Recovering from Chronic Fatigue Syndrome:
A Guide to Self-Empowerment

By William Collinge, Ph.D.

Table of Contents

Chapter 7. The Benefits of Mind/Body Medicine

      "The imagery and relaxation training have helped me more than any medication. I can actually feel physical changes in my body. That takes away the anxiety I feel with this illness."  --Alice
     In this chapter we will survey the range of psychological therapies that can be used to promote recovery from CFS. This includes individual and group therapies, as well as mind/body medicine techniques you can use on your own. This will lay the groundwork for the "how to" chapters that follow, dealing with specific techniques.
      In 1987, Alice participated in my self-help program in Incline Village, Nevada. At the time she was undergoing a two week intensive treatment of intravenous acyclovir therapy in the hospital. Acyclovir is a drug which inhibits the reproduction of viruses of the herpes family, to which HHV6 and Epstein Barr virus belong. One of the side effects of acyclovir therapy is escalating blood pressure, which needs to be closely monitored.
      Alice was about half way through her treatment protocol when she enrolled in the group. She brought her stainless steel drip apparatus with her from the hospital, and stood it up beside her in the circle with the other patients and their spouses. 
      The first day involved a series of relaxation and deep breathing exercises. The next day Alice returned to the group bubbling with excitement. She reported that the previous evening her blood pressure had returned to normal. The nursing staff were mystified, and wanted to know how she had done it.
      The benefits Alice received are not at all uncommon. They illustrate the fact that we can directly influence what goes on in our body. The branch of medicine that uses behavior change for influencing the physical body is called behavioral medicine, or more popularly, mind/body medicine. In recent years mind/body medicine has been increasingly finding its way into the mainstream. In chronic illnesses like CFS, HIV, cancer, it lies at the heart of self-empowerment. In this chapter we will examine the benefits--and some unexpected problems--that can arise in using mind/body medicine in CFS.
      Perhaps this is a good time to reiterate the fact that CFS is not a psychosomatic disease. "Psycho-somatic" means the mind is the root cause of symptoms in the body. If anything, CFS is a "somato-psychic" disease. The events in the body--specifically the immune system--influence the brain, mind, and emotions. In mind/body medicine, however, we are deliberately using the pathways of connection between mind and body to influence what goes on in the body. In a sense we are exploiting the mind/body connections to make things happen in our favor.
      The person with CFS is likely to encounter several different forms of psychological services, and mind/body techniques may be a part of any of them. Possible forms of psychological help include individual or family therapy, group therapy, hypnotherapy, and medical hypnosis, and several derivatives of these. 
      Because they are used to help with a physical illness, these are all forms of "complementary therapy." This means they work along side medical treatment in a supportive way. I like this term because it communicates its relationship with medical treatment--that it does not replace or compete with it, but acts in partnership with it. This is an important distinction because many people erroneously think of mind/body medicine as "alternative" medicine, something which you would use instead of medical treatment. No responsible health professional would recommend these approaches as alternatives to established treatment.

WHAT KINDS OF PSYCHOLOGICAL HELP ARE AVAILABLE FOR CFS?
      Very little research has been done to study the benefits of psychological therapies with CFS. However, we can borrow insights from work with other immune-related illnesses to gauge the role and likely benefits of such intervention in CFS. Below we will consider the benefits of the various approaches you are most likely to encounter.

