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Volume 2, Number 1

SYMPOSIUM
The Role of Belief in the Healing Process*

J.0. GODDEN, MD, CM, FRCP(C)

This paper takes its title from a symposium held at McMaster University in Hamilton, Ontario, February 3 and 4, 1983. The purpose of the symposium was (and of this paper is) to stimulate interest in and communication among the diverse disciplines involved in helping or healing. A tone of hope was set at the symposium when Dr. J. C. Laidlaw, Dean of the Faculty of Health Sciences, welcoming the registrants, speculated that in time we may discover a group of substances to be known as "the compassion neuropeptides"; then "the face of clinical medicine would be changed forever."

Dr. Joel Elkes, Professor of Psychiatry at the University of Louisville, Kentucky, gave the Royal College lecture, "Faith and Healing: An Overview." He pointed out that historically, healing began in the churches and was closely related to the religious beliefs of both healer and "healee." In this century, however, Western man's concentration on the reductionist mode of modern science has separated his knowledge from his belief and has resulted in "the war of the part against the whole." Dr. Elkes pointed out that the word "religion" comes from the Latin religare (to connect); hence the religious state is one of being connected. The words "whole," "hale," "holy" and "hallowed" all come from the same root and refer back to the original state of unity. The physician who is a whole person has the opportunity to act as a catalyst, as a conduit of the energies flowing from wholeness.

Jerome Frank and others have provided evidence for an interaction between belief, mental state, and body function. The observant clinician notes repeatedly that "giving up is dangerous" and that a strong morale has awesome power. The work of Norman Cousins, for example, has demonstrated that attitudes ("morale") can make a significant contribution to the individual's capacity to recover from illness or injury. As philosophy, religion and tradition amply testify, "the physician dwells within."

Nearly a century ago, Sir William Osler insisted that faith was a most precious commodity and that it often represented the crucial difference in recovery. Although it has not become the subject of scientific investigation, physicians and others have discerned a relationship between the patient's attitude before an operation, his personality traits, and the speed of subsequent healing. This may explain that most remarkable of events - spontaneous remission of cancer, in which "faith" is reflected in the metabolic triumph of a host whose belief system has given him unique powers. Recent studies in cancer suggest that disease progresses rapidly in "polite and painfully nice" patients who have a high index of vulnerability. The large literature on the placebo effect shows that the patient's expectations affect his somatic response. Both the placebo and hypnotic suggestion seem to draw upon a potent "internal pharmacy."

The patient who has the support of a caring group such as a close-knit family shows increased resistance to disease and trauma. Each family has the potential for potent therapy and can act as a healing group. As Dr. Elkes noted, these relationships work largely through the "non-word"; that is, much of the healing is conducted silently through group relationships. The body also functions as a society; the organs are interdependent communities that keep in continuous, intimate contact through the nervous system, the endocrine system and the immune systems. Communication in the external world is in its infancy compared to the centuries over which the "society within our skin" has developed its complex methods of communication. Much of what we call "illness" represents a less-than-optimal effort at adaptation.

The revolution in this area started with the discovery of psychotropic drugs; new knowledge in neurochemistry suggests that all such drugs act through families of neuroregulatory compounds - particularly the neuropeptides, and especially the endorphins. The brain is now seen to be both a "wet computer" and a factory for neuroregulatory agents. Mental events are chemically induced and chemical events are translated into signals, which direct behavior. Relationships are now apparent between a "symbolic" self, represented by the nervous system and the brain, and the somatic self, represented by the immune surveillance system. For example, biofeedback and other forms of autoregulation show that we can exert voluntary control over (allegedly) involuntary activity. As modern cognitive psychology suggests, we appear to construct our external world through a process closely akin to a self-fulfilling prophecy. "What is important is not what is 'out there' but our response to it." It is for this reason that ancient exercises such as meditation and relaxation have remarkable powers even in the ultimate "organic" disease - cancer.

Dr. Elkes summed up by saying:

The body is a very moral structure. Morality consists in being oneself and being responsive to the moral law encoded in our very being. Religion is a bond with the past, and connects the person to the life of the group. Each religion gives a map by which to maintain this relationship and to draw strength from it. Faith is no idle mutation: it has survived because each individual has a deep biological need to believe.

