
ratings. Discrepancies between raters were resolved by re-listening
to the tape and then arriving at an averaged score of the three

ratings. Interrater reliabilities ranged from .65 to .92.

DESIGN AND STATISTICAL ANALYSIS

The study took the form of a quasi-experimental designiwith the
16 subjects serving as their own control group as shown on the Design
Graph. The factor over the subjects was sex and consisted of two levels--
male and female. The repeated measures design was a 2 x 2 design
where one factor was the time element (pre and post) and the second
factor was the treatment factor (control and imagery). The inde-
pendent variable of interest was a comparison of change of neutrophil
functions under the imagery condition and the control condition.

The dependent variables associated with this design are the neutro-
phil functions described earlier.

The other dependent variables were the psychological and
imagery measures. These measures were collected to examine their
relationship to blood neutrophil function.

The data were analyzed according to five considerations. A

repeated measures multivariate analysis of variance (Finn, 1967) was

65

DESIGN GRAPH

 

 

Control Imagery
Pre1 Post1 Pre2 Post2

Males 1
2

3

4

5

6

7

8

Females 1
2

3

4

5

6

7

8

 

 

 

 

 

computed for the treatment effect on (1) total white blood cell
count, (2) adherence, and (3) cellular shape change. When there
were significant differences, the Student t-test was used as a post-
hoc comparison procedure. Pearson product moment correlation
coefficients were computed to examine the relationship of blood
changes to imagery ratings and personality variables.

The primary hypotheses tested were:

Hypothesis 1: There will be changes in peripheral blood
neutrophils as a result of a 20 minute
relaxation/specific imagery experience.
Specifically:

(a) The total white blood cell count will drop
following the imagery experience.

(b) The neutrophils will become more adhesive
as a result of the imagery experience.

 

66

(c) The neutrophils will change from a circular
to a more elongated shape as a result of
the imagery experience.

Hypothesis 2: Correlation coefficients between imagery ratings
and blood neutrophil measures will be greater
for subjects who received higher ratings on
the adequacy of their imagery process.
Specifically:

(a) Higher vividness scores will correspond
with greater neutrophil change scores.

(b) Higher leaving-the-blood-stream scores will
correspond with greater neutrophil change
scores.

(c) Higher strength of white blood cells scores
will correspond with greater neutrophil
change scores.

) Higher overall feeling scores will correspond

with greater neutrophil change scores.

e) Higher symbolism scores will correspond with

greater neutrophil change scores.

) Higher overall scores will correspond with

greater neutrophil change scores.

) Higher white blood count scores will
correspond with a decrease in white blood
cell count.

(h) Higher shape change scores will correspond

with a more elongated shape change.

(i) Higher adherence scores will correspond

with a greater neutrophil adhesiveness.

Exploratory Hypotheses: Three personality variables will
correlate with changes in the white blood cells.

Specifically:

(a) Lower Type A scores will correspond with
greater neutrophil change scores.

(b) Higher Internal Locus of Control scores will
correspond with greater neutrophil change
scores.

(c) Higher Wellness scores will correspond
with greater neutrophil change scores.

SUMMARY
Sixteen healthy volunteers were trained over an eight week

period in a relaxation/imagery procedure. Blood samples were taken

67

20 minutes apart before the training program began while the subjects
filled out three personality inventories--i.e., a blood sample was
taken, subjects filled out the personality measure, and a second sample
was taken 20 minutes after the first one. Blood samples were taken
again prior to and immediately following the 20 minute imagery
session. Subjects were then asked a series of questions about their
imagery experience. Their responses to these questions were later
scored, according to specified criteria, by three raters.

The blood samples were examined for changes associated with
motility--i.e., white blood cell count, adhesiveness, and cellular
shape. The imagery ratings and the personality inventories were
correlated with the blood results.

A repeated measures multivariate analysis of variance was
computed for the effect of imagery on white blood cell count,
adherence, and shape change. Significant differences were determined
by Student t-tests. Correlation coefficients examined the relation-

ships of blood results to imagery ratings and personality factors.

CHAPTER III

ANALYSIS OF DATA

The research hypotheses can be divided into three broad areas
of interest: (1) the effect of relaxation and imagery on blood
neutrophil function, (2) the correlation between imagery ratings
and changes in neutrophil function, and (3) the correlation between
personality variables and changes in neutrophil function.

HYPOTHESIS 1: RELAXATION/SPECIFIC IMAGERY
AND CHANGES IN NEUTROPHIL FUNCTION

Hypothesis 1 states that there will be changes in peripheral

blood neutrophils as a result of a 20 minute relaxation/specific

imagery experience. As the probability levels in Table 3 show,

TABLE 3.--Probability Levels for Analysis of Variance of Blood
Function Measures.

 

 

 

White Blood Shape

Source Cell Count Adherence Change
Sex Effect .515 .4003 .9726
Repeated Measures Effect .000l** .0779* .0089**
Sex x Repeated
Measures Effect .6628 .4304 .8066

*p < .10

**p < .01

68

69

there were no significant p levels for the sex by repeated measures
effect and the main effect for sex. There were significant differ-
ences for the white blood count and shape change functions. The
differences observed for adherence were marginally significant.

The means and standard deviations of the blood variables
for each cell in the repeated measures design are reported in
Table 4. There was little change in blood function for any of the
pre to post control samples. There was, however, a drop in white
blood cell count and unstimulated adherence following the imagery
condition. Significant shape change occurred but not following the
imagery condition. All three variables were then examined separately.

Hypotheses 1a states that the total white blood cell count
(WBC) will drop following the specific imagery experience. The raw
data for WBC is shown in Figure 1. The mean WBC for the first
control blood sample was 7290 cells (per milimeter of blood), and
the mean WBC for the second control sample was 7260 cells, showing
little change for the control condition. WBC dropped 33 cells for
males and 25 cells for females. The mean WBC before imagery was
8168 cells, and the mean WBC after imagery was 6405 cells which
represents a 2763 cell drop in total WBC. There was a 1825 WBC
drop for males and 1699 WBC drop for females. T-tests were computed
showing a probability of < .0001 for the imagery difference.

Hypothesis 1b states that the neutrophils will become more
adhesive as a result of the imagery experience. The change in
adherence (Ad) means is illustrated in Figure 2. Control means for

unstimulated adherence dropped from 41 to 38 (a 3 point difference),

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10,000 -
9,000 -
8,000 _ 8168
7,000 _ 7290 7260 \\\\\\\\\\\§395
6,000 -
5,000 -
4,000 -
Sample 1 Sample 2 Sample 3 Sample 4
(Pre) (Post) (Pre) (Post)
Control Imagery

Figure 1.--Pre and Post WBC Means for Control and Imagery Conditions.

 

 

100 -
9O -
80 -

73

70 - 59 _____-___ZO 7? ---------
60 -

50 - 41 45
20 -
10 -
Sample 1 Sample 2 Sample 3 Sample 4
(Pre) (Post) (Pre) (Post)
Control Imagery
Key: —————-= unstimulated adherence

----- = stimulated adherence

Figure 2.--Pre and Post Adherence Means for Control and Imagery
Conditions.

72

and imagery means dropped form 45 to 32 (a 13 point difference).
T-tests were computed showing a probability of <.035 for the
adherence difference. The means of the stimulated cells are also
shown. The drop was caused primarily by changes in females
adherence function; unstimulated adherence dropped one point for
males and 18 points for females.

Hypothesis 1c states that the neutrophils will change from
a circular to a more elongated shape as a result of the imagery
experinece. The raw data for shape change (SC), illustrated in
Figure 3, shows no significant elongation of the neutrophils

(p < .663) before or after chemotactic stimulation.

HYPOTHESIS 2: IMAGERY RATINGS AND
CHANGES IN NEUTROPHIL FUNCTION

Hypothesis 2 states that subjects who receive higher
ratings on the adequacy of their imagery process will have greater
changes in blood neutrophil function. Interrater reliabilities, as
reported earlier, ranged from .65 to .92. The means, standard
deviations, and range for each imagery category is given in Table 5.
The total possible range was from 1 (low) to 5 (high).

Pearson product moment correlation coefficients for imagery
ratings and blood changes are shown in Table 6 (see Appendix F for
all correlations). The blood function measures on the left represent
difference scores, i.e., the difference between the pre and post
blood samples for each condition. Most of the significant correla-
tions (shape change, adherence, leaving the blood stream, strength,

general feeling, clinical judgment, and WBC count) correlate with

73

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170 q

160 - 158 ________ 1 _59

150 4 '--'

140 -
130 -
120 -
110 -
100 -
90 -
80 -
7o -
6O -
50 -

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30 -
20 -

10 _ 12 11

 

 

Sample 1 Sample 2 Sample 3 Sample 4
(Pre) (Post) (Pre) (Post)

Control Imagery

unstimulated shape change

7<
m
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ll

----- = stimulated shape change

Figure 3.--Pre and Post Shape Change Means for Control and Imagery
Conditions.

74

TABLE 5.--Means and Range of Scores for Imagery Ratings.

 

 

Imagery Category Mean Range

Vividness 3.656 (.8107)a 2 - 5
Shape Change 3.5625 (.8342) 2 - 5
Leaving the Blood Stream 3.78125 (.8944) 2 - 5
Strength 3.03125 (.8360) 1 - 5
Overall Feeling 3.46875 (1.3098) 2 - 5
Symbolism 2.84375 (.8654) 1.5- 5
Clinical Judgment 3.0625 (1.2479) 2 - 5
WBC Change 3.53125 (.8165) 2 - 5
Adherence Change 3.5 (.8845) 2 -5

 

aStandard deviations are given in parentheses.

decreased adherence, which are represented by negative correlations.
The highest correlations are for shape change and clinical judgment
ratings (p < .001). Also the ratings for symbolism (p < .001) and
white blood cell count (p < .Ol) correlate with changes in white
blood cell count.

Tables 7 and 8 illustrate correlations between imagery
ratings and blood measures for gggfl pre Egg post sample, rather
than difference scores. Significant correlations between control
blood function measures and imagery ratings are shown in Table 7.
Most of the significant correlations are clustered in white blood

cell count and adherence functions. Since only 17 percent of the

75

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78

correlations were significant, they could have occurred by chance.
Table 8 shows the significant correlations between imagery blood
function measures and imagery ratings. The highest number of cor-
relations were found in adherence (unstimulated, post) and shape
change (unstimulated, pre) functions.
HYPOTHESIS 3: PERSONALITY FACTORS AND
CHANGES IN NEUTROPHIL FUNCTION

Three personality variables--Type A, Locus of Control, and
Wellness--were correlated with changes in white blood cell function.
It was expected that lower Type A scores would correspond with
greater neutrophil change scores; higher Internal Locus of Control
scores would correspond with greater neutrophil change scores; and
higher Wellness scores would correspond with greater neutrophil
change scores.

Pearson product moment correlation coefficients for person-
ality factors and blood changes were computed. Few significant
correlations were found between Type A personality and Locus of
Control scores and blood changes. There were some correlations,
however, between Wellness scores and blood changes as illustrated
in Tables 9 and 10. (Only the significant correlations are shown.)
A few significant correlations were found in all three blood
function categories as shown in Table 9. Table 10, which illustrates
correlations between each blood function measure and Wellness scores,
shows that the highest number of correlations are clustered in

productivity and auto safety categories. Significant correlations

‘79

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80

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81

are distributed fairly evenly among the blood function measures

(see Appendix F for all correlations).

SUMMARY

The results of the neutrophil function tests, summarized in
Table 11, show that significant changes occurred for two of the
three blood functions. The total white blood cell count dropped
significantly (p < .0001) as predicted. This finding is particu-
larly significant when restricted to neutrophils. There was a 38
percent drop in neutrophil count, as compared with a 20 percent drop
in total white blood cell count. When neutrophils are removed from
the total white blood cell count, there are essentially no differ-
ences for other white blood cells. Thus it appears that the
imagery experience was highly specific in its effects on only neutro-
phils, which were the particular white blood cells the subjects
were trained to visualize.

The second blood measure, adherence, also dropped signifi-
cantly (p < .05). Subjects were instructed to visualize an increase
in adherence, therefore this finding was in the opposite of the
expected direction.

The third blood measure, shape change, remained unchanged.
Although there is a treatment effect for Measure 1 (Table 3), there
was no significant change following the imagery condition.

Despite a relatively small sample size (n = 16), significant
correlations were found between imagery ratings and changes in blood

functions. High correlations (Table 9) were found between ratings

82

TABLE 11.--Neutrophil Function Test Means Before and After a 20
Minute Relaxation/Imagery Session.

 

 

 

Blood Function Measures Pre Post

White Blood Cell Count 8200 (1500)6 6400 (1300)
Neutrophil Count 4900 (650) 3100 (600)
Adherence, Unstimulated 45 (13) 32 (18)
Shape Change, Unstimulated 12 (13) 11 (13)

 

for symbolism and white blood cell count and changes in white

blood cell count. Results were highly significant in the opposite
of the expected direction in terms of adherence, however, indicating

that imagery effectiveness was related to a decrease in neutrophil

adherence.

Finally, some correlations were found between Wellness

scores and blood function measures. Few significant correlations

were found between Type A and Locus of Control scores and blood

changes.

CHAPTER IV
SUMMARY AND CONCLUSIONS

SUMMARY

The purpose of this study was to investigate two primary
hypotheses: (1) that white blood cell function could be influenced
by a relaxation/imagery experience, and (2) that ratings of imagery
effectiveness would correlate with blood changes. Although it is
well known that imagery can affect mental and physical functioning
(Sarbin 8. Slagle, 1979; Schwartz, 1973; Benson, 1975), few con-
trolled studies appear in the literature that measure a specific
physiological change, such as white blood cell function, resulting
from imagery.

Neutrophils are a type of white blood cell which provide a
major defense against bacterial infections. In order for neutrophils
to carry out their defensive role, they must be capable of motility
so that they can emigrate into inflammatory sites. While it appears
that alterations in the cells' ability to migrate predisposes indi-
viduals to infection (Smith & Hollers, 1980; Jadwin, Smith & Meadows,
1980, Anderson & Smith, 1981), little information is available on
endogenous control mechanisms in normal individuals. Procedures to
examine the chemotactic responsiveness of neutrophils have been
developed to a high degree of reliability (Smith, Hollers, Patrick &
Hassett, 1979). These procedures enable the researcher to isolate

83

84

neutrophils and examine changes associated with motility, i.e., white
blood cell count, adhesiveness, and cellular shape change.

Prolonged stress and certain personality and life-style
factors are believed to affect an individual's susceptibility to
illness (Friedman & Rosenman, 1979; Pelletier, 1977; Shealy, 1977;
Ardell, 1979; Rotter, l954; Strickland, 1977). Three inventories
which measure personality and life-style characteristics thought to
be associated with health were used in this study. These inventories
are Type A, Locus of Control, and the Wellness Inventory.

Imagery has been used for centuries as a tool in healing
(Samuels & Samuels, 1975; Achterberg 8 Lawlis, 1980). Visual imagery
has been used more recently as part of a comprehensive treatment pro-
gram for cancer patients (Simonton & Simonton, 1978). A study by
Achterberg and Lawlis (1978) found a .78 correlation between ratings
of effectiveness of visual imagery and progress or remission of
cancer growth two months later. Another study (Achterberg, Lawlis,
Simonton & Simonton, 1977) examined the relationships between
psychological variables, blood chemistries, and course of cancer.
They concluded that psychological factors are predictive of subse-
quent disease state, and among the psychological factors studied,
type of imagery was found to be the most important predictor of sub-
sequent disease state. Some preliminary in vitro experiments, using
healthy adult donors, have been performed at Michigan State University
(Schneider & Smith, 1981). These studies suggest that neutrophil

function can be influenced in different directions by factors such as

85

stress, relaxation, and imagery. These experiments, together with
the Achterberg and Lawlis studies (1977, 1978), provide a basis for
this study.

In the present study, 16 healthy volunteers were trained
over an eight week period in a relaxation/imagery procedure. Blood
samples were taken 20 minutes apart before the training program
began while the subjects filled out three personality inventories
and consent and demographic data forms. Blood samples were taken
again prior to and immediately following the 20 minute imagery
session. Subjects were then asked a series of questions about their
imagery experience. Their responses to these questions were later
scored, according to specified criteria, by three raters. The blood
samples were examined for changes associated with motility--i.e.,
white blood cell count, adhesiveness, and cellular shape change.

The imagery ratings and the personality inventories were correlated
with the blood results. A repeated measures analysis of variance
was computed for the effect of imagery on white blood cell count,
adherence, and shape change. Significant differences were detennined
by Student t-tests. Correlation coefficients examined the relation-

ships of blood results to imagery ratings and personality factors.

CONCLUSIONS
The results of the neutrophil function tests, as shown in
Table 11, indicate that changes occurred for two of the three neutro-
phil functions. Following the imagery session, the total white

blood cell count dropped significantly (p < .00l), as did the

 

 

 

86

neutrophil count (p < .0001). Adherence of the neutrophils also
dropped significantly (p < .05), while shape change remained
unchanged.

Some significant correlations were found between imagery
ratings and changes in blood function as shown in Table 6. High
ratings for symbolism and decrease in white blood cell count corre-
late with changes in the white blood cell count. High imagery
ratings in several categories (shape change, adherence, leaving
the blood stream, strength, general feeling, clinical judgment,
and WBC count) correlate with decreased adherence.

0f the three personality variables, some significant correla-
tions were found between Wellness scores and the blood measures

(see Tables 9 and 10).

DISCUSSION

Blood Measures

 

The results of this study support the primary hypothesis
that a 20 minute relaxation/imagery experience can affect neutrophil
function. The results are mixed, however, with white blood cell
count being affected in the expected direction, adherence being
affected in the opposite of the expected direction, and shape change
not being significantly affected.

There was a 20 percent drop in total white blood cell count,
as expected, following the imagery session. The drop was even
greater (38%) when restricted to neutrophils, the particular white

blood cell the subjects were trained to visualize. Thus it appears

87

that healthy, motivated subjects can be trained to significantly
lower their neutrophil count by relaxing for 20 minutes and
visualizing their neutrophils leaving the blood stream.

The drop in adherence was in the opposite of the expected
direction, since subjects were asked to visualize their neutrophils
getting stickier. One possible explanation for this finding is
that the most adherent cells were unavailable for sampling by vena-
puncture because they were part of the 38 percent that had marginated
and/or left the blood stream. Thus, the decrease in adherence might
be related to the drop in white blood cell count.

There was no significant neutrophil shape change. Again,
it is possible that some neutrophils did change shape and left the
blood stream, in which case they would be unobtainable for the post-
imagery sample. Another explanation is that, biochemically, there
are separate pathways that lead to adherence and shape change, so

that imagery might affect one function and not the other.

Imagery Ratings

 

The results support the hypothesis that imagery ratings would
correspond with changes in neutrophil function. It appears, there-
fore, that effective imagery is related to neutrophil function
changes. Specifically, ratings of overall effectiveness and of the
symbolic nature of the imagery show the strongest relationship to
changes in white blood cells. This finding is consistent with the
Achterberg and Lawlis study (1978) which found a high correlation

between symbolism of imagery and change in cancer status. It would

88

appear that the more individuals are able to visualize their white
blood cells in an abstract and symbolically meaningful manner, the
more the blood cells are affected. Perhaps, as the literature sug-
gests, imagery has a healing effect because it integrates left and
right brain functions (Bry, 1979; Achterberg & Lawlis, 1980; Jaffe,
1980; Simonton, Simonton & Creighton, 1978). Therefore, subjects
who are able to transform factual infonnation (a left brain function)
into playful, abstract symbolic images (a right brain function) are
able to achieve a greater physiological effect. This interpretation
is consistent with contemporary explanations of the imagery experi-
ence (Gunnison, 1982). The imagery experience involves both left
and right brain functions in a synergistic way so as to alter basic
physiological functions. The finding is also supported by the
results of Meichenbaum and Turk's "stress-inoculation training" pro-
cedure where imagery was the most effective of three strategies
taught to subjects for reducing pain (1976).

The correlations between imagery ratings and adherence was
in the opposite of the expected direction. Again, as with the drop
in adherence of white blood cells, this finding might be explained
by the drop in neutrophil count, i.e., the adherent cells either
left the blood stream or became marginated, thereby becoming inacces-
sible to sampling by venapuncture. The results do suggest, however,
that effective imagery is related to marked change in adherence of
the neutrophils.

One unexpected and surprising finding is the correlations

between imagery ratings and control adherence values. Although

89

these correlations could have occurred by chance, this finding is
consistent with the Achterberg and Lawlis study (1978) which found
significant correlations between imagery ratings and cancer status
two months later. One possible explanation for both findings is that
the imagery ratings may reflect a relatively enduring characteristic
of the individual, i.e., their capacity for effective imagery. This
idea is supported by the nature of the training process which was
geared toward helping subjects learn how to image as effectively as
possible. All subjects received the same training, yet sizeable

differences were obtained.

Personality Measures

 

Some significant correlations were found between Wellness
scores and the blood measures. The highest number of correlations
were clustered in the productivity and auto safety categories. The
significant correlations were somewhat randomly distributed among
the blood function measures, and both positive and negative correla-
tions were found.

The lack of consistent findings might be due to several
factors. The sample size was small (n = 16) and restricted in range.
All of the subjects were self-selected, educated, and highly moti-
vated. This homogeneous group undoubtedly scored more similarly on
the three measures than a more heterogeneous sample would have
scored. A second limiting factor is the somewhat low reliability
and validity of the measures in terms of individuals. The Internal

versus External Control of Reinforcement Scale, for example, has not

90

demonstrated high discriminant ability for individuals (Rotter,
1966). A larger and more heterogeneous sample, however, might

offset this second limitation.

IMPLICATIONS FOR FUTURE RESEARCH

The results of the preliminary investigations and of this
study seem significant enough to warrant further investigation.
Current research indicates that neutrophils are an important part of
the body's defense system. The results of this study suggest that a
20 minute relaxation/imagery experience can alter certain functions
of neutrophils. If this is the case, the number of possible impli-
cations in tenns of healing benefits and increased awareness of
mind-body connections is virtually limitless. Further research is
necessary, however, before any cause-and-effect relationships can
be established.

Future research might include a replication of this study,
increasing the power by using a larger sample, and then varying the
imagery instructions. Such a study has been conducted at Michigan
State University subsequent to this one (Smith, Schneider & Whitcher,
1981). The same 16 subjects plus an additional 16 subjects partici-
pated. All conditions were exactly the same except the subjects
were asked, during training and the imagery session, to imagine
their neutrophils getting stickier but staying in the blood stream.
As expected, there was little change in white blood cell count and
adherence increased significantly (40-58%). The two studies together

suggest that relaxation alone was not responsible for the blood

91

changes, since by varying one aspect of the imagery procedure, very
different results in white blood cell count and adherence of neutro-
phils were obtained. Apparently the content of the imagery process
is an important variable in affecting neutrophil function.

Another interesting finding is that the drop in white blood
cell count was highly specific to neutrophils. It is possible that
specific types of cells, like neutrophils, could be the focus of an
imagery training procedure, and reveal shifts in availability and
function as a result. Replications with other types of white blood
cells would further understanding of this effect. Other variations
of this study might include measuring white blood cell functions at
various points in time--i.e., 5, 10, or 15 minutes--or comparing
imagery with other altered states of consciousness such as hypnosis.

The correlations between imagery ratings and control blood
samples suggest that some persons may be more capable of effective
imagery than others. Further studies which examine the nature of
these response capabilities would help clarify this question. Such
studies might take into account the relationship of factors such as
personality characteristics, stress, depression, and creativity to
imagery ability.

An unresolved issue is the extent to which the imagery
experience or the placebo effect or some combination thereof pro-
duced the results of this study. Numerous studies have demonstrated
the power of expectancies (Volgyesi, 1954; Beecher, 1961; Jaffe, 1980).
Although some believe that imagery is the basis for the placebo

effect (Achterberg & Lawlis, 1980), it is possible that the placebo

92

effect is the basis for guided imagery. It seems probable that both
are interrelated factors. This study utilized both the placebo
effect and the imagery experience to attempt to produce changes in
neutrophil function. Further investigations which control for the
placebo effect would help to clarify the contribution of these
independent variables. For example, to detennine the effect of
imagery alone, an investigator might replicate this study without
telling subjects what to expect, thereby controlling for the placebo
effect.

