Medicine and the Mind

Miracles happen all the time. Doctors call them spontaneous remissions.

In 1964, Norman Cousins, then editor of Saturday Review, exhausted himself in Russia as chairman of an American delegation on cultural exchange and, upon returning to America, fell critically ill with ankylosing spondylitis, a degenerative disease of the connective tissues in the spine. The glue that bound his cells together was disintegrating. Cousins, one of the most active and respected humanists of our time, a man whose career had always been marked by flexibility of intellect, was becoming physically rigid. He had spent a lifetime being outspoken and now he was so paralyzed he could hardly open his mouth.

"The prognosis," says Cousins, "was progressive paralysis; I was told I'd have to make a choice between having my body freeze sitting up or lying down." The doctors told Cousins his chance for recovery was one in 500.

"I didn't care what the doctors said the disease was. They could have said it was cancer multiplied by ten. And I would have said, 'OK, boys, you just tend to your business; I'll tend to mine.'"

Cousins smiles sweetly and, stretching his legs, crosses his feet at the ankles. His pants cuff catches on the top of one of his Wellingtons and he nimbly reaches down to free it. Not the gesture of a man who 16 years ago was told by specialists that he would have to get used to a life as a living statue.

"When I discovered the disease was serious," he says, "I had a much better attitude toward it than when I thought it was transient. Before, it was something to accept passively; I had put myself in other people's hands. Now it became a challenge; I realized I'd better get into the act and take an interest in the case."

His smile widens. The happier he grows at the memory, the more clearly marked his features become--as though joy, in a very real way, defines him. "I was curious," he says, "and had this great experimental desire. I didn't have to kill any sheep or dogs to do my experiment. I had a beautifully self-contained laboratory: me."

He had remembered the work of a Montreal doctor, Hans Selye, who a decade earlier, in 1956, had published a book based on his pioneer study of how stress could adversely affect body chemistry and cause illness. Cousins had assumed the reverse was also true, that positive emotions, like love, hope, faith, the will to live and joy, could promote health. So he discharged himself from the hospital--a very stressful environment, "the last place someone sick should go," he now claims--and checked into a hotel, where he was more comfortable, the service was better and the cost was less. From Alan Funt, Cousins borrowed a movie projector and some classic reels of Candid Camera. He also stocked his medicine cabinet with Marx Brothers films, E. B. and Katharine White's Subtreasury of American Humor, Max Eastman's The Enjoyment of Laughter and the works of P. G. Wodehouse, James Thurber, Ogden Nash, S. J. Perelman and--he confides, "if you promise not to tell anybody" (I didn't promise)--"even Bennett Cerf.

"I made a very interesting discovery," he says. "Ten minutes of solid belly laughter would give me two hours of pain-free sleep."

A decade later, in the mid-Seventies, scientists discovered that the brain produces proteins called endorphins, which are natural morphinelike painkillers. Apparently, laughter--and, in general, any happy, relaxed state--triggers the production of endorphins. So the anesthetic effect of Cousins' self-prescribed therapy of joy has a scientific basis. Furthermore, laughter seemed not only to reduce his pain but also to help cure him. Because of its anesthetic effect, he no longer had to take sleeping pills and painkillers, which affect the endocrine system and interfere with the body's own healing mechanisms. Cousins found that after each session of laughter, his sedimentation rate--a gauge of how severe an infection or inflammation is--dropped a significant five points.

He also took massive doses--25 grams--of vitamin C, which lowered his sedimentation rate even more. "At the end of the critical two weeks during which I took the love, laughter and ascorbic-acid [vitamin C] therapy, I was able to move my thumbs," says Cousins, working his thumbs like Danny Kaye singing Thumbelina in Hans Christian Andersen, "and I knew I was going to make it all the way." He now plays tennis an average of three times a week.

Orthodox doctors have trouble with Cousins' case. If he had gone to Lourdes, they would have been skeptical enough. But a pilgrimage to the Marx Brothers? Traditional physicians tend to explain Cousins' improvement as something that would have happened anyway--that one-in-500 chance--or, as the result of the placebo effect--improvement due to a patient's (and sometimes also a doctor's) belief in an otherwise useless therapy. But neither of those cautious explanations explains much. What was it that made Cousins that one in 500? If love, laughter and vitamin C did not cure him, how did the belief that they would cure him make him healthier? Just what is the connection between the spirit and the flesh--between a healthy body and a healthy mind?

•

If Cousins' cure were the only one on record, it would be easy to dismiss it as a fluke. But doctors have often had to deal with miracle cures--and with equally inexplicable declines in health--associated with dramatic changes in mood or expectation. Sixty-four miracle cures--including regeneration of withered limbs--have been documented at Lourdes alone since the turn of the century. And about 200 cases of regressions of terminal cancers have been published. Then there are thousands of cases of widows and widowers who die within days of their spouses, of people who have heart attacks shortly after being fired from their jobs, of others who fall seriously ill following divorces. There are the results of a study done recently by Caroline Thomas and Karen Duszynski of Johns Hopkins University School of Medicine that found a significant psychological similarity among medical students who later developed malignant tumors; the patients seemed to share a feeling that they were not close to their parents. How can a feeling of estrangement from parents lead to cancer? And what can a medical doctor do about it? There are no pills that can heal a rupture within a family.

There are the results of startling--and ethically questionable--experiments reported by the late Dr. Henry K. Beecher of the Harvard Medical School. Patients suffering from angina pectoris were given sham arterial-bypass operations: They were merely cut and sewn up. But the patients generally expected the operation to improve their condition and, in fact, they did as well as patients who were given real bypass operations. Apparently, something other than surgery was at work.

