Publication Date: Wednesday Apr 14, 1999

Prescription hope

Stanford psychiatrist David Spiegel opens the heavy door to a lecture hall at the university's School of Medicine on a March afternoon and sweeps into the room where he is to speak about his ground-breaking research into the effects of psychological stress on illness. The hall is nearly empty. The medical students who accompanied him take their seats in the middle row. Without a trace of hesitation, Spiegel begins setting up his slides, paying little attention to the seemingly sparse turnout.

But there has been a mistake: The correct room is next door, a student tells him. Spiegel packs up his material and moves to the adjoining hall, which is packed with students, doctors and clinicians waiting patiently for his lecture. The audience overflows into the aisles.

Ten years ago, Spiegel's talk might well have drawn only a small audience. Although he was already a leading figure in psychosomatic research and treatment, and in particular an authority on therapeutic hypnosis and reactions to traumatic stress, his work was familiar to a more selective audience. Moreover, one of Spiegel's primary research areas, psycho-oncology--the relationship between the mind and cancer--was considered by many to be on the fringe of mainstream medicine.

Now, all that has changed. Having captured international attention for his cutting-edge research in psycho-oncology and being at the forefront of his profession, Spiegel's work draws crowds from Paris to Hong Kong.

The audience at last month's lecture at Stanford epitomizes what students and doctors have come to expect. Spiegel delivers a flawless lecture. With no notes, he describes his latest research findings and that of his colleagues, illustrating his points with a passage from "Macbeth," as well as drawings and writings from women in his breast cancer support groups. Blazingly articulate, funny and profound, he rips through the complex presentation, which pours out of him like it is an essential part of his being.

"Doctors are closet Cartesians," he says to the assembled group. "They say the mind and body are connected, but the way we practice medicine belies that."

Spiegel catapulted himself to top of his profession following a landmark study he published in 1989 in the distinguished medical journal The Lancet. A 10-year scientific trial demonstrated that women with metastatic breast cancer who received social and emotional support, as well as medical care, had less anxiety and depression than women who did not receive such support.

Even more significant, the women participating in support groups lived on average more than twice as long as their counterparts, a research finding that surprised even Spiegel. Some health professionals consider the results of the study to be among the most important health research milestones of the 20th century.

Cancer is a series of stressors, Spiegel argues; moreover, cancer treatments are often worse than the disease itself. His research shows that patients who express their emotions and take more control over their response to the disease reduce the flood of stress hormones in the body, such as cortisol. By contrast, when patients suppress their emotions, it results in higher cortison levels. These stress hormones starve normal cells and feed cancer cells.

Fellow doctors said Spiegel's findings gave credence to what many in the medical community already suspected.

"Everyone had a sense (emotional support) probably helped, but the fact he was able to show an 18-month increase in survival time really opened up people's eyes," said Dr. Susan Love, a prominent breast cancer surgeon, researcher and author. "It gave credibility to the believers and helped nonbelievers wake up."

Spiegel's research helped pave the way for increased acceptance of support groups as a critical adjunct in the care of cancer patients. Nevertheless, one quarter of women with breast cancer still don't have access to group support, he says.

The message from his research is simple: The medical profession must humanize its treatment of critically ill patients and care for the emotional as well as the physical consequences of the disease. Spiegel is not a subscriber to the belief that negative thoughts cause disease and positive thoughts cure it. Instead, he believes the mind influences how the body and its immune system copes with and fights life-threatening illness.

Those who know Spiegel said he is particularly adept at getting his message out to a wide audience and doing so in a way that's clear to both laymen and professionals.

"David is very passionate about his ideas, and he's able to communicate them clearly and compellingly," says Dr. Catherine Classen, a senior clinician at Stanford's Psychosocial Research Lab. "He's a very good messenger, an ambassador to the public at large. I see that as his greatest gift."

Spiegel has been featured on television news magazines, repeatedly interviewed on national public radio. His research is regularly written up in national and international newspapers and magazines. He was interviewed at length in 1993 by journalist Bill Moyers for the Emmy Award-winning series "Healing and The Mind."

