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1 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Applied Psychophysiology and Biofeedback, Vol. 27, No. 4, December 2002 ( C 2002) The Circle of the Soul: The Role of Spirituality in Health Care1 Donald Moss2 LY This paper examines the critical attitude of behavioral professionals toward spiritual phe- N nomena, and the current growing openness toward a scientific study of spirituality and O its effects on health. Health care professionals work amidst sickness and suffering, and become immersed in the struggles of suffering persons for meaning and spiritual direc- G tion. Biofeedback and neurofeedback training can facilitate relaxation, mental stillness, and the emergence of spiritual experiences. A growing body of empirical studies docu- IN ments largely positive effects of religious involvement on health. The effects of religion and spirituality on health are diverse, ranging from such tangible and easily understood D phenomena as a reduction of health-risk behaviors in church-goers, to more elusive phe- nomena such as the distant effects of prayer on health and physiology. Psychophysiologi- EA cal methods may prove useful in identifying specific physiological mechanisms mediating such effects. Spirituality is also a dimension in much of complementary and alternative medicine (CAM), and the CAM arena may offer a window of opportunity for biofeedback FR practice. KEY WORDS: religion; spirituality; health care; biofeedback; complementary and alternative medicine. O O INTRODUCTION PR This paper addresses the impact of religion and spirituality in health care, and the place of biofeedback within complementary and alternative medicine. The paper is organized R into the following topics: (1) the critics and patrons of the soul and spirituality in science, FO (2) the dreams of the founders of the biofeedback movement, (3) the presence of spiritual dimensions in biofeedback practice, (4) the impact of spirituality and religion on health, (5) psychophysiological research on spirituality and paranormal phenomena, and (6) the role of biofeedback and neurofeedback in the movement of complementary and alternative medicine (CAM). 1 This paper was presented as a presidential address at the annual meeting of the Association for Applied Psychophysiology and Biofeedback in Las Vegas, Nevada, March 24, 2002. 2 West Michigan Behavioral Health Services, LC, 1703 S. Despelder, Grand Haven, Miami 49417; e-mail: [email protected] chartermi.net. 273 1090-0586/02/1200-0273/0 C 2002 Plenum Publishing Corporation

2 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 274 Moss CRITICS AND PATRONS OF THE SOUL IN SCIENCE European Psychology Sigmund Freud was a primary source for the critical attitude of many behavioral scientists toward spirituality, anomalous phenomena, and nonrational phenomena. His 1928 book The Future of an Illusion (Frend, 1928/1964) portrays religion as a projection of human fears and wishes, and portrays religious persons as superstitious individuals too weak to face objective realities; this double message captures Freuds attitude toward spirituality. This understanding of religion as an illusory projection is grounded in the critical tradition of German philosophy that included Feuerbach (1841/1969), Marx (2002), and Nietzsche (1886/1966). On the other hand, Carl Jung broke with Freud, and opened the windows of psychology to religion and spiritual experience. Jung saw spirituality as a pathway for personal integration and wholeness. He utilized religious symbols, myths, and archetypes as therapeutic tools for healing troubled souls and argued for the scientific significance of writings and wisdom from religion and literary sources (Jung, 1964). American Psychology In seeking to establish psychology as an empirical science, separate from its academic siblings of theology and philosophy, early twentieth century psychologists emphasized a measurement-oriented approach, and distanced psychology sharply from the metaphysical cobwebs of its longtime incarceration (Williams, cited in Pickren, 2000, p. 1022). The behavioral movement within psychology radicalized this critical attitude within psychology, rejecting the study of any phenomenon that could not be observed as behavior. Watson categorized consciousness along with soul as a magical concept (1930, pp. 23; Moss, 1998b, pp. 1621). This attitude persisted until quite recently, as evidenced in Sarasons 1992 address to the American Psychological Association: I think I am safe to say that the bulk of the membership of the APA would, if asked, describe them- selves as agnostic or atheistic. I am also safe in assuming that any or all of the