Where Today is Tomorrow in Health Care

Comparing two worlds of feelings using biofeedback (DISPROF - logical world & EMOTE - picture world). Education, 113(4),520-531.

Cassel R.N., Costello, B.R., and Pullar, B.M. (1993).

"There are two worlds: the world that we can measure with line and rule, and the world we feel with our hearts and imagination."
--Lehigh Hunt

In Client Centred Counselling as taught by Carl Rogers (1942), we learned about the importance of one's feelings in relation to health care. Here the person becomes the focus, as opposed to the problem, and feelings are believed to be the central feature of all human behaviour.

"We come now to a consideration of what many would regard as one of the central feature of any type of therapy; the release of feelings. Certainly one of the significant goals of any counselling experience is to bring into the open those thoughts and attitudes, those feelings and emotionally charged impulses which centre around the problem and conflicts of the individual ... This newer therapy endeavours to work as directly as possible in the realm of feelings and emotion rather than attempting to achieve emotional reorganisation through an intellectual approach."

It is clear, of course, that people live in many different worlds and that these worlds are often in a continuous state of change. The perceived world is the thinking and logical world. A world that for years we have been able to measure with line and rule. Now with improved technology and computers we are able to measure the hidden worlds of feelings in a similar manner. The present study seeks to give evidence towards such a promise.

Endogenous Opioids and Feelings

The feelings of individuals may be traced directly to the endogenous opioids and one's endocrine system. The reticular formation of the brain working in conjunction with the pituitary gland and hypothalamus (limbic system) play a major role, and where one's own personal expectations serve as the primary mover (Cassel, 1989). Dr. David S. Goldstein, The National Institute of Health, (1990) explains that the endogenous opiod system is intimately connected physiologically to the CRH-pituitary adrenalcortical and adrenal medullary systems. Here the enkephalines (related to pain) play a primary role clustered largely in the dorsal columns of the spinal cord. The highest concentration of the b-endorphins (related to pleasure) are in the pituitary gland. The CCK (related to food satisfaction) are in the stomach. Then dopamine (basis of sensitivity to reward and punishment) is in the white blood cells. It is from clusters of such neurotransmitters that our feelings are generated, and a molecular code links emotions, mind and health (Hall, 1989).

Neural Functioning

Because opioids derive exclusively through an electrical discharge from select nerve endings, the product of their activity is referred to as one's "neural system." Neural, of course, because it derives from nerves. A characteristic element of all opioids is the possession of antennas or receptors with which they communicate directly to specific parts of one's brain. While these antenna or receptors often require a catalyst necessary for the communication (for example, zinc for the enkephalins), the communication is direct and by passes the control of the reticular formation in limbic system; traditionally thought to control all entrance to one's brain (Cassel, 1989). It is now clear that white blood cells have qualities in common with the brain (Hall, 1989).

"Then Pert and her NIMH collaborator, Michael Ruff, discovered the same thing: white blood cells were equipped with the molecular equivalent of antennas tuned specifically to receive messages from the brain."

Gut Feelings

The first of such peptides ever discovered, too often overlooked in the health care arena, are the acetylcholines associated with the parasympathetic system. They were first identified by Loewi in a series of brilliant experiments in the early 1920s, and for his work he shared the Noble Prize in Physiology of Medicine in 1936. It stimulates digestive processes and gut mobility; increases salivation; increases sweating; and decreases heart rate (Goldstein, 1990). It serves as the nucleus for our 'gut' feelings.

Where Feelings are Born

It is from clusters of such peptides that our feelings are generated, and which appropriately is referred to as our neural functioning. Regulation and harmony in the neural functioning helps us understand the connection between state of mind (feelings) and state of health (Hall, 1989).

"The discipline travels under various aliases-'psychoneuroimmunology' is perhaps the best known of several tongue-tieing alternatives. The informational substances, many of which are known to have a powerful effect on mood and emotion, provide a molecular way to understand the long-suspected connection between state of mind and state of health . . . Pert, Ruff and their colleagues, then of NIMH, theorised about a "neuropeptide and psycho-somatic network," where the mind and body constantly chatter back and forth using a vocabulary of biochemicals, the detectable results of which is the full range of human emotions."

Biofeedback Instruments

Four different biofeedback instruments interfaced with a computer have been designed to measure change in the two hidden worlds (Cassel TRI-BI-SENSOR). One's functioning in these hidden worlds of feelings is somewhat analogous to that of a symphony orchestra, and where the four different feelings being assessed represent the musical instruments. Harmony of the orchestra is based on feelings where one's cultural expectations always involve the presently perceived situation, i.e., wedding, fiesta, funeral, sports event, etc.