Psychotherapy
      Psychotherapy is conducted by a trained, licensed or certified therapist (clinical psychologist, clinical social worker, marriage and family therapist, psychiatrist). Of course, before entering into such a relationship with a therapist, you should determine whether they are informed about CFS. Many are not, and may be inclined to take a "psychosomatic" orientation toward this condition. Always make sure they have done their homework.
      Psychotherapy offers an excellent opportunity to explore your feelings about your situation, identify problems in relating with your family, learn how to manage symptoms, or explore the challenges to coping with chronic illness. Though such therapy may be brief, it can have important benefits. One of the greatest benefits is improving the quality of life. 
      As discussed earlier, the challenges of CFS require a great deal of coping, not only with the symptoms but with the stress of illness in general. Therapy can be very helpful in reminding you to respect your limits, that symptoms are transitory, that healing is possible, and to follow through with self-help practices. By keeping all these challenges in perspective, the quality of your day to day living can be much improved over living in a state of constant despair of fear.
      Aside from improving the quality of life, can psychotherapy influence the course of CFS? There are no definitive studies that answer this question, although a great deal of clinical experience strongly suggests this. And when you consider the importance of lifestyle change and reduced stress in promoting recovery, obviously therapy can, if it helps with these issues, contribute to faster recovery. On this point we may borrow from the cancer literature, which seems directly relevant to this issue in CFS. The value of psychotherapy is articulated by psychologist Dr. Alastair Cunningham, who states:
      Although epidemiological considerations suggest that the contribution of psychological factors to cancer onset is small... compared to purely biological and social factors (e.g., environmental carcinogens), no upper limit to what can be achieved by psychotherapy is necessarily thereby set: the relative influence of the psyche on outcome may be greatly expanded by such therapy, overriding the usual progression of disease.
      There are certain risks in placing a great deal of emphasis on psychotherapy for physical healing, however. These will be discussed at length later in this chapter.

Group Programs
      There is no question that group participation can be valuable. A group can be a source of inspiration, emotional support, and information about handling symptoms. Two basic kinds of groups are available: support groups led by peers, and group programs led by professionally trained therapists.

      Support groups. These groups offer an especially good arena for exchanging information about physicians, treatment, and research news. Support groups are also helpful in overcoming the isolation and lack of social support which so many people with CFS experience. And they can be a source of reinforcement for continuing on your path of self-empowerment. 
       You can gain a great deal from witnessing how others handle the challenge of illness, and in what ways their journey might parallel your own. The support group can also be a rich resource of wisdom and experience in devising coping strategies for symptoms and for the emotional distress of illness. 
      There is a downside to support groups. You are not likely to meet people who have recovered in such a group, leaving the impression that no one recovers. Also some groups can inadvertently reinforce the "victim" role. That is, they can become a place where your identity as a "victim of CFS" is actually strengthened, and this can subtly work against your sense of hope and positive expectancy about recovery. The risks of this happening are especially high in those few groups where the emphasis seems to be on exchanging horror stories about symptoms. 
      I have heard many patients say they have chosen to quit attending support groups because of this problem of dwelling on the negative. Yet there are times, especially early in the illness, when it is a relief to know that you are not alone in your experience of your symptoms. 
      You must judge for yourself whether a particular support group has its focus in the right place for you. Is it reinforcing self-empowerment? This is a good question to discuss with the other participants.
      You can determine whether there is a CFS support group in your area by contacting the resources listed in Appendix C.