The maiden who pines away for love and the healthy Haitian who dies after having a voodoo curse placed on him are not fictions. They are realities traditional modern medicine has tended to deny or ignore. If civilization is a hospital ward, the maiden and the Haitian live in the forest surrounding the hospital grounds. And the rest of us--with a few brave and inquisitive exceptions--try unsuccessfully to reassure one another that their howls of pain are the sound of the wind in the woods. Mysterious changes in health seem, at least at first, to threaten the rational myths upon which our culture is based. We want to believe medicine is technology, because if it is, we can improve our health merely by building better machines. Any other model of medicine might suggest that to improve our health, we must somehow improve our very selves.

We could understand it if mood or behavior changes followed improvements or declines in health. But often the mood or behavior change occurs simultaneously with or even before the change. This sounds too much like magic--or, worse, religion. At least in magic, the one spinning the spells is human; if magic proved useful, doctors could grab the wands. If religion rules health, doctors must defer to divines. We drown in disease or wait for an almighty hand to still the waters.

Whatever the agent of these mysterious cures and illnesses, doctors have found it harder and harder to deny that such improvements and declines have some significance in the practice of responsible medicine: first, because the more they look, the more they find that expectation--or attitude, temperament, mood, personality, call it what you will-- (continued on page 211) Medicine and the Mind (continued from page 122) seems to have a direct bearing on, an active feedback relationship with, physical health; and, second, because traditional modern medicine has found itself in the embarrassing position of being able to cure more and more specific diseases without being able, in certain respects, fundamentally to improve health.

"The extension of man's life span attributable to medical intervention is very, very minimal," says Ken Pelletier, a professor at the School of Medicine of the University of California, San Francisco and one of the leading developers of and spokesmen for a new approach to health care, one that considers the mind--or spirit, if you will--as at least an equal partner with medicine in the maintenance of health. "Increased distribution of adequate food supplies, economic equality, hygiene and the quality of the environment--despite recent appearances to the contrary--have had a great deal more to do with our increase in longevity and the apparent improvement in our health than has any specific medical intervention."

As befits a general in the growing army of new-age health experts, Pelletier wears a shirt with epaulets: battle fatigues. And, also appropriately, he looks unnaturally healthy. Unnaturally. Even in California, the appearance of such splendid health is not common. The whites of his eyes are as white as the glare of sun on a car's windshield. Not a thread of blood or a spot of yellow. His skin glows with such a vital tan it seems as though, if I stayed long enough in his presence, my own skin would brown from his stored-up and reflected radiance. His chin is dimpled--also appropriately--with an inverted peace sign. Sensibility of the Sixties informing medicine for the Eighties.

"By 1950 to 1955," Pelletier says, "medications like the sulfa drugs and polio vaccine had in a major way stemmed the infectious disorders. The classic plagues." What should have happened then was that more and more people would live longer and healthier lives. What did happen was that more and more people lived longer but not particularly healthier lives.

"What we saw," says Pelletier, "was an increase in noninfectious, nonspecific, stress-related disorders like ulcers. And those have been steadily increasing. Today, you could conservatively say that 50 to 80 percent of all disorders in the United States are stress related. I think it's probably closer to 90 percent."

The stress-related diseases were not simply the chorus suddenly stepping to the apron of the stage once the stars were gone, he believes. "If," he says, "after around 1955, once the infectious diseases were largely stemmed in this country, you suddenly saw an enormous mushrooming of these noninfectious, nonspecific, stress-related afflictions of civilization, you could say, 'Well, these were all masked by the infectious diseases that we have gotten under control. All the people who would have gotten these stress-related diseases went from polio or one of the sulfa-related infections like pneumonia instead.' But there wasn't that sudden mushrooming. What happened after around 1955, 1956, was a gradual incremental increase in both the ratio of individuals succumbing to these disorders and their absolute numbers. So it wasn't that these stress-related disorders were simply masked by the infectious diseases."

At first glance, it almost seems as though, deprived of our old diseases, we have invented new ones to manifest some essential dysfunction or lack of harmony within, something corrupt at the core of our being--as though all disease were merely an expression of something that, blocked in one direction, would find an outlet in another.

At second glance, the increase in stress-related diseases may seem a function of the change in our understanding of disease. Many disorders that formerly were not considered stress-related--even some infectious diseases--are now being redefined as having some stress-related component.

"If you look at the most recent literature in the field," says Pelletier, "you might even conclude that virtually all states of disease, all states of health are to some degree psychosomatic. The four major categories of disease in the United States today--cardiovascular diseases, cancer, arthritis and respiratory disorders--are increasingly seen as psychosomatic. I think that virtually all viral infections are stress-related, virtually all inflammatory disorders are stress-related. The only disorders that are not are traumatic injuries. Accidents."

After considering for a moment, he admits that even some accidents could be the result of psychological states. A husband separates from his wife and within a few months breaks an arm, which tempts the sympathetic wife to take him back and nurse him. If the husband knows the wife well enough to be reasonably sure that, if he were injured, she would unbolt the door to him, he unconsciously may have promoted the accident.

If virtually all states of disease have a psychosomatic component (psychosomatic meaning not that the mind causes the disease but that the mind and body are so interrelated that they act on each other in an intimate, direct and inseparable way), then the question becomes not just why there has been a rise in stress-related disorders but also why one person contracts a disease and another person doesn't. Why does one two-pack-a-day smoker get lung cancer and another doesn't? Why, in a world in which almost everything--from the air we breathe to the water we drink--seems to be carcinogenic, don't we all get cancer?

Two of the most health-obsessed people I know--friends from Vermont--jog 12 miles a day, are vegetarians, drink only bottled water, and always have sickly pallors, constantly complain about ailments and frequently get colds. And a friend who lives in what is apparently the least healthy way--slurping up fatty gravies, drinking to excess, snorting-smoking-popping powders-weeds-pills, getting exercise only as a by-product of his hell raising--radiates health.

Life-denying versus life-affirming behavior. Stress versus joy. Calvin versus Rabelais.

But how does it work?