Electromyograph-EMG

The EMG, as one of four biofeedback instruments, seeks to deal with tension in the skeletal muscles, and the degree of harmony and rhythm in relation to bodily movements. This ranges from that of a wrestler or football player to the ballet dancer or actor on the stage. Rhythm and timbre are major components in determining harmony.

Galvanic Skin Conductance-GSR

The GSR, as the second of the four biofeedback instruments, deals with one's emotional feelings, ranging from deep depression to high elation: Always it involves an affective state of an individual where love, hate, fear, joy, sorrow and the like are being experienced for a particular moment of time. The harmony of such feelings must always be reckoned in relation to the expectations of culture embraced by person involved, and not by that of another culture, or value system.

Pulse Rate-PULSE

The pulse meter, a third biofeedback instrument, measures pulse rate which is created largely on the basis of one's perceived stress load, real or imagined. Often the imaginary stress serves to create a greater burden than the real. Stress, of course, as Selye described it is both bad and good. It is good to the degree that it serves to facilitate one's goal progress, and bad where it serves to inhibit such goal attainment and success.

Good stress promotes harmony in the feelings of individuals; while bad stress fosters disharmony.

External Temperature-TEMP

A thermistor, the fourth biofeedback instrument, is used to measure change in temperature of one's finger. The temperature of one's finger at waist level tends to be about 92 degrees F. For persons diagnosed with Type-A personality this temperature tends to be 80 degrees, or 70 degrees, and even sometimes as low as 65 degrees F. When the temperature of the finger gets colder under normal temperatures, it is because of a decline of blood flow to that area. The reason for such decline in blood flow is related to the triggering of the sympathetic syndrome, where the individual is prepared to devour his/her enemy. It is here where the blood is directed to the vital organs, and which results in the decrease in blood flow to the fingers. Typically, of course, this means that the persons is in a self imposed emergency state.

Life Space Areas

The same twelve different areas of one's life space have been used for each of the two worlds (DISPROF and EMOTE) to insure full coverage in the assessment of changes taking place:

1. Home & Family.
2. Religion & Inner Development.
3. Social and Affiliation.
4. Security & Law.
5. School & Learning.
6. Romance & Psychosexual.
7. Sports and Risk Taking.
8. Health and Safety.
9. Travel & Relaxation.
10. Aesthetics & Beauty.
11. Money & Productivity.
12. Survival & Pollution.

DISPROF, the World of Logic (Discovering Great Moments) This world is created by use of "Guided Imagery" with cognitive structure. For each of the 12 area of one's life space as described above (Home and Family, Religion and Inner Development, etc.) four different questions are asked the individual. The first two are symbolic of the area involved, with the first being positive and the second negative:

1. Is your home warm and friendly?
2. Is your home broken by death or divorce?

The second two questions are always personal, with the first being positive and the second one being negative:

1. Did your mother hug you as a child?
2. Did some members of your family dislike you?

All questions are answered in secret to self, and only the feelings of the four neural areas measured by the four different biofeedback instruments are recorded by the computer.

To increase personal motivation and make the situation seem more real, the individual is shown changes in the four neural areas on the computer monitor screen. An "E" is used for EMG, "G" for GSR. "T" for TEM, and "P" for pulse. The higher on the screen, the greater the neural function. Ale "'1"' is reversed- The GSR is re-set to median for each new area of the life space (Home and Family, etc.). It is this display of change that is intended to add face validity to the assessment, and to increase the personal motivation for subjects involved.

Factored Clusters

Based on a principal component factor analysis 14 independently organised factors were identified; one of which was bipolar (this for an earlier study involving 216 typical individuals) (Cassel, 1992a). A K-Mean cluster analysis was accomplished to further identify the 14 different clusters used for interpretation of DISPROF of individuals involved.

Interpretation

The interpretation for DISPROF is based on from 1 to 4 of the following clusters, depending on the individual involved. Clusters based on general factor loadings tend to be more immature; as opposed to those associated with one or more life space areas. This except for two or three highly related life space areas, i.e., HOM (home), SOC (social), and AES (aesthetics), for example.
CLUSTER I-Perceived Stress Load general increased PUL -satisfaction derives from heavy responsibility.
CLUSTER II-Perceived Tension -increased EM (skeletal muscle tension) -satisfaction derives from kinesthetic muscle activity for communication.
CLUSTER III-Emergency State -colder finger TEM (temperature) -satisfaction derives from working at peak performance.
CLUSTER IV-Home Association home area yields high GSR (emotions) - satisfactions found in home and family.
CLUSTER V-Survival Threat -survival yields high GSR -emotions associated with survival and pollution.
CLUSTER VI-Security Plan -security yields high GSR -feeling secure and prepared for future.
CLUSTER VII-Education Plan -education yields high GSR -satisfaction associated with educational efforts.
CLUSTER VIII-Social Status -high scores on EMG for SOC, REL, HOM, & SUR.
CLUSTER IX-Event Anticipation -high scores on INIGSR (GSR taken before DISPROF is begun).
CLUSTER X-Sports Affiliation -high GSR scores on SPO.
CLUSTER XI-Romance and Psychosexual -high GSR on ROM.
CLUSTER XII-Economic Plan -high GSR scores on MON
CLUSTER XIII-Travel Plans -high GSR scores on TRA.
CLUSTER XIV-Religion & Social high GSR scores on REL and SOC.

