Guided Imagery As A Psychoneuroimmunological Intervention For HIV

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Dissertations, Theses, and Masters Projects Theses, Dissertations, & Master Projects
1996
Guided imagery as a psychoneuroimmunological intervention for

HIV-positive individuals
Christopher Dale Keene
College of William & Mary - School of Education
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Keene, Christopher Dale, "Guided imagery as a psychoneuroimmunological intervention for HIV-positive
individuals" (1996). Dissertations, Theses, and Masters Projects. Paper 1539618578.
https://dx.doi.org/doi:10.25774/w4-gxe7-cw95
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HIV an d G uided Imagery
1
GUIDED IMAGERY AS A PSYCHONEUROIMMUNOLOGICAL

INTERVENTION FOR HIV-positive INDIVIDUALS
A D issertation
P resen ted to
The F aculty of th e School of E ducation
The College of William & Mary in Virginia
In Partial Fulfillm ent

of th e R equirem ents for th e Degree of
Doctor of E ducation
ty
C hristopher Dale Keene
May, 1996
UMI Number: 9622281
Copyright 1996 by
Keene, Christopher Dale
All rights reserved.
UMI Microform 9622281

Copyright 1996, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized

copying under Title 17, United States Code.
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HIV and G uided Imagery
2

INTERVENTION FOR HIV-POSITIVE INDIVIDUALS
by
C hristo p h er Dale Keene
A pproved A pril 24, 1996, by
C harles M atthews, Ph. D.
<5
George Greenia, Ph. D.
V ictoria Foster, Ed. D.

C hairperson o f Doctoral C om m ittee
3
DEDICATION
To my p a rtn e r Bret Sawyer who h a s been my love an d support.

To m y family who h a s given m e th e gift of learning.
and
To J o h n a th a n Bronson who lived his life with AIDS in dignity
an d w as an inspiration to th o se who knew him.
4
TABLE OF CONTENTS
Page
DEDICATION.............................................................................................3
TABLE OF CONTENTS............................................................................. 4
USTOFTABLES........................................................................................7
CHAPTERS
1. INTRODUCTION....................................................................... 8
Justification for Research................................... ........... ........8
Statement of the Problem.........................................................10
Theoretical Rationale.................................................................11
Definition of Terms....................................................................18
Research Hypotheses................................................................ 19
Sample Description...................................................................20
Limitations of the Stucty........................................................... 21
2. REVIEW OF THE LITERATURE............................................. 24
HIV/AIDS: Information.............................................................24
HIV/AIDS and PNI....................................................................26
HIV/AIDS and Stress............................................................... 27
PNI: Theoretical C onstructs and Research........................31
Guided Imagery: Theoretical C onstructs
and Research.............................................................................41
HIV and Guided Imagery
5
3. METHODOLOGY.....................................................................47
The Sample............................................................................... 47
Materials and Equipment........................................................48
Health Questionnaire..............................................................48
Secretory IgA (S-IgA)............................................................... 49

Research Design...................................................................... 50
Procedure................................................................................. 51
Data Analysis........................................................................... 52
Specific Null Hypotheses........................................................ 52
Ethical Safeguards and Considerations..............................53
Summary of Methodology.......................................................54
4. RESULTS..................................................................................56
Specific Research Hypotheses...............................................56
Hypothesis 1......................................................................56
Hypothesis 2 ......................................................................58
Summary..................................................................................60
5. SUMMARY, CONCLUSIONS,
DISCUSSION, and RECOMMENDATIONS.......................62
Summary..................................................................................62
Conclusions.............................................................................. 66
Discussion................................................................................ 67
Recommendations................................................................... 73
6
6. APPENDIXES
Appendix A: Consent Form............................................... 76

Appendix B: Medical History Q uestionnaire.................78
Appendix C: Imagery Script...............................................80
7. REFERENCES...........................................................................83
8. VITA.......................................................................................... 90
9. ABSTRACT.................................................................................91
HIV an d Guided Imagery
7
LIST OF TABLES
TABLE Page
1. Hypothesis 1: Sum m ary of ANCOVA Analysis for
T reatm en t Effects of P ost (Immediate) w ith
Pretest Total IgA Measures............................................................57
2. Hypothesis 1: Sum m ary of Means, S tan d ard

Deviations and Standard Errors.................................................. 57
3. H ypothesis 1: Sum m ary of th e Newman-Keuls
Method of Multiple Comparisons................................................. 58
4. Hypothesis 2: Sum m ary of ANCOVA Analysis for
T reatm en t Effects of P ost (Delayed) w ith
Pretest Total IgA Measures........................................................... 59
5. H ypothesis 2: Sum m ary of Means, S tan d ard
Deviations and Standard Errors.................................................. 59
6. H ypothesis 2: Sum m ary of the Newman-Keuls
Method of Multiple Comparisons................................................. 59
8
CHAPTER I
INTRODUCTION
Justification for Research
Surgeon G eneral Antonia Coello Novello opened h er 1993
report to the Am erican people by saying, "It began, like so m an y
epidemics, with a few isolated cases, a w hisper th a t caught th e
ea r of only a few in medical research. Today, th a t w hisper h a s
becom e a ro ar h eard around the world" (Novello, 1993). Few
people will argue th a t Acquired Im m une Deficiency Syndrome
(AIDS) is the m ajor m edical crisis of our country today. In 1993,
th e Surgeon G eneral reported 1,000,000 cases of H um an
Im m unodeficiency Virus (HIV) infection in th e U nited S tates.
By 1995, the World H ealth Organization reported th a t
betw een 13 an d 15 million people are HIV-infected worldwide:
HIV is infecting ab o u t 6,000 people per day, h a lf of whom are
u n d e r th e age of 25. Since the first identified case in 1981,
m ore th a n 501,310 people have developed AIDS, an d of those
infected, 325,851 have died (Centers for D isease Control, 1995).
Of th e total AIDS cases, 10 percent were reported during 1981-
1987, 41 p ercen t during 1988-1992, and 49 p ercen t during
1993- O ctober 1995. The prognosis for people living with HIV
a n d AIDS is n o t good, with only 35% of those first infected still
living. It is estim ated th a t in 1993 alone betw een 47,000 an d
66,000 Am ericans died of AIDS. The disease ca n no longer be
identified exclusively with white gay males. Among women, th e
9
proportion of cases increased from 8 percent betw een 1981 and
1987 to 18 p ercen t between 1993 an d O ctober 1995. D uring
th e sam e intervals, cases rose from 25 percent to 38 percent
a n d from 14 percent to 18 percent am ong blacks an d H ispanics,
respectively. In addition, 10 percent of new HIV cases stem
from heterosexual contact, an increase of 7 percent since 1987.
In the gay population, where m any educational efforts have
focused, the proportion of cases decreased from 64 p ercen t to
45 percent.
To add fu rth e r concern, research ers now believe th a t
there are two d istin ct strain s of the virus, HIV-1 an d HIV-2.
However, a n u m b er of m edical research ers no longer believe
th a t the virus is solely responsible for AIDS; these scien tists now
em phasize the im portance of "cofactors" th a t can ran g e from
frequency of sexual intercourse to em otional affect, including the
HIV-infected individual’s ability to handle stress b o th in tern al
an d external (Gorman & Kertzner, 1991).
Psychoneuroim m unology (PNI) is a n em erging field in
science exploring th e psychological/im m unological relationship.
Investigators in PNI are guided by a theoiy w hich predicts th a t a
p erso n 's im m unity can be enhanced th ro u g h psychological
intervention. PNI research also h a s revealed the influences th a t
psychosocial factors have on im m unity. B ecause PNI focuses on
th e psychological relationship of im m unity to the o n set of
imm unologically resisted diseases, PNI research on HIV seem s
logical. Solomon (1987) underscored th is point by sta tin g th a t
HIV a n d Guided Imagery
10
"[it] se em s clear th a t AIDS is 'ideal' for stu d y from a
psychneuroim m unologic frame of reference, in view of its being
a disease resisted by imm unity, a disease of im m une dysfunction
... and a disease th a t can involve th e central nervous system " (p.
629).
PNI literature does dem onstrate a positive relationship
betw een psychologically-based treatm en t interventions a n d the
hum an im m une system . In light of the devastating im pact th a t
HIV h a s o n th at line of bodily defense, there is justification to
research th e relationship a p artic u lar counseling intervention
may have to an individual’s im m unocom petence. The p u rp o se of
this s tu d y is to exam ine the effect of im m une system guided
imagery o n HIV-infected individuals' production of secretory
im m unoglobulin A (S-IgA), an essen tial secretory antibody. This
study m a y contribute significantly to existing knowledge o n the
relatio n sh ip between emotional sta te s and im m unocom petence
and m ore im portantly, may validate a th erap eu tic technique th a t
can im prove the q u ality of life for HIV-infected people.
Problem S tatem ent