ingredients of religious worldview are of neither personal nor professional interest to most psychologists . . . (Sarason, cited by Plant, 1999, p. 541) The great patron of spirituality and anomalous phenomena within modern American psychological science was William James. James is recognized as the founder of scientific psychology and psychophysiology because of his 1890 bookThe Principles of Psychol- ogy; but he also wrote The Varieties of Religious Experience (1902/1958), which is a phenomenology of spiritual experience. Abraham Maslow is renowned as the founder of humanistic psychology. By the mid-60s, however, Maslow moved beyond a strictly humanistic viewpoint and founded a transpersonal or spiritually based psychology (Moss, 1998b, 2001b). His later books car- ried such titles as Religions, Values and Peak Experiences, and The Farther Reaches of Human Nature. Maslow added to his familiar hierarchy of human needs a new top level of self-transcendence. Maslows studies of self-actualized individuals, such as Eleanore Roosevelt, forced him to conclude that the highest level of self-actualization involves movement beyond the self. Todays movement of positive psychology echoes Maslows message, and emphasizes the study of healthy vibrant persons, and attention to those

3 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Circle of the Soul 275 factorsincluding spiritualitythat support their positive adjustment (Meyers, 2000; Seligman, 1998; Seligman & Csikszentmihaly, 2000). The Science of the Soul Today there is an empirical science of the soul, and a growing body of methodologically guided research on spirituality and on the impact of spirituality on health (MacDonald & Friedman, 2001). Harold Koenig, an authority in the field of religion and spirituality, published a 1999 book that cites 1,100 empirical studies on religion, spirituality, and health. Koenig is also co-editor of The Handbook of Religion and Health (Koenig, McCullough, & Larson, 2001), which cites 1,200 studies on religion and health, and carefully rates the quality of studies highlighting the impact of spiritual practices on health. The field of health care and medicine has seen a flood of publications on the impact of spirituality on health in mainstream medical journals (Byrd, 1988; Helm, Hays, Flint, Koenig, & Blazer, 2000; Koenig, 2000; Post, Puchalski, & Larson, 2000). Psychology is lagging behind medicine in attending to spirituality in research and clinical practice, with initial progress taking place in church affiliated graduate schools and mainstream departments of psychology now following suit (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002, p. 203). The psychophysiological investigation of spirituality and paranormal phenomena is also growing. The Proceedings of AAPBs 2002 annual meeting show a number of excellent posters measuring the impact of spiritual experiences on physiology. The section titled Psychological Studies on Soul Phenomena will highlight examples of psychophysiological research on spirituality. Finally a word about science and methodology in studying the soul. The scientific study of religion begins with the adoption of the phenomenological attitude, that is, a suspension of personal and metaphysical assumptions about the object of research (Moss, 1980). Research can describe the subjective experience and measure the physiology and neurophysiology of an individual during prayer, meditation, or a near-death experience. Research can con- clude a great deal about the psychological conditions favorable to religious experience and about neurophysiological processes facilitating such experiences. However, this scientific observation tells us nothing about the ultimate truth of the individuals religious beliefs. One can determine which physiological changes accompany the spiritual experience, but this neither explains the belief in a God nor determines whether there is a God. DREAMS OF THE FOUNDERS From the beginning the biofeedback movement has echoed Abraham Maslows pursuit for the highest potential of the human being, at times emphasizing the pursuit of spiritual potential. Let us turn briefly to the dreams and values of the founders of the biofeedback movement, beginning with Elmer Green. The publications of Elmer Green and Alyce Green convey a vision of self-regulation and human potential (E. Green & A. Green, 1971, 1977; E. Green, A. Green, & Walters, 1970). For Elmer Green, biofeedback is a tool to assist the individual to actively participate in his/her health, overcome illness, enhance creativity, and seek optimal performance. Green continues today to promote attention to subtle energies, paranormal phenomena, and spiritual experiences.