In addition, the question of generalizability beyond a
highly motivated, healthy, educated sample is unanswered. It would
be interesting to replicate this study using a larger and more
heterogeneous sample. This study may have demonstrated that subjects
could self—select for their capacity to engage in this type of
imagery, since_all 16 subjects achieved a drop in their white blood
cell count. The capacity of individuals to realize more of their

bodies' potential deserves further study.

BIBLIOGRAPHY

93

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Esdaile, J. Hypnosis in Medicine and Surgery. New York: The Julian
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Finn, J. Multivariance: Univariate and multivariate analysis of
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97

Gunnison, H. Fantasy door approach: Merging the left-right hemi-
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APPENDICES

105

APPENDIX A

CONSENT FORM, DEMOGRAPHIC DATA FORM,
AND PERSONALITY INVENTORIES

106

1.

2.

5.

.9.

10.

Michigan State University

Department of Psychiatry

I have freely consented to take part in a scientific study being conducted

 

 

by: Christy Minning
under the supervision of: John Schneider, Ph.D.
Academic title: Associate Professor of Psychiatry

 

\
I agree to donate a maximum of 30 c.c. of whole blood per venapuncture, and
no more than 55 c.c. in a 24 hour period for this scientific study. Blood
samples will be taken up to a maximum of 5 times.

I have no known health problem for which blood donations might be detrimental,
and I will report any change in my health, or blood donations given elsewhere
before any donation.

I understand that in the unlikely event of physical injury resulting from
research procedures, Michigan State University, its agents, and employees
will assume that responsibility as required by law. Emergency medical
treatment for injuries or illness is available where the injury or illness

is incurred in the course of an experiment. I have been advised that I should
look toward my own health insurance program for payment of said medical expenses.

I will not participate in the Exercise Condition unless I have been jogging
for a minimum duration of 20 minutes at least three days per week for the
previous six months.

The study has been explained to me and I understand the explanation that has
been given and what my participation will involve.

I have not been coerced in any way to participate in this experiment and I
understand that I am free to discontinue my participation in the study at
any time without penalty.

I understand that the results of the study will be treated in strict confidence
and that I will remain anonymous. Within these restrictions, results of the
study will be made available to me at my request.

I understand that my participation in the study does not guarantee any
beneficial results to me.

I understand that, at my request, I can receive additional explanation of
the study after my participation is completed.

Signed

 

Date

 

lO7

10.

11.

108

Demographic Data

Name

 

Sex ‘N F
Age
Occupation

 

 

Educational level

 

What exposure, if any, have you had to wholistic health?

Why did you volunteer for this research?

Diet (check one): organic
vegetarian
other Explain:

 

Have you taken any dietary supplements during the past week?
If so, what? How much?

(vitamins, etc.)

 

Are you currently under much stress? Explain:

Are you taking medication for anything? (includes birth control pills)

If so, what?

 

Have you consumed any alcohol during the past 24 hours?

 

If so, how much?

 

lO9

‘ $6? “Ila- err-vague

TEE JENKINS ACTIVITY SURVEY

Porn I ’r

Medical research is trying to track down the causes of several diseases which are
attacking increasing numbers of people. This survey is part of such a research effort.

Please answer the questions on the following pages by marking the answers that are true
ternygg. Each person is different, so there are no "right" or "wrong" answers. Of
course, all you tell us is strictly confidential-to be seen only by the research team.
Do not ask anyone else about how to reply to the items. It is your personal opinion
that we want. Z

Your assistance will be greatly appreciated.

 

For each of the following items, please circle the number of the ONE best answer:

1. Do you ever”have‘frouble finding time to get your hair cut or styled?
I. Never ' 2. Occasionally 3. Almost always

2. Does college "stir you into action"?
1. Less often than most college students 2. About average
2. More often than most college students

3. Is your everyday life filled mostly by

1. Problems needing solution 3. A rather predictable routine of events
2. Challenges needing to be met 4. not enough things to keep‘me
interested or busy

4. Some people live a calm, predictable life. Others find themselves often facing
unexpected changes, frequent interruptions, inconveniences or "things going wrong".
How often are you faced with these minor (or major) annoyances or frustrations?

1. Several times a day 3. A few times a week 5. Once a month or less
2. About once a day 4. Once a week

5. When you are under pressure or stress, do you usually:
I. Do something about it immediately
2. Plan carefully before taking any action

6. Ordinarily, how rapidly do you eat?

° 1. I'm usually the first one finished 3. I eat at about the same speed as
2. I eat a little faster than average most people
A. I eat more slowly than most people

7. Has your spouse or some friend ever told you that you eat too fast?
1. Yes, often 2. Yes, once or twice 3. No, no one has told‘ae this
8. How often do you find yourself doing more than one thing at a time, such as working
while eating, reading while dressing, figuring out problems while driving?

1. I do two things at once whenever practical
2. I do this only when I‘m short of time
3. I rarely or never do more than one thing at a time

HO

-2-

Por each of the following items, please circle the number of the one best answer:

9. When you listen to someone talking, and this person takes too long to come to
the point, do you feel like hurrying him along?

1. Frequently 2. Occasionally 3. Almost never

10. How often do you actually "put words in his mouth" in order to speed things up?

1. Irequently 2. Occasionally 3. Almost never

11. If you tell your spouse or a friend that you will meet them somewhere at a
definite time, how often do you arrive late?

1. Once in a while 2. Rarely 3. I am never late

12. Do you find yourself hurrying to get places even when there is plenty of time?

1. Often 2. Occasionally 3. Barely or never

13. Suppose you are to meet someone at a public place (street corner, building lobby,
restuarant) and the other person is already 10 minutes late. Will you

1. Sit and wait?

2. walk about while waiting?

3. Usually carry some reading matter or writing paper so you can get
something done while waiting?

14. When you have to "wait in line". such as at a restaurant, a store. or the post
office, do you

‘ 1. Accept it calmly?
2. Feel impatient but do not show it?
3. Feel so impatient that someone watching could tell you were restless?
4. Refuse to wait in line, and find ways to avoid such delays?

15. When you play games with young children about 10 years old, how often do.you
purposely let them win?

1. Most of the time 2. Half the time 3. Only occasionally 4. Never

16. Do most people consider you to be

1. Definitely hard-driving and competitive? 3. Probably more relaxed and
2. Probably hard-driving and competitive? easy going?
4. Definitely more relaxed and
easy going?

17. Nowadays, do you consider yourself to be
1. Definitely hard-driving and competitive? 3. Probably relaxed and easy going

2. Probably hard-driving and competitive? 4. Definitely more relaxed and
' easy going?
18. How would your spouse (or closest friend) rate you?
1. Definitely hard-driving and competitive? 3. Probably more relaxed and easy
2. Probably hard-driving and competitive? going?

4. Definitely more relaxed and
easy going?

Ill

3

For esch of the following items, please circle the number of the ONE best answer:

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

How would your spouse (or best friend) rate your general level of activity?
1. Too slow. Should be more active '
2. About average. Is busy much of the time.
3. Too active. Needs to slow down.

Would people who know you well agree that you take your work too seriously?

1. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no
would people who know you well agree that you have less energy than most people?

1. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no
would people who know you well agree that you tend to get irritated easily?

1. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no
would people who know you well agree that you tend to do most things in a hurry?

l. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no

would people who know you well agree that you enjoy "a contest" (competition) and
try hard to win?

1. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no
would people who know you well agree that you get a lot of fun out of your life?
1. Definitely yes 2. Probably yes 3. Probably no 4. Definitely no

How was your "temper" when you were younger?

1. Fiery and hard to control . 3. No problem
- 2. Strong, but controllable 4. I almost never got angry
How is your "temper" nowadays?

l. Fiery and hard to control 3. No problem

2. Strong, but controllable 4. I almost never get angry

When you are in the midst of studying and someone interrupts you, how do you
usually feel inside?

1. I feel 0.x. because I work better after an occasional break
2. I feel only mildly annoyed
3. I really feel irritated because most such interruptions are unnecessary

'Bow often are there deadlines in your courses? (If deadlines occur irregularly,

please circle the closest answer below).

1. Daily or more often 3. Monthly
2. weekly 4. never

Do these deadlines usually
1. Carry minor pressure because of their routine nature?
2. Carry considerable pressure, since delay would upset things a great deal?

Do you ever set deadlines or quotas for yourself in courses or other things?

1. so 2. Yes, but only occasionally 3. Yes, once per week or more

112

(Remember, the answers on these questionnaires are confidential information and will not
be revealed to officials of your university).

32. When you have to work against a deadline, is the quality of your work

1. Better? 2. Wcrse? 3. The same? (Pressure makes no difference)

33. In school do you ever keep two projects moving forward at the same time by
shifting back and forth rapidly from one to the other?

1. No, never 2. Yes, but only in emergencies 3. Yes, regularly

34. Do you maintain a regular study schedule during vacations such as Thanksgiving,
Christmas, or Easter? -

1. Yes 2. No 3. Sometimes

35. How often do you bring your work home with you at night or study materials
relative to your courses?

1. Rarely or never 2. Once a week or less often 3. More than once a week

36. How often do you go the University when it is officially closed (such as night or
weekends)?_ If this is not possible, Circle here: 0

l. Rarely or never
2. Occasionally (less than once a week)
3. Once or more a week

37. When you find yourself getting tired while studying, do you usually

1. Slow down for a while until your strength comes back
2. Keep pushing yourself at the same pace in spite of the tiredness

38. When you are in a group, do the other people tend to look to you to provide
leadership?

1. Rarely

2. About as often as they look to others

3. More often than they look to others

39. Do you make yourself written lists of "things to do"
needs to be done?

to help you remember what

1, Never 2. Occasionally 3. Frequently

IN EACH OF THE FOLLOWIHG QUESTIONS, PLEASE COMPARE YOURSELF WITH THE AVERAGE STUDENT AT
TEE UNVERISTY. PLEASE CIRCLE THE MOST ACCURATE DESCRIPTION.

40. In amount of effort put forth, I give

_Much more A little more A little less Much less
effort effort effort effort

41. In sense of responsibility, I am

Much.more A.little more A little less Much less
responsible responsible responsible responsible

IN EACH OF THE FOLLOWING QUESTIONS,
AT YOUR UNIVERSITY. PLEASE CIRCLE THE MOST ACCURATE DESCRIPTICN.

42.

43.

44.

H3

I find it necessary to hurry
Much more ' A little more A little less
of the time of the time of the time
In being precise (careful about detail), I am
Much more A little more A little less
precise precise precise
I approach life in general

Much more A little more A little less
seriously seriously seriously

Thank you for your cooperation.

PLEASE COMPARE YOURSELF WITH THE AVERAGE STUDENT

Much less
of the time

Much less
precise

Much less
seriously

H4

4" for a'MFIDJL‘Q PLVJ‘W‘U

Please answer the questions on the following pages by marking the answers that are
true £1: you. Each person is different, so there is no "right" or "wrong" answer.
Of course, all you tell us is strictly confidential—to be seen only by the research

team. Do not ask anyone else about how to reply to the items. It is your personal
opinion that we want.

Your assistance will be greatly appreciated.

 

rm: JENKINS ACTIVITY SURVEY (Pom r)"’_
For each of the following items, please circle the nmber of. the 032 best answer:

1. Do you ever have trouble finding time to get your hair cut or style:d?

1. Never 2. Occasionally 3. Almost always
2. Does work "stir you into action"?

1. Less often than most working adults

2. About average

3. lbre often than most working adults
3. Is your everyday life filled mostly by .

1. Problems needing solution 3. A rather predictable routine of events
2. Challenges needing to be met 4. Not enough things to keep me interested
or busy

4. Some people live a calm, predictable life. Others find themselves often facing
unexpected changes, frequent interruptions, inconveniences or "things going
wrong". How often are you faced with these minor (or major) annoyances or

frustrations?
1. Several times a day 3. A few times a week 5. Chase a month or less
2. About once a day 4. Once a week

5. When you are under pressure or stress, do you usually
1. Do something about it inediately
2. . Plan carefully before taking any action

6. Ordinarily, how rapidly do you eat?

1. I'm usually the first she finished 3. I eat at about the same speed as
most people
2. I eat a little faster than sverage 4.. I eat more slowly than most people

7. Has your spouse or some friend ever told you that you eat too fast?
1. Yes, often 2. Yes, once or twice 3. No, no one has told me that

3. How often do you find yourself doing more than one thing at a time, such as
working while eating, reading while dressing, figuring out problems while
driving?

I. I do two things at once whenever practical.
2. 1 do this only when I'm short at cm
3. Irarelyorneverdomorethanonethingatatime .

'115

For each of the following items, please circle the nuzber of the at: best answer"

9.

10.

13.

14.

16.

17.

18.

when you listen to someone talking, and this person takes too long to come to
th‘ point, do you feel like hurrying bin along?

1. Frequently 2. Occasionally 3. Almost never
How often do you actually "put words in his mouth" in order to speed things up?
1. Frequently 2. Occasionally 3. Almost never

If you tell your spouse or a friend that you will meet them somewhere at a
definite time, how often do you arrive late? '

1. Once in a while 2. Rarely 3. I an never late
Do you find yourself hurrying to get places even when there is plenty of tine?
l. Often 2. Occasionally 3. Barely or never '

Suppose you are to meet soneone at a public place (street corner, building lobby,
restaurant) and the other person is already 10 minutes late. Will you

1. Sit and wait?
2. Balk about while waiting?

3. Usually carry some reading matter or writing paper so you can get something
done while waiting?

When you have to “wait in line," such as at a restaurant, a store, or the post
office, do you

1. Accept it calmly?

2. Peel inpatient but do not 9h€V it?

3. Feel so inpatient that someone watching could tell you were restless?
4. Refuse to'wait in line, and find‘weys to avoid such delays?

When you play games with young children.ahout 10 years old, how often do you
purposely let then win?

1. Host of the time 2. Half the time 3. Only occasionally 4. .aever
Do most people consider you to he

1. Definitely hard-driving and competitive? 3. Prs’ably more relaxed and easy-
> going?
2.. Probably hard-driving and competitive? 4. Definitely more relaxed and easy-
. . going?

nowadays, dovyou consider yourself to be

1. Definitely hard-driving and anpetitive? 3. Probably more relaxed and easy-
going?

2. Probably hard-driving and competitive? 4. Definitely more relaxed and easy-
going?

Bow'would your spouse rate you?
1. Definitely hard-driving and competitive? 3. Probably relaxed and easy-going?

2. Probably hard-driving and competitive? 4. Definitely relaxed and easy-
going?

116

Per each of the following items, please circle the number of the 0112 best answer:

19.

20.

23.

24.

26.

27.

28.

29.

now would your spouse rate your general level of activity?

1. Ice slow. Should be more active.

2. About average. Is busy much of the time.

3. Too active. needs to slow data. .

Would people who know you well agrct. that you take your work too seriously?

1. Definitely Yes 2. Probably Yes 3. Probably Ho 4. Definitely Ho

would people who know you well agree that you have less energy than most people?
1. Definitely Yes 2. Probably Yes 3. Probably Ho 4. Definitely he

would people who know you well agree.that you tend to get irritated easily?

1. Definitely u. 2. Probably Yes 3. Probably Ho '4. Definitely so

would people who know you well agree that you. tend to do most things in a hurry?
l. Definitely Yes 2. Probably Yes 3. Probably No 4. Definitely No

Would people who know you well agree that you enjoy "a contest" (competition)
and try hard to win?

I. Definitely Yes 2. Probably Yes 3. Probably Ho 4. Definitely No

Would people who know you well agree that you get a lot of fun out of your life?
I. Definitely Yes 2. Probably Yes 3. Probably No 4. Definitely No

How was your "temper" when you were younger?

l. Fiery and hard to control 3. 230 problem

2. Strong, but controllable 4. I abost never get angry.
how is your "temper" nowadays?

l. Fiery and hard to control 3. No problem

2. Strong, but controllable 4. I almost never get angry

When you are in the midst of working and someone interrupts you, how do you
usually feel inside?

1. I feel 0.1:. because I work better after an occasional break.
2. I feel only mildly annoyed.
3. I really feel irritated because most such irterruptions are unnecessary.

How often are there deadlines in your work? (If deadlines occur irregularly,
please circle the closest 'answer below)

1. Daily or more often 2. Weekly 3. Monthly 4. lever

Do these deadlines usually

1. Carry minor pressure because of their routine nature? .

2. Carry considerable pressure, since delay would upset things a great deal?

117

For each of the followiu items, please circle the nunber of the 02:! best aswer:
31. Do you ever set deadlines or quotas for yourself at work or at home?

l. No 2. Yes, but only occasionally 3. Yes, once per week or more often
32. When you have to work against a deadline, is the quality of your work

1. Better? 2. Horse? 3. The same? (Pressure makes no difference‘

33. At work or at home do you ever hecp two projects moving forward at the same
time by shifting back ad forth rapidly from one to the other?

1. No, never 2. Yes, but only in aergencias 3. Yes, regularly

34. Do you maintain a regular work schedule dtn'ing vacations such as Thanksgiving,
Christmas, ad Easter?

1. Yes 2. No 3. Sometimes

35. now often do you bring your work home with you at night or study materials .
related to your work? - '

1. Barely or never 2. Once a week or less often 3. More than once a week

36. How often do you go to your place of employment when it is officially closed
(such as nights or weekends)? If this is not possible, circle here: 0

1. Barely or never
2. Occasionally (less than once a week)
3. Once or more a week
37. when you find yourself getting tired while working, do you usually
1. Slow down for a while until your strength comes back.
2. Keep pushing yourself at the sane pace in spite of the tiredness.

38. When you are in a g'roup, do the other people tend to look to you to provide
leadership?

1. Barely
2. About as often as they look to others
3. More often tha they look to others

39. Do you make yourself written lists of "things to do" to help you remember what
needs to be done: '

1. Never 2. Occasionally 3. Frequently

IN EACH OF m renown-1c QUESTIONS, PLEASE MARS YCL'T'SELF WITH TEE AVERAGE
EMPLOYEE AT_ YOUR PLACE O'r‘ BIPLOYIIENT. PLEASE CIRCLE rm: HOST ACCURATE DESCRIPTION.

40. In mat of effort put forth, I. give

Hush more - A little more A little less Much less'

effort effort effort effort
41. In sense of responsibility, I in

Pinch more A little more A little less hush less

responsible responsible responsible responsible

118

IF EACH OF THE FOLLOWING QUESIICI:S, P ‘3 COIS’ARE YOURSELF m rm: AVERAGE
DPIDYEE AT YOUR PIACE OP ETLOYISIT. PLUS: CIRCLE THE 2108? ACCURATE DZSCRIP‘IIOH.

42. I find it necessary to hurry

nuch nore A little nore A little less ‘ Huch less

of the tine of the tine of the tine of the tine
63. In being precise (careful about detail), I am -

Much more A little nore A little less Much less

precise ' precise precise precise

41.. I approach life in general

lluch more A little. more A little less much less
seriously seriously seriously ' seriously

119

international Opinion Surfl

 

Below are a number of statements about various topics. They have been
mllected frail-different groups of people and represent a variety of opinions.
There are no right or wrong answers to this questionnaire: for every statement
there are large numbers of people who agree and disagree. Please indicate
whether you agree or disagree by marking an ”X" under the agree, or disagree
calm. if you have no opinion or can't decide, place an "X" in the no opin-
im alum.

men you finish all 59 items, select two statements which you agree with
wet strongly, and two statements which you disagree with most strongly.
Identify these items on the answer sheet by putting the letter "A" next to the
two you agree with, and a "D" next to the two you disagree with.

Please read each item carefully and be sure that you indicate the
response which lost closely corresponds to the way which you personally feel.

I. i think the government owes every citizen a decent living.

2. Most students in school would 2E cheat even if they were sure of
gifting away with it.

3. lhen people are nice to me, it is generally because i have done something
to make them that way.

4. l definitely cannot go along with the philosophy of "Eat, drink and be
merry for tomorrow, who knows?"

5. flat has happened to me in the past is my own fault. No one is reSpon-
sible but me.

6., A pod leader makes it clear to everybody what their jobs are.

1. By taking an active part in political and social affairs, the people
can control world events.

8. Most students don't real lze the extent to which their grades are
influenced by accidental happenings.

9. Capable people who fail to become leaders have not taken advantage of
their opportunities.

lO. - Host repairman will not overcharge even if they think you are ignorant
of their specialty.

ll. I believe that the government has been taking over too many of the
affairs of private industry.

l2. Most parents can be relied upon to carry out their threats of punishment.

1}.
l4.
IS.

IS.
§

27.
28.

29.
30s

3'.

120

-2-

in the long run, people get the respect they deserve in this world.
“any of the unhappy things in people's lives are partly due to bad luck.

When people are "mean" to me, it is generally because i have done some-
thing to make them that way.

Using the Honor System of not having a teacher present during exams
mid probably result in increased cheating.

The average citizen can have an influence on government decisions.
The idea that teachers are unfair to students is nonsense.

A person can succeed no matter what his previous background is.
Most people can be counted on to do what they say they will do.
My political views are more liberal than most peoples'. ~

i an not as honest with myself as i should be.

men saneone gets mad at me, i can usually do something to make him
Iy friend again.

Many times we might Just as well decide what to do by flipping a coin.

it is seldom profitable to try to be friends with someone if he doesn't
want to be. .

This country has a dark future unless we can attract better people
into politics.

flith enough effort, we can wipe out political corruption.

In with case of the well prepared student, there is rarely if ever
such a thing as an unfair test.

A good leader molds the opinions of the group he is leading rather than
merely following the wishes of the majority.

Most elected public officials are really sincere in their campaign
promises.

Labor unions have acquired too much power in this country.

32. ~The United Nations will never be an effective force in keeping world peace.

4'.
‘2e‘

43.

45.

46.
47.

‘ 48.

49.
50..

51.
52.'

53.

121

-3-

it is hard to know whether or not a person really likes you.
i have often found that what is going to happen will happen.

Every person should be held accountable for his own actions.

. Parents usually can be relied upon to keep their promises.

in the long run, the people are responsible for bad government on a
national as well as a local level.

Samtimes i can't understand how teachers arrive at the grades they give.
i can seidan make other people do the things i want them to do.

Most of the time i can‘t mderstand why politicians behave the way
they do.

One should not attack the political beliefs of other people.

if we really knew what was going on in international politics, the public
would have more reason to be frightened than they now seem to be.

People who can't get others to like them don't understand how to get
along with others.

i think that life is largely a gamble.

Unfortunately, an individual's worth often passes unrecognized no matter
how hard he tries.

The Judiciary is a place where we can all get unbiased treatment.

it is difficult for people to have much control over the things
politicians do in office.

There is a direct commotion between how hard i study and the grades
I get.

lihen i make plans, i an almost certain that I can make them work.

Most people would be horrified if they knew how much news the public
hears and see is distorted.

Canpleteiy free enterprise is the best policy a country can have.

Even though we have reports in newspapers, radio and television, it is
hard to get objective accounts of public events.

llhen i get into an argment, it is sometimes my fault.

58.

59.

122

.4-
Most people don't realize the extent to which their lives are controlled
by accidental happenings.'
No matter how hard you try some people just don't like you.
Most people answer public opinion polls honestly.

All wars could be stopped if countries would put forth more effort
to prevent them.

flany times exam questions tend to be so unrelated to course work that
studying is really useless.

i can usually influence people to my way of thinking if I wish.

123

NAME

 

 

iNSTRUCTlONS

Please put a mark in the box before each statement which is true for you. Total
each section. then copy the subtotals to the back page. Average total scores range
from 65 to 75. (If you are answering this questionnaire as pan of a wellness
evaluation, when the evaluation is completed. this copy of the booklet will be given to
y0u for future reference.) .

 

WHAT IS MEANT BY WELLNESS?

The ideas of mea5uri'ng wellness and helping people attain high levels of
wellness are relatively new. Most of us think in terms of illness and assume that the
absence of illness indicates wellness. This is not true. There are many degrees of
wellness as there are many degrees of illness. The diagram below is a model used by
well medicine,

     

Traditional NEUTRAL
Medicine ‘

[Filo discernible illness
or uellness]

Moving from the unter to the left shows a progressively worsening state of health.
Mavmg to the right of center shows increasing levels of health and well—being.
Traditional medicine is oriented towards curing evidence of disease. but usually stops
at the midpoint. Well medicrne begins at any point on the scale will the goal of helping
a person to move as far to the right as possible.