•

The natural field for dealing with such an issue, psychosomatic medicine, has expanded and changed, as medical doctors have become more psychologically oriented and psychiatrists more biologically oriented. But psychosomatic medicine, bound to its classical Freudian roots, did not easily allow for the kind of interdisciplinary approach that was necessary to tackle the mystery, an approach that involved not just medicine and psychiatry but also epidemiology, sociology, anthropology, preventive medicine, nutrition, learning theory and techniques and studies of patient compliance (a crucial area, since it's been estimated that fewer than half of all prescriptions made out in the United States are filled and, of those that are filled, many are misused, people not taking the medication when or for as long as they should or taking it when they shouldn't).

The field rapidly moved from infancy through adolescence. The kid was growing up; the old coat no longer fit, so he looked around for a new, snazzy reversible style. The sober side, charcoal with chalk pinstripes, was behavioral medicine. The flashy side, multicolored silk, was holistic medicine.

Behavioral medicine, when it first gained currency (in a book called Bio-feedback: Behavioral Medicine, edited by Lee Burke and published in 1973), meant a behavioral approach to the treatment of disease. "Not only the cause of disease," says Dr. Gary Schwartz of Yale, one of the researchers responsible for the development of this new field, "but literally modifying people's behavior as a way of treating disease."

In 1977, Schwartz and Stephen Weiss of the National Heart, Lung and Blood Institute put together a conference at Yale to bring some order to a field that was growing rapidly and chaotically. The thin air in the upper stratosphere of science tends to inflate egos; and, while Schwartz--like more than half of the over three dozen people I talked with while researching this article--was amiable, modest and helpful, more than a baker's dozen were remarkable for their arrogance. The lure of a Nobel Prize hangs as brilliant and uncanny as a moon in their skies. Many of these scientists are on the prowl for whatever immortality our doomed planet still offers. Ravenous as werewolves, they will feed off any innocent who crosses their path. All of which is not as irrelevant as it might seem, because research fueled by egoism can run into problems. The spark struck by the collision of two such egos can ignite the fuel and cause the whole business to go up in flames. Which means that the organizing of any new field of science is as much a product of soothing babies in white smocks as it is the result of meetings of coolheaded professors. At any rate, in the past two years, behavioral medicine has metastasized throughout the country and today is being taught in 20 medical schools.

Now we turn the coat inside out and, voilà! Holistic medicine.

"Holistic medicine," Schwartz explains, "is a loose term that implies treating the whole person in a system"; that is, seeing the patient within his or her own context: family, community, society. "And holistic medicine has become a catchall phrase that justifies trying any school of thought or technique that might be related to health. Consequently, it often picks up the so-called lunatic fringe of health care."

The difference between behavioral medicine and holistic medicine is that behavioral medicine is grounded within the scientific community--which means that any claim must be backed by repeatable experiments.

To go forward, the advocates of a new approach to medicine--whether it be called psychosomatic, behavioral or holistic--have had to go backward. In the West, certain personality types have been associated with particular diseases since at least the Second Century A.D., when Galen noticed that depressed women were more likely to get cancer than happy women were. In the 17th Century, Descartes--as though separating the egg yolk from the white--divorced the mind and the body; after that, the correlation between personality and disease seemed less and less valid. The body was merely a machine that the mind drove around, a model that today inclines us to search through terminal wards of hospitals for spare parts. If the transmission of your car breaks down, you take it out and put in a new one; if your heart breaks down, you take it out and put in a new one.

But although the correlation between personality and disease tended to be officially ignored, it was not entirely lost. Lay people, free of medical prejudices, observed what seemed to be commonsense connections between the way people behaved and the ailments they suffered from. And while common sense, like a king's fool, can sometimes dwell on the irrelevant, more often, also like a king's fool, it tells us in an unofficial way the truths we otherwise ignore.

Gradually, the medical community began to recognize the mind's ability to affect the body in a few disease states, the classic psychosomatic complaints like ulcers, asthma and hypertension. This wedge opened the field. It's as though we had been chopping up the tree of knowledge for fuel and, splitting the log in logic, found trapped inside, like some mythological sprite, the spirit of the new medicine. One by one, psychological components were connected to disorders. For example, in 1955, G. L. Engel published a study that suggested patients suffering from colitis tended to be obsessive, compulsive, indecisive, fanatically neat, morally rigid, overintellectual, conforming and anxious--fastidious sheep desperate to stay within the herd. In 1965, R. H. Moos and G. F. Solomon published a study that suggested patients suffering from rheumatoid arthritis tended to be martyrs, self-conscious, shy, intolerant of anything less than perfection, inhibited, tense, nervous, moody; convinced their mothers had rejected them and their fathers had been extremely strict; unable to express anger; and--oddly--fond of sports.

Evidence of correlation continued to mount and, in the early Seventies, reached a critical mass. The explosion, a modest enough bomb, a mere nitroglycerin pill set off in the heart of the matter, was the publication in 1974 of Meyer Friedman and Ray H. Rosenman's Type A Behavior and Your Heart.

"That book, even more than the study that preceded it"--in the professional publication Annals of Clinical Research in 1971--"opened things up a lot," says Pelletier. "It came from an absolutely reputable source and, probably more importantly for its impact on the general public, hit the major killer: cardiovascular disease."

What a shock: The mailed fist that punches up your left arm and grabs your heart, squeezing it like a ripe persimmon and trying to drive it across your chest, up your throat and out your mouth, that armored fist that seems to be the very hand of death itself turns out to be your own. If you are a Type A personality--which means if you are short-tempered, competitive, aggressive, urgent, impatient, constantly feeling under pressure and fighting time, as though time were the enemy, an evil magician, a Proteus, capable of transforming himself into any form, a deadline, a wife, a child, a car that refuses to get out of your way, a slow elevator, a secretary, a boss, anyone or anything that impedes forward motion, progress--if you are this type of frustrated, angry overachiever, then chances are good that you are going to give yourself a heart attack, an ultimate, perhaps final struggle against time: How long can you last without the normal flow of blood to your brain, sucker?