      Group therapy programs. These groups are usually led by credentialed, professional therapists. Such group programs are certainly supportive and therapeutic, but they usually are organized around teaching specific skills such as relaxation, meditation, imagery, pain control, stress reduction, and coping with the stress of illness. 
      Many such groups have been studied and found to have positive impact, not only on quality of life, but in some cases on immune functioning and health status.
      One example is the Self-Help Intensive at the Cancer Support and Education Center, Menlo Park, CA. While originally designed for cancer patients, the program also serves people with CFS and other chronic illnesses. The ten-day, 60-hour program helps people with imagery and relaxation training, lifestyle change, emotional expression, strengthening fighting spirit, and using their illness as a teacher. 
      I conducted an outcome study of this program as part of my doctoral dissertation at U. C. Berkeley, before joining the staff of the Center. The study involved 59 cancer patients who took the Self-Help Intensive, and found significant improvements in emotional expression, fighting spirit, and several aspects of quality of life. It also showed that people in even the more advanced stages of illness can benefit from such training. The benefits were still present three months after completing the program, indicating that the effects can be lasting. 
      A similar study of 48 patients with H.I.V. who also took the same Self-Help Intensive found significant improvement in emotional expression and health locus of control, and reduced tension, anxiety, fatigue, depression, and total mood disturbance. These findings, as well of those of the cancer patient study, represent improvements that have been found in the more general PNI research to be associated with better immune functioning.
      At U.C.L.A., a team of researchers studied outcomes of a group program for 66 post-surgical malignant melanoma patients. The six-week structured group program included health education, stress management, training in problem-solving, and psychological support. Results showed significant improvement in both psychological coping and immune functioning. Six months after the program, there were significantly lower levels of psychological distress, and higher levels of positive coping methods in comparison to patients who did not have the group. There were also significant increases in the percentage of NK cells and in NK cell cytotoxic activity (their functional effectiveness).
      One of the more exciting studies in this field dealt with increasing survival time in cancer. David Spiegel, M.D. and his colleagues at Stanford University and U.C. Berkeley conducted a ten-year study of 86 women with metastatic breast cancer. The groups lasted a year, meeting weekly for ninety minutes, and used a form of therapy called "supportive-expressive therapy." Though the researchers had set out to study quality of life, they were surprised to find that survival time was nearly double that of a comparable group of women not receiving the group therapy (averaging 36 months versus 18 months). 
     This highly regarded study represents a breakthrough in linking psychological treatment with medical outcome. How could the difference in survival time have occurred? We do not know whether the benefit was due to a particular technique of therapy, the experience of belonging or affiliation in the group, emotional expression, shifts in attitude, improved compliance with medical recommendations, or changes in other lifestyle behaviors that were encouraged by the group. 
     It is also possible that, since the immune system is the main line of defense in cancer, the results were due to improved immune responses alone. Or, perhaps most likely, the results were multicausal, and many different impacts of the program had a synergistic effect. These questions are now being pursued by Spiegel and his research team. Meanwhile, as a result of this study, group therapy is now being seen in a different light compared to before when it was thought of as only a quality of life intervention.
     The effects reported in the above studies represent a growing body of findings about benefits of group programs for people with immune-related illnesses. I consider it highly likely that when similar studies are conducted for people with CFS, we will find similar benefits. In the meantime, I encourage you to seek out group therapy programs--taking care, of course, to be sure that whoever is leading the program has an accurate understanding of CFS.

MIND/BODY MEDICINE
      The term "mind/body medicine" covers a variety of techniques you can use to help the mind influence the body. The basic tools of mind/body medicine include relaxation training, meditation, imagery, and related approaches. These are frequently used in the group and individual therapy programs discussed above. 
       Later chapters will be devoted to showing you how to use these methods with CFS. But first, I would like to acquaint you with the rationale, and especially the research backing, for the use of these techniques.
     Mind/body medicine is usually thought of as something new, controversial, subject to abuse or false claims, and needing a lot of study to prove that it has any value. However, the principles of mind/body medicine are actually among the most thoroughly tested in all of medical science. I can make this unusual statement because the mind/body connection is tested in virtually all research on new drugs.
     Typically, when a new drug is being tested, some patients are given the drug and some are given a "placebo," a fake pill such as a useless sugar pill. The placebo triggers a positive expectancy or hope in the mind of the person taking it. Often this will result in changes in the body, called placebo effects.  The drug might then be rejected because it is found to be no better than the placebo effect. The researchers may say in disappointment, "We found nothing of value. The drug was no better than placebo." The flip side of this statement, of course, is, "We have proven once again the power of mind/body medicine. It is just as effective as the drug."
     In mind/body medicine, we are deliberately exploiting the pathways used in the placebo response. The viability of these pathways has been proven by literally thousands of drug studies. Let us now turn to the techniques.