Thus religion is an appropriate object of study for the scientist concerned with psychobiology. Almost 70 years ago, Dr. James Crichton-Browne said "Much vice, many mental disorders and diseases arise out of deficiency of the psychovitamins - family affection, moral principles and religious beliefs." Dr. Elkes cited the advice of Billy, aged eight. "You must take care of love: if you don't, it will go bad."

Dr. Bruce H. Pomeranz of the Department of Zoology, University of Toronto, who is widely known for his work on the neurophysiological basis of acupuncture, spoke about the healing mechanisms of the body as "the neurology of faith." Until recently, acupuncture was considered a form of faith healing, but since 1976, research has shown that acupuncture works by well-established neurological mechanisms. For pain relief, acupuncture stimulates peripheral nerves, which send messages to the brain to release endorphins (morphine-like substances in the brain), which in turn suppress pain transmission. For the relief of arthritis or asthma, acupuncture may work through release of cortisone. In neuropathy, it may create currents of injury, which promote nerve growth. Traditionally, the Chinese used acupuncture to heal, not merely to relieve pain. Other forms of "faith healing" may operate through similar neurological pathways. Preliminary evidence suggests that placebo analgesia (pain relief by inactive pills) works through release of endorphins. Meditation lowers blood pressure, and relieves pain by increasing brain alpha waves. The endorphins function both as neurotransmitters and as independent hormones. Through the stimulation of specific nerve endings, acupuncture releases these neurotransmitters from specialized tissue in the midbrain. A synthetic morphine, naloxone, has the power to block the endorphins and hence to block the acupuncture effect. Also agents which increase the concentration of the serotonin in the midbrain have the power to enhance the response to acupuncture. To date, 10 different endorphins have been described and antibodies have been induced to each of these. It is noteworthy that acupuncture stimulates cortisone release, and the cortisone so released is said not to have the side effects of exogenous cortisone. More research is needed into the neurophysiological basis of the placebo effect, acupuncture and the healing associated with meditation and prayer.

Dr. John J. Pilch, a Biblical scholar who also is Assistant Clinical Professor of Preventive Medicine at the Medical College of Wisconsin in Milwaukee, emphasized a concept of "wellness" characterized by, for one, purpose in life. Surveys in the United States estimate that four of every five individuals are "misemployed" - that is, unfulfilled - and hence unhappy in their work. God's work consists of creation and redemption: creation is life-giving activity and redemption is any action that restores meaning to life. Wellness is founded in the individual's values - those internal concepts that guide behavior. Dr. Pilch told the story of an engineer named Mitchell, who in the years just before World War II became convinced that Britain must have an air force capable of meeting the Nazi threat. He labored night and day to create a superior aircraft. In the midst of his fierce labors, he developed cancer and went to a friend to get relief from his pain so that his work could continue. The doctor warned him that his exertions would shorten his life. Mitchell said, "I accept that, but I must complete my work." In the spring of 1939, the prototype of the Spitfire flew: in the fall of that year (shortly after the outbreak of war), Mitchell died. However, he died a well man, because his life contained something of much greater value than physical survival. The final element in wellness is change and the individual's capacity for change. The advice which many people with a terminal illness offer to their peers is: "Wise up before it gets too late."

In the round-table discussion, Dr. Elkes pointed out that we pursue values that bring either harm or healing. As health-care professionals, we need to demystify our work and to teach our patients how to care for themselves. Dr. Elkes urged his listeners: "People have much unused power. Empower them and more power to you." In subtle ways, Western culture blocks our personal "empowering" by sending such messages as "He who treats himself has a fool for a doctor." This and similar pernicious advice bars us from those natural and inward healings which are part of our heritage. Someone asked, "If the brain is a healing organ, why does the ill person need stimulus from the outside? Can he not stimulate his own healing?" We were urged to distinguish "disease from without," such as polio, from "disease from within," which operates on a different model and needs a different approach.