A barrier was broken. Or, rather, a membrane was passed through. The correlations between personality and states of disease and health have become so clear that, according to Pelletier, "by looking at half a dozen or so factors--genetic, biological, nutritional, amount of physical activity, psychological profile, environment, etc.--you can make a pretty accurate prediction of what diseases a person is likely to get."

Last year, Drs. Barbara Betz, a psychiatrist with the Southern California Permanente Medical Group in Los Angeles, and Caroline Thomas of Johns Hopkins parsed the person even further by making a distinction between personality and temperament. "Temperament is a given at birth, an inborn disposition that may come from your immediate clan," Betz says. "Personality is the product of everything that has happened to you, a kind of learned behavior."

Inherited versus acquired characteristics.

Betz holds up the index fingers of both hands, as though she were about to do the hokeypokey. "Temperament has to do not with cognitive skills or intelligence but with traits like rate of movement--vivacity or calmness," she says, "things that are recognized in the dog-breeding world, for instance. Nurses in newborn nurseries know that babies aren't all alike. From the moment they're born, there are the little stinkers, the calm smily ones and the shy ones. The lay person tends to recognize temperament more than the scientist does."

In fact, although before World War Two scientists had conducted a number of studies on what was called constitution (inborn characteristics), since World War Two, scientists have avoided the subject as though it carried a moral plague bacillus--which, in a way, it did. The step from discussing inborn characteristics (emotional, mental, physical--and perhaps even spiritual--heirlooms passed down from generation to generation) to discussing racial types is very short and leads into an abyss of propaganda.

Added to this natural hesitation to tackle a subject that could be so dangerously misrepresented was the equally natural interest in why many fine young men who went off to war returned home basket cases--apparently demonstrating the effect of environment on personality.

"At the same time, psychoanalysis was getting stronger and stronger, offering a marvelous tool for understanding human beings," says Betz. "The focus of research in this area went into how we get to be the way we are. People began assuming that you'd turn out fine if only you had good enough parenting, adequate food supply, clean air to breathe. This is important. But that emphasis left out something equally important: temperament."

To see if temperament--as distinct from personality--could be correlated with particular states of disease or health, Betz and Thomas exhumed and autopsied a body of work Betz had buried 30 years before, in 1948. At that time, she had studied 45 students and classified them as Alphas (who were steady, self-reliant and cautious), Betas (who were easygoing, spontaneous and cheerful) and Gammas (who were quick to anger, moody and either over- or underdemanding). Each year thereafter, subjects were to write back regarding the status of their health. In 1978, Betz analyzed the data that had accumulated. Only 25 percent of the Alphas and 26.7 percent of the Betas had been stricken with severe illness, while about three times that number, 77.3 percent, of the Gammas had suffered from serious physical or mental disorders. A follow-up study confirmed the findings.

When the results of the studies were published in 1979, the public and the press reacted like--well, Gammas. Frantic, demanding, moody; fascinated, of course--Betz is astounded at how many people contacted her--but the fascination roller-coastered from joyful satisfaction (at getting nature by the balls again and showing that our species, this collection of Alphas, Betas and Gammas, could understand the mysteries) to dread. After all, it was not like learning that you were a Type A personality. Personality was made up of acquired characteristics, so you could learn new ones, learn how to change. But inherited Gamma traits? It sounded like a death sentence from which there was no appeal.

"This theory scares people a little," Betz says, "because it seems as if you have a fate. And I believe you do--to a certain extent."

Disease as fate.

Well, one doctor, respected in the community of new-medicine advocates and influential in Government circles, says:

"One of the things some people in the field talk about when they let their hair down--never for attribution but when they're with friends; one of the odd questions that keeps coming up--speculation only, you understand, just the kind of daydreaming that people do at the end of a hard day; one of the farthest-out possibilities is--and it's not that anyone takes it too seriously, but, you know, it's there--is... ."

And here he takes a breath and the plunge.

"Is how much of disease and health is karma."

Karma?

Wages we must pay for how we lived in previous lives.

•

Whether disease is something we do to ourselves, generic inheritance or karmic judgment, everyone apparently has some complicity in the state of his or her health, from the ghost of pain to the ghoul of cancer. And it may be useful to examine these two conditions in some detail to get a sense of how the new medicine understands them.

"Pain," says Dr. David E. Bresler, the director of the UCLA Pain Control Unit, "is the most common, expensive and disabling disorder in the United States today."

And what is pain?

Attitude--to a great degree. "We know the football player who breaks his arm in a game is getting a lot of sensations into his spinal cord and brain," says Bresler. "Why doesn't he call it painful? When you hypnotize a patient, take a scalpel and make an incision, there are some strong signals coming up the neuraxis. Why is that not painful to that patient? What's going on? Obviously, the mind and the body interact to suppress the experience of pain. How? Or take two patients with osteoarthritis, the same degree of physical degeneration involved. One patient is in agony, can't sleep, eat, hold a pencil. He goes around clutching his hand in genuine, agonizing discomfort. The other patient says, 'Yeah, my hand feels a little stiff. It's achy. But I write as best I can with it. I still work, do other things. It doesn't bother me that much.'

"Why? You can count on the endorphins as an intermediary to explain how this happens, but what is that second patient doing to produce the endorphins? I think it has to do unconsciously with that patient's belief system, his expectations, self-image, basically a whole variety of psychological strategies he isn't even aware he is using. The first patient may see himself as a hopeless, helpless victim of an incurable, horrifying, painful disorder. The second patient may see himself as somewhat slowed down by a little arthritis in his hands, but he's sure not going to let that stop him. It's helpful to distinguish two aspects of all this. When you have a physical injury or a disease like osteoarthritis, it's sending electrical messages through your nervous system. Those messages in themselves are not painful; they're strong, urgent signals, but it's how your nervous system interprets them that determines whether they are painful or not. That's the component called suffering."

Pain is an energy monster; we give it the power to hurt us. And we can take that power away--depending on how we choose to view ourselves. All pain is real, but you can change your reality.