Relaxation Training
      By now is should be clear that stress plays an important role in CFS. It contributes to your vulnerability to developing the syndrome, it can aggravate symptoms that are already present, and it can serve as a trigger of relapse. This all happens because stress sets off physiological and chemical changes in your body that can have toxic effects and can disturb immunity. These changes are collectively called the stress response.
      Fortunately there is an antidote to the stress response. It is natural, everyone is capable of it, and it is free. It is called the relaxation response. This too is a set of physiological and chemical changes in your body. However, the changes comprising the relaxation response are opposite to the stress response--they are almost like a mirror image. 
      The relaxation response was discovered and named by Harvard psychiatrist Herbert Benson, M.D. and his colleagues in 1974., They were studying a pattern of physiological changes that occurs in people practicing a form of meditation called TM (transcendental meditation). This pattern of changes was found to represent a very beneficial state, one to which meditation naturally leads. 
     Rather than capillaries constricting and limiting the flow of blood, they open and blood flows more freely. Rather than hands and feet being cold and clammy, they are warm. Rather than heart rate increasing, it slows and relaxes. Rather than muscles being tense and tight, they become more flexible, allowing circulation to flow freely through them. Rather than breathing being rapid, shallow and constricted, it becomes more full and deep. These are a few of the important benefits discovered by Benson and his colleagues.
      We now also have evidence of its benefits for the immune system. In one study, 45 geriatric residents were randomly assigned to one of three groups: relaxation training, social contact, and no intervention. Those in the first two groups were seen individually three times per week for a month. Blood samples were drawn before the program, immediately after the month, and a month later. Those who were trained in relaxation showed a significant improvement in NK cell activity, as well as lower antibody titers to a herpes simplex type one antigen. In addition, there were significant decreases in symptoms of emotional distress.
      The finding about higher NK cell functioning is especially important for CFS in that as we have seen earlier, depressed natural killer cell activity is one of the features of this syndrome. 
      Further evidence of benefit to immunity comes from a study we discussed earlier, of the relationship between exam stress and immunity in 34 medical students. Half the students were randomly assigned to a relaxation training program. The results showed that the frequency of relaxation practice was significantly associated with the percentage of T-helper cells circulating in the blood during the exam period. In other words, the more the students practiced the relaxation response, the higher was the percentage of T-helper cells. These cells, of course, stimulate the immune response. The researchers concluded that relaxation achieved in this way may enhance at least some components of the immune system, and perhaps influence the incidence and course of disease.
      The regular use of the relaxation response may be one of the most healing activities we can do, yet because it's free, people tend not to value it as such. It's a simple, subtle, and powerful way of helping make room for your body's healing resources to express themselves. 

Imagery
      Imagery is a popular tool of most mind/body programs, although few scientific studies have tried to measure its effects. The use of imagery with CFS involves inventing symbols in your mind's eye which will help you play out in a visualization how you want things to occur in your body. This may involve visualizing your immune system working harmoniously and in balance, seeing your immune system eliminating viruses or other pathogens, or perhaps a general symbol to represent the syndrome, and another symbol to represent all your healing forces. In any event, visualization is a process in which you see the desired outcome develop.
       How does imagery produce its effects? Scientists are investigating exactly how. It could be that the messages we are sending through the pathways connecting mind and body--the neuroimmune network discussed in Chapter 4--are heard at the cellular level, and the body respectfully responds to our commands. We could call this the "specificity hypothesis," meaning that the effects are very specific and depend on the details of the message we want to send.
      There is now evidence for the specificity hypothesis. In a study at the University of Arkansas, an experienced meditator using imagery techniques was able to manipulate her immune system's reaction to an injection of harmless virus particles just below the skin. The material injected, called a "varicella zoster test reagent," ordinarily gives rise to a type of inflammation called a delayed hypersensitivity reaction. This reaction is created by white cells releasing chemicals, such as histamine, which have the effect of causing inflammation. 
      It was found that on demand, the woman being studied could alternately (1) suppress her inflammatory reaction and white cell responsiveness, and (2) allow her inflammatory reaction to respond normally. This experiment suggests that she was able to communicate with and influence the behavior of her white cells.
       In another study involving imagery, researchers at Michigan State University found that students could use guided imagery could improve the functioning of certain white cells called neutrophils. They could also decrease, but not increase, white cell counts. At one point in the study, a form of imagery intended to increase neutrophil count unexpectedly caused a drop instead. Subsequently, students were taught imagery explicitly intended to keep the neutrophil count steady, while increasing their effectiveness. Both goals were achieved.
      These studies suggest intriguing questions about whether it might be possible for people with CFS to deal with the problem of chronic immune activation through such methods. Could it be that by imagining the white cells becoming more relaxed and practicing the relaxation response themselves, their hyperactivity could be reduced?
      The specificity hypothesis is not the only avenue being explored for how imagery may benefit immunity. Another point of view is the "general effect" hypothesis. This means that benefits can arise from the general overall feeling of greater control that comes when you believe you can influence your health through these methods, and as your confidence grows. There is evidence for this in studies where a sense of control over the source of stress has been linked to better immunity, compared to the sense of having no control. 
      For example, in a study at Stanford University, 20 subjects who were afraid of snakes agreed to have blood samples taken to test the changes in immune responsiveness as they got close to and, eventually, handled snakes. As their sense of mastery and confidence, or "self-efficacy" increased, their blood chemistry changed to reflect significantly better immune functioning.
     This increasing sense of self-efficacy may have been the factor at work in a study of cancer patients which found improvement in immunity associated with imagery practice. Ten metastatic cancer patients attended monthly group sessions for a year in which they were supervised in imagery practice. Between sessions they performed the exercises twice a day. After each monthly meeting, blood samples were drawn to monitor immunologic changes. Significant improvements were found in several immune functions, including natural killer cell activity.
      If feelings of confidence or competence are really the key, then whatever method you choose--if you use it regularly--can contribute to restored balance in immune functioning. This is consistent with the advice of Carl Simonton, M.D. who once told me that if you feel hopeful, powerful, and optimistic after doing your imagery, then that is the criterion of success, much more than the details of the images used. It follows that if you are confident in your ability to influence your health, this confidence will reduce the degree of stress you feel as a result of CFS. Then your healing can progress more readily.