4 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 276 Moss Barbara Brown, the first president of the fledgling Biofeedback Research Society, played a major role in popularizing biofeedback. Her writings emphasized a search for the highest limits of the human being. In her book Super Mind, she wrote that The discovery of the biofeedback phenomena has revealed the universal, innate ability of the unconscious mind to control and regulate all physical processes (1980, p. 252). Similarly Kenneth Pelletier saw biofeedback and self-regulation as not just a medical modality for sick people; rather he emphasized that each time a human being undertakes self-regulation, he or she becomes a participant in a profound transformation of human consciousness (1977, p. 322). RETURN TO THE SOUL: SPIRITUAL DIMENSIONS IN BIOFEEDBACK PRACTICE the great malady of the 20th century, implicated in all our troubles and affecting us individually and socially, is loss of soul. (Moore, Care of the Soul, 1992, p. xi) The Encounter With Illness and Suffering Biofeedback practice involves several elements that bring practitioners into confronta- tions with soul. Patient populations directly involve health professionals in their suffering and in their search for the spiritual meaning of their suffering. When human beings face illness, pain, suffering, and death, they often turn inward and seek the meaning of their illness, posing such questions as Why me, God? Is my illness part of a larger design? or Has the purpose of my living ended? Many chronic pain patients, for example, fear that they can never have a worthwhile life again, unless they can recover full physical ca- pacities. Such patients struggle with a recurrent human problem: Can I discover worth in simply being, when I can no longer achieve? This problem takes us back to the words of the English poet John Milton. Milton lost his sight and wrote a sonnet about his blindness: When I consider how my light is spent, Ere half my days, in this dark world and wide, And that one talent which is death to hide, lodged with me useless. Milton went on to write some familiar lines, which accomplish what we today would call a cognitive reframing of his disability: God doth not need Either mans work or his own gifts, who best Bear his mild yoke, they serve Him best . . . He contrasted his own blinded and disabled condition to that of the busy, healthy people around him: Thousands at his bidding speed And post ore Land and Ocean without rest: They also serve who only stand and waite. (On his Blindness, in Quiller-Couch, 1939, p. 353)

5 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Circle of the Soul 277 These lines express, in an archaic poetic language, the struggle of many individuals today with their illnesses and physical disabilities. Biofeedback and the Inward Journey The Hebrew Psalmist advised the listener to Be still and know that I am God (Psalm 46:10). Biofeedback teaches inner quieting. In the stillness many individuals find emotional release and many discover the presence of spirit. Biofeedback and relaxation therapy also emphasize letting goletting go physiologically, and letting go emotionally. Both Luthe (1969) and Benson (1975) advocated a passive volition or passive attitude of mind, as a component of the relaxation response. This same process of relinquishing personal control and detaching from effortful striving is a part of most meditative traditions, from Buddhism to Christianity. About one thousand years ago the Christian mystics of the German Rhineland saw letting be and letting go as the first step toward an inner encounter with God and spirit (Moss, 1980). Thus, when we invite our patients to let go and relax, we inadvertently participate in an age-old spiritual tradition. Self-Regulation and a Harmony With Nature Self-regulation has a specific cybernetic definition, but in clinical practice becomes a symbol for a much broader philosophy of organic biological balance. Biofeedback therapists teach their patients to listen to subtle signals from their bodies and to live in close harmony with their ever changing physiology. Patients learn an increased awareness of the environ- ment, identifying sources of stress and modifying their behavioral and cognitive responses to events. Implicitly and explicitly biofeedback therapists emphasize more natural, less intrusive, and less invasive interventions in health care. Changes in coping, nutrition, and lifestyle become first line remedies, and medications and surgery take second place. This is a complete reversal of common attitudes in medical practice, yet both research and medical authority increasingly support the priority of behavioral interventions. For example, both the Agency for Health Care Policy and Research and the Federal Health Care Financing Administration have recommended pelvic floor biofeedback as a first line intervention for urinary incontinence, before medication or surgery (Palsson, in press; Whitehead, 1995). Biofeedback in this sense becomes a practical form of Taoism, a gentle seeking of harmony in the body and in ones world. The founder of Taoism, Lao Tzu (sixth century B.C.), taught the doctrine of wu wei, meaning to discern and follow natural harmonies, to minimize strivings, and not to pit oneself against the natural order of things (Simkins & Simkins, 1999). When applied to health care, this philosophy of balance replaces the more alienated efforts of mainstream medicine to suppress symptoms by aggressive intervention. Neurofeedback and the Neurotheology Model By training patients to modify brain states, neurofeedback may induce states of con- sciousness conducive to spiritual awakening and personal transformation. Joe Kamiyas early research (Kamiya, 1969) initially showed that with feedback a human subject can