Many people lack physical symptoms but are bored. depressed. tense. anxious or
generally unhappy With their lives. These emotional states often lead to physical
disease through the lowering of the body's resistance. The same feelings can also
lead to abuse of the body through smoking. drinking and Overeating. These behaviors
are usually substmrles for other more basic human needs such as recognition from
others. a stimulating environment. caring and affection from friends. and growth
towards higher levels of sell- ”awareness

Wellness is not a static state. It results when a person begins to see himself as a
growing. changing person. High level wellness means giving good care to your
physical sell. using your mind constructively. expressing your emotions effectively.
being creatively involved with those around you. being concerned about your physical
and psychological environment and becoming aware of other levels of consciousness.

This questionnaire will help to give you an idea about where you presently are on
the wellness scale.

 

© 1977 John W. Travis. MD.

124

u

1. PRODUCTIVITY. RELAXATION. SLEEP - . _' ' - .... . .
00 D I usually enjoy my work. '
01 D lseldom feel tired and rundown (except after strenuous work)? -
02 D lfall asleep easily at bedtime.
03 D I usually get a full night's sleep.
04 D If awakened. it is usually easy for me to go to sleep again
05 D I rarely bite or pick at my nails.
06 D Rather than worrying. I can temporarily shelve my problems and enjoy myself at

D times when i can do nothing about solving them immediately.
07 D I leel financially secure.
Total 08 D lam content with my sexual life.

Checked 09 D I meditate or center myself for 15 to 20 minutes at least once a day.‘

 

2. PERSONAL CARE AND HOME SAFETY

10 D I take measures to protect my living space from fire and safety hazards (such as
imprOper sized fuses and storage of volatile chemicals).

11 D I have a dry chemical fire extinguisher in my kitchen and at least one other
extinguisher elsewhere in my living quarters. (If very small apartment. kitchen
extinguisher alone is adequate).'

12 D I regularly use dental floss and a soft toothbrush.‘

13 D I smoke less than one pack of cigarettes or equivalent cigars or pipes
per week.

14 D I don't smoke at all (it this statement is true. mark item above true as well).

15 D I keep an up-to-date record of my immunizations.

16 D I have fewer than three colds per year.’

17 D I minimize my exposure to sprays, chemical fumes or exhaust gases.‘

18 D I avoid extremely noisy areas (or wear protective ear plugs).'

19 D I am aware of changes in my physical or mental state and seek professional
advice about any which seem unusual.

WOMEN
100 D I check my breasts for unusual lumps once a month.
101 D l have a pap test annually.

MEN

D 102 D If uncircumcised. I am aware of the special need for regular cleansing under
Total myloreskin.
‘Checked 103D Ifover45. Ihavemyprostatecheckedmally.

 

. Ahasteriskattl'ieendhofastatemntindicetesthattl'iereisafootnoteforthat .
statementonthelastpege. - ‘ '

Total
Checked

Total
Checked

Total
Checked

125

 

3. NUTRITIONAL AWARENESS

20 D I eat at least one uncooked truit or vegetable each day.‘

21 D I have fewer than three alcoholic drinks (including beer) per week

22 D I rarely take medications. including prescription drugs.

23 D I drink fewer than live soft drinks per week‘

24 D I avoid eating refined foods or foods with sugar added.

25D Iadd Iittlesaltto myfood. '

26 D I read the labels tor the ingredients of the toods I buy

27 D I add unprocessed bran to my diet to provide roughage. '

28 D I drink lower than three cups of coffee or tea (with the exception of herbal teas)
a day.‘

29 D I have a good appetite and maintain a weight within 15% of my ideal weight.

 

4. ENVIRONMENTAL AWARENESS'

30 D I use public transportation or car pools when possible.

31 D I turn oft unneeded lights or appliances.

32 D I recycle papers. cans. glass. clothing. books and organic waste (mark true if
you do at least three of these).

33 D I set my thermostat at 68° or lower in winter.

34 D I use air conditioning only when necessary and keep the thermostat at 76°
or higher.

35 D I am conscientious about wasted energy and materials both at home and at work.

36 D I use nonpolluting cleaning agents.

37 D My car gets at least 18 miles per gallon. (If you don't own a car. check this
statement as tme).

38 D l have storm windows and adequate insulation in attic and walls. (It you don‘t
own your home or live in a mild climate. check this statement as true).

39 D I have a humidifier tor use in winter. (If you don't have central heating check this
statement as true).'

 

5. PHYSICAL ACTIVITY /

40 D l climb stairs rather than ride elevators.

41 D My daily activities include moderate physical effort (such as rearing young
children. gardening. scrubbing floors. or work which involves being on my feet.
etc).

42 D My daily activities include vigorous physical eflort (such as heavy construction
work. farming. moving heavy objects by hand. etc).

43 D I am at least one mile twice a week (or equivalent aerobic exercise).'

44 D I run at least one mile four times a week or equivalent (if this statement is true.
mark the item above true as well).‘

45 D I regularly walk or ride a bike tor exercise.

46 D Iparticipate in astrenuous sport silentonceaweek.

47D Iparticipate II'l astrenuous sportmorethanonceaweek (iftl'iisstatementis
true. marktheitemabcvetrueaswell). . ‘

48 D I do yoga or some form at stretching-Iimbering exercise for 15 to 20 minutes at
least twice per week.‘

49 D I do yoga orsome form otstretching exercise tor15t020 minutes at least
four times per week (it this statement is true. mark the item above true as well).

 

126

 

. e. EXPRESSION OF EMOTIONS mo FEELINGS ' .

50D Iamfrequentlyhappy. ‘ '.

51 D lthinkitisOKtofeel angry. afraid. joyfulorsad. ‘

52 D I do not deny my anger. fear. joy or sadness. but instead find constructive ways
to express these feelings most of the time.

53 D I am able to say ‘no' to people without feeling guilty.

54 D Itiseasyformeto laugh.

55 D I like getting compliments and recognition from other people.

D 56D lfeeIOKaboul crying.andallowmyselftodoso.‘
57 D I listen to and think about constructive criticism rather than react defensively.
Total 58 D I would seek help from friends or professional counselors if needed.

Checked 59 D It is easy for me to give other people sincere compliments and recognition.

 

7. COMMUNITY INVOLVEMENT

60 D I keep informed of local. national and world events.

61 D I vote regularly.

62 D I take interest in community. national and world events and work to support
issues and people of my choice. (If this statement is true. mark both items
above true as well.)

63 D When I am able. I contribute time or money to worthy causes.

64 D I make an attempt to know my neighbors and be on good terms with them.

65 D If I saw a crime being committed. I would call the police.

66 D If I saw a broken bottle lying in the road or on the sidewalk. I would remove it.

67 D When driving. I am considerate of pedestrians and other drivers.

D 68 D If I saw a car with faulty lights. leaking gasoline or another dangerous condition.
I would attempt to inform the driver.
Total 69 D I am a member of one or more community organizations (social change group.
Checked singing group. club. church or political group).

 

8. CREATIVITY. SELF EXPRESSION

70 D I enjoy expressing myself through art. dance. music. drama. sports. etc.

71 D I enjoy spending some time without planned or structured activities.‘

72 D I usually meet several people a month who I would like to get to know better.
73 D I enjoy touching other people.‘

74 D I enjoy being touched by other people.‘

75 D I have at least five close friends.

D 76 D At times I like to be alone.
77 D I like myself and look forward to the future.
Total 78 D I look toward to living to be at least 75.‘

Checked 79D Ifinditeesytoexpreasconcem.bveandwannhtohoulcareabout

127

9. AUTOMOBILE SAFETY

Ifyoudon'town anautomobile and ridelessthan 1.000 milesperyearin one.
enter 7 points in the box at left and skip the next 10 questions. (If you ride more
than 1.000 miles per year but don‘t own a car. answer as many statements

as you can and show this copy to the car’s owner.)

80 D I never drink when driving.
81 D Iwearalapsafety belt at least90°loofthetimematlrideina car.‘
81 a D I wear a shoulder-lap belt at least 90% of the time that I ride in a car. (If this
statement is true. mark the item above true as well.)‘
82 D I stay within 5 mph of the speed limit
83 D My car has head restraints on the front seats and I keep them adjusted high
enough to protect myself and passengers from whiplash injuries.‘
84 D I frequently inspect my automobile tires. lights. etc. and have my car serviced
regularly.
85 D I have disc brakes on my car.‘
D 86 D I drive on belted radial tires.‘
87 D I carry emergency flares or reflectors and a fire extinguisher in my car.
Total 88 D I stop on yellow when a traffic light is changing.
Checked 89 D For every 1 0 mph of speed. I maintain a car Iength's distance from the car
ahead of me.

—

10. PARENTING

If you don't have any responsibility for young children. enter 7 in the box at left and
skip the next 10 questions. (If some of the questions are not applicable because your

children are no longer young. answer them as you would if they were youngsters
again.)

90 D When riding in a car. I make certain that any child weighing under 50 pounds is
secured in an approved child's safety seat or safety harness similar to those
sold by the major auto manufacturers.‘

91 D When riding in a car. I make certain that any child weighing over 50 pounds is
wearing an adult seat belt/shoulder hamess.‘

92 D When leaving my child(ren). I make certain that the person in charge has the
telephone numbers of my pediatrician or a hospital for emergency use.

93 D I don‘t let my children ride escalators in bare feet or tennis shoes.‘

94 D I do not store cleaning products under the sink or in unlocked cabinets where a
child could reach them.

95 D I have a lock on the medicine cabinet or other places where medicines are
stored

96 D I prepare my own baby food with a babyfood grinder—thus avoiding commercial
foods."
D 97 D I have sought information on parenting and raising children.
Total 98D lfrequentlytouchorholdmychildren.
Checked 99D Irespectmychildasanevolving.growingbeing.

- ENTER SUBTOTALS ON BACK COVER

 

128

FOOTNOTES

Numbers before each statement refer to a statement above. Numbers following statements indicate
references (next page). --

01. Fatigue without apparent cause is not a normal condition and usually indicates illness. stress or
denial of emotional expression. (14)

09. Meditation or centering greatly enhances one‘s sense of well being. (1 . 2. 12. 13)

11. Many injuries and much damage can be prevented by putting out fires when they first start. Dry
chemical or CO: fire extinguishers are necessary for oil. grease and electrical tires.

12. Regular flossing and using a good soft toothbrush with rounded tip bristles prevent the premature
loss of teeth in one’s 405 and 505. Be sure to Ieam the proper techniques of use from a dental
hygienist or dentist. (3)

16. If you have more than three colds a year. you may not be getting enough rest. eating a good diet or
meeting other energy needs properly. (4)

17. All such toxins have a harmful effect on the liver and other tissues over long periods of time.

18. Very loud noises which leave your ears ringing can cause permanent hearing loss which
accumulates and is usually not noticeable until one reaches 40 or 50. Small cushioned ear plugs
(not the type designed for swimmers). wax ear plugs and accoustic ear muffs (which look like
stereo headphones without wires) can often be purchased in sporting goods stores.

20. Fresh fruits and vegetables provide vitamins, minerals. trace nutrients and roughage which are
often lacking in modern diets. (5. 11)

23. Soft drinks are high in refined sugar which provides only 'empty' calories and usually replace
foods which have more nutritional value. Artificially sweetened soft drinks consumed in excess may
have long-range consecuences as yet not known. (Both types of soft drinks contain caffeine or
other stimulants.)

25. Salting foods during cooking draws many vitamins out of the food and into the water which is
usually discarded Heavy selling of foods at the table may cause a strain on the kidneys and result
in high blood pressure. (4)

27. Wheat bran. usually removed in the commercial milling of wheat is the single best source of dietary
fiber available. The use of approximately two tablespoons per day (individual needs vary) can
substantially reduce cplon cancer. diverticulOSis. heart disease and other conditions related to
refined food diets.

28. Coffee and tea (other than herbal teas) contain stimulants which. if abused. do not allow one‘s body
to function normally. (4)

ENVIRONMENTAL AWARENESS. Taking care of your environment affects your own wellness as well
as everyone else‘s.

39. Humidified heated air allows one to set the thermostat several degrees lower and still feel as warm
as without humidification. It also helps prevent many respiratory ailments. House plants will require
less watering and will be happier too.

43. 44. Vigorous aerobic exercise (such as running) must keep the heart rate at 150 beats per minute for
12 to 20 minutes to produce the "training effect.“ Less vigorous aerobic exercise (lower heart rate)
must be maintained for much longer periods to produce the same benefit. The ‘training effect“ is
necessary to prepare the heart for meeting extra strain. (6)

48. Such exercise prevents stiffness of joints and musculoskeletal degeneration. It also promotes a
greater feeling of well-being. (7)

51. Basic emotions. if repressed. often cause anxiety. depression, irrational behavior or physical
disease. People can releam to feel and express their emotions with a resulting improvement in
their well-being. Some people. however. exaggerate emotions to control and manipulate others:
this can be detrimental to their well-being. (8. 9)

52. Learning ways to constructively express these emotions (so that all parties concerned feel
better) leads to more satisfying relationships and problem solving. (8. 9)

56. Crying over a loss or sad event is an important discharge of emotional energy. It is. however.
sometimes used as a manipulative tool. or as a substitute expression of anger. Many males in
particular have been erroneously taught that it is not OK to cry. (8)

.—

129

W

FOOTNOTES (conl'd)

71. Spending time spontaneously without relying on an external structure can be self-renewing. (8)

73. 74. Physical touch is important for the maintenance of life for young children and remains important
throughout adult life. (10)

78. With proper self care. most individuals can easily reach this age in good health.

81. Shoulder/ lap belts are much safer than lap belts alone. (Shoulder belts should never be worn
without a lap belt)

83. Whiplash injuries can be prevented by properly adjusted head restraints. These are required. in
the US. on the front seats of all autos made since 1968 but are often not raised high enough to
protect passengers and driver.

85. Disc brakes provide considerably better braking power than conventional drum brakes.

86. For most cars. radial tires maintain firmer contact with the road and improve braking and handling
better than bias ply tires. They also have less rolling friction and give better gas mileage.

90. 91 . Over 1.000 young children a year are killed in motor vehicle accidents In the US. Many deaths can
be prevented by keeping the child from flying about in a car crash. Most car seats do not provide
enough protection—as government Standards are very low. Check consumer magazines for
up-to-date information. Never use an adult seat belt for a child weighing less than 50 pounds.

93. The bare feet of young children are often injured at the end of escalators. Wearing tennis shoes
is equally dangerous because their sturdy long laces get pulled into the mechanism and their
thin canvas walls offer little protection.

96. Commercial baby foods contain high amounts of sugar. salt. modified starches and preservatives
which may adversely affect a baby's future eating habits and health. Federal legislation has been
introduced to help correct this problem. Ponable baby food grinders and blenders can be used to
prepare for an infant the same food as eaten by the rest of the family. Individual servings can be
packaged and frozen for future meals.

REFERENCES
SCORING 1. Human Life Styling - McCamy
2. Be Here Now - Ram Dass
Eme' SUDFOlBIS "0m 3. The Tooth Trip - McGuire
each section below 4. Well Body Book - Samuels and Bennett
and compute your '0‘“ 5. Nutrition Against Disease - Williams
500' e. 6. The New Aerobics and Aerobics for Women - Cooper
7. Fundamentals of Yoga - Mishra
8. Born to Win - James and Jongeward
1 D PRODUCTIVITY 9. The Angry Book - Rubin
10. Touching - Montague
2 D CARE 8‘ SAFETY 11. Diet Ibra Small Planet ~ Lappe
3 D NUTRITION 12. Center Of the Q’CIODE nUIIy
13. The Crack in the Cosmic Egg - Pearce
4 D ENV'RONMENT 14. Stress - McOuade a Aiken
s [:1 PHYSICAL
s [j EMOTIONS
7 D COMMUNITY
Copies available from:
8 D CHEM-W” ' . Wellness Resource Center
. , - , 42 Miller Ave.
9 D AUTO , Mill Valley. CA 94941
10 D PARENTING , Single copies $1.00
Bulk rates on request

Total

APPENDIX B

NEUTROPHIL SLIDES

130

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APPENDIX C

IMAGERY INSTRUCTIONS

135

APPENDIX C

IMAGERY INSTRUCTIONS

General Imagery

 

This is a tape that will help you relax. All you have to do
is just relax and listen to the tape. Don't worry about the time
because I will let you know when the time is up. Just relax and
listen to the instructions on the tape.

First of all, I would like for you to be sitting in a way that
you can be very relaxed and very comfortable. I will give you a
few seconds to situate yourself in the chair so that your anns and
legs can be relaxed and comfortable and so that your back can be
supported. Lean the chair as far back as is comfortable for you.

Now I would like for you to pick a spot on the wall or ceiling,
comfortably look at it, and as I count downwards from 10, I want you
to continue to stare at the spot, until your eyes become very heavy.
10, 9, 8, 7, 6, 5, 4, 3, 2, 1. Now gently close your eyes and just
concentrate on my voice. Take some deep breaths, breathing slowly
and deeply, letting the air come in and go out. Each time you breathe
out, let some of the tension leave your body. Breathe in; breathe out.
As you breathe in, say to yourself--I am; as you breathe out, say to
yourself--relaxed. Iam--relaxed. (Pause) Let that relaxed feeling
spread all over your body. Now, think for a moment about your feet.

Let all of the tension flow out of your feet. Let the muscles become
136

137

very loose and very smooth; very warm. Imagine the blood warming
your feet, making them tingly. (Pause) Think for a moment about
your legs, your lower legs, your calves. Let all the tension dissolve
out of them, melting away, making them soft and smooth. Your upper
legs, your thighs, let them become very warm. Now, at the count of
3,] would like you to be twice as relaxed as you are now. 1, 2, 3.
(Pause) In your mind's eye, concentrate for a moment on your hips,
letting them come very loose. And now, relax your abdomen. Just let
go of all the tension in your abdomen. Let the blood flow through
like the wind through the wheat, carrying good oxygen to all of your
body. (Pause) Continue to breathe regularly and deeply. (Pause)
Think for a moment about the many muscles in your back . . . Mentally,
tell them to relax, to let go of all the tension and stress and
anxiety that they may be showing. Imagine the tension knots in your
back and in your shoulders dissolving, melting, going away. The
muscles in your neck, relax - become very soft - just let them go.
All up and down the back of your head and the top of your head, let
the tension free, flowing out. Allow the tiny muscles around your
eyes to relax, around your jaw. Now, if you are still feeling any
pain or tension in some part of your body, I'm going to pause for a
moment and let you concentrate on that area. (Pause) Just let it
relax. (Pause)

Now, while your body is quiet and relaxed, imagine yourself
at the seashore. Imagine a quiet, empty beach with waves gently

billowing onto the sand. Experience the sand between your toes.

138

(Pause) the smell and taste of the salt water’ (Pause) and the
sound of the waves as they roll in onto the sand. (Pause)

When you feel yourself very comfortable in this relaxing
place, look around for a person or an animal. (Pause) If you don't
see it at first, keep looking. (Pause)

When the figure appears, ask it to talk with you. (Pause)

Allow yourself to be with this figure as comfortably as you
would be with a friend in your own living room. It is a part of you.
It is your own creation. It is benign. It is there to help you.
(Pause)

When you feel comfortable and accepting of your adviser, ask
it any questions you would like to ask. (Pause)

Then wait patiently and receptively for the answer. (Pause)

If an answer doesn't come immediately, ask your adviser how
you can find the answer to your question. (Pause)

Keep asking questions until you have the answers that you

have sought. (Long Pause)

DUB OCEAN SOUNDS

When your answers come and you feel satisfied that they are
what you sought, thank your advisor and tell it that you will return
again to visit with it. (Pause)

Allow yourself to come back into the here and now of outer
reality.

Allow yourself to feel good and to feel that you have found

out something you wanted to know.

139

Allow yourself to use the information you have received with
wisdom and love.

Allow yourself to return to the relaxing place where you meet
with our adviser whenever you feel a need for guidance.

Now, when you're ready, slowly let the muscles in your eye-

lids lighten up, become ready to open your eyes, and become aware of

the room around you.

Specific Imagery

 

This exercise will help you relax and understand how your body
works. Everyone participates in his or her health or illness to some
degree. You participate in your health through your beliefs, your
feelings and yout attitudes toward life as well as in more direct ways,
such as through exercise and diet. Your mind can help create
susceptibility to illness but it can also contribute to health. Your
white blood cells are a part of your body's natural defense system for
controlling and defeating infectious processes such as viruses. We
know that white blood cells have as a purpose getting rid of anything
they see as not being a part of the self. They remember very well and
can combat old fonns of illness. White blood cells profit from being
exercised and used. We are attempting to study the extent to which
you can influence these cells, particularly the shape and movement of
your white blood cells simply by visualizing them becoming more
flexible and sticky, and being able to leave the blood stream and to
go to the parts where they may be needed. During the next few
minutes you will have an opportunity to exercise your white blood
cells. All you have to do is just relax and listen. Don't worry
about the time because I will let you know when the time is up. The
entire process will take about 20 minutes. Just relax and listen to

the instructions.

140

141

First of all I would like for you to be sitting in a way you
can be very relaxed and comfortable. I'll give you a few seconds to
situate yourself in the chair so that your arms and legs can be
relaxed and comfortable, and so that your back and your head are
supported. Lean in the chair as far back as is comfortable for you.
(Pause) Now I would like for you to pick a spot on the wall or ceiling,
comfortably look at'Hg then kind of let your eyes go soft. Take a deep
breath, hold it, and then push it all out. Resume normal breathing,
and just notice your breath. As I count downwards from 10, continue
to stare at the spot until your eyes become very heavy. Ten, nine,
eight, seven, six, five, four, three, two, one. Now gently close your
eyes and just concentrate on my voice. Breathe in slowly and deeply.
Breathe in warmth and heaviness and comfort. Breathe out any tension.
As you breathe in, say to yourself under your breath, "I am," and
as you breathe out, say to yourself, "relaxed," "I am . . . relaxed,"
"I am . . . relaxed." (Pause) Let any kind of thoughts that come
into your head just kind of pass through and by, or any noises that
you might hear just kind of note them and let them pass through.
(Pause) Let your body begin to quiet down. You've let yourself quiet
down, and you feel your body getting more and more quiet, and perhaps
you can hear and feel your pulse, perhaps in your throat or in some
other part of your body. Feel your blood pulsing, carrying warmth
and relaxation throughout your body, flowing slowly throughout your
body. Feel the kind of strength and power in your blood carrying
soothing warmth and relaxation. (Pause) Imagine your white blood

cells and feel yourself becoming a part of them. Imagine them moving

142

around in your blood stream. See if you can imagine your white blood
cells becoming more flexible, pliant, changing shape and form, getting
longer. Imagine them being able to get more sticky and adhere to
various parts of the vessel wall and to each other, getting stickier
and stickier so they can attach to the blood vessel wall. (Pause)
Imagine the sticky cells beginning to squeeze through the blood vessel
\Nans, going to places in the body where there is garbage collected-—
old cells, kind of useless, or weak and confused. Imagine your white
blood cells, oh, perhaps as garbage collectors of some sort, picking
up the garbage in your body and taking it away, dumping it outside
your body somewhere. Continue to imagine your white blood cells
becoming more flexible and sticky and moving from the blood stream. (Pause)

When you're ready, at your own pace, slowly let the muscles
ofjw1W'eyelids lighten up. Let the muscles of your body kind of come
back to life and get light, and wiggle your toes and your fingers.

And you can open your eyes and become aware of the room around you.

In a few minutes someone will come in to take another blood
sample. Stay relaxed and seated until after the blood sample is
taken, then someone else will be coming in to ask you a few questions
about what you have been imagining.

Just let yourself relax and feel good about yourself.

APPENDIX D

IMAGERY AND LEUKOCYTE ARTICLES

143

1
The Mind-Body Connection:
A Psychological Approach
to Cancer Treatment

Everyone participates in his
or her health or illness at all times.