W h a t is the efficacy of im m une system guided im agery in
enhancing th e (unstim ulated) production of S-IgA in a n HIV-
infected individual?
11
Theoretical Rationale
J o h n B. Jem m o tt III h as sta ted th a t "A fundam ental ta sk
for h e a lth psychology is to clarify th e complex interactions
betw een psychological variables an d physical health" {1985, p.
497). T he research field interested In this connection w as first
called psychoimmunology, a term coined 29 y ears ago by
p sy c h iatrist George Solomon (Solomon, 1987). Solomon
supp o rted his theory of an actu al link between th e m ind a n d th e
im m une system by citing scientific evidence su c h as his 1969
dem onstration of stress-in d u ced suppression of hum oral
im m unity in rats. Over the p a st th ree decades, an
interdisciplinary field h a s em erged focusing on th e nervous,
im m une, an d endocrine system s a n d now referred to by m o st
re se a rc h e rs as psychoneuroim m unology (PNI) (Vollhardt, 1991).
A lthough a sizable body of research underscores th e psycho
im m unity relationship, a definitive explanation into the process
h a s yet to be articulated. One possible explanation stresses th a t
m ost PNI research designs do n o t adequately ad d ress the full
com plexity of th e h u m a n im m une system (Jem m ott, 1985).
Some stu d ies on th e physiological process suggest a direct
anatom ic connection between th e central nervous system an d
the im m une system . Nerve fibers, for example, have been found
linking th e two sy stem s (Gorman & Kertzner, 1991). A nother
theory, on the healing powers of imagery, cen ters on activating
the rig h t b rain hem isphere w ith im ages in order to inhibit th e
12
release of im m u n o su p p resan t chem icals from th e left
h em isp h ere (Sheikh, 1984).
Though th e processes are not fully understood, PNI
research is guided by a n accepted general theory. Simply stated ,
th e brain an d im m une system are p art of a n intricate, interactive
system . Foss an d Rothenberg (Vollhardt, 1991) affirm th a t, "PNI
is b e s t conceptualized as a cybernetics or system s approach" (p.
45). These system s have in p u ts, o utputs, boundaries, and, m ost
im portantly, interactions. D espite th e new ness of the field, PNI
theory is w ell-supported by a diverse body of research.
Lower-animal studies, notew orthy because they exercise
g reater experim ental control th a n is possible w ith h u m an
subjects, provide some of th e m o st credible a n d convincing
re su lts su p porting PNI theory. The first im p o rtan t discovery
related to the m in d /im m u n e system link w as achieved in 1974
by Ader and Cohen who found th a t the im m une system of w hite
r a ts could be classically conditioned (Vollhardt, 1991).
Investigators paired the sw eet ta ste of saccharin-laced w ater (a
conditioned stim ulus) with a n intravenous injection of an
im m unosuppressive drug (an unconditioned stim ulus) w hich
c a u se s n a u se a (an unconditioned response) in th e rodents. After
several repeated adm inistrations of the sa c c h a rin /d ru g stim uli,
th e ra ts were th e n exposed to a novel, second pairing: sacch arin
w ith a n antigen. The resu lts were compelling; th e ra ts show ed
significant im m unosupression despite the absence of the drug,
suggesting a conditioned response. To acco u n t for the possible
13
effect th a t n au sea-related stress m ay have h ad on the rats,
d u rin g the second treatm en t th e rodents w ere injected w ith
lith iu m chloride w h ich causes stom ach u p se t w ithout
im m unosuppression. The investigators concluded th a t "there
w as no ensuing im m uno su p p ressio n with lithium chloride"
(Vollhardt, 1991, p. 42) Ader an d Cohen's early experim ent
su g g ests th a t th e im m une system is not a sep arate entity from
th e b rain , b u t ra th e r th a t "there is bidirectional com m unication
betw een the central nervous sy stem —the se at of thought,
m em ory, and em otion—and th e im m une system " (Vollhardt,
1991). Since th e early work in th e 1970s, o th er research ers
have dem onstrated com m unication between th e nervous system
a n d im m une system . In one stu d y , for example, b rain lesions
chang ed imm une system response rates in laboratory anim als
(Vollhardt, 1991). S tudies on b ra in stim ulation an d
lateralization have offered fu rth er evidence of th e relationship
betw een the central nervous sy stem (CNS) an d im m une system s.
O ther reports have posited th a t activity levels in the
im m un e system c a n b e influenced by stim ulating certain area s in
th e b ra in (Plotnikoff, 1987). R esearchers discovered th a t
antibody levels in anim als can be changed by placing lesions in
th e su b je cts’ hypothalam us (Vollhardt, 1991), a n d related
stu d ie s on the lateralization of em otions suggested th a t th e left
hem isphere of th e b ra in may be responsible for positive
em otions and im m unom odulation (Pelletier, 1988).
14
The effects of stress on im m unity have also been explored
in anim al research. Overcrowding, electric shock, an d exposure
to inten se so u n d all reduced im m unocom petence and increased
susceptibility to cancers and diseases in laboratory anim als
(Pelletier & Pelletier, 1988). M any em pirical stu d ies found th a t
im m unity is su p p ressed w hen anim als feel helpless or hopeless
u n d e r a stresso r (Vollhardt, 1991). One stu d y found th a t
chronic physical stress can en hance im m unity in some anim als,
a phenom enon th a t may be caused by a n im m une system
tem porarily overreacting to a stressful event (Borysenko, 1984).
S tartin g w ith well-controlled anim al stu d ies, research ers
are beginning to compile a body of em pirical evidence w hich
stren g th en s th e PNI work w ith h u m an subjects. To date, m o st
PNI research h a s been published in psychiatric jo u rn a ls although
PNI is a n interdisciplinary field an d offers a b ro ad view of
science (Jem m ott, 1985). For example, one interdisciplinary
stu d y focused on the relationship between im m unity and
depression (Weisse, 1992). Investigators have also exam ined
psychological influences on cancer, stress, an d AIDS
(Thackw ray-Em m erson, 1988).
B ecause HIV prim arily destroys the im m une system , PNI
interventions, theoretically, sh o u ld benefit th e infected
individual. In th e ir recent book on PNI, G orm an and K ertzner
(1991) devote a n entire ch a p ter to the im portance of fu tu re
PNI/HIV research. As early a s 1987 Solomon addressed th e
relevance of research on the relationship th a t psychological
15
factors m ay have on th e presence or severity of sym ptom s in
AIDS p atients. If th e theory is valid, PNI techniques m ay provide
a valuable p art of a holistic treatm en t protocol.
Several general PNI interventions have been suggested.
G roup a n d individual therapy m odels have included health
education, problem-solving training, relaxation, a n d stress
m anag em en t tech n iq u es (Antoni, 1991a). O ther stu d y protocols
have im plem ented m en tal imagery, cognitive restru ctu rin g , a n d
assertiv en ess train in g (Antoni, S chneiderm an, Fletcher,
G oldstein, Ironson, & LaPerriere 1990). Im m une system
imagery, in particular, h a s produced encouraging resu lts, an d in
one s tu d y app ears to be potentially effective in treatin g HIV-
positive individuals (Rider, 1990). Specifically, im m une system
im agery is based on th e belief th a t by evoking m en tal images of a
ro b u st im m une system , people ca n physiologically enhance th e ir
own im m unity. S uch images m ay involve antibodies attacking a
cancer cell, for exam ple. To date, however, th e efficacy of
guided im m une system imagery on HIV-positive su b jects h a s n o t
been docum ented.
Im agery as a treatm en t technique h a s dem onstrated
effectiveness, b u t th e actu al psychological and physiological
processes involved are n o t fully understood (Achterberg, 1984).
C onsequently, a universal imagery theory h a s n o t emerged
despite various theoretical models. An early exam ple is
A ristotle's observation th a t im agination can produce
physiological arousal (Sheikh, 1984). The efficacy of imagery h a s
16
a rich history rooted in m any cultures. For example, initiatory
ritu als u n ique to Siberian and central Asian sham anism include a
series of "waking dream s," while in China, Taoist m editation is
u sed as a m ethod to m ain tain an "eternal calm in the m idst of
changing conditions" (Mishlove, 1993, p.36). Imagery is n o t
exclusively a n E astern tradition however.
In exploring th e m odem W estern u n d erstan d in g of
spirituality, Ju n g ia n p sychotherapist Thom as Moore reaches
b ack to a rich E uropean history of m yth an d symbol. He states,
"W hether we know it or not, our ideas about th e family are
rooted in th e ways we imagine th e family. T h at family, w hich
seem s so concrete, is always an im aginal entity" (Moore, 1992,
p. 32). Moore opines th a t the im aginal family figures can be
fu rth e r understood th ro u g h myth. For example, Moore
questions, "How can I evoke a father m yth in a way th a t will give
m y life th e governance it needs?" (Moore, 1992, p. 33). To
answ er th is question, h e explores th e paternal im ages found in
H om er's The Qdvssev. Even though Moore com m ents on the
im portance of the image to the an cien t Greek, th e u se of
im agery in W estem -style psychotherapy w as n o t p opular u n til
rece n t y ears (Sheikh, 1984). The u se of th erap eu tic imagery
w as accepted even m ore slowly by Am erican m ental h ealth
professionals. The prim acy of behaviorism in th e United S tates
helped to lim it w idespread u se of imagery, b u t th e em ergence of
th e h u m an istic m ovem ent in the middle of the 2 0 th century h a s
reversed th e prejudices of m any th erap ists. S heikh notes, "from
17
a position of n e a r disgrace, imagery recently h a s risen to be one
of th e h o ttest issu es in both clinical an d experim ental cognitive
psychology" (p. 28).
In sum , psychoneuroim m unology provides a theoretical
rationale th a t can be arguably described a s elegant in its
sim plicity. The theory is b o th ancient an d m odem , scientific
a n d spiritual. W hen PNI theory is applied through th e technique
of imagery, it becom es a lucid archetype for expanding our
c u rre n t u n d erstan d in g into the complexities of th e h u m a n m ind
an d body.
18
Definition of Terms
A cquired Im m unodeficiency Syndrom e (AIDS) Stage IV— The
clinical diagnosis th a t may be given when a n individual h a s a
CD4+ cell count u n d e r 200 a n d /o r h as h ad a n AIDS-related
opportu n istic infection (e.g. Pneum ocystis carinii pneum onia,
Kaposi’s sarcom a, Cytomegalovirus, M ycobacterium avium
intracullalare, etc).
A ntibody— Antibodies are highly specific m olecules th a t com bine
w ith a harm ful antigen in order to neutralize th e invader or tag it
for a tta c k by other chem icals or cells.
Antigen— Antigens Eire foreign materials that invade a body; they
include bacteria, parasites, fungi, and viruses.
H elper T Cell— T his is an im m une system lym phocyte th a t
identifies antigens a n d stim ulates the production of other
im m une cells to fight an infection. Helper T cells are also called
CD4+ cells. A CD4+ cell count is a m easure of th e dam age to a
p erson 's im m une system ; the probability of a n opportunistic
infection is increased as CD4+ cell counts becom e lower. A
healthy person w ithout HIV infection typically h a s CD4+ co u n ts
betw een 800 and 1100.
H um an Immunodeficiency Virus (HIV or HIV-11— A h u m a n
retrovirus th a t invades and destroys helper T cells which in tu rn
reduce a n infected individual's ability to defend against other
harm ful antigens. HIV can be tran sm itted th ro u g h the blood,
sem en, or vaginal secretions of a n infected perso n . O ther
HIV an d Guided Im agery
19
potentially infectious m aterials include: cerebrospinal fluid,
synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid,
am niotic fluid, and saliva which co n tain s blood (Virginia Dept, of
Labor an d Industry, 1992)
HIV-positive—This is th e sta tu s given to an individual who te s ts
seropositive for the presence of th e HIV retrovirus.
Im m une System G uided Imagery— T his is a therapeutic
technique in which individuals m entally visualize the
m anipulation and enhancem ent of th e ir im m une system.
Psvchoneuroim m unologv (PNI)— T his is the field guided by th e
theory asserting th a t nervous, endocrine, and im m une system s
are interconnected a n d interdependent.
Radial Im m unodiffusion (RID)—T his is an assay m ethod
providing an accurate m easurem ent of a n antibody in a m ixture
of diverse antibodies. The RID m ethod can be u se d in obtaining
S-IgA m easures in h u m a n saliva.
Secretory Im m unoglobulin A fS-IgA)— S-IgA is a predom inant
antibody class in bodily secretions. S-IgA is p rese n t in the oral
cavity providing a defense against u p p e r respiratory infections.
Specific Research H ypotheses

H ypothesis 1
H i: HIV-positive subjects who are adm inistered guided
im agery will have significantly elevated S-IgA concentrations
im m ediately following treatm en t com pared to control HIV-
positive subjects.
HIV and Guided Imageiy
20
H ypothesis 2
H 2 : HIV-positive sub jects adm inistered guided im ageiy
will have significantly elevated S-IgA concentrations two weeks
following trea tm en t com pared to control HIV-positive su b jects.
Sam ple D escription and G eneral D ata G athering P rocedures

Twenty-four ad u lt HIV-positive m en w ith CD-4 cell co u n ts
below 200 were th e focus of th is study. All individuals w ere
p articip an ts in a n AIDS treatm en t program and were recruited
th ro u g h th eir trea tm en t coordinator. W hen a person agreed to
p articip ate in th e study, a con sen t form (Appendix A), w hich
outlined the overall focus and procedures of the experim ent,
articu lated the subject's rights, an d cited any m ental o r physical
risk s, w as signed by the individual.
P articip an ts were random ly assigned into either th e
experim ental or control group. The experim ental group m et for
90 m in u tes to com plete a h ealth questionnaire and p arta k e in
th e im m une system guided im ageiy intervention. A p re te st an d
p o stte st saliva sam ple w as collected a t th e meeting. T he control
group com pleted the health questionnaire and h ad saliva
sam p les collected w ithout receiving any treatm ent. The tim e
delay betw een th e p retest and p o sttest sam ple collection w as 60
m in u tes for both groups. Fourteen days following the first d a ta
collection, b oth groups provided a second p o sttest saliva sam ple.
21
Limitations of th e Study
T hreats to internal an d external validity are listed below

along with th e attem p ts th a t were m ade to minimize their
negative effects on the study.
To lessen th e im pact of m atu ratio n effect an d
experim ental m ortality, th e entire research period w as limited
to 14 days. T his consideration is especially im p o rtan t w henever
studying su b jects with HIV. Using ran d o m assig n m en t to
experim ental an d control groups helps control for m a tu ratio n
effect (Best, 1989) The lim ited tim e interval betw een the
p re te st and final p o sttest m ay have reduced the influence of
history on th e subjects.
Testing effect w as likely limited becau se th e p rete st an d
p o sttest m easu res were saliva sam ples. It is unlikely th a t any
"practice effect" developed considering th e d ep en d en t variable
u se d in th is study. However, even with a saliva m easure,
u n stab le in stru m en tatio n can be a th re a t to internal validity.
The sam pling procedures used in th is study w ere based on
protocols used in several stu d ies using a S-IgA m easu re
(McClelland & McClelland, 1988). In addition, un iv ersal
precau tio n s for handling body fluids were observed a n d the
sam ples were collected by a licensed healthcare provider. The
RID assay u sed to m easure th e p re /p o stte st sam ples is a stable
HIV an d Guided Im ageiy
22
and accu rate m ethod for for S-IgA. In addition, the assay w as
perform ed u n d er the supervision of a biologist.
Selection b ias is an o th er th reat to th e internal validity of
this study. All su b jects were volunteers. It is likely th a t they
m ay n o t be representative of the greater population of HIV-
positive individuals. However, random assig n m en t of th e
p artic p an ts to the experim ental or control group is th e m o st
effective d eterren t to nonequivalence betw een the two groups.
In an attem p t to control for the contam inating effect of
experim enter bias, th e investigator h ad no contact w ith th e
subjects. Participants were identified only by th e la st six digits
of th e ir Social Security num ber. All sam ples were collected by a
healthcare professional not involved with th e study, an d the
intervention w as adm inistered on audiotape.
Possible th re a ts to external validity were also considered.
Inference of prior o r co n cu rren t treatm en t m ay have influenced
the resu lts; the investigator could not control for any m edical or
psychological interventions th a t occured prior to or along w ith
the guided imagery treatm en t in this study. The h ealth
questionnaire revealed th a t only one individual reported having
done "trance work," b u t all p articipants reported group
counseling experience. In addition, the su b jects were tak in g
various m edications for AIDS.
The artificiality of the experim ental settin g is an o th er
possible th reat to external validity. Though th e audiotape w as
adm inistered in a settin g fam iliar to all experim ental group
23
subjects, th e environm ent would be considered typically
"clinical." The room w as well-lighted an d had padded,
institutional-style chairs; however, th e setting is n o t optim al for
imagery exercises. U sually a softly-lighted, comfortable, "warm"
environm ent is desired for imagery, trance, or hypnotic
interven tio n s.
One final th reat to external validity centers aro u n d the
verification of treatm ent. By using a colleague to collect sam ples
an d ad m in ister the intervention, th e investigator looses some
experim ental control. Ideally, a verification procedure
(observer, videotape) sh o u ld be added. U nfortunately, personnel
lim itations a n d confidentiality concerns prevented precise
verification. T he investigator relied u p o n a thorough procedural
review w ith th e cohort p rio r to the experim ent an d a
conversation regarding th e process following th e experim ent.
The stu d y did n o t control for th e medical conditions of
group p articip an ts outside of a diagnosis for Stage IV AIDS.
The stu d y did n o t control for th e effect th a t th e following
m ay have h a d on participants: age, sex, race, height, weight,
date of first diagnosis, la st CD-4 count, cu rren t illnesses, sexual
orientation, profession, m edications presently tak en , and self-
reported s tre s s o rs /s tre s s level.
This stu d y , because of the aforem entioned lim itations,
should be viewed cautiously in regards to the generalizability of
results.
24
CHAPTER II
REVIEW OF THE LITERATURE
Sum m ary of the Rationale and Its Relationship to the Problem
The literature relevant to th e rationale of th is study falls

into th ree broad categories for review: Psycho-social effects of
HIV/AIDS, PNI, and Imagery.
HIV/AIDS: Inform ation