6 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 278 Moss modify cortical states at will, and by so doing modify the state of consciousness as well. Increased alpha range rhythms in the cortex are accompanied by an increase in creative, open awareness and a meditative, receptive attitude of mind. Les Fehmi later developed Open Focusan approach training students to cultivate alpha-dominant meditative states of awareness (Fehmi & Fritz, 1980; Fehmi & Selzer, 1980). The 1970s alpha training movement mixed a pursuit of counterculture spiritual growth with optimal performance training (Moss, 1998a). Today the Penniston alpha/theta protocol is applied regularly to treatment of the addictions and anxiety disorders, and many individuals who undergo the alpha/theta protocol experience a spiritual transformation as part of the treatment process. Neuroscience research is providing at least the beginnings of a more precise neurophys- iology of spiritual experiencespopularly called the neurotheology model. Newberg, DAquili, and Rause (2001) examined brain activity or brain function as a basis for the spiritual experience of being one with God. Newberg et al. wrote that . . . we saw evidence of a neurological process that has evolved to allow us humans to transcend material existence and acknowledge and connect with a deeper, more spiritual part of ourselves perceived us as an absolute, universal reality that connects us to all that is. (Newberg et al., 2001, p. 9) Newberg et al. refer to an area in the orientation association cortex in the parietal lobe, which shows lower frequency activity during meditation experiences. The increasingly sophisticated technology of QEEG assessment and EEG training may elaborate these initial findings in future research. THE IMPACT OF RELIGION AND SPIRITUALITY ON HEALTH What is the place of the soul in health care? The authors Larson and Larson asked the question as follows If you heard that research had demonstrated a factor which could lower your blood pressure, help you recover from surgery, provide a greater sense of well-being, add years to your life and help protect your children from drug abuse, alcohol abuse or suicide, would you be interested in discovering what it might be? (Larson & Larson, 1994, pp. 1, 6384) Their answer is that empirical research shows that some aspect of either spiritual experience or religious practices influences each of these aspects of overall health. Let us define terms first: Spirituality refers to a personal quest for ultimate meaning in life and for a personal relationship with a transcendent or sacred realm. Religion refers to the organized system of beliefs, practices, rituals, and symbols that are designed to facilitate closeness to the sacred and that provide the average person with moral and social guidelines for behavior. Many intellectually minded persons are quick to emphasize the importance of spirituality and the lesser importance of religion; however, empirical research supports the value of both (Koenig et al., 2001). For the average North American, religion and spirituality overlap greatly, and the average individual finds spirituality with the help of a religion. Inward spiritual life, prayer, and finding meaning in life have an immediate experiential and physiological effect, but outward practices such as church membership, attendance at services, and interactions within the congregation also have many social buffering effects on life stress.

7 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Circle of the Soul 279 When examining the impact of spirituality on health, it is essential to recall the power- ful impact of placebo effects or faith in pain management and many other areas of medical care. Specific physiological mechanisms account for only a small amount of the variance in most health care interventions, whereas a vast research literature documents that non- specific or placebo effects can account for anywhere from 30 to 90% of pain relief or healing (Wickramasekera, in press). Faith, spiritual experience, and hope can enhance the nonspecific effect in any medical care. Let us examine a sampling of research reports: High intrinsic religiousness, an inward involvement in religion, predicts more rapid remission from depression, and religious in- volvement predicts successful coping with physical illness (Koenig et al., 1999). Religious people, on average, are generally healthier, lead healthier lifestyles, and require fewer health services (Koenig, 2000; Koenig et al., 2001). One of the bases for the positive health effects of religion is that church affiliation reduces health risk