This book will show people with cancer or other
.serious illnesses how they can participate in getting
well again. It will also show those who are not ' 1 how
they can participate in maintaining their health.

We use the word participate to indicate the vital role
you play in creating your own level of health. Most of
us assume that healing is something done to us, that if
we have a medical problem our responsibility is simply
to get to a physician who will then heal us. That’s true
to a degree, but it is only part of the story.

We all participate in our own health through our be-
liefs, our feelings, and our attitudes toward life, as well
as in more direct ways, such as through exercise and
diet. In addition, our response to medical treatment is
influenced by our beliefs about the effectiveness of the
treatment and by the confidence we have in the medi-
cal team.

This book in no way minimizes the role of the physi—
cian and other health professionals engaged in medical
treatment. Rather, Getting Well Again will describe what
you can do in conjunction with medical treatment to
gain the health you deserve.

Understanding how much you can participate in
your health or illness is a significant first step for
everyone in getting well. For manyof our patients it is
the critically important step. It may well be for you,
too.

T44

145

4 The Mind and Cancer

We are Carl and Ste hanie Simonton, and we oper-
ate the Cancer Counse ing and Research Center in Fort
Worth, Texas. Carl, the medical director of the center, is
a radiation oncologist, a physician specializing in the
treatment of cancer. Stephanie is director of counseling
and is trained in psychology.

Most of our patients, who come to us from all over
the country, have received a ”medically incurable”
diagnosis from their doctors. According to national can-
cer statistics, they have an average life expectancy of
one year. When these people believe that only medical
treatment can help them — but their physicians have
said that medicine is no longer of much avail and that
they robably have only a few months to live -—- they
feel oomed, trapped, helpless, and usually fulfill the
doctors’ expectations. But if patients mobilize their own
resources and actively participate in their recover ,
they may well exceed their life expectancy and signi i-
cantly alter the quality of life.

The ideas and techniques described in this book are
the approach we employ at our Cancer Counseling and
Research Center to show cancer patients how they can
participate in getting well again and live a rewarding
and fulfilling life.

THE STARTING POINT:
THE ”WILL TO LIVE”

Why do some patients recover their health and others
die, when the diagnosis is the same for both? Carl be-
came interested in this problem while he was complet-
ing his residency as a cancer specialist at the University
of Oregon Medical School. There he noticed that pa-
tients who stated they wanted to live would often act
as if they did not. There were lung cancer patients who
refused to stop smoking, liver cancer patients who
wouldn’t cut down on alcohol, and others who
wouldn’t show up for treatment regularly.

In many cases, these were people whose medical

rognosis indicated that, with treatment, they could
ook forward to many more years of life. Yet while they

M6

The Mind-Body Connection 5

affirmed again and again that they had countless
reasons to live, these patients showed a greater apathy,
depression, and attitude of giving up than did a
number of others diagnosed with terminal disease.

In the latter category was a small group of patients
who had been sent home after minimal treatment, with
little expectation that they would live to see their first
follow-up appointment. Yet several years later, they
were still arriving for their annual or semiannual
examinations, remaining in quite good health, and in-
explicably beating the statistics.

When Carl asked them to account for their good
health they would frequently give such answers as, ”I
can’t die until my son graduates from college,” or
”1‘ hey need me too much at work,” or ”I won’t die
until I’ve solved the problem with my daughter." The
common thread running through these replies was the
belief that they exerted some influence over the course of
their disease. The essential difference between these pa-
tients and those who would not cooperate was in their
attitude toward their disease and their positive stance
toward life. The patients who continued to do well, for
one reason or another, had a stronger ”will to live.”
This discovery fascinated us.

Stephanie, whose background was in motivational
counseling, had an interest in unusual achievers -—
those people who in business seemed destined to go to
the top. She had studied the behavior of exceptional

erformers and had taught the principles of that be-

avior to average achievers. It seemed reasonable to
study cancer patients in the same way — to learn what
those who were doing well had in common, and how
they differed from those who were doing poorly.

If the difference between the patient who regains his
health and the one who does not is in part a matter of
attitude toward the disease and belief that he could
somehow influence it, then, we wondered, how could
we influence patients’ beliefs in that positive direction?
Might we be able to apply techniques from motiva-
tional psychology to induce and enhance a ”will to
live?” Beginning in 1969, we began looking at all the
possibilities, exploring such diverse psychological

147

6 The Mind and Cancer

techniques as encounter groups, group therapy, medi-
tation, mental imagery, positive thinking, motixational
techniques, "mind development” cou1ses like Silva
Mind Control and Mind Dynamics, and biofeedback.

From our study of biofeedback, we learned that cer-
tain techniques were enabling people to influence their
own internal body processes, such as heart rate and
blood pressure. An important aspect of biofeedback,
called visual imagery, was also a principal component
of other techniques we had studied. The more we
learned about the process, the more intrigued we be-
came.

Essentially, the visual imagery process involved a
period of relaxation, during which the patient would
mentally picture a desired goal or result. With the
cancer patient, this would mean his attempting to vis-
ualize the cancer, the treatment destroying it and, most
importantly, his body’ 5 natural defenses helping him
recover. After discussions with two leading biofeed-
back researchers, Drs. Joe Kamiya and Elmer Green, of
the Menninger Clinic, we decided to use visual imag—
ery techniques with cancer patients.

THE FIRST PATIENT:
A DRAMATIC EXAMPLE

The first patient with whom an attempt was made to
apply our deveIOping theories was a sixty-one-year—old
man who came to the medical school in 1971 with a
form of throat cancer that carried a grave prognosis.
He was very weak, his weight had dropped from 130
to 98 pounds, he could barely swallow his own saliva,
and was having difficulty breathing. There was less
than a 5 percent chance that he would survive five
years. Indeed, the medical school doctors had seriously
debated whether to treat him at all, since it was dis-
tinctly possible that therapy would only make him
more miserable without significantly diminishing his
cancer.

Carl went into the examining room determined to
help this man actively participate in his treatment. This

I48

\I

The Mind-Body Connection

was a case that justified using exceptional 111easures.
Carl began treating the patient b explaining how the
patient himself could influence tie course of his own
disease. Carl then outlined a program of relaxation and
mental imagery based on the research we had been ac-
cumulating. The man was to set aside three, five- to
fifteen-minute periods during the day — in the morn-
ing on arising, at noon after lunch, and at night before
going to bed. During these periods he was first to
compose himself by sitting quietly and concentrating
on the muscles of his body, starting with his head and
going all the way to his feet, telling each muscle group
to relax. Then, in this more relaxed state, he was to
picture himself in a pleasant, quiet place — sitting
under a tree, by a creek, or anywhere that suited his
fancy, so long as it was pleasurable. Following this he
was to imagine his cancer vividly in whatever form it
seemed to take.

Next, Car] asked him to picture his treatment, radia-
tion therapy, as consisting of millions of tiny bullets of
energy that would hit all the cells, both normal and
cancerous, in their path. Because the cancer cells
were weaker and more confused than the normal cells,
they would not be able to repair the damage, Carl sug-
gested, and so the normal cells would remain healthy
while the cancer cells would die.

Carl then asked the patient to form a mental picture
of the last and most important step — his body’s white
blood cells coming in, swarming over the cancer cells,
picking up and carrying off the dead and dying ones,
flushing them out of his body through his liver and
kidneys. In his mind’s eye he was to visualize his
cancer decreasing in size and his health returning to
normal. After he completed each such exercise, he was
to go about whatever he had to do the rest of the day.

What happened was beyond any of Carl’s previous
experience in treating cancer patients with purely
physical intervention. The radiation therapy worked
exceptionally well, and the man showed almost no
negative reaction to the radiation on his skin or in the
mucous membranes of his mouth and throat. Halfway
through treatment he was able to eat again. He gained

149

8 The Mind and Cancer

strength and weight. The cancer progressively disap-
peared.

During the course of treatment ——-— both the radiation
therapy and the mental imagery —- the patient re-
ported missing only one mental imagery session on a
day when he went for a drive with a friend and was
caught in a traffic jam. He was most upset, both with
himself and with his friend, for in missing just that one
session he felt his control over his condition was slip-
ping away.

Treating this patient in this way was very exciting,
but it was also somewhat frightening. The possibilities
for methods of healing that seemed to be opening up
before us went beyond anything that Carl’s formal
medical education had prepared him for.

The patient continued to progress until finally, two
months later, he showed no signs of cancer. The
strength of his conviction that he could influence the
course of his own illness was evident when, close to
the end of his treatment, he said to Carl: ”Doctor, in
the beginning I needed you in order to get well. Now I
think you could disappear and I could still make it on
my own."

Following the remission of his cancer, the patient de-
cided on his own to apply the mental imagery
technique to alleviate his arthritis, which had troubled
him for years. He mentally pictured his white blood
cells smoothing over the joint surfaces of his arms and
legs, carrying away any debris, until the surfaces be-
came smooth and glistening. His arthritic symptoms
progressively decreased, and although they returned
from time to time, he was able to diminish them to the
point where he could go stream fishing regularly, not
an easy sport even without arthritis.

In addition, he decided to use the relaxation and im-
agery approach to influence his sex life. Although he
had suffered from impotence for over twenty years,
within a few weeks of practicing the imagery tech-
niques he was able to resume full sexual activity, and
his condition in all of these areas has remained healthy
for over six years.

150

The Mind-Body Connection 9

It is fortunate that the results of this first case were
as dramatic as they were, for as we began to talk
openly in medical circles about our experiences and to
put forward the idea that patients had a much larger
influence over the course 0 their disease than we gave
them credit for, we received strong negative reactions.
Indeed, there were many times when we, too, doubted
our own conclusions. Like everyone else — and par-
ticularly anyone with medical training — we had been
taught to see illness as ”happening" to people, without
any possibility of individual psychological control over
its course, or little cause-and-effect relationship be-
tween the illness and what was going on in the rest of
their lives.

However, we continued to use this new approach to
cancer. Although it sometimes made no difference in
the illness, in most cases it made significant changes in
patients' responses to treatment. Today, in the more
than seven years since Carl worked with that first pa-
tient, we have evolved a number of other processes in
addition to mental imagery that we have used with pa-
tients, first at Travis Air Force Base, where Carl was
chief of radiation therapy, and now at our center in
Fort Worth. These techniques are the basis of “Path-
ways to Health," Part Two of Getting Well Again.

A WHOLE-PERSON APPROACH TO
CANCER TREATMENT

Because cancer is such a dread disease, the minute
people know someone has cancer, it often becomes the
person’s defining characteristic. The individual may
play numerous other roles — parent, boss, lover —
and have numerous valuable personal characteristics
— intelligence, charm, a sense of humor — but from
that moment on he or she is a ”cancer patient.” The
person's full human identity is lost to his or her cancer
identity. All anyone is aware of, often including the
physician, is the physical fact of the cancer, and all
treatment is aimed at the patient as a body, not as a
person.

.4
(.1!
.. .1

10 the Mind and Cancer

It is our central premise that an illness is not purely a
physical problem but rather a problem of the whole
person, that it includes not only body but mind and
emotions. We believe that emotional and mental states
play a significant role both in susceptibility to disease,
including cancer, and in recovery from all disease. We
believe that cancer is often an indication of problems
elsewhere in an individual’s life, problems aggravated
or compounded by a series of stresses six to eighteen
months prior to the onset of cancer. The cancer patient
has typically responded to these problems and stresses
with a deep sense of hopelessness, or ”giving up.”
This emotional response, we believe, in turn triggers a
set of physiological responses that suppress the body’s
natural defenses and make it susceptible to producing
abnormal cells.

Assuming our beliefs are essentially accurate — and
much of the next seven chapters will show you why
we hold them as strongly as we do — then it becomes
necessary for patient and physician in working toward
recovery to consider not only what is happening on a
physical level but, just as importantly, what is going on
in the rest of the patient’s life. If the total integrated
system of mind, body and emotions, which constitutes
the whole person, is not working in the direction of
health, then purely physical interventions may not
succeed. An effective treatment program, then, will
deal with the total human being and not focus on the
disease alone, for that would be like trying to treat a
yellow fever epidemic with sulfa alone, without also
draining the ditches in which the sickness-bearing
mosquitoes breed.

THE RESULTS OF THIS APPROACH

After three years of teaching patients to use their
minds and emotions to alter the course of their malig-
nancies, we decided to conduct a study aimed at dis—
tinguishing the effects of emotional and medical treat-
ments to demonstrate scientifically that the emotional
treatment was indeed having an effect.

152

The Mind-Body Connection 1]

We began studying a group of patients with malig-
nancies deemed medically incurable. Expected survival
time for the average patient with such a malignancy is
twelve months.

In the past four years, we have treated 159 patients
with a diagnosis of medically incurable malignancy.
Sixty-three of the patients are alive, with an average
survival time of 24.4 months since the diagnosis. Life
expectancy for this group, based on national norms, is
12 months. A matched control population is being de-
veloped and preliminary results indicate survival com-
parable with national norms and less than half the sur-
vival time of our patients. Nth the patients in our
study who have died, their average survival time was
20.3 months. In other words, the patients in our study
who are alive have lived, on the average, two times
longer than patients who received medical treatment
alone. Even those patients in the study who have died
still lived one and one-half times longer than the con-
trol group.

As of January 1978, the status of the disease in the
patients still living is as follows:

Number
of patients Percent
No evidence of disease 14 22.2%
Tumor regressing 12 19.1%
Disease stable 17 27.1%
New tumor growth 20 31.8%

Keep in mind that 100 percent of these patients were
considered medically incurable.

Of course, duration of life after diagnosis is only one
aspect of the disease. Of equal (or perhaps greater) im-
portance is the quality of life while the patient sur-
vives. There are few existing objective measures of
quality of life; however, one measure we keep is the
level of daily activity maintained during and after
treatment compared to the level of activity prior to
diagnosis. At present, 51 percent of our patients main-
tain the same level of activity they had prior to the

153

12 The Mind and Cancer

diagnosis; 76 percent are at least 75 percent as active as
they were prior to diagnosis. Based on our clinical ex—
perience, this level of activity for "medically incurable"
patients is no less than extraordinary.

The results from our approch to cancer treatment
make us confident that the conclusions we have drawn
are correct — that an active and positive participation
can influence the onset of the disease, the outcome of
treatment, and the quality of life.

Some people may be concerned that we are offering
"false hope," that by suggesting people can influence
the course of their disease we are raising unrealistic
expectations. It is true that the course of cancer differs
so dramatically from person to person that we would
not presume to offer guarantees. There is always un-
certainty, as there is with standard medical procedures,
but hope, we feel, is an appropriate stance to take to-
ward uncertainty.

As we shall see in detail in future chapters, expec—
tancy, either positive or negative, can play a significant
role in determining an outcome. A negative expecta-
tion will prevent the possibility of disappointment, but
it may also contribute to a negative outcome that was
not inevitable.

There are no guarantees at this time that a positive
expectation of recovery will be realized. But without
hope the person has only hopelessness (a feeling that,
as we will see, is already too much a part of the cancer
patient’s life and personality). We do not deny the pos-
sibility of death; indeed, we work hard with ourgpa-
tients to help them confront it as a possible outcome.
We also work to help them believe that they can influ-
ence their condition and that their mind, body, and
emotions can work together to create health.

THEORY INTO PRACTICE

Getting Well Again is divided into two major parts.
The first describes the theory on which our psychologi-
cal approach to cancer treatment is based; the second
presents a program for recovery for patients and their

154

The Mind-Body Connection l3

families. The chapters in Part One, ”The Mind and
Cancer,” are not an effort to prove the validity of this
approach to the scientific community. Rather, they are
an effort to provide a simple, straightforward explana-
tion so that you can evaluate for yourself whether our
approach is reasonable and whether you wish to use it.

Part Two begins “Pathways to Health,” the program
we use with our patients at the Cancer Counse ing and
Research Center in Fort Worth. We urge you to try the
specific techniques. Reading about them but not prac-
ticing them is no more effective than filling a prescrip-
tion and not taking the pills. By participating in the
program, you will participate in your health.

In the final chapter, we turn to the problems of living
with a loved one who has a life-threatening disease.
We describe some of the communication problems that
occur, the kaleidoscope of feelings, and the possibility
of increased closeness and love from the experience. If
you have cancer, we not only encourage you to read
this chapter but to give it to your Spouse, your chil-
dren, your family, and your close friends.

We invite all our readers to join us in the search for
new methods for recovering from illness and maintain-
ing health.

155

2
The Mysteries of Healing:
The Individual and His Beliefs

The awesome technology
of modern medicine casts an image of such great po-
tency and knowledge that it is hard to believe our indi-
vidual resources can make much difference. Of course,
no one would responsibly dismiss the advances of
medicine in this age. Its accomplishments are among
the greatest products of the human mind. I11 cancer
treatment alone, great advances have been made in
radiation therapy, in sophisticated procedures for
chemotherapy, and in surgical techniques. As a result
of this technology, from 30 to 40 cpercent of all cancer
patients will be ”cured" of their isease.

Some cancer patients receive their treatment from
machines housed in special rooms posted with signs
warning of the dangers of radiation. The patients are
left alone to wonder why, if the treatment is supposed
to do so much good, all the medical staff members
avoid it so. Other machines emit such loud noises and
whines that the patient must wear earmuffs. The latest
diagnostic equipment is so vast that the patient is
wheeled into the machine, where scans may be taken
of cross sections of the body. Surgical teams use in-
credibly sophisticated and expensive equipment in
hours-long Operations involving the most elaborate
procedures. The technology is brilliant and powerful.
Some cancer therapies are so potent, in fact, that pa-
tients fear the side effects of the treatment as much as
the disease itself.

156

The Mysteries of Healing l'i

So much time, money, and knowledge have gone
into our medical technology that it is easy to think of
medical science as all-powerful. But when, in spite of
everything, people still die, it is illness that seems all-
powerful. The glittering machines, the giant lab-
oratories, and the genuine medical accomplishments
of our time can cause us to forget that many of
the essential ingredients of healing are still mysterious.
It is im ortant that we remember the limits of our
knowledge.

THE IMPORTANCE OF THE INDIVIDUAL

There is no cancer specialist who has not asked him—
self why one patient died whereas another, with virtu-
ally the same prognosis and the same treatment, re-
covered. Such a situation occurred with two patients
who participated in our program. Each received the
best available medical treatment. Each participated in
the processes and techniques described in this book.
But their responses were very different. Jerry Green
and Bill Spinoza (fictitious names) had virtually identi-
cal diagnoses of lung cancer, which had also spread to
the brain.

The day he received his diagnosis, Jerry resigned
from life. He quit his job and, after taking care of his
financial affairs, he settled in front of the television set,
staring blankly hour after hour. VV1thin twenty-four
hours he was experiencing severe pain and lack of
energy.

No one was able to get him interested in much of
anything. He did remember that he had always
wanted to make some bar stools for the house, so for a
week or two he worked in his shop, with some signs of
increased energy and reduced pain. But as soon as the
bar stools were completed, he returned to the TV. His
wife reported that he did not really watch it as much as
he watched the clock, for fear that he would miss the
time for taking his pain medication. Jerry showed no
signs of response to radiation therapy, and within

157

16 The Mind and Cancer

three months he was dead. Jerry’s wife later recalled
that both his parents and many of his close relatives
had died of cancer, and in fact, Jerry had warned her
when they were first married that he would die of
cancer, too.

Bill Spinoza was also diagnosed with cancer of the
lung, which had spread to his brain. The prognosis for
his survival and the treatment were nearly identical to
Jerry’s. But Bill’s response to the diagnosis was very
different. For one thing, he took the illness as a time to
review the priorities of his life. As a traveling sales
manager he had been constantly on the go and, he
said, had ”never taken time to see the trees.” Although
he continued working, he rearranged his schedule so
that he could take more time to do things that were
enjoyable to him.

At our clinic, he participated actively in the therapy
group and regularly used a mental imagery process he
had learned there. He responded favorably to radiation
therapy and became virtually symptom free. All the
while he remained active. Approximately a year and a
half after Bill left our program, he experienced several
major emotional blows and, within a short time, he
suffered a recurrence and died shortly thereafter.

Both patients had had the same diagnosis, both had
received the same treatment. Yet Bill outlived Jerry by
more than a year and considerably outlived the medi-
cal prognosis for that form of cancer. Furthermore, the
quality of life that Bill lived was quite different: he was
involved in life, active, enjoying his family and friends.
Each patient responded to his treatment in ways that
are not considered typical. Jerry’s decline was more
precipitous than would normally be expected. On the
other hand, Bill outlived his prognosis by many
months.

A MYSTERIOUS RECOVERY
While Bill and Jerry’s cases illustrate the differences

that the individual's personality can make, the mys-
teries of recovery are even more dramatically illus-

158

The Mysteries of Healing l7

trated in the case of Bob Gilley, a highly successful
insurance executive from Charlotte, North Carolina.
Bob had always had near-perfect health and, as a re-
sult, had never thou ht much about illness. For years
he had been an avid racquetball player. However, in
the months preceding his diagnosis Bob was aware
that he was ”down" emotionally, feeling discouraged
and depressed about some relationships in his life. But
when he went in for his annual physical examination
in 1973 he was ”feeling good” physically: in fact, he
had played a rather strenuous hour of racquetball the
morning of his exam.

By virtue of his business, Bob was very conscious of
the value of regular physical exams, although he usu-
ally approached them with boredom since they had
rarely turned up any signs of illness. The EKG, the
X-rays, the blood work were all normal, but after a
thorough examination, a lump was discovered in his
groin. A surgical biopsy was scheduled for the follow—
ing week.

Bob described his experience recently in a presenta-
tion to cancer patients and health professionals in-
terested in our approach: -

I was told that there would be a very small cut,
perhaps an inch in length, much like the incision
in an appendectomy. However, when I woke up
several hours after the biopsy, I found that they
had opened my whole abdomen, both vertically
and horizontally.

When the surgeon arrived, he told me it was
very hard to diagnose the particular kind of tissue
he had removed. It was some sort of a malignant
mass, but I had a good chance of pulling through
it. Early the next morning the chance was changed
to 50 percent. When my own doctor arrived on the
scene, the diagnosis was changed again. I was
given a 30 percent chance of survival.

After much debate, the pathologist, the on-
cologist, and the surgeon finally called it a ”sec-
ondary undifferentiated carcinoma." The chances
for my cure were dropped to less than 1 percent.

159

IN The Mind and Cancer

Bob was then sent to a very large cancer clinic for
chemotherapy treatment:

It was a bizarre experience. I arrived there very
weak from surgery and for an entire day sat in a
waiting room with hundreds of other cancer pa-
tients. Everyone seemed to be treated very imper-
sonally, but I’m sure it was just because of the
incredible case load. I became ”Undifferentiated
Carcinoma in Room 351-A."

When I was strong enough, I got passes for ev-
erything: passes to go for a walk in the park, pass—
es to go to breakfast, lunch, dinner — I even got
passes to go to the bathroom at the service station
across the street, because it was very important for
me to remain a member of the outside world and
not become a patient entombed in a cancer hospi—
tal. I got more passes than anybody in the history
of that clinic. I also ran my office from my hospital
bed.

The chemotherapy types and dosages were fi-
nally decided upon, and I was introduced to
another stressful aspect of cancer. Three-quarters
of the time I remained deathly ill. I lost all my hair,
my appetite, and a considerable amount of weight.
I was constant] nauseated, had diarrhea, burned
veins [veins irr1tated from chemotherapy], mouth
blisters, and was pallid and weak. In a very short
time I looked like a reject from a concentration
camp.

I could tell that in the eyes of all but a few
people — a very precious few who mattered — I
was a dying man. During my ten months of in-
tense chemotherapy, I was on a miracle chase,
working with nutrition, vitamin therapy, faith
healers, psychic readers, and so on. Many times I
would scream, ”Damn you, cancer! Get out of my

body?’

Bob made several trips back to the cancer clinic, re-
ceiving intensive chemotherapy. At the end of a ten-
month period he had reached the point where con-

160

The Mysteries of Healing It.)

tinued chemotherapr held little promise and high
danger of causing eterioration of the heart muscles.
And the mass in his groin had not diminished in size.