To fully u n d erstan d the population u n d e r investigation in
this study, accurate inform ation on HIV and AIDS will be
reviewed. HIV is a retrovirus th a t gradually destroys the body's
ability to defend itself by inhibiting cell and body functions th a t
help w ith im m unity. Specifically, HIV attach es itself to T-
lymphocyte (CD-4) cells. The CD-4 cell is th e activating
m echanism in the im m une system th a t alerts th e white blood
cells to a tta c k a harm ful pathogen or "intruder." As HIV destroys
CD-4 cells, the body's abilty to dectect pathogens is
com prom ised and th e protective properties of th e white blood
cells are never mobilized. As a resu lt, the HIV-positive
individual is vulnerable to pathogens th a t Eire u su ally of no
consequence to the p erso n with uncom prom ised im m une
system. T h e CD-4 cell count is considered an accurate m easu re
of the progression tow ard Stage IV AIDS. B ecause HIV
challenges n o t only th e physical h ealth b u t also th e m ental well-
25
being of th e infected individual, there is extensive inform ation
on HIV/AIDS in the psychological literature. There also exists a
large body of inform ation addressing th e needs and care of the
HIV-positive person (Breuer, 1991).
The m o st recent m edical/biological inform ation o n AIDS
and HIV in th e psychological literature is in M cCutchan
"Virology. Immunology, an d Clinical C ourse of HIV
Infection"!1990) and G lasner and Kaslow The Epidemiology of
H um an Im m unodeficiency V irus Infection !1990). Both articles
contain im p o rtan t inform ation on th e virology of HIV an d the
course of AIDS. The M cCutchan essay is especially su ited for
counselors because the a u th o r addresses possible th erap eu tic
issues a t each stage of a p atien t's illness. For example:
For th e preterm inal patient, m ajor issu es are ad ju stm en t
of goals and expectations of m edical treatm ent, relief of
pain a n d anxiety th ro u g h reassu ran ce and m edications,
m arsh alin g em otional an d physical support, an d dealing
with wills, power of attorney, and funeral an d b u rial plans.
(1990, p. 11)
Both of these sources detail the devastating effects the
virus h a s on th e h u m an body: however, m ost non-m edical
treatm en t issu e s have already been explored in the PNI
literature.
26
HFV/AIDS an d PNI: Researching th e Relationship

An early article addressing PNI an d AIDS did focus on questions
regarding the research role PNI m ay have in investigating the
disease itself. Published in 1987, Solomon’s article is essentially
a "call to action" for PNI researchers to concentrate on AIDS.
The a u th o r stressed th a t "AIDS is ’ideal' for stu d y from a
psychoneuroim m unologic fram e of reference..."(Solomon, 1987,
p. 629). Solomon also hypothesized th a t behavioral
interventions (including imagery) should enhance im m unity. He
su ppo rted h is hypothesis with evidence of im m u noenhancem ent
found in a stu d y using hypnotic imagery as a n independent
variable. A nother factor Solomon believed relevant to AIDS/PNI
research relates to an individual's coping style, w hich he felt
m ay positively influence a person's ability to extend survival.
Solomon fu rth e r explored th e developm ent of th e coping style
hypothesis in a co-authored stu d y on long-term survival of
people living w ith AIDS (Solomon, Temoshok, O'Leary, & Zich,
1987).
Solomon’s w ork is significant for one lucid reason, the w ay
h e views th e HIV-positive individual. Solomon fram es the
research problem as a figure an d ground exercise. On analysis,
h is approach to AIDS research focused on ground (survival
factors) ra th e r th a n on figure (disease factors). By investigating
survival factors in people with AIDS, Solomon extends beyond
th e m edical profession’s traditional research strategy of focusing
27
on the infecting virus alone. In h is later 1987 study, Solomon
reported th a t long-term survivors have certain coping skills th a t
enhance th eir survival possibilities. He found in them a sen se of
personal responsibility regarding th eir h ealth an d a belief th a t
one can influence personal health. The survivors take an active
role in th e ir treatm ent, n eith er passive nor defiant. These
individuals also have personalized m eans of active coping a n d are
sensitive to th eir bodies and psychological/physical needs
(Solomon, et al., 1987). Solomon's hypotheses suggest the
im portance of coping styles as a PNI factor in long-term survival,
an d imply th a t enhancing coping skills may extend lives.
More recen t research suggested th a t a n active coping style
m ay help deter th e loss of im m une cell function. The
research ers reported th a t active coping skills a s m easured by
several objective te sts (Profile of Mood S tates, Coping
O rientations to Problem s Experienced, Life Experience Survey,
etc.) w ere positively correlated to n a tu ra l killer cell cytotoxcity
(NKCC) (Goodkin, Blaney, Feaster, & Fletcher, 1992). The
au th o rs stated, "the m ajor finding w as th a t active coping style
w as positively associated w ith NKCC, independent of all o th er
variables" (p. 643).
HIV/AIDS and Stress

The role of stre ss and HIV h a s also been investigated. In
an article by Blaney, et al., the au th o rs found th a t negative life
events a n d positive social su p p o rt are "direct predictors of
28
psychological d istress during early HIV-1 infection" (Blaney,
Goodkin, Morgan, & Feaster, 1991, p. 301). T his observation is
m ost significant "given th e recent research show ing th a t social
su p p o rt is related to th e control of disease" (p. 303). In
addition, they noted th a t "variables shown to influence
psychological outcom e in HIV-1 infection (such a s negative life
events an d social su p p o rt in the p resen t study) m ay be fruitful
intervention targets in efforts to enhance ad ju stm e n t to HIV-1
infection an d retard disease progression" (p. 303) T hough th e
study focused on personality factors, th e research underscores
the theory th a t im m unity enhancem ent is possible th ro u g h Em
appro p riate psychological intervention.
A nother research er in the field of PNI an d HIV is M ichael
H. A ntoni a t the University of Miami Center for th e
Biopsychosocial S tudy of AIDS. His co-authored study
"Psychoneuroim m unology and HIV-1" (1990) is a n importEmt
work on PNI and its effect on th e progression of HIV. The stu d y
stressed th a t early behavioral interventions m ay have physical
and psychological im p act on the HIV-infected individual.
Antoni, e t al. wrote, "we have noted significEmt benefits of
behavioral interventions on psychological an d im m unological
functioning among asym ptom atic HIV-1 seropositive an d
seronegative gay men" (p. 46). In general, th e reseEirchers
postulated th a t a psychosociEil treatm en t regim en m ay have a
desirable im pact on (HIV-positive) individuals. Specifically, they
suggested th a t su ch a treatm en t protocol m ay include
29
progressive m uscle relaxation training, m ental imagery,
cognitive restru ctu rin g , assertiveness training, an d social
su p p o rt sen sitizatio n /en rich m en t. However, m ost PNI research
does n o t ad d ress HIV factors directly, b u t the stu d ies do
em phasize th e im pact psychological influences have on the
h u m a n im m une system.
A ntoni also h a s investigated th e relationship between
stress an d im m unity. In 1989, Antoni, LaPerriere,
S chneiderm an, an d Fletcher p resen ted evidence th a t a 10-week
program of aerobic exercise or psychosocial stress m anagem ent
buffered th e psychological im pact of notification of HIV
seropositivity. The psychosocial intervention included relaxation
training an d cognitive stress m anagem ent. Subjects in the
psychosocial trial m et twice weekly for 10 weeks. At the
conclusion of th e 10-week intervention period, research ers
found significant increases in im m unocom petence in both
seropositive an d seronegative su b jects (Antoni, 1991b).
Consequently, the au th o rs concluded th a t psychosocial
interventions m ay have a broader b ase of potential applications:
If the interventions we are u sin g can re ta rd th e
progressive decrease in CD4+ n u m b er th a t norm ally
accom panies th e course of th e disease, th ere is som e
likelihood th a t we m ay be able to retard th e o n set of
sym ptom s in som e patients. The im m une en h an cem en t
th a t we have show n in HIV-1 seronegative gay m en m ay
30
also enhance th e health of individuals in th is high risk
group, (p. 42)
A ntoni h as investigated th e effects of several other
behavioral interventions. In a stu d y of gay, HIV-positive men, he
constructed an intervention th a t ta u g h t a variety of active coping
strateg ies such as cognitive restructuring, relaxation exercises,
an d assertive resp o n ses (Antoni, 1991a). The intervention
protocol centered aro u n d increasing perceptions of self-efficacy,
personal control, an d mastery. In addition, building an d utilizing
a social su p p o rt netw ork was an im portant p art of th e
intervention. Antoni stated th a t psychosocial interventions
"appear to offer prom ise in addressing th e issues of loss of
person al control, coping dem ands, social isolation, an d
d ep ressio n —all salien t for HIV-1-infected hom osexual men"
(Antoni, 1991a, p. 390). Regarding th e intervention protocol's
relatio n sh ip to im m unocom petence, Antoni reported th a t the
"frequency with w hich HIV-positive subjects hom e-practiced
their newly learned m uscle relaxation skills was positively
correlated" with im m unocom petence (p. 391). The a u th o r
concluded by stating th a t behavioral interventions m ay buffer
disease progression in HIV-positive individuals.
In another stu d y on PNI an d HIV, Mulder an d Antoni
(1992) found fu rth er evidence th a t behavioral factors m ay effect
th e cou rse of infection in HIV-1 infected individuals. The
a u th o rs reviewed th e existing body of literature on psychosocial
correlates of im m une s ta tu s and disease progression in HIV-
31
positive hom osexual men. Overall, the research supported the
relationship betw een imm unocompetence and a psychosocial
intervention. However, the au th o rs stated th a t "changes in
im m une param eters following a n intervention, e.g., a rise in CD4
cells, do not necessarily have any relationship to disease
progression" (p. 187). The research ers underscored the need
for fu rth e r PNI/HIV research, especially studies focusing on the
clinical effects of PNI interventions.
Psychoneuroimmunologv: Theoretical C onstructs and Research