behaviors such as smoking and alcohol abuse. Several studies show lower smoking in individuals who attend church more or who label themselves as more religious and these findings hold true for Christians, Muslims, and Jews in North America (Koenig et al., 1998). Religiously active senior citizens smoke less than nonreligious seniors, largely because they never began to smoke (Koenig et al., 1998). Similar data shows lower alcohol use in those with greater religious involvement (Koenig et al., 2001). Religious involvement is associated with reduced suicides. Comstock and Partridge (1972) studied 50,000 subjects for 6 years. Those who attended church once or more per week had a suicide rate of 0.45 per thousand. Those who attended less than once per week had a suicide rate of 0.95 per thousand, almost double. A more recent study of Kibbutz communities in Israel looked at a 16-year period and found that the risk of completed suicide was four times higher for those people who lived in secular Kibbutz communities than those who lived in religious Kibbutzs (Kark et al., 1996). Levin and Vanderpool (1987) cite two dozen studies showing that regular attendance at church or synagogue has documented health-promoting effects. Turning to cardiac health, Oxman, Freeman, and Manheimer (1995) found reduced mortality after coronary artery bypass in church attendees (5%) compared to nonattendees (12%). There is also a powerful interaction between two factors: Individuals who gain comfort or solace from their religion and also participate in social groups show a 14 times reduced mortality risk compared to individuals who gain no comfort from religion and participate in no groups (Oxman et al., 1995). Thus far, the studies cited make sense within a scientific paradigm including health risk behaviors, cognitive variables, the buffering effects of church social supports, the experience of meaningfulness in life, and similar tangible factors. The next section will review reports that strain the bounds of Western science, and appear to cry out for nontraditional models or concepts (such as the idea of spiritual or subtle energies). Larry Dossey has summarized an accumulation of studies finding that prayer impacts the physiology and health of the prayed-for individual, whether or not the individual knows that he or she is being prayed for (Dossey, 1993, 1999). Christian, Jewish, and Buddhist prayer appears to have similar effects in facilitating healing. Further, the distance between the individual praying and the patient has negligible effect. In other words, if I pray for an individual here in this room, it is going to have the same effect as if I prayed for the same person when she is home in Tennessee. For this reason Dossey posits the nonlocal effects of prayer. In the future, one might ask, if this research continues to compile, will physicians be liable if they fail to pray

8 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 280 Moss on a given day for their patients well being? Fortunately, if there truly is a nonlocal and non-timebound effect of prayer on healing and on physiology, physicians can make up for their omission by praying retroactively. Byrd (1988) conducted a random double blind assignment of 393 coronary care patients to control or experimental groups. Patients, physicians, and experimenters did not know which patients were prayed for. Religious groups were organized and prayed daily for the experimental group. Each volunteer prayed for several patients by the patients first name, using that volunteers own style of prayer. The prayed-for patients in Byrds experimental group were five times less likely to require antibiotics and three times less likely to have pulmonary edema; none of them required endotracheal intubation compared to 12 in the control group, and proportionately fewer died. In a more recent randomized, controlled study, Harris et al. (1999) found that prayed-for coronary care patients improved on a summed and weighted coronary care unit score. Byrds findings and those of Harris et al. tell us that one cannot account for the entire effect of prayer on health in terms of cognitive expectations, if the effect prevails under blinded conditions. Several studies took the research on the effects of prayer beyond the human level and showed the benefits of prayer for lower forms of life (Dossey, 1993, p. 135). For exam- ple, Braud (1990) at the Mind Science Foundation used 10 tubes of red blood cells in an experimental group and 10 identical tubes in the control group. Thirty-two unskilled vol- unteers visualized protecting the red blood cells in the experimental group. Experimenters and technicians were blinded as to which tubes were prayed for. All of the blood cells were exposed to a salt solution. Those in the experimental group showed less hemolysis, swelling, bursting, and dissolving. CAUTION: RED FLAGS ON THE COURSE Negative Effects of Religious and Spiritual Involvements Several concerns qualify this papers enthusiasm for the positive effects of religion on health. The first red flag is a clinical concern: When a health professional communicates this kind of information about religion and health to patients, caution is in order. Many