Dr. Alistair Cunningham of the Ontario Cancer Institute and the Princess Margaret Hospital, Toronto, spoke about "The Influence of Mental Processes on Cancer." He recommends that we concentrate on in formational transactions between the organism and its environment, rather than on energy exchange. Information from the external world is stored in the body in various "languages": DNA, neurological structure, immune memory and various organic responses such as muscle enlargement. In a sense the form of the organism is a representation of the information it and its evolutionary ancestors have received. Individuals adapt according to information received, and this adaptation can be described at many levels, from the molecular and cellular through to the psychological and the spiritual -the relation of the individual to a self-transcending order. Science and philosophies based on rational analysis have difficulty with the higher levels of meaning, which religion and mysticism approach through other modes.

Therapy for cancer, as for most physical disease, is offered chiefly at the material level. More highly focused consciousness would be a powerful additional tool, if we could learn how to use it. Personality outcome correlations, especially in people who chronically repress feelings of anger, have been demonstrated in six prospective studies that show definite personality differences among those who later develop cancer. However, we need a theoretical base from which to propose hypotheses to explain these and similar phenomena and help us design a series of controlled experiments on the informational relationships of mind and body.

The capacity to find meaning in human life underlies all adaptation. Disease can be conceptualized as a maladaptive form, triggered by stimuli from inside or outside; the individual's perception often plays an important part in his response. It has been postulated, for example, that cancer may sometimes be promoted by a psychological perception of loss, which provokes a physiological (hormonal) response aimed at enhancing tissue growth to compensate for what is (mistakenly) perceived as cellular loss. Also, an attack of asthma - a disease that provides a model for disorders of adaptation - may be induced by associations with past experience.

With respect to therapy, we can remain within "the black box," believing only in what our four senses tell us and relying only on material modes of therapy, or we can supplement material therapy with the heightened consciousness available through meditation, and the increased self-awareness available through psychotherapy and introspection. Methods such as meditation, visualization and other altered states are "arational" -i.e., independent of the rational mind. Any effort to broaden the scope of medical therapy calls for a general increase in cultural awareness, which would close the gap between scientific knowledge and that available through arational "mystical" and intuitive approaches.

Dr. Sheila Pennington, a Toronto psychotherapist, described her study of six individuals who survived more than two years after receiving a "terminal" diagnosis. '~ Her interviews with the six "doomed" people concentrated on their reactions to the fatal diagnosis and their interpersonal relationships before and after the diagnosis. Repeatedly these people said that the shock of the terminal diagnosis "set them going." One man said, "I accepted death and recognized the struggle between life-giving agencies in my body and death-tending depression and rejection." A principal stimulus to personal action was "making sense" of the meaning of the diagnosis. All recognized that this stimulus and the power to change came from within themselves. Hans Selye, the father of stress theory, said, "What is most important is not what has happened, but what I do with it." Each of these people became their own agent of change - a phenomenon indicated by the term "personal agency." On receiving his terminal diagnosis, Selye said, "I will not be beaten." Another participant declared, "I have changed from asking 'Why me?' to asking 'Why not me?" These six people moved from a dependency on doctors, hospitals and medical science to an independent response, in which they held themselves totally responsible for personal growth and healing. Many of them had recognized that, over years of involvement with medicine, the arts, and other professional activities, they had lost touch with "The Higher Power." One of the six, who was present at the symposium, said, "Through meditation I got in touch with my death wish and through the technique of guided meditation became able to visualize the cancer in my body and begin to work upon it." All of these people recognized a steady improvement in interpersonal relations beginning with their own acceptance of self. Some said, "The search for health became a search for self." Dr. Pennington made a powerful appeal for general support of such patients and for a broad sympathy with these remarkable efforts in self-healing. Paradoxically, these people were dying of cancer but were well.

Dr. Norman White, of the McMaster Department of Psychiatry, who spoke on "Faith: Panacea or Pathogen," found it remarkable, given the frequency both of sick-bed conversions and of incorrect diagnoses, that "remissions" attributed to some faith-related event or act are reported so seldom: i.e., rather than having to account for a commonly believed high incidence of "faith-cures," what we really have to explain is the infrequency of such reports. Nonetheless, despite the absence of reported cases, he was prepared to accept the clinical folklore which says that these things happen. However, he argued that if the word "healing" is to have any real meaning in this context, it would be necessary to show that actual lesions had regressed or disappeared, and there appear to be no well-documented reports of this happening. White pointed out that physicians have long relied upon such affective-cognitive behavioral manipulation as a part of the clinical art, and the results have been studied as the placebo effect, but it is only recently, with the arrival of new models for morbidity and with the introduction of the social and behavioral sciences to clinical medicine, that we have had the conceptual tools to study these things properly.