AVOIDING THE PERILS OF MIND/BODY MEDICINE
      The explosive growth of interest in mind/body medicine has spawned a shift in our attitudes and beliefs about healing. However, in their enthusiasm to jump on the bandwagon, many popular books and magazines have fostered some erroneous beliefs which can lead to feelings of guilt, self-blame, confusion, despair, or hopelessness in people attempting to deal with CFS through a mind/body model. We can call this the "psychosocial morbidity" of mind/body medicine.
     Some doctors take a conservative approach, discouraging patients from using complementary therapies for fear of the psychosocial morbidity which may result if the patient doesn't do well or if their condition deteriorates. This approach has its own risks, however, namely that the person may miss a helpful service; or worse, may interpret the physician's attitude as suggesting a hopeless situation, leading to false despair. Other physicians support complementary therapies but help the patient to explore their expectations to make sure they are realistic.
     The way to avoid the risks is to have a realistic understanding of the benefits and limits of mind/body medicine. I have found five key principles of mind/body medicine to be sources of trouble for many people. While many of these principles are based on well-intentioned ideas, we need to refine our ways of thinking--our "paradigms"--to be more in step with the psychology of healing. I will discuss these from the point of view of shifting from old to new paradigms.

The Meaning of Responsibility
      You've probably heard these sayings: "Take responsibility for your health." "You are responsible for your health." "You are the creator of your health." The movement is away from the passive orientation ("Here, doctor, my health is none of my business, you take care of it"), and toward personal empowerment. Unfortunately some patients have followed this line of thinking to undesirable conclusions. 

      Old Paradigm: Responsibility Means Ultimate Control and Ultimate Blame. Most of us grew up in a culture in which the word "responsibility" had a definite charge to it. As children we associated irresponsibility with misbehavior, punishment, blame, fault, shame and guilt. It was often used in the context of discipline or threats of discipline at home or school. This old idea of "taking responsibility" is usually oriented to self-judgment for one's past behavior. By applying these attitudes to health, it's not difficult to see how some people conclude: 
       Since I am responsible for my health, I must have given myself CFS. It's my fault, and it serves me right. I brought it on myself, and I must figure out why so I can correct it. Whether I get well depends on how hard I work on myself...

      New Paradigm: Responsibility as Here and Now. Rather than having a retrospective, punitive focus, responsibility is here and now, present tense. It has to do with how you live your life from this moment forward. In fact it's irresponsible to indulge in self-condemnation about the past. We probably would all have lived differently if we had known then what we know now, but that's not the case. Responsibility means responding here and now to the challenges you face, given the resources you have now, both inner and outer. This includes the intelligent use of medical treatment, as well as lifestyle change and self-help. 
      There can be value in looking at the past to see how we may have contributed to our vulnerability, especially if we engaged in risky or unhealthy behavior which continues today. This kind of looking within is done with an exploratory attitude toward life's lessons, not with a blameful attitude. If you remember the multicausal perspective, it's impossible to say to what extent past behavior contributed to the onset of CFS. To blame yourself about the past is a distraction from helping yourself now. The key is to shift from self-blame for the past to self-support for the present.