individuals manifest guilt over their own illness. This phenomena occurs in two quite diverse groups, including conservative religious individuals and those with a New Age orientation. Many conservative Christians blame themselves when they get ill, making statements such as If my relationship with Christ were right, I wouldnt be ill. The New Age oriented individuals engage in similar kind of self-blame, but with a psychological flavor. They frequently make statements such as I must have an unhealthy attitude that caused my illness, or I wonder why I have bad karma? Health professionals must remember, with humility, that illness has been an ever-present part of human existence and human history. No degree of spiritual enlightenment and no amount of spiritual practices can guarantee good health for any human being. It is essential to assure patients with serious illness and pain that their stricken condition is real and tragic and largely beyond personal control. Pargament and his colleagues have conducted interesting research on positive effects of spirituality, but have also identified negative religious coping strategies that fail to produce positive outcomes and sometimes show negative effects (Bush et al., 1999; Pargament et al., 1994). One study found increased morbidity in elderly persons with religious struggles

9 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Circle of the Soul 281 (Pargament, Koenig, Tarakeshwar, & Hahn, 2001). Religious struggles refer to negative cognitions such as the following, I wonder whether God has abandoned me, maybe God doesnt love me, or maybe the devil is making this happen. Methodological Questions About Research on Religion, Spirituality, and Health Another red flag regards methodological issues in research on the impact of religion and spiritual practice on health. A 1999 Lancet article concluded that published work on religion and health lacks consistency even in some of the more well-conducted studies (Sloan, Bagiella, & Powell, 1999). More recently, Sloan and Bagiella (2002) reviewed articles on religious effects on health status published in 2000, including two comprehensive review articles in the area of cardiovascular disorders and hypertension. They concluded that many articles were irrelevant to the claim of health effects, many were methodologically flawed, others were misrepresented in reviews, and only a few articles could reliably be described as demonstrating health effects of religious involvement. It is essential to pursue rigorous empirical research in this area. Ethical Issues Arising When Religion and Health Care Overlap Ethical concerns come into play as well when religion and health care cross. An evangelical Christian surgeon telling a Buddhist patient to follow Jesus Christ for a better surgical outcome is not anyones idea of optimal, clinical use of religious perspectives. Any health care provider pushing a personal religious preference on a patient, especially without knowledge and respect for the patients religious background, is violating ethics and practice standards. Health professionals will serve better by drawing out and affirming the religious orientation the patient already possesses. Several relevant practice guidelines have emerged in the last couple of years. Post et al., (2000) suggested four simple questions, which any clinician can ask seriously ill patients. Is faith, religion or spirituality important to you in this illness? Has faith been important at other times in your life? Do you have someone to talk to about religious matters? and Would you like to explore religious matters with someone? We do a favor to our patients when we open a door for them to express themselves about their spiritual concerns, doubts, questions, and needs. Koenig (2000, p. 1708) provides another practice guideline: Consider taking a spiritual history with your patients, especially if you are already aware that the individual is struggling somewhat or seeking spiritual awakening or guidance. Ask the individual, Did your family teach you about religion and morality? What milestones and turning points have shaped your current faith? Many individuals struggle to escape an overly rigid religious childhood, and the experience that religion was something pressed on them forcibly in childhood (Sloat, 1986). On the other hand, many individuals today are simply un-churched and have no spiritual or moral education of any kind, Eastern or Western. PSYCHOPHYSIOLOGICAL STUDIES ON SOUL PHENOMENA Psychophysiological research may contribute to understanding spiritual phenomena. Psychophysiology remains a discipline steeped in empirical investigation. Once a