Bob heard about our program and attended one of
our patient sessions in Fort Worth. Prior to the meeting
he was sent some materials describing our work as
well as a tape recording that taught him the mental
imagery process. Although his initial stay was only for
a few days, the first session gave him renewed hope.
In Bob’s words: ”When I got off the plane in Charlotte,
my wife said, ’You look different.’ And Iwas different.
I had hope. I had returned home full of enthusiasm
and new direction."

Bob’s chemotherapy was discontinued and his local
oncologist evaluated him monthly. Bob found the dis-
cipline of practicing mental imagery regularly to be dif-
ficult but he kept it up. He also began to exercise regu-
larly and soon was able to play twenty minutes of light
racquetball. He began to build up slowly, regaining
some of his weight. But the spectre of cancer still hung
on. As he reported:

No medical differences showed up for two,
three, even four weeks. But I kept holding on to
the belief that this system would work. After six
weeks, I was examined by my doctor in Charlotte.
As he began probing my body, I can’t begin to de-
scribe the absolute terror that came over me.
”Maybe it’s spread!" I thought. ”Maybe it’s five
times bigger than it was before.” My doctor turned
to me in amazement and said with a very tender
expression, ”It is considerably smaller. As a matter
of fact, I would say that it's shrunk 75 percent in
mass size." We rejoiced together, but cautiously.

Two weeks later — which was only two months
after I had met the Simontons — I was given a gal-
lium scan and various other tests and examina-
tions. There was absolutely no disease present,
only a residual scar nodule about the size of a
small marble. Within two months of beginning re-
laxation and imagery, I was cancer-free! My doc-
tors in Charlotte didn't believe it.

161

20 The Mind and Cancer

Over the next few months Bob's energy and vitality
continued to increase, until he felt his energy and vital-
ity were as great as or greater than they had been be-
fore his diagnosis.

Bob still had a good deal of work to do. In sub-
sequent sessions with us, he began to resolve many of
the personal problems that had caused him to be emo-
tionally ”down" before the onset of the cancer. He also
worked hard on changing behaviors that were interfer-
ing with his relationships. At this writing, he continues
to show no evidence of cancer. In fact, he reports that:

Today my vitality is greater than before the
cancer. If I had no medical records, I could pass
any insurance exam in America. I don’t want to
sound overly confident, because I have many
down moments. Fears of the disease return when I
have abdominal pain from indigestion, for in-
stance. Sometimes I even doubt that all of this is a
reality, and my logical mind says, ”Maybe it was a
delayed effect of the chemotherapy, or maybe it
was the vitamins. Maybe there was no cancer
there to begin with.” But most of the time I feel
very confident that this was the way for me, and it
can be a way for many, many others.

Bob has done much to educate people in Charlotte
about the role patients can play in overcoming cancer
and has instituted a cancer counseling service known
as Dayspring. He sums up his experience by saying:
”I’ve learned a lot about my responsibility for my dis-
ease, my responsibility for healing, and about the
techniques for unlocking powers that can be found
within all of us.”

”SPONTANEOUS" REMISSION AND
THE PLACEBO EFFECT

Bob's case is dramatic because he did not appear to
respond well to standard medical treatment, yet four
years later he continues not to show any sign of cancer.

The Mysteries of Healing 2|

Ilis turnaround could have been a delayed response to
the chemotherapy, although most physicians would
not predict or expect such an occurrence. We believe
that his recovery had to do with Bob himself. It cannot
be attributed to a normal response to medical treat-
ment. This is an apparent case of spontaneous remis-
sion; it ”just happened."

When a disease does not proceed in ways that can be
explained by physical intervention, the result is called
”spontaneous.” The word covers today’s ignorance in
much the same way as the term "spontaneous genera-
tion" covered medical ignorance during the late Middle
Ages. In those times, no explanation was available as
to why living organisms, such as maggots, could grow
out of nonliving matter, such as spoiled foods, and so
it was said they were "spontaneously" generated. (It
was not until 1765 that Spallanzani showed that
when food was placed in airtight jars the living or-
ganisms that normally appeared in spoiled food did
not a pear. In other words, something in the air car-
ried t e larvae. When no air reached the food, there
was no ”spontaneous generation”) ”Spontaneous re-
mission," too, results from processes or mechanisms
that are not yet understood.

The number of spontaneous remissions from cancer
appears to be small, though all estimates are guesses
because we have no idea how many such remissions
take place before patients are diagnosed as having the
disease. Yet however many cases there are, none of
them is "spontaneous.” In each case there is some kind
of cause-and-effect process. The process by which
spontaneous remission takes place is simply beyond
our present understanding. It may be that we are un-
able to recognize the processes because we are not pay-
ing sufficient attention to the effect on the body of the
mental and emotional aspects of human beings, includ-
ing their beliefs about their illness, their treatment, and
their chances for recovery.

This exclusion of beliefs and feelings from medical
practice is unwarranted and in a way, surprising, be-
cause it fails to take into account the si nificance of
what many physicians regard as one 0 their most

163

22 The Mind and Cancer

powerful drugs, the placebo. Every physician knows
the effectiveness of treatments which use only a sugar
pill or other medicineless preparation. This is known
as the ”placebo effect." A patient is told that a prescrip-
tion will produce a certain beneficial side effect —— and
it does —- even though there is no medication in the
pill that could produce it.

A physician may give a placebo either because
medicine is not required (for example, to a chronic
complainer) or because an appropriate treatment is not
available and the doctor does not want the patient to
feel abandoned. (For obvious reasons, doctors do not
frequently discuss placebos with their patients.) In
many cases, the placebo proves to be exceedingly effec-
tive in reducing or eliminating physical symptoms, in-
cluding ailments for which there are no known cures.
The only active ingredient in the treatment appears to
be the power of the belief — the positive ewcctations -—
patients have that they have received a helpful treat-
ment. Since they believe the placebo is helpful, be-
cause the physician has created positive expectations
about the results, the treatment does, in fact, help.

A striking illustration of the placebo effect occurred
in a research study conducted with two groups of pa-
tients who had bleeding ulcers. One group was told by
a physician that they were to receive a new drug that
wou d undoubtedly produce relief. The second group
was told by nurses that a new experimental drug
would be administered, but that little was known
about its effects. The same drug was then administered
to both groups. Seventy percent of the patients in the
first group showed significant improvement in their ul-
cers; in the second group 25 percent showed significant
improvement. The only difference in treatment was the
positive expectancy created in the first group by the
physician.

Countless other studies have confirmed the results
of positive expectancy on treatment.

- Dr. Henry K. Beecher and Dr. Louis Lasagna of
Harvard University conducted a study of post-

164

The Mysteries of Healing 2.1

operative pain. Some patients were given mor-
phine, others placebos. Fifty-two percent of the
people who took the morphine reported relief
from pain; 40 percent who took the placebos re-
ported relief. In other words, the placebo was
more than three-quarters as effective as mor-
phine. In fact, Drs. Beecher and Lasagna discov-
ered that the more severe the pain, the more ef-
fective the placebo.

° Eighty-three arthritic patients were given sugar
pills instead of their usual medicine, aspirin or
cortisone. A second group received their usual
medication. The percentage of patients who re-
ported relief was the same among those who re-
ceived the sugar pills as among those who re-
ceived conventional medication. In addition,
when those patients who received sugar pills but
reports no relief were given placebo injections of
sterile water, 64 percent reported relief or im—
provement. (Apparently, injections inspired
greater positive ex ectanc than did pills, re-
gardless of the me ical va ue of either.)

' Medical officials at the National Institute of
Geriatrics in Bucharest, Romania, conducted a
study of a new drug designed to enhance health
and longevity by activating the endocrine sys—
tem. One hundred fifty patients were divided
into three equal groups. T e first group received
no medication, the second received a placebo,
and the third was given the new drug. The three
groups were then observed for several years.

Members of the group that received nothing
had similar mortality rates and incidence of ill-
ness as people in the same age groups in the pa-
tients’ geographical areas. The second group,
which had received the placebo, showed a sub-
stantial improvement in health and a lower
death rate than the first group. The third group,

165

24 The Mind and Cancer

which had received the drug, showed about the
same improvement over the placebo group that
the placebo group showed over the first group.
Thus, although the drug made an important dif-
ference in longevity and health, the placebo ef-
fect by itself was able to produce improvements

in both the degree of illness and the length of
life.

The placebo effect is not limited to the administration
of sugar pills. Throughout medical history there have
been countless practices, such as “bleeding" the pa-
tient (which was common during the Middle Ages), that
have no physiological basis for curing but still fre-
quently worked, apparently because everyone — in-
cluding the physician — believed in their efficacy. In-
deed, some surgical procedures that were in vogue
during the last fifty years seemed to produce remark-
able results even though we now know that, in many
cases, there are serious questions about their value.
Thus, patients not infrequently reported feeling much
better after unnecessary hysterectomies or tonsillec-
tomies were performed. Once again, the results can be
attributed largely to the patient's belief that the treat-
ments would work and because of his confidence in
the doctor.

The placebo effect may also account for a portion of
the benefit received from real medication. The effect is
created both by the doctor's manner in administering
the drug and also by the process by which drugs are
approved by the medical profession. Everyone knows
that new drugs must undergo extensive testing by
pharmaceutical companies and receive approval by
agencies of the federal government. These same fed-
eral agencies are also actively involved in attempting to
remove harmful foods and drugs from the market, fur-
ther inspiring public confidence. So when research,
testing, and approval by respected federal agencies are
combined with a few publicly acclaimed successes,
such as the polio vaccine, the ritual for establishing so-

166

The Mysteries of Healing 23

cial belief in medical treatment is complete, and the
public comes to believe that a medicine prescribed by a
doctor must be effective.

A most dramatic case of the placebo effect has been
reported by Dr. Bruno Klopfer, a researcher involved in
the testing of the drug Krebiozen. In 1950, Krebiozen
had received sensational national publicity as a ”cure”
for cancer and was being tested by, the American Medi-
cal Association and the US. Food and Drug Adminis-
tration.

One of Dr. Klopfer's patients had lymphosarcoma, a
generalized, far—advanced malignancy involving the
lymph nodes. The patient had huge tumor masses
throughout his body and was in such desperate physi-
cal condition that he frequently had to take oxygen by
mask, and fluid had to be removed from his chest
every two days. When the patient discovered that Dr.
Klopfer was involved in research on Krebiozen, he
begged to be given Krebiozen treatments. Klopfer did
so, and the patient’s recovery was startling. VV1thin a
short time the tumors had shrunk dramatically, and the
patient was able to resume a normal life, including
flying his private plane.

Then as AMA and FDA reports of the negative re-
sults of Krebiozen started being publicized, the patient
took a dramatic turn for the worse. Thinking the cir—
cumstances extreme enough to justify unusual mea-
sures, Klopfer told his patient that he had obtained a
new, superrefined, double-strength Krebiozen that
would produce better results. Actually, the injections
Klopfer gave were simply sterile water. Yet the pa-
tient’s recovery was even more remarkable. Once
again the tumor masses melted, chest fluid vanished,
and he became ambulatory and even went back to fly-
ing. The patient remained symptom-free for over two
months. The patient's belief alone, independent of the
value of the medication, produced his recovery.

Then further stories of the AMA and FDA’s tests ap-
peared in the press: ”Nationwide tests show Krebiozen
to be a worthless drug in the treatment of cancer.”
VV1thin a few days the patient was dead.

167

26 The Mind and Cancer

PSYCHOSOMATIC HEALTH

How can the placebo effect be explained? Some will
dismiss it by saying the patient’s illness was
”psychosomatic." It was ”all in his head," a figment of
his ”imagination,” and therefore not "real."

But this is a distortion of the meaning of the word
psychosomatic, which simply means that an illness
originated as a result of, or is aggravated by, an indi-
vidual’s psychological processes. It does not mean that
the illness is any less real because it is not solely physi-
cal in origin — if any illness ever is. An ulcer may have
originated as a resu t of, and be aggravated by, anxiety
and tension. This does not make the ulcer any less real.

While almost everyone acknowledges that there are
psychosomatic factors in high blood pressure, heart at-
tacks, headaches, and certain skin disorders, the
psychosomatic connection with cancer is not generally
accepted even though the idea that such connections
may exist is not a new or revolutionary one. As early
as 1959, Dr. Eugene P. Pendergrass, president of the
American Cancer Society, emphasized the necessity of
treating the whole patient, not just the physical man-
ifestations of cancer.

Anyone who has had an extensive experience in
the treatment of cancer is aware that there are
great differences among patients. . . . I personally
iave observed cancer patients who have under-
gone successful treatment and were living and
well for years. Then an emotional stress such as
the death of a son in World War II, the infidelity of
a daughter-in-law, or the burden of long un-
employment seems to have been precipitating fac-
tors in the reactivation of their disease which re-

sulted in death. . . . There is solid evidence that
the course of the disease in general is affected by
emotional distress. . . . Thus, we as doctors may

begin to emphasize treatment of the patient as a
whole as well as the disease from which the patient
is suffering. We may learn how to influence gen-
eral body systems and through them modify the
neoplasm which resides within the body.

168

The Mysteries of Healing 27

As we go forward . . . searching for new means
of controlling growth both within the cell and
through systemic influences it is my sincere hope
that we can widen the quest to include the distinct
possibility that within one's mind is a power capa-
ble of exerting forces which can either enhance or
inhibit the progress of this disease. [Emphasis
addedJ

The importance of Dr. Pendergrass’s view is not just
that it underscores the role that psychological factors
play in aggravating a disease, it also emphasizes the
possibility that psychological factors, including the pa-
tient’s beliefs, may be mobilized to move toward
health. Not only can mental and emotional conditions
originate or aggravate physical conditions, they can
also contribute to health. Just as one can become
psychosomatically ill, so one who is ill can move in the
other direction and become psychosomatically healthy.

Although at times we may say that someone
”wanted" to make himself or herself sick, psychosomat-
ic illness is generally attributed to unconscious process-
es. Basically our belief has been that the unconscious
aspect of psychosomatic illness made it something that
was beyond our control, and therefore something that
simply ”happened” to us. Although the mind might
make the body sick, we did not think about the degree
to which we might consciously influence the mind to
make the body well again.

One of the greatest advances in modern medicine,
however, is the new vision that doctors and others are
gaining in regard to the amount of control a person
may learn to exert over the mental processes that influ-
ence a wide variety of physical processes.

BIOFEEDBACK AND THE ABILITY
TO INFLUENCE HEALTH

For years Westerners have heard reports about amaz-
ing feats of physical control performed most frequently
by Indian yogis. They were, it was reported, able to

I69

28 The Mind and Cancer

stick large needles into parts of their bodies and not
bleed or experience ain. Others were reported to have
been buried in co fins in the ground for extended
periods of time and, long after the normal consump-
tion of air should have left them dead, emerged alive
and healthy. Still other yogis were reported to be able
to walk over burning coals and experience neither pain
nor blistering. Most people doubted these reports or
dismissed them as magician’s tricks. But some research-
ers had learned from their own work that such reports
might be true.

These exotic stories and common individual experi-
ences are part of the impetus to the development of the
new science of biofeedback. During the sixties biofeed-
back studies demonstrated how people could exercise
substantial influence over bodily states that were for-
merly thought not to be subject to conscious control.

Researchers in biofeedback have discovered that it is
possible for average people, not just yogis, to learn to
control voluntarily heart rate, muscle tension, sweat-
gland activity, skin temperature, and a wide range of
internal physical states normally considered to be
under involuntary control by the autonomic nervous
system. The procedure by which the trainee learns to
control these physical states is not very complex. Elec-
trodes are attached to the skin of the person receiving
the training so that a biofeedback machine can monitor
some of his physiological functions, such as heart rate,
brain waves, or muscle tension. The machine gives the
trainee visual and/or sound signals that indicate what
is happening to the physical function.

If, for example, you were learning how to alter your
heart rate, a tone might sound at a higher frequency as
the heart rate increased, and at a lower frequency as
the heart rate declined. Initially, it might seem to you
that the higher and lower frequency sounds were
purely random, that there was no connection be-
tween what you were thinking and your heart rate. But
soon you would become aware that you were ex-
periencing certain thoughts or feelings when your
heart rate declined, or that certain physical postures
had an effect. Over time you would learn to exercise

170

The Mysteries of Healing 29

sufficient control over the physiological function to
raise or lower the sound (and your heart rate) pretty
much as you wished.

To date, every physiological function that can be ac-
curately and predictably measured and “fed back” to
trainees has been subject to learned control. Using
biofeedback, people have been taught to reduce high
blood pressure, eliminate migraine headaches, control
irregular heartbeats, increase and decrease blood flow,
cure insomnia, and control numerous other "involun-
tary” physiological functions.

Elmer and Alyce Green of the Menninger Clinic,
pioneers in the field of biofeedback, have reported ex-
periments in which trainees learned to control through
their own volition a single nerve cell. They believe that
biofeedback technique has clearly demonstrated the
physiological principle that, “Every change in the
physiological state is accompanied by an appropriate
change in the mental emotional state, conscious or un-
conscious, and conversely, eveiy change in the mental
emotional state, conscious or unconscious, is accompanied by
an appropriate change in the physiological state.” In other
words, mind, body, and emotions are a unitary system
— affect one and you affect the others. As Dr. Barbara
Brown, another pioneer in biofeedback research, states:

If some medical researchers are now teaching
hearts, or the minds of hearts, to reverse a
pathological condition, then medicine must be
learning that relationships between mind and
body are more powerful than they once thought.
The concept of ”psychosomatic” is generally accept-
ed as indicating the mental origin of physical path-
ology; research into biofeedback is the first med-
ically testable indication that the mind can relieve
illnesses as well as create them. [Emphasis added]

A SYSTEM CONCEPT OF HEALTH

The results of countless placebo studies and the in-
creasingly sophisticated use of biofeedback technology

171

30 i The Mind and Cancer

have caused the physical orientation of medicine to
begin to undergo a change. It is no longer possible to
see the body as an object waiting for replacement parts
from the factory. Instead we now view the mind and
body as an integrated system.

In this view, physical treatment remains an integral
and essential part of the battle with a life-threatening
disease such as cancer. Yet without beliefs — those of
the patient and of the medical team — to support the
treatment and create an expectancy of health, the
physical treatment is incomplete. Recovery is more
likely when we mobilize the whole person in the direc-
tion of health.

It is this concept, that the whole person be
mobilized, that creates — even demands — a role for
the patient in overcoming cancer and other diseases.
The limits of the patient’s responsibility extend far be-
yond getting himself to a physician who will "fix him
up.” Each person can assume responsibility for ex-
amining, even altering, beliefs and feelings that do not
support the treatment, that do not move in the direc-
tion of affirming life and health.

Each of the next four chapters deals with one part of
this changing conception of our role in illness and
health. Each draws together a few more strands that tie
the system together. The starting place is a definition of
cancer that will be new to many, and an increased
appreciation for our own resources to influence the
disease.

172

3
The Search for the
Causes of Cancer

Many of our patients come
to us puzzling over what cancer is and what causes it.
Most of them wonder, "Why me?” While we can offer a
definition of the disease and describe the research into
its causes, it is the third question — why a particular
person contracts cancer — that is the real core of this
book. However, we need to deal with the first two
questions to set the stage for our evidence on "why
you.”

WHAT IS CANCER?

Because many people have lost a loved one to cancer
or heard of the horrors of cancer, they assume it is a
strong and powerful invader capable of ravaging the
body. Actually, cellular biology tells us the opposite is
true. A cancerous cell is, in fact, a weak and confused
cell.

A cancer begins with a cell that contains incorrect
genetic information so that it is unable to perform its
intended function. This cell may receive the incorrect
information because it has been exposed to harmful
substances or chemicals or damaged by other external
causes, or simply because in the process of constantly
reproducing billions of cells the body will occasionally
make an imperfect one. If this cell reproduces other
cells with the same incorrect genetic makeup, then a

173

124 Pathways to Health

5. Not having to meet their own or others’ high
expectations.

Now review your own list. Consider what underlying
needs were met by your illness: relief from stress, love
and attention, an Opportunity to renew your energy,
and so forth. Next, try to identify the rules or beliefs
that limit you from meeting each of these needs when
you are well.

One of our patients discovered that she felt a lack of
physical closeness from her husband, but it was un-
thinkable for her simply to ask for affection and caring
when she was well. Now she has given herself permis-
sion to say to her husband at any time, ”I want a hug."
She also learned some important things about herself
as she looked at wh it was so diffigglt .32 @3515“er phys-
igg‘lvcl-gseness from e‘fTh'u'sba'nd

Ask yourself if you have been unableto allow your-
self periods of release .fromtension. Whaf‘persofial'be-
Iiefs stop you'lfrom giving yourself this freedom with-
out needing the illness as justification? You might be-
lieve, for example, that 35.1533 ”signjof weakness". to
give in, _t_Q,p_ressure or tension, or that it is your duty to
put others' manganese of your own. Because these
Yule's' are mestly‘unconscious, this self—examination will
take effort. But taking preventive action to avoid future
illness is worth your time and energy. Once you begin

to becomemommmjes and Q13 able to

semernative' ways of viewing situations, you are on
mmammnmé’fiirez‘”

By using the lessons of illness as a starting point, we
can educate ourselves to recognize our needs and take
the opportunity to satisfy them. This is the creative use
of illness.

174

11
Learning to Relax and
Visualize Recovery

The first step in getting
well is to understand how your beliefs and emotional
responses have contributed to your illness. The next
step is to find ways of influencing those responses in
support of your treatment. In this chapter we will tell
you about a relaxation process for reducing the effect
on your body of stress and tension associated with the
onset of cancer and with the fear of the disease, which
itself becomes a major source of stress. We will also
show you how to use mental imagery, once you are
relaxed, to create positive beliefs that will activate your
body’s defenses against disease.

For many cancer patients, the body has become the
enemy. It has betrayed them by getting sick and
threatening their lives. They feel alienated from it and
mistrust its ability to combat their disease. Learning to
relax and influence the body, on the other hafid, helps
peo le accept their body once again and their ability to
wor with it toward health. The body again becomes
a source of pleasure and comfort and an important
iscfiurce of feedback on how effectively pe0ple are living
1 e.

Relaxation also helps reduce fear, which can become
overwhelming at times with a life-threatening disease.
Cancer patients are often terrified they will die a pro-
longed, painful death, impoverishing their families
through medical expenses, and doing their children
psychological harm by the absence of a parent. Such

175

126 Pathways to Health

fears make it almost impossible for patients to develoP
a positive expectancy about the outcome of their ill-
"885- But sweetener. hysicattrhstps thciiilzreak
the cycle'of'l‘tegsion and ear. For a few minutes at
least, while they are relaxing their bodies, cancer is not
the overriding reality of their lives. Many patients re-
port that they have a different perspective and re-
newed energy after using relaxation techniques. It ap-
pears to be a way of recharging their batteries. \Mth the
fear reduced, it is easier to develop a more positive ex-
pectancy, resulting in a further decrease in fear.

It is important to. note that, in clinical terms, rplaxa;

tion doe-$139; mgamspending an evening in front of the,
'tél'eVi‘sion, having a few drinks, or talking with friends)
Although these certainly can be pleasurable activities,
laboratory studies show that such forms of ”relaxation"
do not result in griuadequate discharge of the physical
effe_c__ts‘of stress. " " ' ' "
‘ Begulnrebstical sxsdieeiasexwazef messeng-
Regular exercise acts out the equivalent Bribe "fight-
or-flee" response, which we discussed in Chapter 4,
permitting the body to discharge the buildup of ten-
sion. It is not accidental, in our opinion, that many pa-
tients who have done very well in our program engage
in some form of regular physical exercise. Many jog-
gers and runners say that running is their “therapy"
and that during the running, they are able to get a
perspective on their problems that they cannot get just
by thinking about them. (Later in the book we have a
Ciapter devoted to this subject.)

Still, it is not always possible for peOple to engage in
physical activity whenever they feel stressed. Modern
life often requires considerable effort to handle all the
arrangements necessary for physical activity. Fortu-
nately, researchers have developed a variety of simple
relaxation techniques — certain forms of meditation
and progressive relaxation, autogenic training, and
self-hypnosis, to name a few. Most of these techniques
involve some form of mental concentration. People
may focus their attention on a symbol or a series of
mental images designed to calm the mind, or they may

176

Learning to Relax and Visualize Recovery 127

to through a series of instructions in their mind to
relax the body.