The theory, concepts, and terminology of
psychoneuroim m unology can be b e s t understood through severed
existing PNI literature reviews. E ach review approached PNI in
a sim ilar fashion by researching th e field's historical foundation,
su b se q u en t development, and fu tu re trends; in addition, PNI
literatu re reviewers usually clustered studies by area of focus,
su c h a s immunology, stress, bereavement, etc. Consequently, a
sizable and thorough analysis on PNI exists.
J o h n B. Je m m o tt provides one of the earliest literature
reviews on psychoneuroimmunology. In 1985, he wrote th a t
"Psychoneuroimmunology represents a major shift in the
th o u g h t about immunologic processes because traditionally the
im m une system h a s been viewed a s largely autonom ous,
unaffected by the cen tral nervous system" (Jemm ott, 1985, p.
498). Jem m ott traced the m odem origins of PNI to 1936 with
H ans Selye's "general adaptation syndrome" (GAS). Selye
32
challenged m ind/body dualism with his view th at stre ss is a state
th a t can be inferred from specific physiological changes within
an organism (Goodstein & Calhoun, 1982). Jem m ott
em phasized th a t although Selye had intim ated th a t stre ss may
influence susceptibility to certain diseases, no one proceeded
with thorough research on the hypothesis.
M uch of Jem m ott’s review highlighted the effects of
external stress on im m unocom petence, including a research er
from one stu d y who found subjects who reported a great deal of
life stress over a 12 m onth period had w eaker lymphocytes th an
did su b jects who reported little life stre ss (Jemmott, 1985).
Jem m o tt also included studies on th e effects of academ ic stress
in his review. He found supporting d ata in four articles
regarding th e hypothesis th a t exam stre ss im pairs certain
immunological functions su ch as salivary IgA secretion rates.
In addressing th e effects of PNI interventions, Jem m o tt
found the greatest challenge in h u m an studies is achieving the
necessary high degree of experim ental control. D espite this
challenge, he believes quality PNI research can be conducted;
"Greater em phasis can be placed on random ized experim ents in
w hich researchers identify a population u n d er stress an d use an
intervention in an attem pt to block the effects of stress on
p aram eters of immunologic competence" (p. 505). Therefore,
a n experim ent using HIV-positive subjects could be b o th a
rational an d reasonable endeavor according to Jem m ott.
33
In a com prehensive review of stre ss an d immunology
literatu re, Ann O’Leary revealed em pirical evidence
dem on stratin g the link between em otions an d the h u m a n
im m une system . The au th o r's article provides a so u n d overview
of imm unology and the psychosocial factors th a t affect basic
im m une function. Her review included several articles both
supp o rtin g and challenging the validity of using Im m unoglobulin
A (IgA) a s a n experim ental dependent variable. On th e IgA issue,
sh e opined th a t the "debate m ay not be resolved in th e n e a r
future" (O'Leary, 1990).
A significant section of O’Leary's article addressed th e
ability to enhance im m unocom petence th ro u g h psychosocial
intervention. Overall, she found evidence of enhanced im m une
function in subjects trained in relaxation b u t no conclusive
evidence su p porting psychosocial intervention, an d declared
th a t fu rth e r research w as needed. W hen reviewing the stu d ies
conducting HIV/AIDS subjects, O'Leaiy offered th a t "evidence
does exist for the influence of psychosocial factors on im m une
function in HIV-spectrum illness, although relationships m ay
differ or be less reliable in th is population" (O'Leaiy, 1990). She
concluded th a t com bined m edical an d psychological
intervention m ay prolong life in HIV-infected individuals.
A su b seq u en t literature review in 1991 w as w ritten by
Lawrence Vollhardt. His article cited m any of the sources found
in O 'Leaty’s work, b u t he also explored articles ad dressing o th er
topics su c h a s psychocutaneous disease (stress-related skin
HIV a n d Guided Im ageiy
34
disorders), neoplastic disease (cancer), AIDS, autoim m une
disease, and included a com prehensive review of research on
im m u n o en h an cem en t.
V ollhardt cited evidence su p p o rtin g social support,
relaxatio n training, hypnosis, an d exercise as possible
benefactors for im m unity and offered th a t "many studies have
exam ined the effects of relaxation training on various su b ject
p opulatio n s and have generally found it to be effective in
im m unoenhancem ent" and concerning hypnosis wrote th a t
"Direct shifts in im m unom odulation have also b een noted w ith
m ental imagery..." (Vollhardt, 1991, p. 44). The au th o r
concluded his review by stating th a t PNI is an in fan t field, b u t
th a t "the role of PNI in prevention of and recovery from various
d iseases in an attractive one and m ay prove useful to a wide
range of professionals working in th e behavioral sciences" (p.
45). V ollhardt contributed defining PNI as a new frontier w ith a
creditable empirical foundation an d a prom ising future.
Kiecolt-Glaser a n d Glaser are frequently cited in PNI
lite ra tu re reviews a s notew orthy researchers. T heir early work,
"Psychological Influences on Im m unity," published in 1986,
reviewed the relatio n sh ip betw een depression, stressfu l life
events a n d m easurable changes in th e im m une system . The
a u th o rs stated th a t "evidence indicates th a t m ore distressed
p opulatio n s are m ore susceptible to infectious disease and
cancer" (Kiecolt-Galser, 1986, p. 622). Consequently, they
deduced th a t reduction in stress m ay enhance im m une function.
HIV an d G uided Im ageiy
35
More im portantly, th e au th o rs concluded their stu d y with th e
following suggestion:
D istress-related im m unosuppression m ay have its
m ost im p o rtan t consequences in individuals w ith
preexisting decrem ents in im m une function. W ithin th is
framework, at-risk groups m ay include older adults,
individuals w hose h ealth is already im paired, p atien ts w ith
im m unosuppressive diseases su ch as AIDS, or individuals
who have b een exposed to an infectious ag en t or
carcinogen. It is possible th a t em otional d istress m ay
m ake some contribution to m orbidity an d m ortality in
these and sim ilar groups, (p. 624)
A nother PNI stu d y ad d ressed th e relationship betw een
object relations theory, and th e im m une system (McKay, 1991).
A ccording to th is conceptual model, "object relation is generally
understo o d to rep resen t the residue w ithin the m ind of
relationships w ith im portant people in th e individual's life" (p.
641). Consequently, the rep resen tatio n s of im p o rtan t people in
o ne’s p a s t affect th e outcom es one expects w hen relating an d
interacting w ith others. For example, a person w ith a positive
in te rn a l rep resentation who an ticipates good outcom es from
relationships ten d s to experience less stre ss and m ay have
b e tte r health. McKay's research revealed a relationship betw een
m is tru s t and poor im m une function: "Under aro u sal conditions,
object relations th a t were m ore benevolent th a n m alevolent
w ere associated w ith gains in S-IgA concentrations" (p.642).
HIV and G uided Imageiy
36
This finding suggests th a t positive object relations m ay play a
role in im m unoenhancem ent.
A lthough h u m an -su b ject research often lacks th e stric t
controls of its anim al-subject counterpart, extending PNI theory
to hum an research h as yielded encouraging results. In a study
on im m unity, stress, and the need for power in m ale prisoners,
th e research ers found th a t high power n eed s and high stre ss
levels were associated w ith th e highest levels of reported
illnesses (McClelland, Alexander, & M arks, 1982). S tu d ies on
bereavem ent suggest th a t grief can im pair an individual's
im m une system (Calabrese, Kling, & Gold, 1987).
As in anim al research, the majority of h u m an PNI stu d ies
focus on the im pact th a t stre s s h as on the im m une system .
Thackw ray-Em m erson (1988) reports th a t "as early as th e
1930s, stre s s w as frequently linked w ith physiological changes"
(p. 230). One study on academ ic stress found th a t d uring exam
periods, te s t subjects h ad lower levels of a secretory antibody
(Jemmott, et al. 1983). In a sim ilar study, significant declines in
im m une cell activity were found in 75 m edical stu d e n ts during
final exam inations (Kiecolt-Galser & Glaser, 1986).
Psychological stresso rs m ay also play a role in the onset of
cancer. Frequently observed p recursors in cancer p a tie n ts are
stress-related events su ch a s th e loss of a significant o th er or a
tendency tow ard hopelessness w hen facing a stresso r
(Thackw ray-Em m erson, 1988).
37
S tudies focusing on experim ental im m unom odulation also
provide evidence supporting PNI theory. One stu d y showed th e
effects of viewing a film on S-IgA levels (McClelland, 1988).
McClelland an d K irshnit found th a t a film which aroused
affiliation m otivation w as followed by a n increase in S-IgA
concentrations in subjects although a relationship between the
film intervention an d a reduction in reported illnesses w as n o t
seen. The au th o rs established, "People showing co n sisten t gains
in S-IgA to the film are no more likely to have b een less sick
th a n o th er people" (p. 50). McClelland and K irshnit concluded
th e ir stu d y u n derscoring the need for further research on the
relationship betw een IgA and susceptibility to infections. Their
w ork m ay have b een com promised by using college stu d e n ts as
sub jects becau se research h a s dem onstrated the effects of
academ ic stress on S-IgA (Jem m ott, et al. 1983). The changes
they m easured m ight have been influenced by academ ic stress
generated outside of th e experim ental treatm ent.
Jem m o tt a n d Magloire research ed the relationship
betw een academ ic stress, social su p p o rt and S-IgA. In the study,
th e subjects who h ad reported lower levels of social su p p o rt also
h a d lower concentrations of S-IgA during an exam period
(Jem m ott & Magloire, 1988). However, a m ore in terestin g
finding m ay be th e m ore general effect th a t social su p p o rt h a s on
im m unocom petence. The rese arch ers discovered th a t subjects
reporting more adequate social su p p o rt during a preexam period
h a d significantly higher S-IgA concentrations th a n subjects
38
reporting less social support. The au th o rs stated th a t "This
la tte r finding is c o n so n an t with the social su p p o rt direct effects
hypothesis, which s ta te s th a t social su p p o rt enhances health
outcom es irrespective of w hether th e individual is exposed to
stressfu l experiences" (p. 803).
Even though th e body of literatu re on S-IgA is compelling,
the antibody is not universally accepted as the b e st m easure of
im m unocom petence. T h e greatest criticism com es from Stone,
Cox, V aldim arsdottir, Jan d o rf, and Neale (1987) who asserted
th a t th ere are inconsistencies in S-IgA studies, a n d th a t the
m easu rem en t of S-IgA concentrations is a source of variance
w ithin a n experiment. For example, th ey observe th a t
stim ulating the production of saliva w ith a lemon-flavored candy
can greatly influence th e volume of IgA in the sam ple an d skew
th e resu lts. However, research ers who u sed S-IgA a s a
dependent variable have strongly defended the m easure. In a
reply to Stone, Cox, V aldim arsdottir, a n d Neale, research ers
su p p o rtin g IgA, Je m m o tt an d M cClelland (1989), countered
"that th e re is no em pirical or logical reaso n to reject the
m easu rem en t of S-IgA in whole saliva an d to prefer some other
m easu re of im m une competence" (p. 70). The au th o rs
em phasized th a t S-IgA is th e p redom inant class in secretions
and th a t the antibody provides a key initial defense against
infection in the respiratory, intestinal, an d urino-genital tracts.
They w en t on to say, "Considerable evidence indicates th a t S-IgA
antibodies interfere w ith bacterial a n d viral adherence to
39
m ucosal surfaces an d consequently limit colonization of these
surfaces by pathogens" (p. 63). Jem m o tt an d McClelland
supported using S-IgA m easu res by performing a m eta-analysis
on 11 S-IgA studies. They asserted th a t "this m eta-analysis
clearly indicates th a t th e com bined evidence from
psychoneuroim m unologic stu d ies is co n sisten t w ith
hypothesized relations betw een psychosocial factors an d S-IgA
levels" (p. 65). On th e other hand, Stone, et al. cited only four
stu d ies in th eir critique of S-IgA.
In addressing th e criticism of variance in h eren t in S-IgA
m easu res, Jem m o tt and McClelland cited evidence su pporting
the stability of S-IgA sam ples observing th a t Stone et al. provided
no em pirical evidence on the contrary (Jem m ott & McClelland,
1989).
Pennebaker, Kiecolt-Glaser, an d G laser (1988) have also
defended PNI interventions ag ain st criticism by Neale, Cox,
V aldim arsdottir, an d Stone who challenged th e efficacy of brief
psycho th erap eu tic w riting th erap ies on im m unocom petence.
They dem onstrated th a t having subjects write ab o u t th e ir m o st
trau m atic experiences of th eir lives had been show n to reduce
h ealth cen ter visits for illness. However, Neale, et al. noted
loose experim ental controls in the S-IgA stu d ies they reviewed
an d questioned the existence of a treatm en t effect. In reply,
P ennebaker et al. com m ented th a t th e early findings h a d been
replicated by three stu d ies in two laboratories. P ennebaker e t al.
concluded by statin g th a t they were "cautiously optimistic," an d
40
th a t "this technique m ay affect im m unocom petence in a positive
way" (p. 639).
If we accep t th a t S-IgA is an accu rate gauge of
im m unocom petence b ased upon the evidence, th e n research
u sin g salivary im m unoglobulin m easures is noteworthy. Studies
have dem onstrated significant m odulation in S-IgA levels after a n
intervention.
One stu d y of S-IgA a n d daily relaxation provides evidence
th a t a psychotherapeutic intervention ca n have on a n individual's
im m une system . Green, Green, and Santoro discovered
significant elevations in su b ject S-IgA levels after a 20-m inute
relaxation th erap y experim ental condition (1988). Tw enty-four
sub jects were random ly assigned to a relaxation train in g group
an d 16 to a w aiting list control group. Blood and saliva sam ples
w ere taken a s p re te st/p o s tte s t m easures of IgA, IgG, IgM, and S-
IgA. In addition to the im m unoglobulin dependent variables,
sub jects rated th e severity of their stress-related sym ptom s on a
7-point scale. To evaluate th e relationship between
im m unoglobulin levels, subjective d istress, and self-reported
loneliness, su b jects were adm inistered th e H opkins Sym ptom
Checklist, the UCLA Loneliness Scale, a n d the Taylor M anifest
Anxiety Scale. The subjects also rated th e ir relaxation level on a
10-point scale a t the end of each trea tm en t session.
As stated above, S-IgA levels significantly increased after
th e 20-m inute intervention; however, se ru m im m unoglobulin
levels did n o t change betw een the pre- a n d p o sttest blood
41
sam ples. When analyzed over a 22-day treatm en t period, there
were significant increases in levels of serum IgA, IgG, an d IgM.
The a u th o rs concluded th a t th ere w as a longer-term treatm en t
effect in subjects who had practiced the intervention daily for
three w eeks and th e serum m easu res supported the resu lts
found in the S-IgA sam ples, suggesting th a t relaxation m ay be an
im p o rtan t coping skill to enhance im m unocom petence in both
sh o rt-term and long-term treatm en t strategies. Consequently,
they em phasized th a t the intervention may be suitable for
different applications: "the resu lts indicate th a t relaxation h a s
both rap id and longer-term effects on im m une functioning" (p.
196).
G uided Imagery: Theorectical C onstructs an d Research