10 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 282 Moss phenomenon is recognized as important for human life, psychophysiologists commence to apply electrodes and assess whether physiology is modified in some measurable way by the phenomenon. Such investigations cannot measure soul, but may serve to show that soulful experiences have consequences for physical health, and to identify some of the mechanisms mediating this impact. Au: Kindly In one illustrative study Lehrer, Sasaki, and Saito (1999) studied EKG and respiration include this ref. in Zen monks in Japan. Previous research has found low serum lipid rates and low rates in the ref. list. of cardiovascular disease in Japanese monastic populations. Zen Monks spend hours each day in meditation with very slow breathing. Lehrer et al. found respiration rates slowing in meditation to a range associated with low frequency heart rate variability (0.050.15 Hz) while higher frequency heart rate variability decreased. The authors found some support here for a theory that slow respiration resonates with cardiac function and produces low frequency cardiac oscillation with benefit for cardiac health. In another study, Wirth and Cram (1994) reported on physiological effects of distant prayer in 12 subjects who were not informed of the prayer intervention. They conducted multisite EMG recording and autonomic measures. The experimental condition was as follows: Experienced healing practitioners at another site viewed a subjects name and photograph, and prayed or visualized positive effects for the individual. Prayer lowered surface EMG at lumbar and thoracic sites. Autonomic relaxation did not account for the effects. Research documents that prayer and relaxation are not identical in their physiological effects. Elkins, Anchor, and Sandler (1979) compared religious practices to prayer and found better EMG reduction with relaxation skills practice. Shaffer, Malone, Callahan, and Lipps (2001) studied physiological effects of silent Bible reading and silent self-composed prayer. They found no physiological effect from silent Bible reading, whereas silent prayer reduced EMG but not other measures. Such research is invaluable and will guide the future integrative applications of spiritual disciplines and secular relaxation practices for optimal health effects. THE ROLE OF BIOFEEDBACK AND NEUROFEEDBACK IN COMPLEMENTARY AND ALTERNATIVE MEDICINE Patients want to be seen and treated as a whole person, not as diseases. A whole person is someone whose being has physical, emotional, and spiritual dimensions. Ignoring any of these aspects of humanity leaves the person incomplete and may even interfere with healing. (Koenig, 2000, p. 1708) This paper will close with a consideration of the potential role of biofeedback within the complementary and alternative medicine (CAM) arena. CAM and spiritual practices overlap greatly. CAM therapies include Eastern discipline such as yoga and meditation, healing touch, and conventional prayer and spiritual healing. Popular demand is driving the growth of CAM. Research by Eisenberg shows that 42% of the general public now Au: Kindly uses CAM (Eisenberg et al., 1998). Visits to alternative therapists and practitioners exceed include this ref. the visits to conventional medical doctors. The general public spent 30 billion 4 years ago in the ref. list. on CAM, much of it self-pay, out of pocket expense. Similar trends show that disabled persons are using CAM therapies (Krauss, Godfrey, Kirk, & Eisenberg, 1998). On the other hand, Eisenbergs research shows that 60% of these patients are not telling their doctors about their visits to CAM practitioners (Eisenberg et al., 1998). This creates a discontinuity,

11 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 Circle of the Soul 283 a breach in the continuity of care, and should cause great concern because many CAM therapies, especially herbal preparations, include active ingredients that can conflict with conventional medication. Acceptance of CAM within mainstream health care will aid in restoring the continuity of care. Insurance companies, here and there, are responding to demand for CAM by adding special CAM riders, which some employers are purchasing. Whenever that happens it is critical that biofeedback professionals advocate for the inclusion of biofeedback in the CAM riders. CAM remains controversial for many biofeedback professionals. Several colleagues have angrily insisted to this author that Weve been around for thirty years. We have good efficacy. We are mainstream. We are not alternative. Regardless of the truth of their position, I will argue here that many aspects of the values, approach, and paradigm of biofeedback practice are identical with the values and approach of complementary and alternative medicine. There are also practical advantages for accepting the common per- ception of biofeedback as part of CAM, opening a window of opportunity for biofeedback to reach a broader audience of health consumers. What do we mean by complementary and alternative medicine? Operationally one can define CAM therapies as interventions that are not yet included in most medical school cur- riculums. Complementary medicine derives largely from the same paradigm as mainstream medicine (Lake, in press). Complementary therapies are innovative, and not yet broadly accepted, yet make sense in terms of the familiar models and vocabulary of medicine. Biofeedback, neurofeedback, and herbal medicine are largely complementary therapies. We can understand many of the physiological mechanisms that make biofeedback effica- cious, and some of the cognitive mechanisms that contribute to the efficacy of biofeedback, without introducing alien concepts. On the other hand, alternative medicine