"Yogis can walk on hot coals," says Bresler. "Hypnosis can be used as an anesthetic in surgery."

Norman Cousins can laugh himself pain-free.

"Almost always," says Bresler, "people who have chronic pain are also depressed. It's not just their lower back that hurts; their life hurts, and they have placed that hurt in their lower back."

To get rid of pain, all you have to do is change your mind. As a way of regaining health, changing your mind (which, of course, includes changing your behavior) works most dramatically with terminal-cancer patients. Strong hints that cancer was associated with particular personality traits were dropped throughout the Fifties and Sixties. Serious studies by various researchers were published in 1952, 1954, 1956, 1957, 1958, 1961 and 1967. Those studies, like the trail of bread crumbs left by Hänsel and Gretel, all led out of the woods into the same clearing. The cancer-prone personality tends to have had an unhappy childhood that included either loss (through death or divorce) or estrangement (because parents were always fighting or any number of other reasons) of a parent or parents; as a result, the cancer-prone personality develops into a lonely, anxious, hopeless and self-hating adult, who, to achieve the love he or she missed as a child, strives too hard to please others. Typically, the cancer-prone personality, upon getting some positive feedback from the world--through success in a job or love from a mate or child, say--tends to make the source of that feedback all-important. So if the circuit is broken (by a job loss, retirement, death of or rejection by the loved one), the cancer-prone personality relapses into the lonely, anxious, hopeless, self-hating child he or she had been. And the despair and bitterness--locked up inside, unexpressed, transformed into cancer--begins to eat away at the patient.

Despite the similarity of results in those Fifties and Sixties studies, no significant program of treatment based on such findings was initiated until 1974, when O. Carl Simonton and Stephanie Matthews-Simonton of the Cancer Counseling and Research Center of Fort Worth, Texas, started using therapy designed to treat not just the disease but the whole person.

"As a new oncologist in training, I observed that I could give two patients with the same diagnosis and similar backgrounds the same treatment and get widely divergent results," says Carl Simonton. "And I was curious. I was more than curious. I was hungry to know."

Sitting in his office in an eight-story building that looks as if it were made out of Lego bricks, Simonton leans forward conspiratorially. "Here I was," he says, "in the position of being responsible for telling people how they would respond to treatment, and I knew that I couldn't predict. So I started to ask them why they thought they responded as they did. What I heard from them had to do with attitude, goals in life and some relatively intangible things that lumped together made a lot of folksy sense."

Folksy sense? Asking the patients what they thought and taking it seriously? This was unconventional treatment, indeed--except it seemed to be useful.

"I was able to piece together what I learned," Simonton says, "and develop something that could help patients help themselves improve their chances of getting well. Overcoming medically incurable cancer is a very big task. It's doing the impossible."

An obvious statement--though he means it in a less than obvious way. What was impossible was not just reversing the course of a terminal disease, it was reversing the attitudes that may have generated the disease.

"You run up against the patients' belief in their own limitations," says Simonton, "all the ways they put themselves down. All those things have to be dealt with if the patients are going to consciously participate in regaining their health."

More odd talk. The patient helping to cure him- or herself, not merely going to a doctor to buy health the way we've gotten used to dealing with doctors--they give us health. But for the patient to consciously participate ... ?

"I don't know if it's possible to systematically teach patients how to consciously participate in regaining their health," Simonton says. "I do know that some people with medically incurable cancer we work with do get better."

Although there's no hard data, some revealing estimates can be made. In general, fewer than five percent of cancer patients get dramatically better. Simonton and his wife have had results about twice as good with the 240 cancer patients they have treated. Not a bad record. "Their cancers went away quickly," he says. "The patients regained health and returned to active lives."

Even those who experienced no such dramatic cures often lived longer than the typical terminal cancer patient. "The median survival time of the patients whom we have worked with should have been--according to the national average--12 months," says Simonton. "Across the board, including all kinds of cancer, the median survival time of our patients has been about twice as long, two years. The median survival time for people with bowel cancer is 11 months, ours is 24 months; for breast cancer, it's 16 months, ours is 36 months."

Again, not a bad record.

"Usually," he says, "our patients are only ill a relatively short time before they die. Someone might have had cancer for 36 months but will be severely ill for only about one month, requiring relatively little hospitalization and pain medication. We also try to improve the quality of death. That is, how comfortably the patient dies, how conscious he or she is at the end, how much he or she communicates to the family and in what sorts of messages and how the family is left. In short, we look at the sorts of feelings that surround the patient's death. All this is pretty intangible and there are almost no studies of other patients for us to use for comparisons."

Simonton's best estimate is that nationally, only about 15 percent of cancer deaths are what he would call "good quality." But that's as much an informed guess as it is a statistic. He can, however, get fairly accurate figures by comparing the patients he worked with before his method was quite as far along as it is now with those he works with today.

"In the past," he says, "less than 25 percent of the deaths we saw were good quality. Now we have about 50 percent."

The interest in good-quality deaths is not as grim a business as it might appear. After all, if you're going to die--and, one way or another, we all are--it's better to have a good death than a bad one.

How has Simonton achieved such remarkable results? He started with the profile of the cancer-prone personality--which was pretty much the same as that developed in the earlier studies, although in conversation he emphasized as important factors the inability to express emotion (a trait, he quickly added, that is not limited to the cancer-prone; "a number of other diseases are associated with impaired emotional outlets," he said) and the inability to grieve. He also discussed the usefulness of thinking of cancer as physical metaphor, something other studies and Susan Sontag's book on the subject have implied. For example, women who nurse babies tend to be less susceptible to breast cancer than women who don't. Simonton sees this as suggesting that breast cancer may be associated with confusion over the sex role, the cancer taking up residence in an area of the body associated with sexual identity. According to Simonton, "Studies by the World Health Organization have suggested that changes in incidences of breast cancer occur in cultures that are experiencing changing sex roles." There's also evidence in men that confusion over sex roles can be manifest by cancer of the prostate--a connection that has its own metaphorical logic: Confused by the changing definition of gender, men and women--in a variation of the tradition of killing the bearer of bad news--seem to be destroying those parts of their bodies that define them as male and female.