T he im m unoenhancem ent abilities of im agery techniques
have b ee n dem onstrated in PNI literature. However, sc a n t
research h a s addressed the psychoim m uno-processes behind
imagery; m ost articles focus on th e outcom es of imagery
interventions as evidence of efficacy. One a u th o r who h a s edited
a book o n im agination and healing is Anees A. Sheikh. In
Im agination and H ealing 11984). S heikh b ro u g h t together m any
au th o rs who write on the relationship betw een h ealth an d
imagery.
O ne theory, by Robert Ley an d Richard Freem an, posits a
relationship between imagery, cerebral laterality, and healing
(Sheikh, 1984). The au th o rs cited evidence th a t m ental images
42
are conceptualized in the right hem isphere of the brain, th e h alf
of the b rain characterized as a "holistic, gestalt, an d
sim ultan eo u s processor for w hich spatial relationships are m ost
appropriate" (p. 53]. Conversely, the left hem isphere is believed
to be a logical, analytic, and sequential processor w here language
is based. Ley and Freem an em phasized th a t em otions ap p ear to
be largely the dom ain of th e right hem isphere. They have b ased
th is belief on the em pirical evidence citing th e right
hem isphere as the center of m usic and a r t although th e au th o rs
posit th a t the right hem isphere does n o t necessarily enhan ce
im m unocom petence, b u t in stead com pensates for th e
im m u n o su p p resan t qualities of the left hem isphere. Ley an d
F reem an p resen ted stu d ies w hich indicated th a t norepinephrine
an d dopam ine (the production of both of w hich is stim u lated by
th e left hem isphere) m ay contribute to im m unosuppression.
Therefore, if th e relationship betw een th e cerebral h em isp h eres
is one of reciprocal inhibition, th en "engaging in im ageiy could
activate th e right hem isphere an d thereby relatively inhibit
activation of the left hem isphere" (Sheikh, 1984, p. 61).
A related hypothesis on th e relationship betw een im ageiy
an d healing w as explored by Vija Bergs L usebrink (1990) in
Imagery an d V isual E xpression in Therapy. The a u th o r reviewed
a hem ispheric laterality theory largely b ased on th e w ork of
Je a n n e Achterberg. In essence, Lusebrink's theory sta te s th a t
th e autonom ic functions of th e body are influenced by the right
hem isphere, th e site of m ental images. L usebrink noted th a t
43
'V erbal m essages from th e left hem isphere need to be tran slated
by the rig h t hem isphere into images before they can be
understood by the autonom ic nervous system" (p. 221). In
addition, th e a u th o r stated th a t images become p a rt of th e
symbolic rep resen tatio n of em otions. Consequently, th e images
sh are the n eu ro m u scu lar an d neurophysio logical com ponents of
em otions (Lusebrink, 1990).
A chterb erg's early w ork on imagery w as influential in
shaping c u rre n t PNI theory. In 1984 sh e reviewed th e existing
literature an d found evidence supporting th e b rain /im m u n e
system link. Citing research showing th e interconnection
between th e "image-laden" anterior frontal lobe an d th e limbic
system , A chterberg suggested th a t "every image h a s a
biochem ical, n euroanatom ic com ponent w ith the po ten tial for
changing activities at th e cellular level" (p. 6). In general, she
believed th a t th e reviewed stu d ies were suggestive th a t imagery
m ay be a precursive factor in physiological change. W hen the
au th o r ad d ressed imageiy an d disease, sh e aligned w ith a
theoretical fram ew ork b ased on the Triple Code Model by Ahsen.
A chterberg w rote th a t the research she reviewed "su p p o rt th e
Triple Code Model which considers th e im age to be th e prim ary
phenom enon, followed by th e som atic response, an d lastly by
m eaning or th e lexical an d verbal aspects" (p. 10). In the
sum m ary of h e r review, A chterberg em phasized th a t, "the gross
relationship betw een the im age and healing rem ains undisputed"
(p. 11).
HIV an d G uided Imageiy
44
In addition to theory, there is em pirical evidence
supportin g the effectiveness of guided imagery as a n
im m unoenhancer, For example, a D anish study investigated the
effects of relaxation an d guided im agery on cellular im m une
function (Zachariae, K ristensen, Hokland, Ellegaard, Metze, &
Hokland, 1990). For 10 days, su b jects were daily given 1-hour of
relaxation therapy an d a combined guided im agery/relaxation
procedure. The im agery intervention in stru cted su b jects to
visualize strengthening their im m une system s. The
p re te st/p o s tte s t m easu re was a n a tu ra l killer (NK) cell count.
The re su lts of the stu d y supported th e authors' hypothesis th a t
the interventions w ould elevate NK cell counts. However, they
cautioned, "the investigation does n o t indicate w h eth er the rise
in NK cell activity is due to relaxation, m ental imagery, or both,
and fu rth e r stu d ies should investigate possible differences
betw een different psychological stim uli" (Zachariae, et al., 1990,
p. 37). They concluded th a t th eir stu d y reinforces th e concept
th a t th e im m une system is a cellular extension of th e b rain and
th a t relaxation an d imagery may bolster com prom ised im m une
system s.
An im portant stu d y looked into th e effect of im m une
system im agery on S-IgA (Rider e t al., 1990). The research
team , w hich included noted PNI a u th o r Je an n e A chterberg,
created a n experim ental treatm en t of a 17-m inute tap e of
im agery in stru ctio n s w ith background m usic designed to
enhance imageiy. The imageiy in stru ctio n s focused on subjects
45
visualizing the activation of their im m une system s.
P re te s t/p o stte st m easu res of S-IgA were ta k en to assess th e
tre a tm e n t effect, and su b jects were random ly assigned to one of
three groups: experim ental {imagery/music), placebo control
(music), or control. The intervention w as evaluated in th ree
sep arate trials over a 6-w eek period. The re su lts indicated th a t
th e experim ental tre a tm e n t significantly (jd < 0.05) in creased
subject S-IgA levels an d confirmed th a t im m unoenhancem ent
could be accom plished w ith a 20-m inute tap ed guided im agery
interven tio n .
A nother study involved the com bination of guided im agery
with fam iliar-sedative m u sic (Russell, 1992). R ussell's stu d y
explored techniques to reduce anxiety in university stu d e n ts.
The a u th o r com pared th ree different interventions, alone an d in
com bination: cognitive-behavioral, relaxing m usic, and guided
imagery. Russell used a n u m b e r of anxiety m easu res as th e
d epen d en t variables: a self-report scale, th e S tate T rait Anxiety
Inventory, an d an electrom yography (EMG). One com bination
approach w as found to be m ore effective: m usic team ed w ith
guided imagery. The a u th o r rem arked, 'T he resu lts of th is stu d y
indicate th a t highly anxious university stu d en ts, using m u sic an d
imagery techniques, m ay have a n effective an d alternate m ethod
for reducing state anxiety" (p. 521). The a u th o r suggested th a t
m usic m ay act as a catalyst in enhancing th e m ental image.
Citing a n earlier study th a t dem onstrated m usic as a facilitator
for the production of guided imageiy, Russell also suggested th a t
46
im agery plus m usic m ay have been seen as a new treatm en t
m ethod by the su b jects th a t "would assist them in coping with
overall life stressors" (p. 521).
47
CHAPTER III
METHODOLOGY
The Sam ple
The sam ple consisted of 24 volunteers with Stage IV AIDS
recruited from an on-going HIV care program in Virginia. The
sam ple w as all-male, b u t diverse in age, race, height, weight,
date of first AIDS diagnosis, m ost recent CD-4 count, an d
c u rre n t illnesses. All p articipants were from C entral Virginia.
Sixteen p articip an ts were C aucasian, an d the rem aining eight
were African-American. The m ean age of the p articip an ts w as
32.54 years (range 21 to 47). The m ean num b er of y ears living
w ith HIV infection was 4.5 (range 1 to 9). The original in te n t
w as to obtain 30 individuals from several AIDS service
organizations, b u t this proved problem atic in m aintaining
experim ental control. Instead, a sm aller sam ple allowing for
tig h ter experim ental control w as m ade available th ro u g h
resources in th e m edical profession. Initial contact w as m ade
throug h several h ealth providers specializing in th e trea tm en t of
HIV. V olunteers were recruited from a n AIDS trea tm en t
program m onitored by a Physician at the Medical College of
Virginia (MCV) after a thorough review of th e study proposal.
Twenty-five individuals originally volunteered, b u t one h a d to
w ithdraw prior to the experim ent for h ealth reasons.
P articip an ts provided w ritten consent an d were random ly
assigned to eith er the experim ental or control group. All
48
particip an ts were given general inform ation ab o u t the
experim ent and th eir right to w ithdraw a t any point in th e study.
Follow-up counseling regarding th e experim ent w as offered to
all particip an ts by the principal researcher, a trained m ental
h e a lth th erap ist. The volunteers were informed of the purpose
of th e study an d the control group-assigned p articip an ts were
offered experim ental treatm en t a t the conclusion of th e d ata
collection.
M aterials and E quipm ent

A vocal guided imagery script w as recorded on a high-
quality audio cassette tape. The tap e w as approxim ately 25
m in u tes of relaxation and im m une system guided im agery
(Appendix C). The use of m etaphorical language w as u se d to
en han ce im m unity in the listener. The basic stru c tu re of the
intervention w as based on a relaxation audiotape developed by
the University of California, S an Francisco AIDS H ealth Project
(1985).
Medical History Q uestionnaire

Inform ation w as obtained to assess physical s ta tu s an d th e
m edication background on each participant. Q uestions o n
height, weight, sex, age, w ere asked, in addition to any
inform ation on HIV-related opportunistic infections.
P articip an ts were asked to list any prescription d ru g s th e y were
taking a t the tim e of the d a ta collection. All p articip an ts
49
com pleted th e questionnaire. All questionnaires were coded
w ith the la st six digits of th e p articipant's Social Security
num ber.
Secretory IgA IS-IgA)

Secretory IgA m easu res were used b ecause th e m ethod of
obtaining saliva is unobtrusive and the procedure h as
d em on strated effectiveness as a short-term m easu re of
im m unocom petence (Rider, 1990). A sam ple of whole
un stim u lated saliva w as obtained from each p articip an t a t tim ed
intervals of 0 , 60, an d 120 seconds an d subsequently frozen.
U sing tim ed sam ples helped control for the relationship
betw een S-IgA concentrations and saliva volum e (Jem m ott III &
Magloire, 1988). To control for artificially stim ulated saliva, the
u se of su b stan ces su ch as tobacco, chewing gum, and candy was
discouraged a t least one h o u r prior to sam ple collection.
P articipants, however, were n o t told to ab stain from eating
regular m eals prior to the sam ple collection. All sam ples were
collected using universal precautions for handling body fluids in
accordance to the Virginia D epartm ent of Labor an d In dustry
directive 1910.1030 regarding occupational exposure to
bloodbom e pathogens. Sam ples were collected a n d handled by a
licensed healthcare professional. Saliva sam ples were coded by
th e la st six digits of the participant's Social Security num ber. In
ord er to minimize bias, the prim ary investigator n eith er
adm inistered the trea tm en t condition n o r collected the
50
sam ples. Thawed saliva sam ples were assayed by a single radial
Im m unodiffusion (RID) by a biologist an d th e prim ary
investigator (Garvey, Cremer, & Sussdorf, 1977). S-IgA
m easu res using RID h as been supported in the literature as a
valid a n d reliable procedure (Green et al. 1988; Jem m o tt &
Magloire, 1988; Jem m o tt & McClelland, 1989; McClelland &
K irshnit, 1988; Rider et al., 1990).
The assay procedure w as modeled after the stu d y of Rider
et al. (1990). E qual volum es of sam ple saliva were placed in
cylindrical wells p unched in a n agar plate treated w ith anti-
human-IgA. Over a 24-hour period, the saliva diffused in the
agar, an d the an tiseru m formed a disk-shaped im m une
precipitate w ith the IgA protein for w hich it is specific. All
other proteins freely diffused (Rider, 1990). The area w ithin
th e ring w as m easured as the diam eter squared. T his area
m easu rem en t is proportional to the antibody concentration
(Garvey, Cremer, & Sussdorf, 1977) (McClelland & K irshnit,
1988) A reference concentration of IgA provided a sta n d a rd to
check for possible deterioration of each agar plate.
R esearch Design
A p re te st/p o stte s t control group design w as used. T his
design allowed for a com parison of th e experim ental group to
th e control group. The p articipants were random ly assigned to
one of two conditions: im m une system guided imagery, or
control.
51
Gi R Oj X O2 O3
G2 R Oi O2 O3
G= Group R= Random assignm ent Pretest observation
0 2 = P o sttest observation (immediate)
0 3 = Posttest observation (14 days after treatm ent)
X= T reatm ent
P rocedure
All participants were briefed on the general purpose of the
stu d y and confidentiality issues. At the conclusion of the
briefing, volunteers were asked to review an d sign a Subject's
R ights/Perm ission Slip (Appendix A); the slip was read aloud by
th e sam ple collector to help en su re complete understanding.
V olunteers were only identified by the la st six-digits of th eir
social security num ber on all m aterials an d sam ples collected.
After signing the Subject's R ights/Perm ission Slip, participants
com pleted the MedicalHistory Q uestionnaire (Appendix B).
Participants were random ly assigned to one of two groups:
G roup G i received the guided imagery intervention: Group G 2
w as the non-treatm ent control group. A p retest saliva sam ple
w as taken from each participant ju s t prior to the adm inistration
of the treatm en t procedure. Participants in Group G i were
placed in a comfortable room where they were asked to follow
th e directions given on the audio tape. Group G2 received no
treatm ent. At the conclusion of the treatm ent or control
condition (30 m inutes), a p o sttest saliva sam ple w as obtained
52
from each p articip an t. To control for th e influencing effects of
m ortality, history, an d m atu ratio n , the entire experim ent for
each group took place a t one m eeting w ithin a 90 m inute tim e
sp a n . Two weeks following the first pre- and p o sttest sam ple
collection, a second p o sttest was collected to m easu re long-term
effects of th e guided im agery treatm en t o n the im m une system .
All control p a rtic ip an ts w ere given the option to receive the
treatm ent. Counseling services were m ade available for any
p a rtic ip a n ts who req u ested experim ental desensitization.
D ata Analysis
To determ ine statistically significant differences (a = .05)
betw een groups, an analysis of covariance (ANCOVA) w as
calculated o n the collected data.
Specific Null H ypotheses

Null H ypothesis 1
H oi: HIV-positive p a rtic ip an ts adm inistered guided
im agery will not have significantly different S-IgA concentrations
im m ediately following trea tm en t com pared to control HIV-
positive p articip an ts.
Null H ypothesis 2
H 0 2 : HIV-positive p articip an ts adm inistered guided
im agery will n o t have significantly different S-IgA co ncentrations
53
two w eeks following trea tm en t com pared to control HIV-
positive p articipants.
Ethical Safeguards and Considerations