Hope
      Hope refers to a positive expectancy about the future with the belief that something better than the current circumstances is possible. Its opposite is despair. In CFS this is especially important, since belief in recovery and in your ability to influence it are so central.

      Old Paradigm: Statistical Odds Determine Hope. In the old paradigm, hope is considered a matter of statistical odds. Most illnesses have a predictable course and statistics have been generated about the length and stages of illness. People who hope for some different outcome other than what the statistics suggest would be subject to accusations of "false hope." This is especially true, of course, with illnesses such as advanced cancers or HIV where the prognosis is grim--even though people have been known to defeat the odds.
      In a sense it is good that we do not yet have statistics about recovery time in CFS, for if we did, people might tend to assume that those statistics applied to them as individuals.

      New Paradigm: Hope Amid Uncertainty. Hope can be separated from statistical odds. For example, a person may hope to defy the statistics, or that a cure will be discovered soon, while fully understanding the realistic nature of CFS. He can believe in the possibility of the unusual or unexpected.
      Stories of people surviving normally fatal illnesses have inspired others to be hopeful where they may have not been before. And of course hope applies to dimensions other than just physical recovery. People can hope for healing emotionally, spiritually, and in relationships--even in a dying process.
      In this paradigm, hope by its very nature cannot be false. However, it should exist alongside a realistic understanding of the challenge one faces. Hope can exist with unrealistic understanding as well as with realistic understanding.

Emotions
     Emotions and emotional expression are often difficult areas for both patients and helpers. Yet as we saw earlier, emotion plays an important role in host resistance and quality of life. 

     Old Paradigm: Emotions as "Positive or Negative." Our anti-emotional culture promotes the idea that emotions can be divided into positive and negative. Those that feel good and are pleasant (joy, love, happiness) are labelled positive, and those that feel bad or unpleasant (fear, sadness, anger) are labelled negative.
     Many people who embrace this paradigm believe that emotions are an adversary to be mastered or controlled. It goes something like this:
      Negative emotions are bad for your health and positive emotions are good for your health, so get negative emotions out of your life in order to promote your healing. Negative emotions go against having a positive mental attitude which is necessary for healing. Don't feel negative emotions!
     Unfortunately this conditioning goes very deep and is often shared by health care providers. The result can be a subtle form of conspiracy between helper and patient in believing that there are "negative" emotions, and the patient then seeks to repress or suppress these authentic aspects of life.

       New Paradigm: Emotion as Energy to be Expressed. In the new paradigm, what's important is not attaching a positive or negative value to emotions. Rather it's emotional expression that influences health and quality of life. The need for expression applies to all emotions--anger, fear, and sadness as well as love and joy. Expression is health promoting, and suppression is health negating. As Dr. Lydia Temoshok, a leading mind/body researcher, stated when asked about the role of emotions in immunity, "If there is a hero in this, it's probably emotional expression."
     Rather than thinking of emotions as positive or negative, they are simply one expression of your life energy as it flows through you. Imagine a beam of light shining through a prism that separates the light into a rainbow of colors. The prism is the person, the beam of light his life energy, and the rainbow represents the array of colors that energy can take, or the emotions. Placing your finger on the prism to block out certain colors will disturb the flow of light through the prism, and yield a distorted rainbow. Likewise, attempting to disown or deny any aspects of your emotional experience will disturb the flow of life energy through you, and adversely affect your body's healing processes.
      Many people benefit from freer expression, even to the point of catharsis (e.g. crying, or pounding cushions with a tennis racket, if appropriate). They often find tremendous relief and new stores of energy through emotional release.

Positive Mental Attitude
      Often people think of their mental attitude as a weapon for influencing the course of illness.