Within this framework, White believes that it is important to distinguish a therapeutically useful confidence in the physician from an uncritical abdication of personal responsibility by the patient. The difference often depends upon how successfully the physician educates the patient, and White urged us to do more to inform our patients and the public in general. According to White, "holistic" approaches to health care may be dangerous because they may encourage attitudes that are not amenable to critical analysis; indeed, he believes the postulated utility of belief depends upon the abandonment of skeptical judgement. Dr. White asserted that the person is not rendered more "whole" by virtue of being less critical. He believes that "faith cures" represent reduction in symptoms and illness behaviors:

i.e., an alteration of the illness state but not of the disease process. If we decide to refer to this as "healing," then "faith" can take its place among many other existential events as factors which may affect how people feel and act; but this is not what we ordinarily mean by "cure." Faith may also be a "pathogen" when an individual chooses "quack" remedies in preference to scientifically defensible treatment. On the other hand, misplaced faith also operates in our collective reliance upon heroic high technology, to the resulting neglect of life-quality measures for the elderly and of prevention through public education. In both patients and medical students, our efforts should be directed toward instilling habits of informed skepticism, rather than toward indoctrination.

In a lively panel discussion, Dr. Cunningham noted that conceptual models are a human invention, and said that, as a scientist studying psychological and physical phenomena, he had come to recognize the great limitations of the reductionist approach. Attitudes and other mental states have a powerful effect in increasing or decreasing susceptibility to disease and other tissue damage: hence he pleaded for a broader clinical approach, which would permit us to collect evidence on how "informational events" are converted into physical change. Dr. White said that scientists are paid well to be critical and skeptical, and that those who practice other modes of healing should not expect to be exempted from the same critical examination. However, Dr. Elkes noted, "Skepticism says not, 'I do not believe,' but rather, 'I want to - I need to understand." Science needs to learn how faith works its changes.

We need a new kind of trust within the health system - a trust that operates between provider and recipient of care. Such trust would be extremely cost-effective because it would reduce the frequency and duration of illness and dysfunction. A clergyman in the audience rebuked the physicians present because they seemed to believe that all reality could be assessed via the scientific model. We are urged to abandon linear causation as a mode of examining human illness, and adopt an ecological model, which focuses on relationships. Many phenomena await scientific study, but the system does not recognize the type of data that might measure the benefits of faith. Why? Someone in the audience suggested one answer: "Because Canada does not have a health-care system, we have a disease-care system."

At the closing round-table, the principal speakers professed a sense of excitement and enthusiasm for the possibilities inherent in a comprehensive approach to human illness. Dr. Elkes invited the participants to become "nodes in a network" and, by staying in touch, to continue the work started here. This work envisions a long-term educational process in which those from each discipline - medicine, the clergy, and the social and helping sciences such as nursing and physiotherapy -would educate those around them. "Positive psychobiology" will make a strong contribution to clinical medicine when the patient's expectations, his positive attitudes and his beliefs are harnessed so as to participate alongside traditional scientific therapies.

John 0. Godden, MD, CM, FRCP (c)
Toronto, Ontario

*This report is not a scientific paper or even a formal proceedings. It is published to put into the record a brief account of an important multidisciplinary collaboration on a matter of broad general interest. It is intended for the information of the general reader and as a reminder for professionals, both students and practitioners. The sponsors of the conference have been the Continuing Medical Education Office of McMaster University Medical School, the McMaster Divinity College, and the Toronto Conference Office of the United Church of Canada and Toronto School of Theology. The Conferences held at McMaster University were: "The Role of Belief in the Healing Process" (February 3-4, 1983); "Pain and Suffering" (February 9-10, 1984); and "The Healer" (February 7-8, 1985).

*Available as "Living or Dying: Investigation of the Balance Point," in universities or from the author. A book, "Dying to Live: Journey to Health," is in preparation.