Research on the link between psychological factors and immunology bolsters recognition of psychologists as key healthcare players.
Psychologist Robin Haller, PhD, hopes the heartening outlook she strives to inspire in her patients will help her overpower the malignancy discovered in her breast six months ago. As she recovers from breast cancer surgery performed last month, Haller says she feels strong and finds immense solace nurturing her 4-year-old daughter and 15monthold son. No one else is going to raise them, she says determinedly.
"I could spend all my time crying and worrying about what will happen to my kids," she said. "And I did do a little bit of that. But it's not helpful. I don't have a lot of energy to spare right now, so why waste it on that?"
According to three decades of research, Haller may be inoculating herself with some of humankind's most potent and as yet arcane medicine: a healthy state of mind. Psychologists and medical researchers are amassing dramaticalbeit incompleteevidence that psychological factors influence the human body's ability to control the symptoms of and even survive life threatening illnesses. Studies show, for example, that women who undergo group therapy as part of their treatment for breast cancer live longer than those who receive no such treatment. Research also indicates that men with HIV infection who receive guidance in relaxation or other therapeutic techniques show a delayed onset of AIDS related symptoms.
Psychologists are major players in this area of study, known as psychoneuroimmunology (PNI), giving them a stronger justification for seeking a bigger role in the nation's healthcare arena. While the efficacy of traditional interpersonal psychotherapy is difficult to quantify, the application of PNI can show tangible results to third party payers demanding value.
"One of the most attractive things about this form of health psychology, from a research view, is these are hard outcomes whether an infection is present, for example," said Geoffrey Reed, PhD, the APA Practice Directorate's assistant executive director for professional development. Reed, formerly a research and clinical psychologist at the University of California, Los Angeles School of Medicine, has studied the impact psychological factors have on immunological changes in HIV positive men.
The marriage of mind and body
The lay public has shown a growing interest in what is popularly called the mindbody connection, intrigued about the ways our emotions may affect our health. But PNI science is much narrower, focusing on the relationship between human behavior, psychosocial factors and the body's immunity to viruses and infections.
The long held notion that the human immune system operated independently from the brain met one of its strongest challenges in the mid 1970s, when psychologist Robert Ader, PhD, and immunologist Nicholas Cohen, both of the University of Rochester, gave laboratory rats a drug that suppressed their immunity, and simultaneously fed them saccarin-laced water. They then discontinued the drug, but found that the rats' immune system still responded negatively when they drank the sweetened water.
Later, Ohio State University psychologist Janice Keicolt Glaser, PhD, and her husband, immunologist Ronald Glaser, leading PNI researchers, found that medical students, during the stressful exam time, show a decline in the activity of the cells that fight off tumors and viral infections. They've also found that people who are caring for a spouse with Alzheimer's disease show decreases in immune activity.
In a study published in 1991, psychologist Sheldon Cohen, PhD, of Carnegie Mellon University, injected nearly 400 healthy subjects with a cold virus, and found that those who reported more stress in their lives were more likely to develop colds.
One of the most important examples of the link between psychological factors and health outcomes came from Stanford University psychiatrist David Spiegel, who, along with renowned group psychotherapist Irvin Yalom, MD, led support groups in the 1970s for women with advanced stages of breast cancer. The groups used a technique Yalom developed called supportive expressive group therapy. It involves the patients simply expressing their emotions related to their cancer in the context of group support. Spiegel decided a decade later to review the women's records, and found that they survived twice as long, on average, after starting the therapy as a comparative group of patients who received no such treatment. His findings drew substantial attention from the medical community, and sparked new interest in the use of structured support groups as part of treatment for serious illness.
"One of the most powerful research findings on cancer survival has to do with social support," said Duke University psychologist James Spira, PhD. "Therapeutic groups offer the potential to provide for greater intimate support than even friends and family can often offer."
Meanwhile, psychologists and other scientists have found other indications of the link between psychological interventions and the body's immune response. KeicoltGlaser and Glaser, along with Southern Methodist University psychologist James Pennebaker, PhD, found that research subjects who simply wrote about traumatic events in their lives showed a boost in their immune system activity compared to control subjects.
UCLA psychiatrist Fawzy I. Fawzy, MD, for example, conducted a study involving a 6 week structured group therapy for newly diagnosed malignant melanoma patients with good prognoses. The subjects maintained greater numbers and activity of tumor-killing cells compared to a control group.
Researchers such as Michael Antoni, PhD, associate professor of psychology and psychiatry at the University of Miami, have found that asymptomatic HIV-infected men who undergo stress management training show a slower rate of decline in the immunological cells that the AIDS virus attacks than did men who received no such treatment.
More work to do
Despite the rapid development of PNI research, the relationship between the immune system and psychological states remains largely uncharted, scientists concede. In an article to appear in the 1996 edition of the Annual Review of Psychology, Carnegie Mellon's Cohen argues that researchers have yet to confirm immunological changes as the thread connecting emotions with those life-threatening diseases.
"Psychological factors might affect immunity, but where they affect the immunity that, in turn, affects the disease, is a hard question to answer," he told the Monitor.
Clinicians welcome the idea that they can help people tackle a serious illness, but many seriously illl people may develop an exaggerated view of their potential for recovery, said Sandra Haber, PhD, a New York City psychologist who specializes in treating people with severe illnesses.
"I tell my patients right at the beginning that [psychotherapy] can improve the quality of their life, but might not affect the cancer cells," Haber said. "You want to give them hope, but it has to be realistic hope."
Others worry that the growing knowledge of the mindbody interface can lead to a "blamethevictim" mindset.
"When we say psychotherapy may prolong survival and provide an increased support system, that's very encouraging," said Shirley Glass, PhD, a Baltimore psychologist who underwent breast cancer surgery and chemotherapy three years ago. "But we may also be sending the message that we're holding people accountable for their own prognosis, as if we're saying, "If you don't have the right course of disease, it's because you don't think the right thoughts or image the right images.'"
Glass also warned that research on the effectiveness of group therapy in helping people with serious illness should not be interpreted to include self-help groups that aren't led by professionals trained to help people with medical crises.
"When people are in a group where many members are dealing with breast cancer, they can become frightened and depressed by one after the other dying, if they don't have a trained professional who knows how to help them cope with it," she said.
Indeed, support groups may not be for everyone. Haller said she is not prepared to talk about her breast cancer in a therapy group.
"People tell you the bad as well as the good, and I don't want to hear that right now," she said. "The ability to participate in groups varies with individuals."
But experts say psychological help, particularly the kind that offers the right kind of group support, bears no physical or emotional danger. And even if it can't always help some people overcome their illness, it can no doubt help improve the quality of their lives.
"I can spout off 'brilliant wisdom' to a patient, and they'll nod politely and smile," Spira said. "But when another patient says the exact same thing, suddenly a light goes off in that person's head. The patient is going to listen much more intently because these other group members are people who are experiencing the same thing."
Copyright © 1995 American Psychological Association. All Rights Reserved.
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