      Old Paradigm: Feel Good and Optimistic at All Times. Patients often have the belief that a positive mental attitude is health-promoting, and therefore they should strive at all times to display this. "Positive" is interpreted as meaning feeling only "positive emotions" and never allowing oneself to appear helpless, hopeless, or in despair (even if these feelings are actually present). Patients' efforts are often driven by a feeling of urgency and tension: "If I let down on my attitude, it will have dire consequences for my health." Often such beliefs are based on reading about links between depression and illness, or the healing power of laughter.
      The old paradigm of the positive attitude usually goes hand in glove with the old paradigm of emotions. Of course there is value in maintaining an optimistic outlook. The difficulty arises when belief in the "positive mental attitude" becomes the rationale for suppressing emotions, denying needs, refusing to acknowledge symptoms, or withholding requests for support. Many people misconstrue this belief to mean we should disregard these aspects which we associate with our "dark side." Yet the willingness to embrace and express these aspects of ourselves can play a vital part in healing.

      New Paradigm: Positively Accept and Express All of Your Feelings. A truly positive attitude means having a positive attitude toward all your emotions. This means a positive acknowledgment, a positive acceptance, and a positive expression. You can positively embrace all that you are, and not judge or disown any authentic aspects of your experience, including acknowledgment of those times when you feel hopelessness or despair. Through this positive acceptance of all aspects of yourself, your energy is not bound up in the suppression or repression of feelings and is free to help with healing. 
      Perhaps you can recall a time in the past when you had what you'd call a good cry. Maybe you remember the feeling of freshness or lightness that occurred afterwards. It may sound ironic, but the quickest way to free yourself from feelings of despair or hopelessness is by their full expression. Feelings are transitory if we allow them to be.

The Role of Self-Help
      Patients often have the goal of mastering certain self-help techniques such as imagery or the relaxation response. They have read books or reports in which others attributed their recovery to these techniques, and have heard of research about the effects of such techniques on immunity. They usually do not understand that when such studies report "significant" effects of a technique, this simply means that a measurable impact has occurred, even though that impact may or may not be of a magnitude to influence physical well-being. Such studies are important for instilling hope about the possible pathways to influence health, but they do not guarantee healing for a given patient.

      Old Paradigm: Self-Help is Curative, and Depends on My Performance. Difficulty arises from the belief that these techniques are themselves like a medical treatment. Hence the belief may be something like this:
       I'm going to learn to visualize, practice it regularly, and if I do it well enough, it will be successful in ridding me of CFS. If I don't get better, it will be because I didn't do the techniques well enough or often enough.
      The problem is the belief that the technique itself is curative, and that one's performance is the determining factor of medical outcome. The person may then feel performance anxiety and fear of failure. If these feelings are present during daily practice, the person reinforces precisely those states of anxiety which the techniques are intended to help. Another way of saying this is that the "scared inner child" is the one who does the technique rather than the composed, adequate adult who sees the big picture and relaxes into the process.

      New Paradigm: Self-Help as a Contribution. You can visualize perfectly and do everything right ten times a day, but there is no guarantee of what will happen medically. Such techniques must be seen as contributions to the overall program, but not as determining factors. They can in themselves be rewarding in terms of mood states, feeling of hope and optimism, reducing symptoms, and improving quality of life.
      They are a way of taking responsibility to do the best you can with the resources you have now. They may also contribute to the overall flow of the healing process in the body, but they are not a panacea. The realistic perspective is to realize that self help is an important contribution to the larger multicausal approach.

LIVING WITH AMBIGUITY
      Throughout this book I have been stressing the multicausal perspective, and the idea that both the illness and your recovery are influenced by many combined factors. One difficulty with the multicausal perspective is its ambiguity. It certainly would be easier to organize your response to a single cause such as a virus, than to tolerate the ambiguity of being told the illness is multicausal and there is nowhere to lay the blame. In this ambiguity, some will tend to even blame themselves, for this at least gives them a focus for their anger.
      Likewise, it is easier to place all your hope for recovery in a single medication or even a single self-help strategy. Yet, you must constantly remind yourself of the big picture in coping with this illness. Often it is necessary to close your eyes, take a deep breath, and remind yourself that you can only do the best you can do, bring all the pieces together that you can, and then be patient.
      In the following chapters we will explore in greater depth self-help strategies that will help you take advantage of the mind/body connection.


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