"He's trying to use the attention his research elicits for the benefit of cancer patients and other patients," says Dr. Cheryl Koopman, associate professor of research in Stanford's psychiatry department and project director for the Psychosocial Research Lab's study of support groups for patients with HIV. "His ambition is to influence the way we practice medicine using empirical research. He has really kept his eyes on his goals."

Spiegel's desk in his corner office in the psychiatry department on Quarry Road says it all. One- to 2-foot-high piles of paper cover every square inch of its surface, nearly dwarfing his computer. "His office is a disaster," Classen says. "It's symbolic of the extent to which he's stretched. There's only so much of him." He's taken on so many concurrent responsibilities that he's had only one day off since last Thanksgiving, he says with a sigh. "My patients warn me not to let my whole life become work, to smell the roses, appreciate the trivial, something I try to put into practice in my own life." To cope with his own stress, he runs nearly every morning.

Besides his work with support groups, Spiegel is a professor and associate chair of psychiatry and behavioral sciences at Stanford, where he has been a faculty member since 1975. He is director of the Psychosocial Research Laboratory, which opened in 1990 and studies the interrelationships between psychological distress, external environment and physiological response. In addition, he serves as medical director of the new UCSF/Stanford Complementary Medical Clinic, which offers an array of techniques to help patients better cope with their illnesses, including support groups, exercise, hypnosis, biofeedback, acupuncture, and meditation.

Spiegel says he enjoys the mixture of research, teaching and clinical activity. Moreover, "The questions I'm addressing, how the mind interacts with the body in such a way that it affects the course of disease, is a fundamental and intellectually fascinating problem. I also find it very satisfying to try to help people who are dealing with very difficult life situations. But academic research is a tough business. It's tough and competitive, as it should be. In the long run it's worth it."

Spiegel brings to his work ferocious energy, the unleashed passion of a true believer. (A reviewer for a paper recently submitted by Spiegel to the Journal of the American Medical Association noted that he is "the Michael Jordan of psycho-oncology.") His output is prolific: At age 53, he's written more than 240 research papers and chapters in scientific journals and four books, including the 1993 "Living Beyond Limits."

A textbook, "Group Therapy for Cancer Patients," co-authored with Classen, will be out in the fall. He's also on the editorial boards of 11 journals, as well as series editor for the Progress in Psychiatry Series published by the American Psychiatric Press--51 volumes so far.

His research has helped attract several large grants to the Stanford psychiatry department. He's won scores of awards and fellowships, including The Edward A. Strecker, M.D. Award in 1995 for "outstanding contribution to psychiatric care and treatment" in the United States.

An additional kudo: A 1997 survey by San Francisco Magazine found Spiegel was the first choice of Bay Area physicians if they themselves needed to see a psychiatrist.

Spiegel's wife, Helen Blau, a professor and chair of molecular pharmacology at Stanford, is a powerhouse in her own right. Together they have two children, a 17-year-old son and a 14-year-old daughter.

The hectic pace of Spiegel's life was refected in a recent recollection by Koopman, one of his colleagues at Stanford. She says she has witnessed him talking on the telephone, e-mailing someone, discussing an issue with a staff member who was standing in the doorway, and leading a meeting--all at the same time.

"He's able to give his full attention to a number of different people in such a quick sequence that everyone feels they've been heard," she says.

All his duties, however, never seem to distract him from his most sensitive responsibility: the cancer support groups he leads.

"I know this man cares; he's not just putting in time," says Sheila Moore, a San Jose resident and eight-year member of Spiegel's weekly breast cancer support group at Stanford. The group is part of an NIH-funded 125-person trial attempting to replicate Spiegel's 1989 study that found support groups help prolong life.

Moore has been with the group since its first day and is its longest surviving member. She has beat back not only breast cancer, but brain and spinal tumors.

"With each individual he has a special bonding and relationship," she says. "When we hurt, he hurts. He's a very empathetic person, and he's always been there for me. He's definitely gifted; this is his calling."

Menlo Park resident Jean Nissan, who has been in the same support group for five years, is suffering from metastatic breast cancer and now Parkinson's disease. "He has a deep understanding of how we feel," she says. "I feel honored that he's leading the group."

Spiegel brings back presents for group members from his trips abroad, she says. He gives the eulogies at the many funerals of members who've died. He even took the time to come to Nissan's open house for her new apartment. "He's utterly charming and generous," she says.