Dr. Herbert Benson of Harvard University has doc-
umented the positive physical benefits of several of
these techniques for reducing stress in his book, The
Relaxation Response. Although all of the body’s phy-
siological responses to these various mental relaxa—
tion techniques may not be understood, research has
amply demonstrated that the techniques dischar e the
effects of stress to a much greater degree than 0 the
activities conventionally considered relaxing.

THE RELAXATION TECHNIQUE

The relaxation technique we developed while working
with our patients is taken largely from a program de-
vised by Dr. Edmond Jacobson, who calls his technique
“pmgressive relaxation.” In practice, we combine this
technique with the mental imagery process we describe
later in this chapter. However, we have detailed the re-
laxation process separately here so that you will see its
value for use anytime. We recommend to our patients
that they complete the combined relaxation/mental im-
agery activity three times a day for ten to fifteen min-
utes each time. Most people feel relaxed the first time
they use this technique. But since relaxation is some-
thing that can be learned and improved upon, you will
find that you’ll enter into increasingly relaxed states as
the process is repeated.

To make the relaxation/mental imagery process easier
to learn, we provide our patients with a cassette tape
of instructions. You may also find it helpful to have a
friend read the following instructions to you or to
make a tape recording of them. Allow plenty of time
for completing each step in a comfortable, relaxed
manner.

1. G0 to a quiet room with soft lighting. Shut the
door and sit in a comfortable chair, feet flat on
the floor, eyes closed.

128

10.

177

Pathways to Health

Become aware of your breathing.

. Take in a few deep breaths, and as you let out

each breath, mentally say the word, "relax."

. Concentrate on your face and feel any tension

in your face and eyes. Make a mental picture
of this tension — it might be a rope tied in a
knot or a clenched fist — and then mentally
picture it relaxing and becoming comfortable,
like a limp rubber band.

. Experience your face and eyes becoming re-

laxed. As they relax, feel a wave of relaxation

spreading through your body.

. Tense your eyes and face, squeezing tightly,

then relax them and feel the relaxation spread-
ing throughout your body.

. Apply the previous instructions to other parts

of your body. Move slowly down your body —
jaw, neck, shoulders, back, upper and lower
arms, hands, chest, abdomen, thighs, calves,
ankles, feet, toes — until every part of your
body is relaxed. For each part of the body,
mentally picture the tension, then picture the
tension melting away; tense the area, then
relax it.

. When you have relaxed each part of the body,

rest quietly in this comfortable state for two to
five minutes.

. Then let the muscles in your eyelids lighten

up, become ready to open your eyes, and be-
come aware of the room.

Now let your eyes open, and you are ready to
go on with your usual activities.

178

Learning to Relax and Visualize Recovery IZ‘I

If you have not already done so, we encourage you
to go through this process before reading on. You can
find the relaxation it produces pleasurable and ener-
gizing.

People sometimes experience difficulty picturing the
mental image or keeping their minds from wandering
the first few times they try the process. There's no
need to feel discouraged. It's very natural and criticiz-
ing yourself will only increase your tension. At the end
of this chapter, when you are more familiar with relax-
ation and visualization techniques, we will deal with a
few of the common problems patients have with these
procedures and suggest how to overcome them.

The next section provides instructions for moving di-
rectly from the relaxation process into the mental im-
agery rocess. Although the relaxation technique is
valuab e by itself, as we said‘earlieflrfwe use it primarily
as a prelude to mental imagery, because the physical
Félaxation reduces tension tliat'ctiifld distract from eon-
centrating on“ the niental’imagery. The relaxation tech-
nique is also a prelude to mental imagery in another
sense: Learning to use mental guidance to produce
physical relaxation should help strengthen your belief
that you can use your mind in support of your body.

RELAXATION AND MENTAL IMAGERY

Relaxation and mental imagery are among the most
valuable tools we have found to help patients learn to
believe in their ability to recover from cancer. In fact,
we mark as the conception of our present approach the
first time Carl used mental imagery with a patient.
Since then, we have discovered that mental imagery is
not only an effective motivatior‘iaktool. for recovering
health, but is also an important tool for self-discovery
and for making creative change in'Otlier'ar'eas of life.

We owe our discovery of the relaxation and mental
imagery process to Stephanie’s background in motiva-
tional psychology. Because of her training, we were

179

l3tl l'atlmays to Health

aware that this process for altering expectancies had
been used by people 111 many different disciplines. The
common th111ad 1111111i11g th1ougl1 these 1lis1iplines was
that p1 ople Cieated mental 1111 recs of 1111 1si111d 11\e nts
By forming an imaj'e, a person makes a clear mental
statement of what he or she wants to happen. And, by
repeating the statement, he or she soon comes to ex-
pect that the desired event will indeed occur. As a re-
solt of this positive expectation, the person begins to
act in ways consistent with achieving the desired result
and, in reality, helps to bring it about. (This is similar
to the concept of self— fulfilling prophecy, which we dis-
cussed earlier in the book.)

For example, a golfer would visualize a beautiful golf
swing with the golf ball going to the desired lace. A
business person would visualize a successful usiness
meeting. A stage performer would visualize a smooth
opening night. A person with a malignancy would pic-
ture the tumor shrinking and his body regaining
health.

As we were learning of the effectiveness of the relax-
ation and mental imagery process, we were also learn-
ing of the evidence that biofeedback researchers were
amassing (described more fully in Chapter 2), that
people could learn how to control inner physiological
states,si1ch‘ asf I1ea1t rate, blood pressure, and skin
temperature .)When interviewed, these people fre-
quently stated that they had not been able to command
the body to alter the internal state but instead had
learned a visual and symbolic language by which they
communicated with the body.

One woman, who had a dangerously irregular
heartbeat, created a picture in her mind’s eye of a little
girl on a swing. She would see the little girl rhythmi-
cally swinging back and forth whenever she needed to
bring her heartbeat under control. “hthin a short time,
she needed no heart medication and had no more dif-
ficulties. Her success and the experiences of thousands
of others in using mental imagery to control body
states ”51158315310 us that mental imagery — used in
conjunction with standard medical treatment — might

l80

Learning to Relax and Visualize Recovery Ill

be a way cancer patients could influence their immune
sy stems to become mo1e active in fighting their illness.

Carl first used the mental imagery technique in l‘)7l
(as we described in Chapter ‘I) with a patient whose
cancer was considered medically incurable. The patient
practiced three times a day visualizing his cancer, his
treatment coming in and destroying it, his white blood
cells attacking the cancer cells and flushing them out of
his body, and finally imagining himself regaining
health. The results were spectacular: The "hopeless” pa-
tient overcame his disease and is still alive and healthy.

THE MENTAL IMAGERY PROCESS

In this section, we will lead you through the relax-
ation/mental imagery process, repeating the previous
instructions for relaxation. In Chapter 12, we will iden-
tify beliefs inherent in mental imagery, provide a list of
criteria for creating effective imagery, and analyze
examples drawn from our patients' experiences.

You may want to tape-record instructions, as we do
for our patients, or have a friend read them to you. If
you are reading to someone else, be sure to read
slowly. Allow the other person plenty of time to com-
plete each step. Remember that we encourage our pa-
tients to take ten to fifteen “minutes to complete the en-
tire process and to practice it three, times a day.

Even if you do not have cancer, we ask you to go
through the cancer visualization once to give you an
emotional understanding of this process and insight
into how the cancer patient feels.

1. Go to a quiet room with soft lighting. Shut the
door, sit in a comfortable chair, feet flat on the
floor, eyes closed.

2. Become aware of your breathing.

3. Take in a few deep breaths, and as you let out
each breath, mentally say the word, “relax."

10.

181

I‘athways to Health

. Concentrate on your face and feel any tension

in the muscles of your face and around your
eyes. Make a mental pictine of this tension -—
it might be a rope tied in a knot or a clenched
fist — and then mentally pi1tu1e it relaxing

and becoming comfortable, like a limp rubber
band.

Experience the muscles of your face and eyes

becoming relaxed. As they relax, feel a wave
of relaxation spreading through your body.

. Tense the muscles of your face and around

your eyes, squeezing tightly, then relax them
and feel the relaxation spreading through your
body.

. Move slowly down your body — jaw, neck,

shoulders, back, upper and lower arms,
hands, chest, abdomen, thighs, calves, ankles,
feet — until every part of your body is more
relaxed. For each part of the body, mentally
picture the tension, then picture the tension
melting away, allowing relaxation.

. Now picture yourself in pleasant, natural sur-

roundings — wherever feels comfortable for
you. Mentally fill in the details of color, sound,
texture.

. Continue to picture yourself in a very relaxed

state in this natural place for two to three
minutes.

Then mentally picture the cancer in either
realistic or symbolic terms. Think of the cancer
as consisting of very weak, confused cells.
Remember that our bodies destroy cancerous
cells thousands of times during a normal
lifetime. As you picture your cancer, realize

l82

Learning to Relax and Visualize Recovery I33

11.

12.

13.

that your recovery requires that your body's
own defenses return to a natural, healthy
state.

If you are now receiving treatment, picture
your treatment coming into your body in a
way that you understand. If you are receiving
radiation treatment, picture it as a beam of
millions of bullets of energy hitting any cells in
its path. The normal cells are able to repair
any damage that is done, but the cancerous
cells cannot because they are weak. (This is
one of the basic facts upon which radiation
therapy is built.) If you are receiving chemo-
therapy, picture that drug coming into your
body and entering the bloodstream. Picture
the drug acting like a poison. The normal cells
are intelligent and strong and don't take up
the poison so readily. But the cancer cell is a
weak cell so it takes very little to kill it. It ab-
sorbs the poison, dies, and is flushed out of
your body.

Picture your body’s own white blood cells
coming into the area where the cancer is, rec-
ognizing the abnormal cells, and destroying
them. There is a vast army of white blood
cells. They are very strong and aggressive.
They are also very smart. There is no contest
between them and the cancer cells; they will
win the battle.

Picture the cancer shrinking. See the dead
cells being carried away by the white blood
cells and being flushed from your body
through the liver and kidneys and eliminated
in the urine and stool.

- This is your expectancy of what you want to
happen.

I31

14.

15.

16.

17.

18.

19.

183

l'.1l|1\\ .11“. I11 I l1'.1lll1

° Continue to see the cancer shrinking, until it
is all gone.

1 See yourself having more energy and a bet-
ter appetite and being able to feel comfort-
able and loved in your family as the cancer
shrinks and finally disappears.

If you are experiencing pain anywhere in your
body, picture the army of white blood cells
flowing into that area and soothing the pain.
Whatever the problem, give your body the
command to heal itself. Visualize your body
becoming well.

Imagine yourself well, free of disease, full of
energy.

Picture yourself reaching your goals in life.
See your purpose in life being fulfilled, the
members of your family doing well, your rela-
tionships with people around you becoming
more meaningful. Remember that having
strong reasons for being well will help you get
well, so use this time to focus clearly 011 your
priorities in life.

Give yourself a mental pat on the back for par-
ticipating in your recovery. See yourself doing
this mental imagery exercise three times a day,
staying awake and alert as you do it.

Then let the muscles in your eyelids lighten
up, become ready to open your eyes, and be-
come aware of the room.

Now let your eyes open, and you are ready to
resume your usual activities.

If you have not done so already, please take the time
now to go through this mental imagery process. When

184

tannin): to Relax and \'is11.1li/11 Recovery I):

you have completed the entire exercise, draw a picture
illustrating the images you created, so that you can
analyze your image1y in more det tail, according to the
crite1ia and examples we will present in Chapter I2.
You needn t 11or1y about not being able to’ ’see' ’the
imagery if you were able to’ ’sense" or “i111agine” or
”think" it. The wo1d describing what you were doing
is much less important than the fact of your doing it.
Also, if you found your mind drifting during the pro-
cess, next time just bring it back gently to the imagery
without being harsh on yourself. If you were aware,
while going through the process, that you were unable
to complete certain of the instructions because you
could not believe or accept them, then you have begun
to confront your attitudes about cancer and recovery.
By now you know how important that recognition is.

MENTAL IMAGERY FOR OTHER ILLNESSES

Since many readers of this book do not have cancer but
may want to use mental imagery to help deal with pain
and other ailments, here is a short mental imagery pro-
cess, which can be substituted for steps 10 through 19,
the cancer portion of the previous activity.

1. Create a mental picture of any ailment or pain
that you have now, visualizing it in a form that
makes sense to you.

2. Picture any treatment you are receiving and see
it either eliminating the source of the ailment or
pain or strengthening your body’s ability to
heal itself.

3. Picture your body's natural defenses and
natural processes eliminating the source of the
ailment or pain.

4. Imagine yourself healthy and free of the ail-
ment or pain.

I85

131. l'athwavs to Health

5. See yourself proceeding successfully toward
meeting your goals in life.

6. Give yourself a mental pat on the back for par-
ticipating in your recovery. See vourself doing
this relaxation/mental imagery exer1ise three
times a day, staying awake and alert as you
do it.

7. Let the muscles in your eyelids lighten up, be-
come ready to open your eyes, and become
aware of the room.

8. Now let your eyes open and you are ready to
resume your usual activities.

As an example of how you can use mental imagery to
deal with an illness other than cancer, if you have an
ulcer, your mental picture of the ulcer might be a
crater- type sore in the lining of the stomach or intes-
tine, seeing it rough and raw Picturing the treatment,
visualize antacids coating the area, neutrali7ing the ex-
cess acid and having a soothing effect on the ulcer it-
self. Picture normal cells coming in and doubling, di-
viding, covering over the raw, ulcerated area. See your
body’s white blood cells picking up any debris and
cleaning the area, making it a pink, healthy lining.
The next step is to see yourself free from pain and
healthy, able to deal with the stresses of life without
producing ulcer symptoms.

If you have high blood pressure, ‘you could use the
imagery process to see the problem as little muscles in
the walls of the blood vessels tightening down, so that
it causes much higher pressure necessary for the blood
to be driven through. Now, see the medication relaxing
these little muscles in the blood vessels, your heart
pumping evenly, with less resistance, and blood flow-
ing smoothly through the vascular channels. See your-
self as able to cope with the stresses of life without
producing symptoms of tension.

186

Learning to Relax and Visualize Recovery l3?

If your illness is arthritis," first picture your joints
very irritated and having little granules on the sur-
faces. Then see your white blood cells coming in,
cleaning 11p the debris, picking up the little granules,
and smoothing over the joint surfaces. Then see your-
self active, doing what you like to do, free of joint
pam.

When you complete one of these mental imagery
processes for the first time, draw a picture of your im-
agery. It will help you identify your attitudes toward
participating in your health.

THE VALUE OF RELAXATION AND MENTAL
IMAGERY

To give you a better idea of what to expect from these
exercises, the list below contains some of the benefits
of the relaxation/mental imagery process.

1. The process can decrease fear. Most fear comes
from feeling out of control — 1n the case of
cancer, feeling your body is deteriorating and
you are powerless. Relaxation and mental im-
agery help you see your role in regaining health
so that you begin to sense your own control.

2. The process can bring about attitude changes
and strengthen the ”will to live.”

3. It can effect physical changes, enhancing the
immune system and altering the course of a
malignancy. Since mental processes have a di—
rect influence on the immune s stem and hor-
monal balances in the body, p ysical changes
can be directly attributed to changes in thought
patterns.

4. The process can serve as a method for evaluat-
ing current beliefs and altering those beliefs, if

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138 Pathways to Health

desired. Alterations in the symbols and pictures
that you use can dynamically alter beliefs to
those more compatible with health.

5. The process can be a tool for communicating
with the unconscious — where many of our be-
liefs are at least partially buried.

6. It can be a general tool for decreasing tension
and stress. The process of regular relaxation by
itself can decrease tension and stress and have
a significant effect on underlying body func-
tions.

7. The process can be used to confront and alter
the stance of hopelessness and helplessness.
We have seen again and again how this under-
lying depression is a significant factor in the
development of cancer. As people begin to pic-
ture their bodies regaining health, their ability
to solve the problems that existed prior to the
malignancy, they weaken their sense of help-
lessness and hopelessness. Indeed, as the pa-
tients proceed toward health, they gain a
sense of confidence and optimism.

OVERCOMING POTENTIAL PROBLEMS
WITH THE MENTAL IMAGERY PROCESS

Some people are more visual than others; they think in
images. Some people téii'd'to sense things. Others feel
things. Some think in wordsT'EE'cause of these indi-
vidual differences, we have found that when we use
the word ”see" in our instructions to the mental imag-
ery process, some people might instead ”feel” what it
is like to be well. When we would say, "See yourself
becoming well," they might have the ”sensation" of
energy and health. It has become increasingly clear to
us that a person should stay with the process or way of
thinking that he or she is most comfortable with, rather

.-«-« .

188

Learning to Relax and Visualize Recovery 139

than trying to become primarily visual. In the long run,
all types of thinking tend to intertwine. A person who
is mostly visual will begin to become more feeling, and
a person who is more feeling will begin to become
more visual. Permit yourself to operate first in the
sense that is most natural to you.

Another problem we have found to be very mmmon
during mental imagery is the tendency for a person’ s
mind to wander This often represents a lack of con-
centration, which can be aggravated by certain medica-
tions, by pain, or fear. From time to time it is a problem
that affects everyone using the process regularly. One
of the most effective ways for dealing with distraction
is nto stop~ the process and ask yourself what is going

”Why is my mind wandering?” Pursue that line of
thought fc'1r a short time,pe1haps five minutes. Then
focus back on the exercise and go through it with
whatever degree of sucCess you can attain. ’

A third difficulty 15 the feeling that saying the cancer

s”shrinking" is actually lying to yourself. We’ ve heard
statements such as, ”I’ve got a cancer growing on my
shoulder, I can feel it, it' s not possible for me to see it
shrinking when I know it’ 5 growing bigger.’ The prob-
lem here IS a confusion about the gurpose of the men-
tal imagery process. We are attemp mg to help the pa-
tient visualize the desired outcome, not what may be
happening at the time. It is posSible’ to picture the
cancer shrinking even when in reality it may be grow-
ing; you are picturing in your mind what you want to
come about. Understanding this distinction is very im-
portant. Mental 1mage is not a” method ngelf—
deception it is a metho Tor self- d1rect1on

Now that you know the basic relaxation/mental im-
agery process, the next chapter will help you interpret
and develop specific mental images so that you can
understand your underlying beliefs about cancer and
create a more positive expectancy for recovery.

189

12
The Value of Positive
Mental Images

We first began using men-
tal imagery to motivate patients and provide them with
a tool for influencing their immune systems, but we
soon discovered that the activity revealed extremely
important information about patients’ beliefs. This dis-
covery was somewhat accidental. When we first began
assigning the mental imagery process, we would ask
our patients whether they were practicing it regularly,
but we did not try to ascertain what their imagery was.
However, when one patient’s condition went steadily
downhill, even though he steadfastly maintained he
was using the process three times a day, we asked him
specifically to describe the content of his imagery.

His answer confirmed our fears. When asked what
his cancer looked like, he said, ”It looks like a big black
rat.” When asked how he envisioned his treatment,
which consisted of chemotherapy in the form of small
yellow pills, he replied, ”I see the little yellow pills
going into my bloodstream, and once in a while the rat
eats one of these pills.” Asked what happened when
the rat ate the pills, he said, ”Well, he’s sick for a
while, but he always gets better, and then he bites me
all the harder.” When we asked about his white blood
cell imagery, he replied, ”They look like eggs in an in-
cubator. You know how eggs sit under the warm light?
Well, they’re incubating in there, and one day they’re
going to hatch.”

190

The Value of Positive Mental Images 141

The imagery paralleled his deteriorating condition.
First of all, the cancer was strong and powerful — a
”big black rat.” The treatment was weak and impotent,
”tiny pills” that the rat ate only occasionally and that
had only a temporary effect 011 him. Finally, the white
blood cells, the representatives of the body’s natural
defenses, were completely immobile. Our patient had
created an almost perfect image of total suppression of
the immune system and had been faithfully repeating
this imagery three times a day.

We soon discovered that other patients also showed
strongly negative expectancies in their imagery. One
patient reported that, ”l visualize my cancer as a big
rock. Every once in a while, these little scrub brushes
come to clean up around the edges of the rock, but
they can’t do much good.” Again, the cancer appeared
strong and impregnable while the body’s defenses
were puny and impotent, unable to "do much good.”

Another patient reported that he saw his white
blood cells "as a snowstorm that sweeps over my
whole body and obliterates most of the cancer cells in a
single pass, but a few pop back.” Here the body’s de-
fenses appeared to be more potent, but they did not
really destroy the cancer cells, they only glossed over
them. Moreover, since snowflakes have no directional-
ity or intelligence, this imagery revealed that the pa-
tient did not see his body’s defenses as actually recog-
nizing and destroying the cells: their impact was by
sheer numbers.

These experiences made us realize [19w important it‘.
was to examine the colite'ntsgoL 9.9!..RQUQDES. .. 1mage°fy
asserts see whereitpeetancies were being communi-
cated. ~Since‘then, we have used the sigriifiCanc'e"(1f’tl1e
i'r'r'i'a'gery to determine whether patients show a general
pattern of glossing over, or trying to hide, negative
feelings or otherwise impede their treatments.

We have also discovered that the content of the im-
agery varies with the patient’s psychologicalis‘tate 'at a
particular time. For instance, the scientist John Brown-
ing, whose case was reported in Chapter 10, had de-
veloped a strong mental image for his white blood cells

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142 Pathways to Health

(see Figure 3), visualizing them as a vast army of white
knights on white horses who would line up, their
lances gleaming in the sunlight, and charge through
the landscape killing the cancer cells, which were
, small, slow-moving creatures.

But just prior to his two recurrences, John found his
imagery changing. Sometimes he visualized black
knights in the ranks of his army, which he took to
mean enemy knights. At other times he imagined his
knights’ lances bent and limp, as if made of rubber, so
that clearly they could do no damage. Or the knights’
horses would be the size of dogs, so that they were
ungainly and ineffective. We were soon able to observe
a correlation between the 1n1agery and events in John’ 5
life, and we realized that the 1mage __y could be 11561.1 as
general feedback on his psycholog1cal progress.

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Figure 3. John Browning’s Mental Imagery: White
Knights, on White Horses.

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The Value of Positive Mental Images 143

THE CRITERIA FOR EFFECTIVE IMAGERY

W1th the assistance of Dr. Jean Achterberg-Lawlis, a re-
search psychologist, we have developed a list of tenta-
tive criteria that can be used to evaluate the content of
one’ 5 mental imagery. In our treatment center, patents
use the criteria to analyze each other’ 5 imagery and to
suggest alternatives that cOntain more positive “expec-
tancies. Representing cancer cells as ants, for instance,

we ”have found 15 generally a negative symbol. Have you
ever been able to get rid of the ants at a picnic? Crabs,

the traditional symbol for cancer, and other crustaceans
are also negative symbols. These beasts are tenacious,
they hang 011. They also have hard shells, making
them relatively impregnable, and most people are
afraid of them — the crab symbolizes the potency and
the fear of the disease.

Interpreting mental imagery is similar to inter reting
dreams: It involves a highly personal, symboic lan-
guage. To translate the beliefs inherent in an imave,
then, you must ”try on” the image internally, identi y-
ing the meaning of its characteristics for you. The emo-
tional meaning of a particular symbol may vary greatly
for different individuals, so that a symbol that means
strength and power to you may mean anger and hostil-
ity to someone else. Thus, you should not automati-
cally accept anyone else’s interpretation of your sym-
bols. And, of course, your imagery need not be literally
correct: there are no ants, crabs, white knights, or
black rats crawling around in your body. Whatever the
image, its importance l1es in the meaning it holds for
yo11,a meaning which, in this arcumstance it is up to
you to recognize. our experience has been that pa-
tients have a good feel for this kind of interpretation.

Despite all the potential for individual variations, our
research indicates that effective images generally con-
tain the features listed below. But because imagery is
high] I individual, what we are pointing out are the
signi icant qualities of the symbols, not the symbols
themselves. We will deal with problems related to ef-
fective mental imagery in the next section.

144

193

Pathways to Health

. The cancer cells are weak and confused. It is

important to depict your cancer cells as any-
thing soft that can be broken down, like ham-
burger meat or fish eggs.