"Lung cancer"--which is also increasing--"seems to be associated with intense emotional repression," says Simonton. Not being able to breathe because of all those suffocating bottled-up emotions. Sometimes this metaphorical expression of the disease is, Simonton says, "uncanny. Very clear."

In a real way, disease is a language our body uses to communicate with us. And this is true not just for cancer. Soon after I started researching this article--which involved more work than I had ever done before for a single piece--I developed excruciating stomach pains. No matter how little I ate, I felt bloated. I was nauseated 24 hours a day. A few days before ending the research, I happened to be describing my physical symptoms to one of the doctors I was interviewing and, apparently coincidentally, mentioned how much trouble I was having digesting all the material I had been gathering.

He smiled.

Oh, yes: digesting the material.

My body was telling me in a very graphic way--virtually using a physical pun--just that.

In cancer therapy, Simonton and his wife try to correct destructive thinking. They don't offer their treatment instead of traditional medical therapy, "because moving away from medical treatment can be devastating, even though medical treatment may have little to offer." Their work is an adjunct to a traditional medical approach. They take in only patients who are open to their method and motivated to try it. Just as there is a cancer-prone personality, there apparently is a personality that seems to be able to throw off cancer: someone with high ego strength and high self-esteem, flexibility of thought, the ability to tolerate stress and what Simonton calls social autonomy (that is, a healthy enjoyment of people coupled with a capacity to be comfortably alone).

Critics accuse Simonton of getting good results because he tries to select only those types of patients, but that very accusation admits that there are certain behavioral traits or personality types that seem to be associated with dramatic cancer cures. Simonton admits one potential flaw in his therapy: Unless patients can be taught such behavior, his method is limited to converting the converted, healing those who might have healed themselves.

"I believe these things can be learned," he says, "because I see people who initially have relatively few resources for dealing with the disease improving physically as their psychological profile changes."

The work of others in the field suggests Simonton is right. People can transform themselves or be transformed by disease. The threat of death can shock them into making changes they otherwise might never have risked. Pelletier became interested in seven miracle cancer-cure cases that occurred in the San Francisco area and tried to find out if the people involved shared any lifestyle traits. They did.

"Some emphasized one trait over another," he says, "but, for the most part, all the traits were present in all of them. One, they all changed their diet: a reduction of red meat, more vegetables. Many of them did this without forethought. They simply were responding to what their bodies were demanding. Two, all began to engage in some form of physical activity--not necessarily something strenuous like jogging; even walking a good distance every day sufficed. Three, all began a kind of meditation or deep relaxation: prayer or just sitting quietly for 15 minutes a day. Four, all became religious. Very rarely in an orthodox sense; they had different metaphors. But all believed that there was something higher, bigger or greater than they that helped them. Five, all tended to revise their personal and business lives, so that what they did met more of their personal needs. They began to look at what gave them pleasure. This was a very big change. Six, all became more community oriented, more involved with friends and associates in a kind of selfless outreach."

All those traits, like the traits Simonton describes, share what Wallace Ellerbroek, a psychiatrist at Metropolitan State Hospital in Norwalk, California, calls "positive affect."

"Depression is behind all physical and mental disease," he says. Ellerbroek is a former surgeon who quit his practice and started studying psychiatry when he decided it was more important to change how people thought about the world than to cut them up after they got in trouble for thinking about the world in inappropriate ways. "If you get sick," he says, "it's because you've been thinking screwy."

Diseases, Ellerbroek believes, are behaviors; not things that happen to you but things you do. One doesn't have cancer, one is cancering. Diseases are misinterpretations of and struggles against the real world.

"When your fantasy of how things ought to be doesn't match your fantasy of how things are," Ellerbroek says, "you get into trouble. If you feel you can do something about it, you get angry; if you feel you can't do anything about it, you get depressed. Both states are responsible for diseases."

What actually happens to us is less important than how we interpret what happens to us, he explains; and it is the interpretation of reality--not reality itself (whatever that is)--that kills or cures us.

"The hardest part for people to believe," he says, "is that when you think a stupid thought that leads you to itch or have abnormal gastric acidity or something like that, the thought is translated into every cell in your body."

What you think is true becomes true. "It's been pretty well shown that asthma in kids is due to the so-called overprotective mother. There's only one thing wrong with that. You can have a mother who's a dope addict, an alcoholic, who hasn't been home for six months; and here's her kid with asthma. The critical thing is subjective perception. The kid sees his mother as overprotective, even though she's a neglectful bitch."

On the other hand, according to Ellerbroek, useful thinking--"thinking aimed in the direction of reality, nonneurotic thinking, whatever you want to call it"--can effect positive changes in the body. He cites the case of one woman who had been hollowed out by cancer--her pelvis, bladder and rectum had been removed--until she seemed to be nothing more than a bag of flesh draped over a skeleton that offered shelter not for internal organs but for spreading tumors. She asked to be allowed to die on the shore of a local lake. In those peaceful surroundings, something happened; she jettisoned her anger and depression, her spirit, like a balloon freed of useless weight, soared--and her tumors started to shrink. She was cured.

"Remember, these are cancer miracles," says Ellerbroek. "And you can't make a cancer miracle just because you've got cancer. You've got to be dying, far advanced, untreatable."

And you must want to live more than you want the cancer.

But doesn't everyone want to live? Who would want cancer? Apparently, some people do want their diseases more than health. "I believe we develop our diseases for honorable reasons," says Simonton. "It's our bodies' way of telling us that our needs--not just our bodies' needs but our needs--aren't being met. And the needs that are fulfilled through our illnesses are important needs."

To be noticed. To be cared for. To be loved. More common sense that science is just catching up to.