So much so, Classen says, that he's quickly accepted as the male leader of all-female support groups. "He's charismatic," Classen says. "It's really amazing how unusually open patients are with him. I mean, how many men can lead breast cancer groups?"

Spiegel's humorous side can also aid in his work. "Two weeks ago, we started talking, as women do, about things totally unrelated to cancer," Nissan recalls. "Dr. Spiegel said to us, 'I've think I've lost control of the group!' and everyone roared. He's very relaxed. We laugh a lot."

But inevitably, the work is painful, Spiegel says.

"While we're helping people live better, which I'm pretty confident we're doing, and helping them live longer, we're constantly bumping up against the physical realities: People die," he says. "Death is a constant reminder of our limitations, and it's hard."

Dr. Irvin Yalom, a renowned Stanford professor of psychiatry emeritus and author of many psychiatric texts including "Existential Psychotherapy," is Spiegel's longtime mentor. He knows from experience that the work can be draining.

"It's hard to deal with a lot of losses and the very poignant kind of anguish people have. David is not only quite sensitive and tactful in how he deals with patients, but he's able to keep his equilibrium."

A really good therapist, Yalom says, has to observe as well as enter into the proceedings. "David has a lot of compassion, but at the same time he can keep the part of the observer."

When asked what drew him to practice psychiatry, Spiegel recalls taking a vocational test when he was 15 or 16. After reviewing his scores, the guidance counselor said to him, "David, you love people.'" Spiegel received his undergraduate degree in philosophy at Yale and his medical and psychiatric training at Harvard. He also had the good fortune to watch his parents, both eminent psychoanalysts, flourish in their careers. His mother, feminist analyst Natalie Shainess, has written some 80 papers as well as the book "Sweet Suffering." His father, Dr. Herbert Spiegel, was a clinical professor of psychiatry at Columbia University and a pioneer in the use of hypnosis in clinical practice. Spiegel loved to watch his father's hypnosis course at the university; "Dad's course was legendary at Columbia," he says.

Father and son partnered in writing a seminal textbook on hypnosis, "Trance and Treatment," published in 1978. The younger Spiegel had just finished his residency. "Here I was, striking out on my own, and the first thing I do is write a book with my father," he says laughing. After a moment of hesitation, he realized that a "fantastic opportunity" had been offered to him. He has carried on his father's work, studying the medical and therapeutic uses of hypnosis and self-hypnosis, and is currently conducting a large prospective trial on the usefulness of self-hypnosis on stopping smoking.

His parents loved their work, Spiegel says, and they undoubtedly influenced his choice of profession, but, he adds, they never pressured him to follow in their footsteps. "My parents told me I could be any kind of psychologist I wanted to be," he says jokingly to a group of psychiatric residents. In school, he found himself drawn to "the psychology of how things happen, in literature, history, political science, philosophy; the fundamental issues of how people think and feel."

Amazingly, he recalls, Anna Freud, the daughter of Sigmund Freud, invited him when he was a young man to meet with her after he had written her a letter. "I felt an instant bond with her, stronger than I've felt with anyone," he says.

What sets Spiegel apart, say his colleagues, is his wide range of interests. "He has an exceptionally good mind," Yalom says. "He's well-informed and educated far beyond the medical sciences, which is unusual for someone in the medical field. The first time I saw him, he was giving a talk on stopping smoking through hypnosis, and he referred to Hegel. I was very impressed with his talk; I saw exceptional promise."

Spiegel was asked to help lead Yalom's breast cancer groups two decades ago and "rapidly became extremely contributory and took on major responsibility," says Yalom. "There were few such programs offered at the time, but he realized the support groups had great potential."

Spiegel's work with support groups now goes far beyond just women with breast cancer. He also supervises groups for men with prostrate cancer and people with HIV. In addition, the lab he runs is conducting research on survivors of childhood sexual abuse.

His study of traumatic stress includes research papers on several natural disasters, including the 1989 Loma Prieta earthquake and the 1991 Oakland/Berkeley fire. He's explored the response of journalists witnessing an execution; the fatal shooting of several lawyers and others at 101 California St. in San Francisco a few years ago; the effect of news coverage on children after the Polly Klaas kidnapping; and trauma suffered by Vietnam War veterans.