. The treatment is strong and powerful. Your

imagery should communicate the belief that the
treatment is clearly capable of destro ing the
cancer. The imagery is strengthened i there is
ample interaction between the treatment and
the cancer, so that the impact of the treatment
on the cancer is visible and understandable.
For example, if the cancer is pictured as a
gray glob of cells, the treatment might be a yel-
lowish or greenish fluid that flows over the can-
cer, breaking it down and making it shrink so
that the white blood cells can easily destroy it.

. The healthy cells have no difficulty repairing

any slight damage the treatment might do.
Since the treatment usually touches all cells,
not just the cancerous cells, you should vis-
ualize your normal, healthy cells as being
strong enough so that the treatment does little
damage to them, and they are capable of repair-
ing any minimal damage. The cancerous cells
are destroyed by the treatment because they are
weak and confused.

. The army of white blood cells is vast and

overwhelms the cancer cells. The white blood
cells are a symbol of your body’s natural heal-
ing process, so your imagery should reflect vast
numbers of these cells and great strength. The
victory of the white cells over the cancer should
be seen as inevitable.

. The white blood cells are aggressive, eager for

battle, quick to seek out the cancer cells and
destroy them. Again, the white blood cells are a
symbol of your own defenses — that part of

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The Value of Positive Mental Images 145

you that will help you recover — so make them
intellige t, capable, strong. Visualize your
white b ood cells overwhelming the cancer
cells, leaving no doubt about which cells are
stronger.

6. The dead cancer cells are flushed from the
body normally and naturally. Flushing dead
cells from the body is a wholly natural process,
requiring no special effort or magic. By imagin-
ing this process, you are communicating your
confidence in your body’s normal functioning.

7. By the end of the imagery, you are healthy and
free of cancer. This image represents your de-
sire for the final outcome: it is important that
you see your body clearly as healthy, vital, and
energetic.

8. You see yourself reaching your goals in life,
fulfilling your life’s purpose. This imagery
communicates the fact that you have powerful
reasons for living. You are confirming your
confidence that you can recover and your com-
mitment to living.

Our experience indicates that people who do very well
in our program have developed imagery that matches
these criteria. Yet none of our patients have started out
with imagery containing all these elements. You may
n__eed to experiment before you find strong enou 11' 1m-
ages to capture your new positive expectancy. se the
criteria to help you identify images that need
"strengthening or changing. Although it is not possible
to provide a medically correct' prescription” of images,
it is essential that you see yout body’ s 11atu1al defenses
triumphing over the disease. Stiong images represent
a strong belief in recovery.

It is important that in your imagery the most potent
factor in overcoming your malignancy be your white
blood cells, rather than, for example, chemotherapy.

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I46 Pathways to Health

Patients often have reported seeing the white blood
cells coming in and attacking but leaving behind some
cancerous cells for the chemotherapy to eliminate. This
indicates a basic belief that the medicine will get them
well. While we in cancer therapy appreciate that
medicine can do a great deal, we believe that the
body’s basic defenses eliminating the cancerous cells is
the essential aspect in regaining health.

OVERCOMING PROBLEMS IN YOUR
MENTAL IMAGERY

Now that you are familiar with the criteria for creating
effective mental imagery, let’s take a closer look at the
mental imagery activity you just completed, the possi-
ble beliefs inherent in those images, some of the com-
mon problems patients face in creating such images,
and some of the ways they have gone about overcom-
ing the problems.

Imagery of the Cancer Cells
If you had difficulty visualizing the cancer, this may
represent a strong fear of the disease and is often ac-
companied by a lack of confidence that your body can
naturally and normally defend against the cancer. If
you had difficulty seeing the cancerous cells as weak
and confused, and instead saw them as strong — like
stones or a predatory animal — or if you saw the
cancer more vividly than other symbols in your imag-
ery, you may have a much stronger belief in the po-
tency of the disease than in the potency of treatment or
of your body's defenses

_It is common to have difficulty picturing the cancer.
If you are having trouble with this, picture a mass of
gray cells wherever you know (or believe) tl1ec cancer to
be in your body. Black and red are two very common
colors that people use to desc1ibe tl1ei1cr,ance but
these colors tend to have strong emotional connota-
tions. Gray is a much more neutral color, and part of
our approach is an attempt to neutralize the feelings
about cancer.

I96

The Value of Positive Mental Images 147

Thus, we would suggest using gray rather than a
stronger color. Or, you might picture the cancer as bro-
ken up hamburger meat and your white blood cells as
large numbers of white dogs coming in to devour the
hamburger, licking the surrounding areas clean and
going on to patrol the other parts of your body. The
basic image of the cancer cells should be that they are
neutral, weak, and disorganized.

Imagery of the Treatment

It is important to visualize your treatment as a friend
and ally. Our patients frequently report reduced side
effects to treatment as a result of changing their at-
titudes in positive, supportive directions. For instance,
one patient who had feared his treatment began calling
the machine giving him radiation "George,” and hold-
ing mental conversations with "George” about all the
good things the treatment was going to do for him. In
addition, the patient made efforts to engage the doctor
and nurses in friendly conversations, which included
thanking them for their efforts. Shortly after this
change in attitude, he began to experience fewer and
fewer side effects from the radiation. Personalize your
treatment, make it a helpful friend who is working
with you to overcome the disease.

Imagery of the White Blood Cells

This, we believe, is the most crucial symbol of the im-
agery process because it represents your beliefs about
the body’s natural defenses. The essential relationship
between the white blood cells and the cancer is the
strength and number of the white blood cells relative
to the cancerous cells. The healthiest images are those
in which the cancer is significantly outnumbered and
overpowered by the white blood cells.

One way to strengthen the imagery of your white
blood cells is to do the following: Assume your images
of your white blood cells are fish swimming in and
eating up the grayish cancer cells. Project this image as
if it were on .1 screen that you’re viewing in your
mind’s eye. When you have that image very clear, then
become one of the fish and lead the rest of the pack into

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I48 ’ Pathways to Health

the attack. Feel yourself as the fish eating the cancer
cells, destroying them, cleaning up any remaining de-
bris. Hear the sounds and feel the emotions that are
appropriate to the situation.

Again, the vividness of the imagery is important. Do
you see the imagery of your white blood cells with the
same or greater clarity than you see the cancer? Or do
you see the cancer with greater vividness and clarity? If
the cancer is more vivid, then, as previously men-
tioned, you probably have a greater belief in the power
of the cancer than you do in the potency of your
body’s defenses, and so you will need to consciously
strengthen the imagery representing your white blood
cells.

In addition, the traits you attribute to the white
blood cells often describe significant psychological is-
sues you are facing. For example, patients who do not
see the white blood cells attacking or destroying the
cancer cells usually have difficulty expressing anger
and hostility and have a strong need to impress others.
These problems may have contributed to the onset of
the disease and are standing in the way of recovery.

With this in mind, think of the white cell as having
those characteristics that you consider most admirable
and strong in yourself.

Imagery of Flushing Out Dead Cells

As we have said, how you see the dead and dying cells
flushed from the body by natural and normal processes
indicates your confidence in your body’ 5 natural func-
tioning. Some of our patients include in their imagery
some form of magic or divine intervention to get the
cancer cells out of the body. This is another representa-
tion of their belief in the power of cancer — that is,
even when the cancer cells are dead, they are still so
powerful that it takes a special intervention to rid the

body of them

Imagery of a Healthy Self
Since this is the desired outcome, how you visualize
yourself regaining health, vitality, and energy is impor-

I98

The Value of Positive Mental Images I49

tant. If you can see the battle, the cancer, the treat-
ment, and the white blood cells but have great dif—
ficulty seeing yourself regaining health, you are quite
possibly having difficulties believing you can recover.
Try visualizing yourself engaging in activities you
would pursue if you were healthy or having the overall
feelings you would have if you were well. Picture

ourself at the healthiest time in your life and create
1mages of the present, feeling just that way.

Imagery of Your Goals

Goal setting (discussed in detail in Chapter 14) is a
highly significant phase of the visualization process. If
you have difficulty seeing yourself as healthy and well
and engaged in happy pursuits, this may suggest you
doubt your ability to recover. Try to see yourself reach-
ing your goals and enjoying the satisfaction of having
done so.

DRAWINGS AND INTERPRETATIONS OF OUR
PATIENTS’ MENTAL IMAGERY

We asked you to draw a sketch of your mental imagery
for a simple reason. The drawing documents your be-
liefs at a pa1ticular time so you can later compare how
your beliefs have evolved. In our pro ram, we ask our
oflients to draw such pictures every fhree months and
hen to describe them aloud to us. By comparing their
draWings from the initial session with the drawings
from follow- -11p sessions, we are able to see how the
patients are dealing with the cancer and how their be-
liefs are changing. Here are four case histories showing
how imagery and beliefs changed over time.

Betty

Betty, thirty-five, was first diagnosed with breast
cancer in 1973 and had one breast removed surgically.
Later she had a second cancer requiring that her other
breast be removed. When she began working with 11s
in Fort Worth, she was receiving chemotherapy.

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150 Pathways to Health

 

 

 

 

 

 

Figure 4. Betty's Initial Imagery, Showing Anger and,
Hostility.

Betty’s initial imagery (Figure 4) left little doubt that
the white blood cells were going to win. Her first draw-
ing showed ferocious-looking white blood cells with
sharp, aggressive teeth. She noted that they were ”like
piranha,” the voracious fish of South American rivers.
Our experience tells us that such sharp teeth often in-
dicate strong anger and hostility, and during her first
session with us Betty did express much anger and hos-
tility. Over the short term this works for her in her im-

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The Value of Positive Mental Images 151

agery; because of the potency of the symbol, there is
little doubt that the white blood cells will win.

There are two other elements in the drawings we see
as less positive. First, the cancer cells are either quite
large or the cancer is drawn as a cluster of cells. It is
good if patients are able to see the individual cancer
cells. Those who do not visualize the individual cells
often have difficulty looking at the component parts of
a problem and instead are overwhelmed by the whole.

The second problem in Betty’s imagery is that the
chemotherapy is represented by sharp, pointed ar-
rows. This is a very common symbol, but it often rep-
resents a fear of the treatment and a belief that the
chemotherapy will have a detrimental effect on normal
cells as well as cancerous ones. While such a belief has
a basis in the experience of many patients, it is possible
that the side effects will be reduced if another symbol
for the treatment, such as an individual rubbing ”che-
motherapy ointment” on cancerous cells, is pictured.

 

 

 

 

 

Figure 5. Betty’s Imagery Six Months Later.

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152 Pathways to Health

In Betty’s second drawing six months later (Figure
5), the piranhas (white blood cells) were still there, but
the teeth were less pronounced — though still quite
effective — and now there were prominent eyes in the
fish, indicating alertness and purposeful direction. At
this meeting, Betty seemed considerably less angry and
told the group that she had spent a great deal of time
working on that aspect of her life.

Now, the cancerous cells were depicted as small and
grapelike, and entwined with the normal cells. She as-
sociated this image with a great deal of fear which she
had been experiencing recently. (We have often ob-
served that vinelike, entangling symbols and fingerlike
projections generally represent fear.) In working with
Betty, it became clear to us that in addition to being
more aware of her fear of dying, and particularly of
dying alone, she was also afraid of getting well and
facing the problems that she had suspended during
her illness.

Betty had also picked up some erroneous informa-
tion about precancerous cells, and in this drawing she
portrayed them as corkscrewlike cells that at times al-
most appear to be attacking the white blood cells.
These precancerous cells, she thought, were actually
capable of penetrating normal cells, which is medically
incorrect.

Betty is now doing quite well, both physically and
mentally, and receives her primary counseling in her
hometown.

Jennifer

Jennifer, thirty years old, had advanced ovarian cancer,
and presented herself as a shy woman who had diffi-
culty asserting herself so that she could meet her own
emotional needs.

When given the assignment of drawing her mental
imagery, Jennifer drew two different pictures. 111 the
first (Figure 6), she showed her cancer as a cube of ice
and her white blood cells as the sun, melting the ice.
I'ler chemotherapy was depicted as white dust sprin-

202

The Value of Positive Mental Images 153

 

fl”

 

 

 

 

Figure 6. Jennifer’s Mental Imagery; First Visit.

kled over her cancer, which she had labeled the
"cancer monster.” Obviously, the word monster cap-
tured her dread and fear of the cancer, as well as her
sense of its strength and ferocity. Her image for the
chemotherapy was weak: dust is hardly a match for a
monster. Although the sun (her white blood cells)

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154 Pathways to Health

could melt her cancer ice cube, it is a rather passive
symbol with little direction or intentionality; that is,
while the sun is shining, it incidentally melts the
cancer.

Her second drawing (Figure 7) presented her as
being in an even more hopeless position. Her cancer
was portrayed as logs in a logjam, and one single man,
representing a white blood cell, was shown trying to
unjam the logs. Only if he succeeded could the logs be

 

Cliff

 

 

 

 

Figure 7. Jennifer’s Mental Imagery; First Visit.

204

The Value of Positive Mental Images 155

floated away, and even then they would remain un-
changed; that is, they would still be cancer logs, and it
is certainly undesirable to have cancer logs floating
around in the body. \Mth only one white blood cell
against the entire jam of logs, Jennifer’s odds did not
look good.

The drawing also showed a lack of assertiveness and
power -— the kind of energy that might be able to
break up the logjam in her life. (People who draw only
one ”image of the whiteblood cells tend to have a feel-
ing that if anything gets done in their lives, they have
to do it all by themselves with no outside help. This
feeling intensifies their sense of helplessness and
hopelessness.)

The image of her chemotherapy was still weak. It
appeared to be dripping some kind of poison into the
cancer, again labeled "cancer monster,” but did not
seem to affect it greatly. I11 fact, the monster seemed to
have a humanoid face, an eye and mouth, indicating
intelligence and alertness with which it could defend
itself.

Taken together, Jennifer’s first drawings indicate a
confusion, an inability to stay with one ima 1e, and lit-
tle belief that either her chemotherapy or er body’s
defenses could significantly influence the cancer.

Six months later, Jennifer’s drawing (Figure 8)
showed definite improvement. Her white blood cells
were now depicted as white sharks with angry, point-
ed teeth. F01 Jennifer to show signs of anger or _aggres-
sion, and sharks are certainly aggressive, was a major
step” forward. The cancer cells were also far smaller arid
less malevolent. Unfortunately, there was no interac—
tion between the sl1a1ks and the cancer cells; in fact,
the sharks seemed to be aiming their aggressiveness
toward the chemotherapy (which looked remarkably
like the "cancer logs” in her earlier picture).

These images correlated closely with what was going
on in her life: ller anger at the chemotherapy was sur-
facing. Tliough the sharks symbolized that part of her-
self that would help her get well, their aggressiveness
needed to be aimed at the source of her problem, not

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156 Pathways to Health

 

 

 

 

 

Figure 8. Jennifer’s Mental Imagery, Six Months Later.

at her treatment. Despite her anger at the chemother-
apy, her symbol of the chemical was not very strong:
She associated it with Alka Seltzer tablets, certainly not
a very potent drug, suggesting only a weak belief in
the potency of her treatment. Moreover, though the
tablets apparently dissolved in the bloodstream, again
no interaction was shown between the chemotherapy
and the cancer.

Jennifer was showing signs of progress, but her
newly discovered assertive energy was, at that point,
still not focused on the problem. Over the past two
years, however, she has steadily improved.

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The Value of Positive Mental Images 157

Glenn

Glenn, a fifty-year-old clinical psychologist, has cancer
of the kidney that metastasized to his lung, and he has
remained stable for four years. Therefore, no treatment
was being given, since chemotherapy was considered
inappropriate for his disease.

 

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Figure 9. Glenn’s Initial Mental Imagery.

[11 his first drawing (Figure 9), Glenn showed his
cancer surrounded by white cells and the cancer mass
gradually being reduced to a single cell. During his
relaxation/111ental imagery activity, he had difficulty
eliminating the last cell, but he found when he was

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158 Pathways to Health

jogging that he could see the final cancer cell being ab-
sorbed by a giant white cell and disappearing.

Although in the drawing he does finally succeed in
eliminating the cancer, there were some weaknesses in
the imagery. The white blood cells seemed to work
around the periphery of the cancer; there was little in-
teraction, and they met the cancer only on the surface.
(This desire to stay on the surface of the problem
sometimes indicates an unwillingness to investigate
the details of why one has developed cancer.) Also, de-
stroying the last cancer cell required a tremendous ef-
fort on Glenn’s part: He had to be jogging before it
could occur. There appeared to be something almost
magical about that last cell, almost a hanging on to the
disease and an indication that it would take a very
large white cell and an extraordinary event finally to
get rid of the cancer.

Six months later, his drawing (Figure IO) showed
more interaction between the white blood cells and the

 

Q 0 TU ” {Mmfi

wwa CELLS

 

 

 

 

Figure '10. Glenn's Mental Imagery Six Months Later.

208

The Value of Positive Mental Images 159

cancer, yet the size of the tumor relative to the size of
the white cells did not suggest overwhelming strength
on the part of the body’s defenses. A single, large
white cell was shown suddenly appearing and shatter-
ing the tumor mass, and the tumor fragments were
then absorbed by the ordinary white cells. Again, the
drawing showed that an extraordinary event was re-
quired, and that until this magical event occurred, the
cancer would remain intact. To us, Glenn’s picture il-
lustrated an unwillingness to deal with small compo-
nent problems and a tendency to wait for the one
event that would explain and remedy everything.
Similar to his imagery, Glenn’s cancer has not re-
gressed, though his general health is superb and he
continues as professor and long-distance runner.

Charles
Charles was a successful businessman who, shortly
after his retirement at sixty-two developed multiple
myeloma, a cancer of the bone marrow. Although the
disease showed 11p in laboratory studies, Charles was
free of symptoms, so his doctor decided to wait before
beginning chemotherapy. Now, three years later, his
lab reports show less disease than when he was diag-
nosed, and he has still not received any chemotherapy.
In addition to participating in our program, Charles
has also had several years of private psychotherapy in
which one of the problems dealt with was his difficulty
expressinganger. .... N W...
~Th'e’r’ei'were strong similarities between Charles's two
pictures (Figures 11 and 12), drawn almost a year
apart. Both showed a positive expectanc , in that the
white blood cells (the sharks or large fish were clearly
overwhelming the cancer. The most dramatic differ-
ence between the two drawings was in their size: the
first drawing filled almost the entire page, the second
occupied a much smaller space. The second indicated
how much smaller a part the cancer occupies in
Charles's life, for at that point his blood chemistry
showed the cancer decreasing, he had no physical

209

160 Pathways to Health

 

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a m eJ/L
ONr 4H 7 ”a”;

«1 Idea r ZMmaf/UV'e ch

 

 

 

Figure 11. Charles’ Initial Mental Imagery.

sym toms, and his physical condition had remained
exce lent — regularly beating the authors at tennis at
the age of sixty-five.

Another sign of progress was that in the first pic-
ture, the cancer was shown as being largely sur-
rounded in a highly organized manner by white blood
cells; in effect, the cancer was walled-off, much as
Charles had walled off problems in his life. By the sec-
ond drawing, there was much less organization. We
correlated these images with less need on Charles’s
£11339 protect _himself 'emotionall'y'iarld "a" greater'vv'ill-
ingness to interact openly with the problems In,-h,i5..l,if€-
.. One difficulty was suggested by the lack of defi-
nition of the mouths — the major weapon — of the
sharks or fish in the second drawing. During the

210

The Value of Positive Mental Images 161

 

 

 

 

Figure 12. Charles’ Mental Imagery One Year Later.

period of the first drawing, Charles was very angry
about the death of a close friend, and the anger
showed up in the sharp, aggressive teeth. By the time
of the second drawing, he was expressing much less
anger about problems in his life, an issue we explored
with him again.

IMAGERY AS A DESCRIPTION OF SELF

These interpretations of our patients' drawings take
into account as much as possible all the significant
problems and psychological issues they are facing. We
come to understand the drawing within the context of
what we know of the patient’s personality and life
situation. Thus, it represented progress for Betty to
tone down the anger and hostility expressed in her
piranhalike fish, while it represented progress for Jen-
nifer to portray her defenses as sharks. In one case,
Betty’suangermahnd hostility were causing her to reject
{fie acceptance, ‘afifit'évalyaad recognitionshe‘despe’r-
ately wanted sh'daawhad‘somehope of getting; in the

211

H12 I’athwavs to Health

other, Jennifer, a passive peison, desperately needed
the energizing that anger often accomplishes, even
though she still had to learn how to use the anger ef-
fectively.

We are often able to use the imagery not just as an
indicator of patients’ beliefs about cancer but also as a
description of their situations in life. I11 making this in-
terpretatlon, we see the symbols of the cancer as the
par} of the person that wants to die or that IS killing

1m or her, and the White blood cells as the part Qf the
person that wants to live or that will help him or her
get well. ' '
' The disease becomes a physical manifestation of the
battle being waged between two parts of the self: the
toxic or self-destructive parts and the nurturing or
life-sustaining parts. The symbolic potency of the
cancer in relation to the body's defenses is not just a
measure of the patient’s beliefs about the disease but is
also an indicator of how strongly the patient wants to
live or die.

Our patients go through the drawing procedure
every three months when they return to Fort Worth for
a follow-11p visit. Even though they are fully aware of
the use of this procedure, they still generate revealing
1magery.

We encourage them to use the whole process, includ-
ing their attitudes toward mental imagery and changes
in their imagery, as an important guide to their
psychological states. When ~~they learn to ask, “Why are
these images coming to me now? What changes 111 be-
liefs do these images indicate? Why am I choosing to
see things 111 this light at this particula1 time?” they are
pafliclpating In the process of expectancy and taking a
measure of control over it.

Use relaxation/mental imagery time as an opportu-
nity to work on other issues in your life. During the
first weeks and months, the necessary emphasis is on
getting well. Obviously, without health your ability to
concentrate on other problems is limited. But as you
begin to regain health, we urge you to seek ways to
apply the pfirocess‘tro a_wideflvarietyofllife’snproblgrns.

 

212

The Value of Positive Mental Images ifn

As we have stated, the imagery of positive expectan-
cies, which is also the principle of the self-fulfilling
prophecy, can help you succeed in a limitless number
oftways. -

 

 

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213

 

Sticking

and
emigration

of leucocytes.

One of the most striking phenomena ob-
servable in living blood vessels in the
early stages of acute inflammation is that
the white blood cells cease to float freely
in the blood stream keeping pace with
the red cells as they pass along the van-
ules but adhere closely to the endothe-
tium. Furthermore. the leucocytes not
only stick to the endothelium but also to
each other. All the granulOCytic cells are
involved-particularly the polymorpho-
nuclears and also the monocytes, and
platelets(Figs. 21. 23).The small lympho-
cytes are the notable exceptions.

Since there is increased permeabil.ry
to plasma proteins where sticking is not
observed and in other vessels sticking
where there is no evidence of increased
permeability to colloids. these two proc-
esses seem to be brought about by dif-
ferent mediators.

Sticking and phagocytosis

Whatever the mechanism of sticking, the
phenomenon seems in some way to be
associated with phagocytosis. For exam-
ple. it leucocytes are allowed to phago-
cytize pneumococci in vitro. they stick
to each other and form tightly adherent
clumps. F. Allison and M. G. Lancaster
have studied this phenomenon using
both rabbit and human white cells. They
found that if the medium was deionized
by various means. both phenomena were
inhibited. But they could be restored by
the addition of either calcium or mag-
nesium ions. Of the two. magnesium was
the more effective. Since both Car+ and
Mg++ were divalent, they tested the effi-
cacy of other divalent cations and found
that both manganese and nickel were
very potent for this purpose Cadmium
and lead were moderately effective and

'18

    

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An electron micrograph of a sticking polymorph
shows the plasma membrane of the potymolph
flattened against the lamina! surfaces

at two endothelial cells. whose junction It covers.
The very narrow space between the blood cell
and the endothelial wall may be an artifact.

214

 

so was trivalent iron. Divalent iron and
other monovalent and trivalent metals
had little activity. The fact that other divs.
lent ions were as eftective as calcium Or
more so seemed to rule out any close
relationship to fibrin formation.