E thical safeguards were in accordance w ith th e Am erican
Psychological A ssociation guidelines. The experim ent w as
reviewed an d approved by the School of E ducation and th e
College of William & Mary H um an S ubjects Research
Com m ittees. In addition, access to the p articip an ts was gained
after the experim ent w as reviewed an d approved by a n in te rn ist
providing h ealth care to p atien ts with HIV. Confidentiality of
p artic ip an t identity an d scores were m aintained by strict access
control to collected data. Only the investigator a n d the assisting
biologist saw the p re /p o stte st m easures. In addition, saliva
sam ples were obtained an d m atched via the la st six digits of the
p articip an t's social security num ber. All treatm en t conditions
w ere adm inistered from a n audiotape to assu re consistency of
tre a tm e n t an d reduce experim enter influences. The right of a
p artic ip an t to w ithdraw from th e experim ent a t any tim e w as
outlined in the perm ission slip th a t w as read an d signed by all
particip an ts. All briefings, treatm en t adm inistration, and sam ple
collection w as conducted by a licensed h ealth care professional
(Registered Nurse). At th e com pletion of the p o sttest, all
p articip an ts were debriefed an d subjective com m ents they m ay
h ave h ad were collected regarding th eir im pressions of th e
experim ent. The re su lts of th e experim ent were m ade available
54
to all p articipants at th e conclusion of the d ata analysis and
in te rp re ta tio n .
Sum m ary of Methodology

The sam ple consisted of 2 4 HIV-positive volunteers
recruited from an on-going HIV care program in Virginia. T he
sam ple w as all-male, b u t diverse in age, race, height, weight,
date of first AIDS diagnosis, m ost recent CD-4 count, and
c u rre n t illnesses. P articipants provided w ritten co n sen t an d
were random ly assigned to eith er the experim ental or control
group. All p articip an ts were given general inform ation ab o u t th e
experim ent a n d their rig h t to w ithdraw a t any po in t in the study.
Follow-up counseling regarding th e experim ent w as offered to
all p articip an ts by the principle researcher, a train ed m ental
h ea lth th erap ist.
The volunteers w ere inform ed of the purpose of the stu d y
a n d th e control group-assigned p articip an ts were given the
option of experiencing th e experim ental trea tm en t a t the
conclusion of th e data collection.
The entire experim ent sp an n ed J a n u a ry 8 , to J a n u a ry 22,
1996. P articipants were random ly assigned to the experim ental
or control group. At th e first m eeting, p articip an ts com pleted
th e Medical H istory Q uestionnaire (Appendix B), gave th eir
p re te st saliva sam ple, received th e intervention or control
condition, an d gave th eir p o sttest saliva sam ple. The first
m eeting w as 9 0 m inutes long. Collected saliva sam ples were
55
frozen until th e RID assay. Fourteen days following the first
m eeting, p articip an ts provided a second posttest saliva sam ple.
Interested control group p articip an ts w ere adm inistered th e
intervention upon th e ir request im m ediately following th e
second p o sttest saliva collection. The second m eeting lasted 20
m in u tes for experim ental group m em bers and 20-90 m in u tes for
control group m em bers depending the individual's desire to
experience th e trea tm en t condition.
The research design used in this stu d y was th e
P re te st/P o ste st Control Group design. T he statistical procedure
u sed to test th e null hypotheses w as the analysis of covariance.
Two n u ll hypotheses provided th e basis for determ ining a
significant difference (a = .05) betw een m easures.
56
CHAPTER IV
RESULTS
The resu lts of th e experim ent are reviewed and
interpreted by hypothesis in this chapter. The d ata collected
and analyzed for the dependent variable w as a p articipant's pre-
and po sttest IgA levels. An analysis of covariance (ANCOVA) w as
calculated to reveal any evidence of statistically significant
differences between the control and experim ental groups after
treatm en t (posttest) taking into account pre-treatm en t group
differences (pretest).
Specific R esearch H ypotheses

Hypothesis 1
H j: HIV-positive participants adm inistered guided
imagery will have significantly elevated S-IgA concentrations
im m ediately following treatm en t com pared to control HIV-
positive participants.
An ANCOVA of pretest d ata to the p o sttest d ata collected

immediately after the treatm ent resulted in a n F of 5.68 for
treatm en t m ain effects (Table 1). This w as determ ined to be
significant at the .003 level. Therefore, the null hypothesis w as
rejected; IgA p o sttest m eans among groups were statistically
different. Table 2 sum m arizes the m eans and stan d ard
deviations by group. In order to make a post hoc analysis
57
betw een group m eans, a Newman-Keuls (Glass & Hopkins,
1984) m ethod of m ultiple com parisons w as calculated. (Table 3).
Table 1
H ypothesis 1
S um m ary of ANCOVA Analysis for T reatm ent Effects
of Post-(Immediate) w ith P retest T otal IgA M easures
Source_________________ df______ Sum of Squares Mean Square F - t e s t _________P value

Between subjects 11 11866.41 1078.76 6.85 .0001
Within subjects 36 5668.03 157.45
treatments 3 1930.47 643.49 5.68 .003
residual 33 3737.55 113.26
Total 47 17534.43
Reliability Estimates for All treatments: .85 Single Treatment: .59
Table 2
H ypothesis 1
S um m ary of M eans, S tan d ard Deviations an d S tan d ard E rro rs
Group_____________ n________________ Mean______________ Std. Dev.___________ Std. Error

Control Posttest 12 113.83 17.72 5.12
Exp, Posttest 12 129.62 18.70 5.40

Control Pretest 12 114.76 17.55 5.07
Exp. Pretest 12 117.12 21.14 6.10
58
Table 3
Hypothesis 1
Sum m ary of th e Newman-Keuls Method of Multiple Com parisons
O rdered M eans
P ost, exp P re.exp Pre.con Post.con
129.62 117.12 114.76 113.83
Comparison: 3 value: Table

Post.exp vs. P o st con 4.36* p < .05 .95g 30. 4 = 3.84
Post.exp vs. Pre.con 4.10* p < .05 .95q 30. 3 = 3.49
Post.exp vs. Pre.exp 3.45* p < .05 .95g 30. 2 - 2.89
Post.con vs. Pre.exp 0.91 p > .05 .95g 30, 3 = 3.49
H ypothesis 2
H 2‘ HIV-positive p articip an ts adm inistered guided
im agery will have significantly elevated S-IgA concentrations two

w eeks following trea tm en t com pared to control HIV-positive
participants.
An ANCOVA of p rete st d a ta to the p o stte st d ata collected

14 days after th e treatm en t resulted in a n F of .45 for treatm en t
m a in effects (Table 4). T his was determ ined to be significant a t
only the .7168 level. Therefore, th e null hypothesis w as
accepted. F o u rteen days following treatm ent, th e IgA p o sttest
m e an s am ong groups w ere not statistically different. Table 5
sum m arizes th e m eans an d sta n d ard deviations by group. Table
6 sum m arizes th e post hoc analysis between group m ean s using
th e Newman-Keuls m ethod of m ultiple com parisons.
59
Table 4
H ypothesis 2
S um m ary of ANCOVA Analysis for T reatm ent Effects
of Post (Delayed) with P retest Total IgA M easures
Source_________________ df______ Sum of Squares Mean Square F-test____________P value

Between subjects 11 12069.85 1097.26 8.79 .0001
Within subjects 36 4493.94 124.83
treatments 3 177.79 59.26 .45 .7168
residual 33 4316.15 130.79
Total 47 16563.79
Reliability Estimates for All treatments: .89 Single Treatment: .66
Table 5
Hypothesis 2
Sum m ary of Means, S tandard Deviations an d S tan d ard E rrors
Group______________ n_________________ Mean______________ Std. Dev.___________Std. Error

Control Posttest 2 12 116.21 17.79 5.13
Exp. Posttest 2 12 120.03 20.45 5.90
Control Pretest 12 114.76 17.55 5.07
Exp. Pretest 12 117.12 21.14 6.10
Table 6
H ypothesis 2
S um m ary of the Newman-Keuls M ethod of M ultiple C om parisons
O rdered M eans
Post.exp Pre.exp Post.con Pre.con
120.03 117.12 116.21 114.76
Com parison: value: Table cp

Post.exp vs. Pre con 1.63 p > .05 .95q 30, 4 = 3.84
60
Sum m ary
The p re te s t/p o stte s t control group research design w as
chosen to determ ine the efficacy of im m une system guided
im agery on enhancing the S-IgA levels in HIV-positive
individuals. The sam ple w as draw n from volunteers belonging to
a n on-going AIDS su p p o rt group in C entral Virginia. Collected
d a ta w as examined u sin g a n analysis of covariance (ANCOVA)
resultin g in the rejection of th e null hypothesis 1 an d the
acceptance of the null hypothesis 2 .
At the 0.05 level of significance:

H 0 1: HIV-positive p articip an ts adm inistered guided
im agery will not have significantly elevated S-IgA concentrations
im m ediately following tre a tm e n t com pared to control HIV-
positive p articip an ts.
H 0 2: HIV-positive p articip an ts adm inistered guided
im agery will not have significantly elevated S-IgA concentrations
14 days following trea tm en t com pared to control HIV-positive
particip an ts.
W hen the Newman-Keuls m ethod of m ultiple post hoc

com parisons w as employed on hypothesis 1 d a ta (treatm ent
effect im m ediately following intervention), a significant
difference w as found betw een the p o sttest m eans of th e
experim ental an d control groups (p < .05). In addition, the
61
p o stte st experim ental group m ean w as significantly different
from the p rete st control group m ean (p. < .05). W hen com paring
th e experim ental group pre and p o stte st m eans, significant
difference w as also found.
A p o st hoc analysis of hypothesis 2 d ata (treatm ent effect
14 days following intervention) revealed no significant
differences group m ean s (p > .05).
62
CHAPTER V
SUMMARY, CONCLUSIONS, DISCUSSION an d
RECOMMENDATIONS,
Sum m ary
The prim ary purpose of th is study w as to determ ine the
efficacy of a psychoneuroimmunological intervention on
im m unocom petence in people w ith com promised im m une
system s resulting from HIV infection. Medical science h a s
show n th a t S-IgA provides a n initial defense in the oral cavity
against potentially harm ful pathogens (Tomasi, 1976). W e do
know th a t m ales with low levels of S-IgA a re more likely to have
respiratory tract infections th a n males w ith higher levels of S-
IgA (McClelland, Alexander, & M arks, 1982). People w ho are
infected with HIV have im paired immunity an d are a t-risk for
m any opportunistic infections. If HIV-infected individuals could
enhance their im m unity through either m edical or psychological
intervention, they would be m ore resistan t to opportunistic
disease. Though a core of research has dem onstrated im m une
system m odulation through psychological techniques, n o n e h as
investigated a technique with a n HIV-positive sample.
Specifically, S-IgA levels have been shown to change w h en an
Individual is visually stim ulated (McClelland & Kirshnit, 1988).
R esearch on anxiety reduction using music an d guided imagery
63
h a s dem onstrated th a t auditory-based interventions c a n alter S-
IgA levels in college stu d e n ts (Russell, 1992).
The secondary purpose of th is study w as to investigate
w heth er one treatm en t of an intervention w ould have an y lasting
en h an cem en t of a n individual's im m unity. In 1987, Solomon
undersco red this question w ithin the larger context of increased
survival rates. The researcher also asked w hether th e central
nervous system could "mediate 'com pensatory' m echanism s for
th e im m unodeficiency induced" by HIV (p. 633). If a n
intervention could "train" su c h m echanism s, long term benefits
m ight include increased disease resistance in a n individual.
T his stu d y investigated th e effect of one specific
psychoneuroim m unological intervention on S-IgA levels in HIV-
positive individuals. A guided im agery intervention stressin g th e
activation of the particip an t's im m une system w as chosen as the
experim ental treatm en t. Guided imagery h a s d em onstrated
efficacy in reducing stress, is easily adm inistered, and is
m inim ally invasive. It w as hypothesized th a t p articip an ts in the
im agery experim ental group would have significantly h ig h er S-
IgA levels th a n those in the control group. In theory, th e
elevated S-IgA levels would th e n enhance th e experim ental
group p articip an ts' resistance to respiratory infection. However,
th e actu al relationship between th e trea tm en t an d a p articip an t's
overall h ealth was n o t investigated in th is study.
G uided imagery as an im m unoenhancer of lasting benefit
w as the second hypothesis of the study. To isolate a
64
psychological intervention th a t "re-educates” the com prom ised
im m une system in a n HIV-positive person would be a
notew orthy accom plishm ent. The investigator felt th a t a n
im m une system -guided im agery exercise m ight estab lish
"compensatory" im m une responses u n d er conscious control to
replace the HIV-damaged responses th a t are unconscious.
T he sam ple, consisting of 24 HIV-positive m ale volunteers,
were recruited from an on-going HIV su p p o rt network. All
p articip an ts were from Central Virginia. Sixteen p articip an ts
were C aucasian, a n d the rem aining eight w ere African-American.
The m ean age of th e p articip an ts w as 32.54 years (range 21 to
47). The m ean n u m b e r of y ears living w ith HIV infection was
4.5 (range 1 to 9). The p articip an ts were random ly assigned to
either th e experim ental or control group. P articipants
participated in the stu d y for a to tal 14 days.
T he intervention and d a ta collection took place o n two
days for a total of 2.5 hours of contact time. On the first day,
p artic ip an ts com pleted dem ographic questionnaires, perm ission
statem en ts, received experim ental or control condition, an d
provided pre- and first posttest saliva sam ples. Fourteen days
later, th e second p o stte st saliva sam ple w as collected from each
p articip an t; control group p articip an ts w ere offered th e
experim ental tre a tm e n t after th e second p o stte st sam ple
collection. Eight of th e 12 control p articip an ts req u ested the
experim ental treatm en t.
65
The research design used w as th e p re te s t/p o s tte s t control
group design. The dependent variable w as S-IgA levels as
determ ined by radial imm unodiffusion. An analysis of covariance
w as used to discern differences in group m eans by taking into
consideration p re-treatm en t group differences. As reviewed in
C hapter 4, statistical analysis resulted in the rejection of th e n u ll
on hypothesis I and the acceptance of th e null on hypothesis 2
a t th e .95 level of confidence. The group m eans differed
significantly on the p o sttest im m ediately following the
intervention.
Post hoc m ultiple com parison revealed significant
differences betw een the p rete st an d p o sttest m ean s of the
experim ental group. This finding suggests th a t im m une system
guided im agery affects S-IgA levels because no significant
difference w as found betw een the pre- an d p o sttest m eans in
th e control group. There were significant differences also
betw een th e p o sttest m ean s of the experim ental an d control
group. However, no significant differences were found betw een
th e p retest m ean s of the experim ental an d control group,
suggesting th a t the groups were equal prior to treatm ent. The
final p o st hoc com parison of the sam ples collected im m ediately
following trea tm en t revealed a significant difference betw een
th e p o sttest m ean of the experim ental group an d th e p retest
m ean of the control group. In light of th ere being no differences
betw een the groups on the p retest m eans, th is difference is
likely th e re su lt of the treatm en t on th e experim ental group.
66
To examine the longitudinal im pact of guided im agery on
S-IgA levels, an analysis of covariance on the follow-up p o sttest
w as used. The resu lts dem onstrated no differences betw een
groups 14 days following the intervention. This finding suggests
th a t from a single guided imagery intervention, lastin g change in
S-IgA levels is not likely. In addition, a post hoc m ultiple
com parison analysis between groups found no significant
differences betw een groups.
Conclusions
The following conclusions were draw n from th is study.
1. Im m une system guided imagery app ears in th is study to