and alternative therapies come from an alien paradigm, a paradigm that is unconventional and does not make sense in terms of Western science (Lake, in press). Alternative therapies frequently require a leap of faith for the con- ventional scientist. They rest on concepts such as Qi, subtle energies, or spiritual forces, beyond the bounds of physiological measurement. Alternative therapies include homeopa- thy, Reiki healing, and Ayurvedic medicine. Reiki healing at a distance of someone who does not know he is being prayed for defies the paradigm of proximal causes and tangi- ble mechanisms. Yet research is beginning to show efficacy for some of these alternative therapies (Wirth & Cram, 1994). Below is a compilation of many of the values and emphases commonly found in the CAM literature (Freeman & Lawlis, 2001; Jonas, 2001; Jonas & Levin, 1999; Whorton, 1999): 1) A holistic view of mind, body and spirit 2) Viewing and treating the patient as a unique human being 3) A personal supportive relationship between healer and patient 4) An active role for the patient in the healing process 5) The inherent healing power of the living organism 6) Lifestyle and habit changes as tools to optimize health 7) Interventions to elicit the bodys healing powers 8) An aversion to invasive treatments that crush disease but harm the patient 9) A belief in eclecticism and empiricism 10) An acceptance for unconventional interventions and models that appear to work

12 P1: GVG/FUG/LZX P2: GCV Applied Psychophysiology and Biofeedback [apb] pp646-apbi-453363 September 18, 2002 16:26 Style file version June 4th, 2002 284 Moss 11) An openness to prayer, meditation, and spiritual practice as tools for healing 12) An integration of physical, psychological, and spiritual practices These values clearly overlap with the life philosophy and treatment approach of many biofeedback professionals, as examined earlier in this paper. This commonality of approach argues for a comfortable marriage of biofeedback and CAM practice (Moss, 2001a). The broad range of complementary and alternative medicine includes a wide array of therapies, ranging from acupuncture and aromatherapy to yoga and tai chi. Biofeedback and neurofeedback stand out as unique because of their foundation in empirical science. First, many biofeedback therapies derived from an understanding of physiological mechanisms, and second, in spite of some methodological weaknesses, there is a growing biofeedback efficacy literature. Mindbody medicine overlaps with CAM. Broadly speaking, mindbody medicine includes any clinical intervention with problems of the primary medicine clinicincluding physical diseases, physiological dysfunction, and behavioral and mood disordersusing empirically based, cognitivebehavioral, and psychophysiological interventions (Moss, McGrady, Davies, & Wickramasekera, in press). Meditation, hypnosis, guided imagery, biofeedback, and relaxation therapy are the most studied modalities, and positive outcomes have been documented for chronic pain, headache, insomnia, and anxiety, with prelimi- nary support for coronary artery disease and cancer (Barrows & Jacobs, 2002). Mindbody medicine expands the focus and improves the techniques of traditional psychosomatic medicine. As David Sobel has pointed out, mindbody medicine is not something sep- arate or peripheral to the main tasks of medical care but should be an integral part of evidence-based, cost-effective, quality health care (2000, p. 1705) Integrative medicine combines complementary, alternative, and mindbody thera- pies with mainstream biomedical therapies in one practice. Integrative medicine draws on any models and therapies that offer value, whether they derive from Western labora- tory pathophysiology or Eastern religious traditions. Efficacy and safety will remain pri- mary. Evidence-based research will guide everyday decisions within CAM and integrative medicine, rendering it critical that further research be conducted on all CAM modalities (Jonas, Linde, & Walach, 1999). N. A. Cummings and J. L. Cummings (2000, p. 127) express the vision of integra- tive medicine well, when they project that future patients will visit one house, under one roof, within one integrated health care system, and find the full range of interventions for their health care needs. This author encourages biofeedback professionals to share in the vision of a unified health care and to claim a place for biofeedback within that integrated care. REFERENCES Au: Kindly check Association for Applied Psychophysiology and Biofeedback. (2002). Circle of the soul: The psychophysiology of if the reference is mind/body/spirit. Proceedings of the 33rd Annual Meeting of the Association for Applied Psychophysiology OK as typeset. and Biofeedback. Wheat Ridge, CO: Author. Barrows, K. A., & Jacobs, B. P. (2002). Mindbody medicine: An introduction and review of the literature. Medical Clinics of North America, 86(1), 1131. Benson, H. B. (1975). The relaxation response. New York: Morrow. Braud, W. G. (1990). Distant mental influence on rate of hemolysis of human red blood cells. Journal of the American Society for Psychical Research, 84(1), 124.

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