The possibility of the participation of
an enzyme in this phenomenon was also
considered. and the effect of various en.
zymes and enzyme inhibitors was tried.
Because both phagocytosis and dump-
ing were almost completely inhibited by
epsilon-amino-caproic acid, a known in-
hibitor of proteolytic enzymes, and for
other reasons. Allison and Lancaster felt
that possibly a proteolytic enzyme was
involved. Such an enzyme might act on a
protein that in some way alters the cell
surface.

The behavior of both rabbit and humm
leucocytes was essentially the same. The
experimental procedures usually affected
phagocytosis and clumping of leucocytes
equally. but there were some slight dif-
ferences so that the processes though
closely related may not be identical.
Since leucocytes tend to stick to each
other as well as to the endothelial cells.
It is probable that whatever causes the
phenomenon acts on both types of cells.
Em
Very soon after sticking is observed. the
leucocytes are seen to work their way
through the endothelium and perivascu-
lat structures into the tissue spaces.
Electron micrographic studies indicate
that this is accomplished by their insinu-
ating a pseudopod into an intercellulat
junction of the endothelial cells. enlarging
this opening somewhat and eventually
squeezing through it (Figs. 22. 24. 25).
Only granulocytes and monocytes ac-
tively work their way out of the vessels
but it would appear that a few red cells
and lymphocytes may take advantaged
the holes they create and emerge with-
out any preliminary sticking (Fig. 26).
flediatora ot emigration
While substances known to promote vas-
cular permeability often occasion sum!
emigration of leucocytes. the “SPOT.
is usually delayed and weak. A grail
many substances produce such re-
sponses. for example. plasma. it is 903‘
sible that any agent producing vascull
permeability might cause mild dell”d
emigration of leucocytes because of 3'
extravasated plasma.

Extracts of burned skin. J. V. M
found. produced a prompt and VOW "'
tense emigration ot leucocytes. Thi' ‘3
the type of response that would be if
pected from a specific mediator of if"
phenomenon. it was also found that I."

215

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A neutrophil. in this electron micrograph.

‘3 passing through an endothelial gap.

As the leading edge advances it is notably empty
0' minutes, which will flow back into it later on.
h the lumen a platelet adheres to the neutrophil
and a portion of a second neutrophil

”r be glimpsed. adhering to the first one

Md b the endothelium.

cocytes extracted with saline produced
an intense migration of leucocytes. To
ascertain whether or not it was the leuco-
cytes in the burned skin that produced
the response. rats were treated with nitro-
gen mustard to the point that they were
devoid of leucocytes and burned. An ex-
tract ot their burned skin was made and
tested. It produced an intense response
even though the skin was almost devoid
of white cells. The inciting material was
then sought in serum. but serum by itself
produced little response. When. how-
ever. serum was incubated with white
cells or minced tissue of various kinds.
potent materials were produced. The ac-
tive substance was nondialyzable. stable
when heated to 60°C for 30 minutes. but
destroyed it kept at this temperature for
one hour. it was destroyed by trypsin. lts
action was not prevented by the prior ad.
ministration of antihistamines. amine axi-
dase inhibitors. quinine or salicylate.

It was hypothesized that some factor
in serum was acted on by a substance
present in injured tissue; this factor
would then produce the active mediator
of leucocyte emigration.

To test the possible relation between
chemotaxis and leucocyte emigration.
the various extracts were tested for
chemotatic activity in a modified Boyden
chamber, and it was found that their abil-
ity to induce emigration of leucocytes
and their chemotactic activity were par-
allel. It appears. therefore. that there is an
endogenous material that can be pro-
duced by injury that is capable of induc-
ing migration ot leucocytes and possibly
attracting them to the site of injury.

There is obviously a relationship be-
tween sticking of leucocytes. their emi-
gration, chemotaxis and phagocytosis
since. in a sense. they are all stages in
the process that gets the phagocytic
cells to the material to be phagocytized.
it would not be surprising therefore it the
same substance mediated more than
one of these stages.

Whether or not this material described
by Hurley is also the substance responsi-
ble for the preliminary sticking of the
white cells to the endothelium and each
other and also probably involved in
phagocytosis remains to be shown.

A complex of three components of
complement Cs. 0.. and C, seems to be
highly chemotactic for polymorphonu-
clear neutrophils and eosinophils, partic—
ularly when it has been fixed in an anti-
gen-antibody reaction. Mononuclears are
also attracted by components of comple-
ment but different ones from those at-
tracting granulocytes.

216

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A monocyte is beginning the journey

thmugh an endothelial gap

by pushing a pseudopod info the opening.

At right. an eosinOphil. already outside the vessel.
partially blocks the emerging monocyte.

Erythrocytes are passive cells.

Here an erythrocyte has probably been washed
into an already existing endothelial gap

and because of its extreme plasticity

it will be squeezed through it.

Chemotaxis

While a straight forward enough phe-
nomenon in vitro. chemotaxis has not
been satisfactorily demonstrated in viva.
In fact. Sumner Wood. Jr. using a cine-
matographic method has plotted in detail
the peregrinations of a single polymor-
phonuclear leucocyte. The movements
were active but there was no indication
that it had any tendency to move toward
an area of injury or a highly chemotactic
substance. It moved quite as often away
from as toward the chemotactic material.
Why the highly chemotactic materials
failed to attract the polymorphs in vivo
remains to be explained.

Most tests made for chemotaxis in re-
cent years have been made in the Boy-
den chamber. two shallow compartments
separated by a millipore filter. The
chemotactic substance is placed in one
compartment and leucocytes in the
other. The pores of the filter are so small
that leucocytes can only get through by
ameboid movement. In so confined a
space. chance alone would bring many
cells to the membrane. Perhaps only then
does the attractant stimulate the cells
to penetrate it. In other words. the attrac-
tion of the chemotactic substance might
actually act only over a very short dis-
tance. Consequently. the demonstration
of chemotaxis by this means does not
necessitate that the leucocyte be able to
follow a concentration gradient toward
the substance for any great distance. but
rather that coming close to it by chance
it remains and attempts to engulf it.-
Lymphocm- .
One cell that is always present in a nor-
mal inflammatory exudate and which ar-
rives there fairly early in the course of the
process is the lymphocyte. This cell has
not been observed by the electronmicro-
scopists to leave normal small blood ves-
sels via the intercellular junctions unless
it is washed through a hole left by a poly-
morph or monocyte. It has. however.
been seen to leave the vessels in lymph
nodes by piercing the endothelial cyto-
plasm. Furthermore. according to the
work of A. R. Page the substances that
induce the emigration of leucocytes do
not induce the emigration of lympho-
cytes: an entirely different mediator
seems involved. In the first place. a prior
emigration of neutrophils seems to be'
required. because in neutropenic ani-
mals the lymphocyte response is either
prevented or greatly delayed. Apparently
this agent is an inducer of new protein
synthesis in the lymphocyte. since the
response is prevented by drugs that in-
terfere with protein synthesis.

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‘ . ’2'A'fl" N .’ . . 9 0.
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Mammary and-nomination).

fifi‘x- .

 

217

Leukocytic Infiltration

When we look at a piece of inflamed tissue under a micro-
scope. the most striking and characteristic thing we see -
the “pathognomonic” feature - is the presence of leuko-
cytes (Figures 27. 28). These cells come from the blood;
they first stick to the walls of the blood vessels.tl1en emf.
grate outward into the tissues (Figures 29-31). and mwl
towards whatever might have provoked the inflammatory
response - perhaps a clump of bacteria. or perhaps a
group of damaged cells. This process of directional
locomotion is called chemotaxis. The leukocytes then
do their best to eat up and digest the ofl’ending agent-—
phagocytosis.

Leukocytic Sticking

In animals without blood vessels. mobile mesodermal
cells accumulate at sites of injury or around bits of foreign
material. These mobile cells are analogous to mammalian
leukocytes. except that the latter are enclosed within the
bloodstream. The first step in getting mammalian leukoo
cytes out into the tissues where they are needed (in an
inflammatory response) is to have them stick to the vessel
walls in the appropriate area. This is obviously a crucial
event in inflammation. but we know remarkably little
about how it occurs. It does not seem to be a nonspecific
result of increased vascular permeability. If histamine is
injected into the skin. the leukocytic infiltration is slight.
On the other hand. if bacteria are present or if there is
tissue damage. than we see massive sticking (and emigra-
tion] of leukocytes. Probably the bacteria and the dam-
aged tissue liberate factors that somehow alter the endo-
thelial lining of the blood vessels so that it becomes sticky
for leukocytes. Cohnheim envisaged “a molecular change
in the vessel walls." but its nature remains a mystery.

It was once thought that a "glue" forms on the luminal
surfaces of the endothelial cells. particularly in the ven-
ules, where most of the sticking occurs. Using special
staining techniques (ruthenium red. colloidal iron). elec-
tron microscopy has revealed the presence of an amor-
phous “cell coat" material on the endothelial surface of
normal blood vessels. But. somewhat disappointingly.
there does not seem to be any change in this layer in in-
flammation; at least there is no alteration that can be
detected morphologically. Another idea is that the attach-
ment is due to the formation of ionic bridges. eg. with
Ca“. between the leukocyte and the endothelial cell sur-

218

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219

face. However. both the leukocyte and the endothelial cell
are negatively charged. so it is difiicult to see how they
could get close enough to form such bridges. It is possible
that inflammation induces an appropriate change in the
endothelial surface (perhaps a change in charge) that
allows closer cell-taco“ contact. but this is obviously a
difficult concept to test. However. there seems little doubt
that divalent ions such as Ca“ play a part in the process.
This has been shown in experiments in which sticking
was inhibited in animals treated with EDTA (ethylene-
diaminotetraacetate). a chelating agent that removes free
calcium ions from the blood. This inhibition was shown
by direct observation of inflamed blood vessels in the
rabbit ear chamber. in the cheek pouch of the hamster.
and in the mouse mesentery. Local anesthetic drugs also
inhibit leukocytic sticking in experimental animals; the
mechanism is obscure. but it is known that such agents
can displace Ca“ from binding sites in membranes.

Leukocytic Emigration (Diapedesis)

In acute inflammation. diapedesis of leukocytes across
the venular wall occurs via the interendothelial junctions
(Figure 32). This fact was recorded in the drawings of
Arnold in 1875 (Figure 33). and was confirmed by elec-
tron microscopy. more than a century later. by Vincent
Marchesi and Sir Howard (later Lord) Florey at Oxford.
We can see this process in Figures 34-36.1ndividual leu-
kocytes usually take from 2 to 12 minutes to get com-
pletely across the vessel wall. .

Perhaps some of the leukocytes sneak out through gaps
prepared for them by histamine-type mediators (this is
not well established). However. it is certain that they do
not need such preformed gaps. because it is possible to
produce diapedesis without an accompanying increase
in permeability. Nor does diapedesis cause vascular
leakage. which shows how tightly the leukocytes must
squeeze themselves between the endothelial cells. Here
is the experiment: in the rat. a subcutaneous injection of
serum produces a lively inflammatory response (with
the rapid onset of increased vascular permeability). Four
hours later. vascular leakage has subsided.whereas dia-
pedesis is at its peak india ink. injected intravenously at
this stage. does not cause “carbon labelling” of the vessels
because the endothelium closes up immediately behind
the emigrating leukocytes.

220

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Although the emigrating leukocytes may not cause
leaks in the endothelium. they temporarily tear apart the
basement membrane around the vessel. They probably
have no alternative. A simple experiment devised by
john Hurley to prove this point is to cause vascular label-
ling by injecting India ink intravenously immediately
after injecting histamine into the skin. If this area of skin
already shows active diapedesis(forexample.in response
to an injection of serum four hours earlier). the labelled
venules spill their carbon out into the tissue spaces
through holes punched in the basement membrane by
the escaping leukocytes.

We do not know what stimulates the leukocytes to emi-
grate. It is possible that chemotactic agents released in
the tissues might seep into the junctions and attract the
pavemented leukocytes out of the vessel. but there is no
evidence to support this theory. nor do we know how the
leukocyte traverses the basement membrane - whether
by pure mechanical force.by enzymatic lysis.or by some
other process.

Before leaving this topic. let us mention a minor con-
troversy concerning another sort of leukocytic emigra-
tion. It has been claimed that lymphocytes cross venular
walls in lymph nodes by passing through the cytoplasm
of the endothelial cells. However. in more recent studies
using careful serial sectioning techniques.Gutta Schoefl
demonstrated that. here too. emigration occurs through
the junctions.

221

What Kinds of Leukocytes Emigrate

in Acute Inflammation - and When?

In the early stages of the acute inflammatory response.
the predominant cell infiltrating the tissues is the neutro-
phil polymorphonuclear leukocyte. After a day or so. as
the intensity of the response subsides. the predominant
cell is the mononuclear phagocyte [usually called a ma-
crophage when found in the tissues); this cell is derived
from the blood monocyte.

lfthe tissue is infected with pyogenic (pus-producing)
bacteria. the influx of neutrOphils is greatly enhanced
and sustained. If the bacteria survive long enough they
can provoke the formation of abscesses. These are newly
formed cavities that contain pus. Pus consists of myriads
of neutrophils in various stages of degeneration.floating
in exudate fluid (Figure 37).

The time sequence for leukocytic emigration has been
worked out experimentally by collecting and counting
exudate cells at various times after injecting phlogistic
agents (an old-fashioned term for inflammatory agents)
into the pleural or peritoneal cavity of rats. A typical ex-
periment is shown in Figure 38; this depicts the numbers
of neutrophils and mononuclear phagocytes found in
the pleural cavity of rats sacrificed at various times after
injecting rat serum. Clearly. the peak polyrnorph emigra-
tion occurs within the first 6 hours. whereas the peak
mononuclear phagocyte emigration is delayed another
6 hours or so. The mononuclear cells predominate after
12 hours.and by 48 hours they are virtually the only cells
found in the exudate. In striking contrast is the pattern
seen after the injection of living Klebsiella pneumoniae
organisms into the pleural cavity of rats (Figure 39). In
this situation. enormous numbers of neutrOphils contin-
ually pour into the cavity while mononuclear emigration
remains relatively insignificant.

It is not understood why the major infiltration of mono-
nuclear phagocytes occurs after the neutrophil peak.
Some investigators have attributed it to a combination of
two factors: first. the locomotion of the macrophages is
relatively sluggish. and secondly. macrophages can live
for days or months. whereas neutrophils only last for a
matter of hours after emigration. This hypothesis may be
a partial explanation for the findings. at least for the pro-
cipitous fall in neutrophil numbers after the peak is
reached compared with the much slower decline in

numbers of mononuclear cells. However. from experi-
ments such as those shown in Figure 38. it is apparent
that proportionally more neutrophils emigrate into the
inflammatory focus in the early stages. whereas more
monocytes enter the lesion later. This biphasic response
could result from the sequential action of specific chem-
Ical mediators. In other words. there may be a mediator
that causes neutrophil emigration. followed by a media-
ta that causes monocyte emigration. In recent years. it has
been demonstrated that certain chemotactic agents may
specifically attract certain kinds of leukocytes. In the
present context. the most relevant of these specific agents
is one described as a monocyte chemotactic factor re-
leased from neutrophils.

Chemotaxis

Chemotaxis - the attraction of cells towards chemical
substances - is a subject that has fascinated biologists for
nearly 100 years.The term was originally used by Pfefl‘er
in 1884 to describe the attraction of spermatozoids of
certain ferns toward malic acid. In 1888. Leber was the
first to observe chemotactically directed movement of
leukocytes. He injected guinea pig corneas with molds
or with products of putrefied rabbit muscle and then.
after waiting for several hours until the corneas were in-

 

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filtrated with leukocytes. he removed the corneas and
examined them under the microsc0pe. He observed the
leukocytes moving directly towards the injection sites.
Over the next 50 years. chemotaxis was studied by many
workers using a wide variety of methods. By the 19405 it
was generally believed that neutrophils were attracted
_ by bacteria and their products. as well as by factors re-
leased during tissue breakdown.

However. at Oxford in the early 19505. Henry Harris
proposed that much of the data concerning leukocyte
chemotaxis were obtained from experiments that were
badly controlled. He attacked the common assumption
that accumulation of leukocytes at a particular site

223

necessarily meant that the cells had been attracted there
chemotactically. He pointed out that such a finding
could just as easily be explained by a local. nonspecific
trapping of randomly moving cells. Harris particularly
stressed that chemotaxis can only be assessed if direc-
tional locomotion of the cells is directly observed or re-
corded. He devised a simple but elegant system in which
neutrophils were incorporated into a film of clotted pla-
ma between a slide and a coverslip. Using dark field rni-
croscopy (in which cells show up as white blobs on a
black background). the paths traced by the cells could be
recorded by making long exposures of a single pheno-
graphic frame (Figure 40). Using this technique. Harris
confirmed that clumps of various bacteria were chemo-
tactic but found no polarization of the tracks towards
fragments of injured or autolysed tissue (we shall reex-
amine this result in a moment).

The next important development occuned in Australia
in 1962. when Stephen Boyden introduced a new assay
system for chemotaxis. This system consists essentially
of a chamber with two compartments separated by a hor-
izontal filter membrane (Figure 41). Leukocytes placed
in the upper compartment crawl through the pores of the
filter (Figure 41) when a chemotactic solution is placed
in the lower compartment. The chemotactic activity of
the fluid in the lower compartment is evaluated by count-
ing the number of cells on the lower side of the filter (or
the extent of penetration of cells into the filter) at the end
of a certain period of time.

As a technique. Boyden's system has enjoyed wide
papularity. It is simple. it can be conveniently used to
assess the chemotactic activity of substances in solution.
and it allows some degree of quantitative comparison of
difl'erent test substances. However. it has been recognized
recently that. as ordinarily used.the system may not dis-
tinguish between accelerated random locomotion of
cells and true chemotaxis. Thus. the test substance may
simply stimulate the cells to crawl around faster. and
this would result in larger numbers of cells reaching fur-
ther into the filter. independent of specific chemotactic-
ally directed locomotion. Boyden also recognized this
problem and performed control experiments in which
the chemotactically active solution was placed with the
cells in the upper compartment of the chamber. In such
cases. the cells showed less tendency to crawl into the

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filter than if the solution were placed only in the lower
compartment. This was interpreted as evidence that ac-
celerated random locomotion was not involved in a pos-
itive result. Recently. however. it has been shown by
Sally Zigmond and james Hirsch that a given substance
may stimulate random locomotion at low concentra-
tions (such as might develop with slow difl‘usion of mol-
ecules through the filter). but may actually inhibit loco-
motion at higher concentrations (such as when the test
solution is placed directly with the cells in the upper
commrtruent). Because of this problem. Hirsch has urged
that data obtained with such indirect techniques as the
Bayden system should be checked by direct microscopic
Observation of leukocytes crawling in thin preparations
(such as in the slide-coverslip system used by Harris).
Now that we have described and evaluated the tech-
nique, let us return to Boyden's original observations.
are most interesting. He discovered that chemo-
tactic activity (for neutrophils) was generated if serum
*8 incubated with antigen-antibody precipitates. He
”posed that such precipitates interact with the serum
complement system to liberate chemotactic factors. john
Hurley soon adapted the same technique to show that se-

rum incubated with minced tissues also became chemo-
tactic. Ryan and Hurley then used Harris' slidecoverslip
technique to directly demonstrate that neutrophils
crawled towards tissue fragments that had been pre-
viously incubated with fresh serum. These findings not
only reinstated the view that chemotactic factors can be
released during tissue damage. but also established a
new concept: chemotactic factors can be derived from an
interaction between tissue products and serum sub
strates. Later. in the section on Mediators. we discuss
how this work has been extended. pinpointing the key
role of serum complement components in the production
of endogenous chemotactic factors. such as C3 fragments
and C5 fragments.

There is also evidence that serum-independent chemo-
tactic factors can be released from certain cells. For ex-
ample. damaged or phagocytizing neutrophils probably
release chemotactic molecules - rather like ants releasing
“alarm pheromones." thereby calling their colleagues to
help them attack a foreign insect invader. From studies
of blood cells in slide-coverslip preparations. Marcel
Bessis gives the following colorful description of such a
process - he calls it “necrotaxis.”

31

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“On a cellular level. the phenomenon calls to mind large
sharks swimming without paying attention to each other. to
fasten upon one of their number which has blood escaping
from a wound. it can sometimes be observed that after ingest-
ing part of a dead cell. leukocytes abandon a piece of the corpse;
this piece does not attract another cell. even ifit is near to it."

Bessis makes the point here that such chemotactic
factors are only released while the cell is in the process
of dying and not at later stages.

Mechanisms Involved in Leukocyte Chemotaxis

First. how does the cell detect a gradient of chemotactic
molecules so that it knows which way to crawl? Secondly.
how does sensing of the gradient actually cause the cell
to crawl in the right direction? These are challenging
questions of broad biologic interest. It is likely that at-
tractants are detected primarily by specific chemorecep-
tors on the surface of cells. This certainly seems to be
true for bacterial cells that respond chemotactically (Es-
cherichia coli has receptors for galactose. glucose. ribose.
aspartate and serine). A gradient could be detected by a) a
“temporal” mechanism whereby the cell “snifl‘s the air”
(available chemotactic molecules bind to the surface
receptor sites) at separate time intervals. or b) a “spatial"
mechanism whereby the cell compares the concentration
of the attractant at two or more separate locations on its
surface at the same time. For bacteria. it seems that a tem-
poral mechanism is involved (implying that individual
cells can possess some sort of “memory” system) because

32

225

sudden decreases in attractant concentrations cause Sq).
monella typhimurium organisms to show uncoordinated
tumbling. whereas sudden increases in concentration
induce smoother. "super-coordinated." straight-line
motion for several minutes. This behavior could result in
a directional response along a gradient. On the other
hand. the available evidence suggests that a spatial mech-
anism is more likely to be involved in leukocyte chemo-
taxis. Sally Zigmond has shown in slide-coverslip pre-
parations that stationary neutrophils exposed to a chemo-
tactic gradient make their first movement towards the
chemotactic source. indicating that a leukocyte can sense
a difl’erence in the number of chemotactic molecules
across its own dimensions —- no mean feat! However. we
are still far from understanding how sensing of such a
gradient can lead to directional movement: in other
words. how the actin-myosin contractile machinery of
the leukocyte is triggered and coordinated to produce the
appropriate response (Figure 42).

The literature is full of studies claiming that chemo-
taxis (in the Boyden system) is inhibited or enhanced
with one treatment or another. For instance. inhibition
has been reported with drugs that increase intracellular
cyclic AMP. However. it is likely that most of these results
are due to inhibition orenhancement of cel lular motility
and not true effects on chemotactic responsiveness.

Years ago. it was thought that leukocytes were repelled
by certain materials. eg. kaolin. This was called negative
chemotaxis.'l'he evidence for this phenomenon. however.
was always rather weak and has not been confirmed in
more recent studies.

Chemotaxis In Vivo

in rabbit ear chambers. early experiments demonstrated
that leukocytes wandered about randomly in injured
areas. This was interpreted to mean that chemotaxis was
simply an in vitro curiosity. This pessimistic view was
challenged by lan Buckley. who prOposed that random
motility in such studies occuned because the injury was
too widespread to allow gradients to develop within the
field of the chamber. To examine the point more precisely.
Buckley induced a very small focus of heat injury in an
ear chamber. He then observed that neutrophils emi-
grated from the surrounding blood vessels and then
crawled directly towards the site of injury.

APPENDIX E

QUESTIONS USED FOR IMAGERY RATINGS

226

APPENDIX E

QUESTIONS USED FOR IMAGERY RATINGS

(Specific Imagery Questions

 

Score: 1 - no visualization
5 - high visualization

SCORE

*1. Describe how your white blood cells looked.

(Score on vividness, clarity, continuity of
description.)

2. Did you see them changing shape? What shape?
How many?

3. Did you see them sticking to the blood vessel
wall? How? How many?

*4. Did you see them leave the blood stream? How many?
*5. Could you tell anything about their strength?
*6. How do you feel about this experience?
7. Any other observations or comments?

*8. How symbolistic vs. how concrete is the visualization?
*9. Clinical judgment--overall strength of imagery?
Summary Variables:

*White blood cell count change

*Shape change

*Adherence change

 

*
Variables correlated with the blood measures.

227

APPENDIX F

CORRELATIONS BETWEEN IMAGERY RATINGS,
PERSONALITY FACTORS, AND
BLOOD MEASURES

228

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