A woman who gets breast cancer may, for the first time in her life, get attention from her husband, affection from her children, even help around the house. She may be given--or, more significantly, give herself--the freedom to express her feelings fully. This does not mean that she is responsible for her illness in a guilty way--and it is crucial for patients to understand that this new approach to medicine is not a court before which they will be condemned. She did not make herself sick. But her sickness is an expression of something more than the activity of a virus, and the problem she faces is to find a less physically compromising way to express her blocked needs or, better yet, to change the situation in which those needs became blocked in the first place.

To do this, Simonton and his wife ask the patient to list five changes that have taken place in his or her life in the past six to 18 months. Some changes are typically more charged with stress than others. According to one scale used by the Simontons--as well as other practitioners of the new medicine--death of a spouse rates the highest: 100. From there, the scale (the Social Readjustment Rating Scale, which was published in 1967 by Dr. Thomas H. Holmes and his co-workers at the University of Washington School of Medicine) descends from the giddy heights of anxiety--divorce, 73; separation, 65; jail term, 63--to the relatively level swamps of apprehensiveness: change in eating habits, 15; vacation, 13; Christmas, 12; minor violation of the law, 11. One or all of those stressful events may have been the trigger--like the A-bomb that sets off an H-bomb--of the cancer.

The Simontons' patients take an extensive battery of--and no doubt battering from--other psychological tests, and then over a period of ten days discuss their lives: early life experiences and decisions; the present family structure, its dynamics and lines of communication; the possible triggers of the cancer; the secondary gains provided by the illness; the secondary gains of any chemotherapy (when your hair falls out from the medication you're taking, it's a wonderful reminder to your family that you are sick and they should pay attention to you); and death. During this time, the patient also is taught how to put him- or herself into a meditative state and to imagine the body's own healing system fighting the cancer. A patient can picture anything from white knights slaying dragons to pleasant music dissipating cacophony.

The bizarre thing is that the immune system seems to respond.

•

"Clinicians have observed for years that at times of stress, there may be changes in the immune response," says one of the country's leading immunologists, Dr. Marvin Stein of Mt. Sinai Hospital in New York. "If you talk to old-time physicians, for example, you hear about kids who under stress develop herpes, fever blisters. Now, herpes viruses are floating around the body all the time. What happens when you develop a fever blister is that the immune system has changed as a result of psychosocial stress. We know this. We've learned in the laboratory that we can modify the immune response by subjecting experimental animals to stress."

Zapping electrical shocks up through the tails of mice is guaranteed to produce very tense mice.

"The old notion that, for example, bacteria or viruses cause illnesses no longer holds water," says Stein. "The host plays just as important a role."

But how? It's not enough to know that certain personalities (Type A's), certain temperaments (Gammas) and people in general under certain conditions (for example, death of a spouse) are more prone to stress, and therefore disease, than others. Nor is it enough to know that diseases get handholds, or footholds, or pseudopodholds, or whatever, in a stressed individual as a result of a suppressed immune system. The big question, the mystery at the root of the other mysteries, is how?

This is the mystery science in the past few years has begun to penetrate--but it is like entering a fun house at an amusement park. "It all interacts in such simple and complex ways that it leaves us baffled," says Dr. Kenneth Greenspan of Columbia University's College of Physicians and Surgeons. Like Pelletier, he is remarkable in the field for his depth of knowledge, breadth of vision and common sense. "We don't have a really tight scientific system to explain the things we're beginning to see."

Everything is in flux. And there seem to be a number of ways of approaching the problem. But it seems clear that a principal mechanism linking emotional states to physical responses can be pictured as an organizational flow chart, which reveals the bureaucracy of the body. Psychosocial stress leads to depression, anger and despair. Those feelings affect the activity of the limbic system (which seems to be associated with our experience of emotion). The limbic system affects the activity of the hypothalamus (which regulates the autonomic responses such as body temperature and blood pressure). And the hypothalamus affects the immune system directly--and indirectly, by influencing the pituitary gland, which regulates the endocrine system, which in turn controls the balance of hormones in the body, which in their turn also affect the immune system. In other words, there are at least two routes to the immune system, one a superhighway, the other a scenic bypass.

The mechanism seems efficient enough, but not particularly reasonable. Why did the hand of God or the blind power of evolution so maladapt us to the world? But we are not maladapted to the world into which mankind first emerged, whether it was Eden or some more Paleolithic paradise. The highways and byways leading to the immune system are simply old footpaths of instinct. "Anthropologists say nothing has changed in our gene pool for the past 10,000 to 50,000 years or so," says Dr. Elmer Green, organizer and director of the Voluntary Controls Program at The Menninger Foundation in Topeka, Kansas. "We still have our cave-man bodies. We still respond in our cave-man ways.

"If you're a cave man," he says, "and, while you're sleeping, a bear comes up, you don't want to have to say to yourself, 'Blood-flow increase. Prepare for an emergency.' You want it to happen automatically. You don't want to have to think about controlling how much you are sweating so your palm will be sweaty enough for your club to stick to it but not so sweaty that it will slide away. You want that to happen automatically. Thinking about these changes would be too long a process. By the time you got your blood pressure up consciously, the bear would be on top of you."

This system worked wonderfully for our cave ancestors, but now, as Green says: "We don't sleep in caves, and the only bears we fight are on Wall Street. But, even though they are symbols, imaginary bears, the blood pressure still rises and the adrenaline still flows."

A response that was designed to operate for short periods of time, a matter of minutes, today operates too often 24 hours a day. Politically, we see bears in our enemies' camps. Professionally, we find bears snarling in the kneeholes of our desks. Our newspapers are full of reports of bears. Our streets are jammed with maniac bears driving back from their jobs. When we at last reach home, our spouses tell us dreadful tales of bears and we eat dinner with bears prowling around the dining-room table. Even at night, when we ought to crank up some positive stress by making love, we have to put up with a bear at the foot of the bed, snarling rude remarks about our performance.

Our body can't take such stress. Our system overloads and burns out. Our immune response falters. We get sick. How can we exile--or at least tame--the bears?