en h an ce S-IgA levels in HIV-positive males.
2. The ability of im m une system guided imagery to

en hance S-IgA levels appears to be of short duration.
3. Individuals w ith com promised im m une system s

can enhance S-IgA levels th ro u g h im m une
system guided imagery.
4. An audiotaped intervention ap p ears to enhance

S-IgA levels, though it is not know n w hether
a "live" intervention is more effective.
67
5. A dm inistering im m une system guided im agery
in a group setting appears to enhance S-IgA levels.
6. Generalizability of resu lts should be limited to

HIV-positive m ales. No d ata w as collected on
HIV-positive females.
Discussion
This stu d y dem onstrated th a t im m une system guided
imagery does influence th e S-IgA levels in HIV-positive men.
The guided imagery treatm en t was show n to be statistically
superior to no treatm ent. However, th e benefits of th e
treatm en t ap p ear to have little long term effect on S-IgA levels.
The lim ited d u ratio n of th e treatm en t effect m ay be affected by
having only one intervention session.
It h a s been found th a t daily relaxation will modify both
salivary and serum imm unoglobulin levels. For example, the
stu d y by Green, Green, an d Santoro (1988) used a 3 week
practice period to in stru c t p articip an ts on proper relaxation
techniques. They found significant differences betw een their
experim ental (practice) an d control (no practice) groups. The
research ers deduced a long-term practice effect in p articip an ts
who h ad employed relaxation once a day for 3 weeks. Though
relaxation therapy and im m une system guided im agery are
different techniques, a sim ilar long-term practice effect m ay
im pact the d u ratio n of imagery. Until practice effect is studied
68
w ith im m une system -guided imagery, daily imagery exercises
m ay have im plications for h ealth by decreasing susceptibility to
u p p e r respiratory illness.
The precise effective m echanism behind im m une system
guided imagery is n o t understood, n o r w as it revealed in th is
study. W hether other forms of guided imagery would bring about
th e sam e change in S-IgA levels is unknow n. It is also possible
th a t th e experim ental p articip an ts responded to the tre a tm e n t
a s a relaxation a n d /o r stress intervention. Antoni, LaPerriere,
Schneiderm an, an d Fletcher (1991) h ad found th a t "stress
m anagem ent interventions can buffer th e psychological d istress
of receiving a positive HIV-1 diagnosis an d can m odestly elevate
th e values of som e im m une param eters in HIV-1 seropositive
individuals" (p. 42).
For individuals living with HIV, overall psychosocial stress
levels are high, especially those who are asym ptom atic (Chuang,
Devins, Hunsley, & Gill, 1989). It ap p ears th a t th e early stages
of HIV infection m ay introduce th reatening stressors, su c h as
uncertainties, fear of pain an d suffering, isolation, physical
deterioration, an d loss ability to p erform /respond sexually.
C huang, Devins, Hunsley, an d Gill found th a t individuals living
w ith AIDS face different stresso rs su ch as issu es of death, dying,
an d th e resolution of unfinished bu sin ess. The p articip an ts used
in th e p resen t stu d y all were diagnosed with AIDS having CD-4
co u n ts below 200. All h ad a medical history of a t least one
opportunistic infection. From the research by Chuang, Devins,
HIV a n d Guided Im agery
69
Hunsley, and Gill, it is likely th a t th is study’s su b jects were n o t
experiencing the h ig h est levels of distress related to HIV-
infection. Consequently, the im m une system guided imagery
may have been activating more th a n a relaxation response in th e
particip an ts.
It is known th a t a n active coping style is associated w ith
enhanced im m une functioning in HIV-positive m e n {Goodkin et
al., 1992). An active coping style is m arked by optim ism , hope,
and em powerm ent, w hereas a passive coping style focuses on
pessim istic, hopeless, an d overly cooperative attitu d es. Passive
coping styles have been associated with m any illnesses which
may be linked to im m une system dysfunction, su c h as cervical
cancer (Goodkin, Antoni, & Blaney, 1986) and b re a s t cancer
(Pettingale, Greer, & Tee, 1977). AIDS and ca n ce r are sim ilar
diseases in both symptomology an d progression. One research
team suggested th at a variety of personality factors were
associated w ith unfavorable prognostic indicators for cutaneous
m alignant m elanom a (Temoshok et al., 1985). They stated th a t
a Type C coping style is associated with unfavorable prognostic
indicators. The Type C individual is usually passive, helpless,
other-focused, inexpressive of em otions, and appeasing.
Conversely, the sam e team identified the Type A personality a s
more aggressive, self-involved, hostile, and im patient. Solomon
(1987) em phasized th a t future PNI research sh o u ld focus on
Type A individuals an d th eir dom inance in the ra n k s of long
term survivors of AIDS.
70
Since HIV-positive individuals with active coping styles
a n d /o r Type A personalities a sse rt more control over th eir
disease an d its treatm ent, they m ay find im m une system guided
imagery to be an effective tool. Guided imagery as a technique
may also enhance a person's overall h ealth outside of d irect
im m une system stim ulation. Gloersen et al. speak of a
philosophy of coping well w ith AIDS w hich em phasizes calm,
peace, or having a sense of control over one's disease (1993).
O thers have com m ented on th e inner power people can a s se rt
to increase th eir survival w hen living w ith AIDS. In a care
m anual published by th e Los Angeles AIDS Project (Moffatt,
1987) B em ie Siegel com m ents on th e characteristics of a long
term survivor;
• Aimless playfulness for its own sake

• Keeping a positive outlook and confidence in th e face of
adversity
• An active im agination, daydream s, m ental play an d

conversations with yourself
(p. 16)
Im m une system -guided imagery does focus on im agination,

m ental play, and the principle of an in tern al locus of control. An
external locus of control an d longterm AIDS survivorship have
been show n to be negatively correlated (Remien, Rabkin, &
Williams, 1992). R esearchers found th a t longterm survivors h ad
a significantly greater belief in chance or in tern al factors
influencing th e ir h ealth th a n a belief in "powerful others."
71
Although an audiotaped im m une system -guided imagery
exercise increases S-IgA and m ay enhance one's sense of
personal control over HIV, the social su p p o rt obtained from a
group process activity should not be ignored. The im agery
intervention in this stu d y w as adm inistered to an ongoing
facilitated AIDS su p p o rt group. It is un clear w hether an
individually adm inistered intervention would have affected
p artic ip an t S-IgA levels as did the group adm inistration model
u sed . However, th is study's dem onstration of th e efficacy in
u sin g a n audiotaped intervention m ay have m ore practical
significance w hen considering the over-taxed tim e, personnel,
an d financial resources of m ost AIDS service organizations.
It is know n th a t lack of social su p p o rt is a strong predictor
of psychological d istress (Blaney, Goodkin, Morgan, & Feaster,
1991). R esearch h as also dem onstrated th a t social su p p o rt is
related to the control of chronic disease (Kaplan & Hartwell,
1987). A compelling example of the role social su p p o rt m ay play
in survivor rate s w as dem onstrated by Speigel, Bloom, Kraemer,
& G ottheil (1989) in a longitudinal stu d y of b re a st cancer
p atien ts. The research team hypothesized th a t women placed in
th erap eu tic su p p o rt groups would suffer less d istress th a n
w om en n o t receiving su c h treatm ent. The rese arch ers were
attem p tin g to improve the quality of life for b re a s t cancer
patients; th e hypothesis w as supported a s group p articip an ts
reported improved quality of life. The team conducted a follow-
u p stu d y 10 years after th e groups h ad disbanded to see how
72
long th e p articip an ts had survived. The records indicated th a t
the wom en in the su p p o rt groups h ad survival rate s twice a s long
as th e control group. On average, 18 m onths were added to the
lives of su p p o rt group m em bers w hich exceeds w hat could be
expected from cancer m edications a t the advanced stage in th e
p articip an ts' disease. Providing scheduled, co n sisten t im m une
system -guided im agery exercises in a group settin g m ay prove to
be highly effective in enhancing im m unity an d reducing social
isolation in HIV-positive individuals. The com bination of th e
in tern al m ental process coupled w ith external social su p p o rt
m ay produce com plex interactions betw een people an d th e ir
environm ent.
Though this stu d y did not reveal a p an acea in the
th erap eu tic trea tm en t of people living with AIDS, the re su lts did
indicate th a t im m une system s can be m anipulated through
targeted guided imagery. Significantly, the investigator found
this effect in m en w ith severely com prom ised im m une system s.
Though th e enhancem ent of im m unity was of sh o rt duration,
several considerations m ight ad d ress this th erap eu tic lim itation.
First, train in g and repeated practice of basic im agery skills m ay
stren g th en an individual's ability to invoke effective m ental
images. Second, com prehensive coaching an d in stru ctio n on
the im m une system -guided im agery exercise m ay increase th e
th erap eu tic effect on a person's im m une system . Third,
consisten t, scheduled "m aintenance" imagery group sessio n s
may lengthen the duration of the treatm en t effect. Finally,
73
training in individual guided imagery with the u se of a n
audiotap e or self-guidance provides a self-adm inistered tool to
th e HIV-positive perso n .
Giving HIV-positive individuals a self-adm inistered
intervention may em power them w ith a greater sen se of control
over th e ir health. P erh ap s the m ost powerful p oint from th is
stu d y is n o t the em pirical observation of a n enh an ced im m une
system , b u t rath er the suggestion th a t im m une system -guided
im agery m ay reinforce a person's feelings of hope an d control in
fighting a disease th a t trys to steal away these vital qualities. A
core condition of h u m a n existence is th e personal capacity to
exercise freedom in affecting ourselves an d others.
U nfortunately, HIV restricts and can even destroy th is freedom.
Offering HIV-positive individuals a therapeutic tool for enhanced
im m unity underscores th eir freedom to fight AIDS.
Significantly, it was th e participants who enhanced th eir
im m unity in this study, n o t an audiotape. Im m une system -
guided imagery only facilitated th e particip an ts' freedom to
control th e ir bodies an d , perhaps, th e ir future.
R ecom m endations
T he following recom m endations are m ade b a se d u p o n
th e findings of th is study:
1. It is recom m ended th a t this stu d y be replicated w ith a

larg er sample to include HIV-positive women.
74
It is recom mended th a t research be developed to

determ ine the effective duration time of im m une system -
guided imagery on enhancing S-IgA.
It is recom mended th a t longitudinal research using

psychoneuroim m unological interventions be conducted
to determ ine the actual correlation betw een PNI
interventions and health (e.g. survival rates, incidence of
infection, T-cell counts, etc.)
It is recom m ended th a t h ealth care providers consider

including im m une system -guided imagery to their HIV
trea tm en t protocol.
It is recom m ended th a t HIV therapeutic su p p o rt groups

consider including im m une system -guided imagery in
th eir sessions.
It is recom m ended th a t repeated practice or training

w ith im m une system -guided imagery m ay increase
an d prolong the treatm en t effect. Additional research
is needed to investigate the im pact of practice effect on
th is intervention.
75
It is recom m ended th a t im m une system -guided imagery

supplem ent a n d not replace existing social su p p o rt m odels
being used by h ealth care providers.
76
Appendix A
Guided Imagery as a Psychoneuroim munological