One of Spiegel's expertise is the process of dissociation--when the mind removes itself psychically from a traumatic situation to protect itself from experiencing the enormity of the event. Such distancing may work in the moment, but afterward the person is often unable to integrate the event back into his or her consciousness. If left untreated, the traumatic event can continue to plague the survivor and impair the ability to function in a healthy way.

The symptoms of dissociation--including a sense of detachment from the body, numbing, dreaminess and an inability to relate to others--has been shown by Spiegel to often lead to a condition called post-traumatic stress disorder. He helped create a new diagnostic category called Acute Stress Disorder and renamed multiple personality syndrome to more accurately reflect the condition: Dissociative Identity Disorder.

Three defining moments helped shape Spiegel's philosophic outlook. One was the 1968 Democratic National Convention in Chicago, where police stormed and brutally clubbed angry Vietnam War protesters. Spiegel, then a 23-year-old medical school student, was wearing a white coat and serving as an on-site medical aide. His medical attire didn't stop the police from clubbing him along with the other protesters, whose opposition to the war he deeply shared. After the violence ended, Spiegel recognized a greater issue: "I was struck with the danger in a social environment when a powerful group abuses their power," he says. "I learned not to take anything for granted, to question everything."

The second moment came a few years later when Spiegel was a third-year medical school student. He hypnotized a 16-year-old asthmatic patient who was unresponsive to medication, frightened and in distress. "He was bolt upright, white-knuckled and wheezing audibly," Spiegel recalls. After the hypnotism, the patient relaxed and began breathing easily again.

A nurse who was informed of what Spiegel did filed a complaint that he had hypnotized a patient without parental consent.

"I told her, 'You can take me off the case and put him back on steroids, or ask the patient what he thinks is best,'" Spiegel recalls. The nurse relented, and the patient, who had previously visited the hospital ever three months, learned self-hypnosis. To Spiegel's knowledge he has never returned. "Anything that could help a patient that much and frustrate a head nurse to the point where she violates nonexistent medical law had to be worth looking into," he says. "It taught me the power of the mind-body connection."

The third moment was discovering, to his amazement, that women lived longer if they participated in an emotionally expressive and caring breast cancer support group. There, the patients are encouraged to face fears of dying and death directly. They bond with each other and rally together to fight depression and the great isolation brought about by serious illness. (They use "battlefield humor," says Spiegel.) They reorder life priorities and are encouraged to express the full range of their emotions. They learn to better manage their relationships with family, friends and physicians, and to control pain and other symptoms through self-hypnosis.

"They learn to parse death into a series of problems they can handle," Spiegel says. "Patients most often are more worried about the process of dying than of death itself. It's not about false optimism, but realistic optimism. . . . It's not about having hope, but having hope for what?"

Rennie Wilsnak, a Palo Alto resident and five-year member of Spiegel's Stanford breast cancer support group, refused to be intimidated by her illness.

"I decided to live my life and not my cancer," she says of her 10-year long battle with the disease. "Sometimes I think being in the group is my reward for getting breast cancer, it's so important to me. It's sort of like going to graduate school. And I'm contributing to medical research."

Wilsnak says there's no guarantee that the results of Spiegel's first study in 1989 into the effectiveness of support groups will be duplicated in the current study. "I think it improves the quality of life, and that's where it's at," she says. As far as Spiegel, "We love him, he's great," she says. "He's a man of compassion, insight and vision. And he's our friend. I know he's a famous man, he deserves all that, but he's our friend."

Even if the results are different, the members of Speigel's support group say the groups have become extremely important parts of their lives.

"If you feel like you're not just taking from people but giving too, then you feel like a productive person, which is very important to your sense of well-being," says longtime group member Sheila Moore. "I feel honored to be involved in something like this. If I can help one person I feel like I've done something big."

In about two years, the results of Spiegel's new trial will be in. In addition, another independent multi-center replication trial is being conducted in Canada with 225 women with advanced breast cancer.

"I'll be a lot happier if we find the survival effect (again)," he says. "But if we don't, I want to publish a clear answer to a scientific question."

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