•

When ancient alchemists tried to change lead into gold, they really were trying to transform their own souls. The lead-into-gold experiments they fussed with were externalizations of an internal process. They believed that if they could change a base metal into a noble metal, they, at the same time, through sympathetic magic, would be changing their base spirits into more noble ones.

Like ancient alchemists, the advocates of the new medicine manipulate what is accessible in order to transform what is inaccessible; manipulate attitude, behavior and consciousness in order to change internal physical states. They are trying to tame the bears at long distance. Some of the methods used are traditional: prayer, meditation, yoga postures. Others are newer: hypnotism; the Jacobson relaxation method (a progressive relaxation technique that involves untensing muscles one by one); using mental images; biofeedback; autogenic training (which is biofeedback without a machine)... . There are dozens of methods, many differing only slightly from the others; the focusing techniques of Dr. Eugene Gendlin of the University of Chicago; the Quieting Response of Dr. Charles Stroebel of the Hartford, Connecticut, Institute of Living; the techniques used to induce the Relaxation Response of Dr. Herb Benson of Harvard. All work.

In working, all raise a final question, one more mystery behind the other mysteries. Do these relaxation techniques work by virtue of omission or commission? Do they work because they reduce stress or are they active forces that promote health? The question is tricky, because it seems to be asking, for example, if the inside of a bowl is concave because the outside is convex. It's possible the answer lies only in the potter's hands.

But there are some hints that a joyful, hopeful, positive attitude promotes healing, not just because it relieves stress but because it also activates some dynamic healing processes within the body. Processes, not process. There may be more than one. Benson at Harvard believes that the Relaxation Response is not just the absence of stress but a distinctive healing physiological state. Schwartz at Yale believes that there is yet another distinctive physiological state associated with not relaxation but joy; he calls it the psychobiology of happiness. Green at The Menninger Foundation believes that by entering profoundly relaxed states, one can have extraordinary control over the body--from preventing infection to even making scars vanish, ultimately to be replaced by smooth skin. Dr. Robert O. Becker at the State University of New York Upstate Medical Center Veterans' Hospital in Syracuse has experimental evidence that electrical currents can cause rats' amputated limbs to partially regenerate--although theoretically they could completely grow back. The implications are staggering. If we could learn through biofeedback techniques to produce those electrical currents within ourselves from the electrical impulses along our nervous system, then, for instance, we would not need heart transplants. We could simply grow the needed new tissue in our own hearts.

These are the outer limits of current research, unfamiliar and somewhat uncanny precincts of science; and yet, by using our map--stress--depression--limbic system--hypothalamus, etc.--we can find our way home. But there is one uncharted area that has been staked out by advocates of the new medicine. It appears on no map. Not yet. To reach it, we must make a leap beyond our own skin. There is some evidence that healing can be effected at a distance, that I can heal you and you can heal me. In charismatic religions, it is called the laying on of hands.

Dr. Robert L. Swearingen, director of the Colorado Health Institute, has evidence that when he uses what he calls a loving approach--which involves relaxing and touching--his patients need half the average amount of painkiller and may exhibit an increased rate of healing. And Dr. Dolores Kriger of New York University has evidence that when she uses what she calls Therapeutic Touch--a technique that is similar to Swearingen's and that is today taught in 33 universities in the U. S. and Canada--her patients experience significant rises in hemoglobin levels. "We know that there is electrical conductivity through the nervous system," Krieger says. "And we know that there has to be a field to carry that conductivity."

She suspects that the healing process works through the interaction of the therapist's electrical field. Patients don't even have to know that their practitioner is using Therapeutic Touch--and, if they don't know, its results cannot be due to any placebo effect. Perhaps we all do wander around with auras and by treating our auras, we can treat our disorders.

"I think that health is not an end product but a by-product," says Swearingen. "I think that if somebody consciously evolves--if a person becomes aware of the factors that are important to him as he goes on his journey that is life, however you want to say it, and if he pays attention to those factors--then health is just a by-product."

Now we have truly strayed from the hospital and gotten lost in the forest beyond the grounds. But that is to be expected if you go searching for the answers to mysteries. You can't pioneer using an old map. When the old map no longer reflects reality, you must explore new terrain, taking notes as you go along. None of the advocates of the new medicine--and they range from the cautious like Stein to the metaphysical like Swearingen--wants to overthrow modern Western medicine, but all want to include within the practice of that medicine new theories and techniques. Whether or not they will be successful is moot. The forces of tradition and self-interest are arrayed against them. Even in a fairly obvious area like delivery of health care, the odds against the new medicine are formidable. After all, if stress does contribute to disease, Norman Cousins is right to say that hospitals are the last places in which to be sick, since they are stressful environments. And to take on the hospitals is to take on a multibillion-dollar-a-year industry--even without tackling the insurance companies that often pay benefits only if the patient is hospitalized.

Still, there are hopeful signs. The Government seems increasingly interested in the new medicine; in fact, the Surgeon General's 1979 report was virtually a mandate to develop the kind of alternative and preventive techniques that most of the doctors involved in the new medicine advocate. The high cost and often ineffectiveness of traditional medicine have turned more and more patients away from orthodox doctors and therapies. And more and more doctors are letting themselves be seduced by the raw excitement of the new field.

"What's thrilling," says Greenspan, "is that everything seems to be coming together. Medicine seems to be getting closer to modern physics. In disease, there's a breakdown of organization. Disease is entropic. In health, there is a new level of complexity. Health is anti-entropic."

Disease, then, is a process of running down and coming apart; health is a process of energizing and coming together. When your body, mind and spirit are not in harmony, you become sick; when they are in harmony, you are well.

"The bottom line," says Pelletier, "is that you are healthy when you are most yourself. There is no prescription for health other than that: Do anything that gives you a sense of enthusiasm and joy--and be yourself."

"Why, in a world in which almost everything seems to be carcinogenic, don't we all get cancer?"