Intervention for HIV-positive Individuals
CONSENT FORM
I , _____________________________, am w illing to p a rtic ip a te

in a stu d y of individuals who have been diagnosed HIV-positive. I
u n d e rsta n d th a t th is stu d y is being conducted by Mr.
C hristopher D. Keene, a doctoral candidate in counseling a t th e
College of William & Mary.
As a particip an t in this study, I am aw are th a t I will be involved

in th e following procedures:
1. I will complete a brief medical history questionnaire.
2. A saliva sam ple will be taken from m e a t th e beginning an d

conclusion of a 45 m inute treatm en t session.
3. I will be random ly assigned to one of two different

types of treatm ent.
As a participant in this study, I am aw are th a t I m ay choose to

w ithdraw a t anytim e during the experim ent. I m ay also choose
to be adm inistered the alternative treatm en t a t th e conclusion of
th e study. In addition, I m ay request debriefing counseling from
Mr. Keene a t the conclusion of the study. I also u n d e rsta n d th a t
a w ritten sum m ary of the resu lts of th is stu d y will be mailed to
m e upo n request, and by doing so, I waive my rig h t of anonym ity
to Mr. Keene.
77
By participating in this study, I u n d erstan d th a t there are no
obvious risks to my physical or m ental health.
Confidentiality Statem ent

As a particip an t in the study, I am aware th a t all records will be
k e p t confidential. I will be identified only by the la st six digits of
m y social security num ber.
I fully u n d e rsta n d the above statem ents, a n d do hereby consent

to participate in this study.
P articipant's Signature
W itness's Signature
Date
78
Appendix B
Medical History Q uestionnaire
Last 6 digits of SSN

H eight W eight ____ Sex ____ Age______
Race ____ (for dem ographic purposes)
1. A pproxim ate date first diagnosed HIV-positive:
2. List history of opportunistic infections if applicable:
3. List an y p resen t HIV-related sym ptom s:
4. W hen w as your last CD4 count tak en and w hat w as the

resu lt?
5. List any presently prescribed m edications:
6. List any m edications tak en today:
7. W hen w as the la st tim e you used a tobacco product?
8. List an d describe any counseling you have received in the

la st th ree m onths (ex. Group-HIV support, Personal-
relationship issues, Personal-career issu es, etc.)
9. Have you ever received guided im agery therapy o r hypnosis?

HIV a n d Guided Im agery
79
10. How would you describe y o u r general sta te of health?

1 2 3 4 5
Bad Poor Average Good E x cellen t
11. How would you describe y o u r present s tre s s level?
1 2 3 4 5
High M oderate Average Low Very Low
12. List an d describe any re c e n t (last two m onths) stressful
life events (ex. death in family, health diagnosis, relocation)
13. D escribe any personal strateg ies for m anaging stress if
applicable (ex. therapy, exercise, m editation, reading)
80
Appendix C
IMMUNE-SYSTEM GUIDED IMAGERY MODEL
(slowly paced for 20-25 m inutes)
Let's begin in a sitting position, feet flat on the floor, arm s by

y o u r side, an d palms in yo u r lap. Close y o u r eyes, take a deep
breath, and slowly release th e air through your m outh. As you
do, feel the ten sio n flow o u t of your body. Repeat th is several
tim es.
REFLECTIVE TIME
Keeping your eyes closed a n d breathing normally, I w an t you to
tell yourself th a t you are going to have a pleasant experience.
Focus on y o u r breathing an d how your body responds to each
inhalation a n d exhalation. You are feeling peace, comfort, and
relaxation.
REFLECTIVE TIME
Keeping your eyes closed a n d breathing normally, I w an t you to
focus on the cycle of breathing, at how inhalation and exhalation
are connected. Visualize y o u r breathing as a loop. Now focus at
th e point th a t inhalation becom es exhalation. At th a t m om ent,
th e re is peace.
REFLECTIVE TIME
Keeping your eyes closed a n d breathing normally, focus on th is
feeling of peace and relaxation. Feel th is warm, relaxed feeling
travel from y o u r feet, to yo ur legs at your next exhalation. At
y o u r next exhalation, feel th e relaxation travel from y o u r legs to
y o u r torso. A t your next exhalation, feel th e relaxation travel
from your torso to your chest. At your n ex t exhalation, feel the
relaxation travel from your chest to your neck. At your n ex t
exhalation, feel the relaxation travel from your neck to y o u r face
through to th e top of your head. Experience this deep sen se of
relaxation...this sense of peace.
REFLECTIVE TIME
Keeping your eyes closed a n d breathing normally, visualize
removing any stress that rem ains in y o u r body, experience the
relaxation...experience the peace. Now a s you feel th is deep
81
sense of relaxation, visualize yourself w ithout stress, w ithout
tension, w ithout discom fort or pain.
REFLECTIVE TIME
Keeping y o u r eyes closed and breathing norm ally in th is state of

deep relaxation, visualize traveling inside your body. Flow
through the inner space of your body. Using your m ind's eye,
explore y o u r body...you see cells flowing around you. Travel w ith
these cells through your body, you visit y our heart, y o u r lungs,
your brain. In these cells flowing around you, you can see the life
force they possess. Notice the n u trien ts, the oxygen... they bring
strength an d life to your body. Relax an d flow w ith th ese life-
givers to y o u r body. Visualize your body’s guardians am ongst
these cells. They protect an d fight against harm ful invaders th a t
try to h arm you. As you flow with your guardians, visualize
yourself calling them together...im agine having the pow er to
increase th e ir n um ber by simply thinking it. Visualize yourself
swimming w ith these cells and everywhere you look the
g u ardian s become stronger and greater in num ber. As you
experience th is relaxation, these g u ard ian s strengthen.
REFLECTIVE TIME
Keeping y o u r eyes closed an d breathing normally, tak e a
m om ent to experience your deep relaxation and peace. Visualize
an arm y of guardians growing within your body.
REFLECTIVE TIME
Keeping y o u r eyes closed an d b reathing normally, visualize
yourself leading this arm y of guardians in your body. Relax and
flow th ro u g h your body. Using your m ind's eye, look for harm ful
invaders th a t you m ay encounter. These invaders try to dam age
your body, b u t cannot because you com m and your arm y of
guardians to destroy an d elim inate th eir num ber. Every
invader you encounter is destroyed...as you cleanse y o u r body of
the invaders, your body feels relaxed an d a t peace. T his feeling
of relaxation is a sign of th e invaders being driven out. You have
the capacity to rally your guardians by your will...visualize this.
Now w henever you wish to mobilize yo u r arm y of
guardians...close your eyes...breath deeply and visualize entering
your body...once inside, you m ake invoke, strengthen, an d
increase y o u r arm y of protectors.
82
REFLECTIVE TIME
Focus on the complete sense of peace and relaxation you are now
experiencing. Remember, th a t you can retu rn to this sta te
whenever you wish. As you focus on your breathing...think of the
atm osphere cleansing your body...as you b reath in, your body is
m ade stronger and your guardians are strengthened. Now, I will
count to TEN...after each num ber feel your body and m ind ONE
re tu rn to a refreshed TWO relaxed THREE invigorated state
FOUR. Remember, the healing FIVE th at took place SIX as you
invoked SEVEN your guardian cells. EIGHT, NINE, now open
your eyes and feel a great sense of relaxation, an d invigoration
TEN.
83
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VITA
C hristopher Dale Keene
Birthdate: November 8, 1962

Birthplace: D earborn, Michigan
Education:
1 9 9 1 -1 9 9 6 The College of William & Mary,
Williamsburg, VA.
E ducational Specialist in Professional
Counseling.
Doctor of Education in Counseling.
1982 -1 9 8 8 The Citadel, The Military College of S outh
Carolina, Charleston, SC.
Bachelor of Arts in Psychology.
M aster of Education in Clinical Counseling.
Professional Experience:
1 9 9 5 -P re se n t A ssistan t Director
The C enter for Counseling an d C areer
Planning
Randolph-M acon College
A shland, Virginia
1988-1991 A ssistant Counselor to the Corps of Cadets:

The Citadel Counseling C enter
Charleston, S outh Carolina
1990-1991 A djunct Instructor, Psychology
The Citadel
Charleston, S outh Carolina
91
ABSTRACT
INTERVENTION FOR HIV-POSITIVE INDIVIDUALS
C hristo p h er Dale Keene

The College of William an d Mary in Virginia, April 1996
Chairperson: Victoria Foster, Ed.D.
The purpose of th is stu d y w as to analyze th e efficacy of
im m une system guided im agery in enhancing secretory
im m unoglobulin A (S-IgA) in individuals who are H um an
Im m unodeficiency V irus (HIV) infected. Tw enty-four m ales
from central Virginia diagnosed w ith Stage IV AIDS participated.
All were volunteers and were radom ly assigned to either th e
control or im agery experim ental group. All p articip an ts
com pleted a m edical h ealth questionnaire. The dependent
variable w as S-IgA level in p re /p o stte st saliva sam ples.
Both groups m et for 90 m in u tes to com plete the
q uestio n n aire and receive th e intervention or control condition.
The experim ental group gave a p retest saliva sam ple w hich w as
im m ediately followed by a 25 m inute audiotaped im m une system
guided im agery exercise. The control group gave a p retest saliva
sam ple w ith no following treatm ent. A p o sttest saliva sam ple
w as collected from both groups im m ediately following the
experim ental group's intervention. A second p o stte st saliva
sam ple w as collected from all p articip an ts 14 days after th e first
92
session to determ ine any lasting treatm en t effect on the
experim ental group.
The research design used in th is study w as th e
P re te st/P o stte st Control Group Design. The statisical procedure
employed w as th e analysis of covariance. The Newman-Keuls
m ethod of m ultiple com parisons w as used for p o st hoc analysis.
Two null hypotheses provided th e b asis for testing for significant
difference (a=.05) am ong the experim ental an d control group on
S-IgA m easures. S-IgA level was assayed by radial
im m unodiffusion (RID)
Analysis of the te st d ata revealed th a t there w as a
significant difference betw een the control an d experim ental
group on the p o sttest sam ple collected im m ediately following
th e intervention. No significant difference w as found on the
second p o sttest sam ples collected 14 days following th e
intervention.
Findings suggest th a t im m une system guided im ageiy is
effective in enhancing S-IgA levels in m ales w ith com prom ised
im m unocom petence resulting from HIV infection. T he duration
of the treatm en t effect is unkown.

Guided Imagery As A Psychoneuroimmunological Intervention For HIV

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GUIDED IMAGERY AS A PSYCHONEUROIMMUNOLOGICAL

C hristo p h er Dale Keene

A pproved A pril 24, 1996, by

C harles M atthews, Ph. D.

V ictoria Foster, Ed. D.

To my p a rtn e r Bret Sawyer who h a s been my love an d support.

Secretory IgA (S-IgA)............................................................... 49

Appendix A: Consent Form............................................... 76

2. Hypothesis 1: Sum m ary of Means, S tan d ard

Problem S tatem ent

Specific Research H ypotheses

Sam ple D escription and G eneral D ata G athering P rocedures

T hreats to internal an d external validity are listed below

The literature relevant to th e rationale of th is study falls

HIV/AIDS: Inform ation

HFV/AIDS an d PNI: Researching th e Relationship

HIV/AIDS and Stress

Psychoneuroimmunologv: Theoretical C onstructs and Research

G uided Imagery: Theorectical C onstructs an d Research

M aterials and E quipm ent

Medical History Q uestionnaire

Secretory IgA IS-IgA)

Specific Null H ypotheses

Ethical Safeguards and Considerations

Sum m ary of Methodology

Specific R esearch H ypotheses

An ANCOVA of pretest d ata to the p o sttest d ata collected

Source_________________ df______ Sum of Squares Mean Square F - t e s t _________P value

Reliability Estimates for All treatments: .85 Single Treatment: .59

Group_____________ n________________ Mean______________ Std. Dev.___________ Std. Error

Exp, Posttest 12 129.62 18.70 5.40

Comparison: 3 value: Table

im agery will have significantly elevated S-IgA concentrations two

An ANCOVA of p rete st d a ta to the p o stte st d ata collected

Source_________________ df______ Sum of Squares Mean Square F-test____________P value

Reliability Estimates for All treatments: .89 Single Treatment: .66

Group______________ n_________________ Mean______________ Std. Dev.___________Std. Error

Com parison: value: Table cp

At the 0.05 level of significance:

W hen the Newman-Keuls m ethod of m ultiple post hoc

1. Im m une system guided imagery app ears in th is study to

2. The ability of im m une system guided imagery to

3. Individuals w ith com promised im m une system s

4. An audiotaped intervention ap p ears to enhance

6. Generalizability of resu lts should be limited to

• Aimless playfulness for its own sake

• An active im agination, daydream s, m ental play an d

Im m une system -guided imagery does focus on im agination,

1. It is recom m ended th a t this stu d y be replicated w ith a

It is recom mended th a t research be developed to

It is recom mended th a t longitudinal research using

It is recom m ended th a t h ealth care providers consider

It is recom m ended th a t HIV therapeutic su p p o rt groups

Source_______ df Sum of Squares Mean Square F - t e s t _P value

Group_ n Mean Std. Dev._ Std. Error

Source___ df Sum of Squares Mean Square F-testP value

Group______ n_ Mean Std. Dev._____Std. Error