EMOTE, the World of Pictures (Discovering Hidden Needs) The EMOTE world is created by use of "guided imagery" where pictures carefully selected to portray each of the same 12 areas of the life space as for DISPOF. They are in the form of slides that are projected on the screen, one at a time, and remaining for precisely 10 seconds of time. During this period the individual is asked to rate each slide in secret on a 10 point scale as to the degree to which it has personal appeal; with 10 being most appealing and 1 least. The 4, 5, and 6 ratings being for slides that are mediocre in terms of appeal. While the individual is rating each slide, the four biofeedback instruments (GSR, EMG, TEM, & PUL) record change taking place during the rating process. To enhance the motivation of subject taking EMOTE, the biofeedback ratings are displayed on the computer monitor in full view of subject, and are the same as described for DISPROF.

Factored Clusters

A principal component factor analysis was computed with 0.5 eigen values, and varimax rotations. Fourteen independently organised factors were extracted, with one of them being bi-polar in nature (Cassel, 1992b). There were 230 typical subjects used.

The interpretation of EMOTE is based on from 1 to 4 clusters, and depending on the individual involved. Again as with DISPROF, the more general the factor loading the less mature the feeling.

CLUSTER I-Perceived Stress -high PUL scores in all areas.
CLUSTER II-Skeletal Tension -high EMG score in all areas.
CLUSTER III-Emergency State -high TEM scores in all areas.
CLUSTER IV-Social Status -high GSR scores in REL, & SOC.
CLUSTER V-Security Plan -high GSR scores in SEC.
CLUSTER VI-Survival Threat -high GSR scores in SUR.
CLUSTER VII-Aesthetic Grandeur high GSR scores in AES.
CLUSTER VIII-Event Anticipation high INIGSR scores.
CLUSTER IX-Economic Threat -high GSR scores in MON
CLUSTER X-Travel Aspirations-high GSR Scores in TRA.
CLUSTER XI-Romance & Psychosexual -high GSR scores in ROM.
CLUSTER XII-Sports Involvement high GSR scores in SPO.
CLUSTER XIII-Home Satisfaction high GSR scores in HOM.
CLUSTER XIV-Moderate Emotions none of the neural scores high; all in moderate range.

Group Involved in Study

The study involved 110 typical individuals who volunteered to take DISPROF and EMOTE. There were 48 females ranging in age from 19 to 42 years with a mean (M) age of 42.33 years, and with a standard deviation (SD) of 15.72 years. Sixty-two of them were males ranging in age from 18 to 81 years, with a M age of 39.36, and a SD of 15.50 years.

Two Hidden Worlds

The two hidden worlds of feelings involved in this study have been created by use of "guided imagery." For one world the guided imagery involved logical reasoning; while for the other it made use of pictures.
1. DISPROF-created using guided imagery with logic, and
2. EMOTE-created using guided imagery with pictures.
DISPROF, of course, is dominant brain based, yet non conscious in nature (if it were unconscious it could not exist). It must be considered to be kin to "free association," determined in an earlier study to be the greatest contribution to society in the first half of the 20th century (New York Times, December, 1949). The EMOTE WORLD, on the other hand involves the non dominant brain where the home of "experience based" learning resides. It too is non conscious in nature, largely because of the veto power of the dominant brain. It is there where the emotional scars and memories of past crisis states and failure are stored, but also the haven of memories related to accomplishments and successes.

Factor Analysis Validity

This study is concerned with determining the degree to which DISPROF and EMOTE, two hidden worlds of feelings, are the same or different. There are 49 different physiological measurements made by biofeedback instruments interfaced with a computer in each world; a total of 98 different measures in the two assessment programs.

Principal components factor analysis is a most rigorous Scientific statistical method to determine the degree of overlap of such variables; the degree to which they might be measuring the same things. K-means cluster analysis is an equally and often complementary statistical technique to ascertain nature of clusters and degree to which persons are distributed therein. Discriminant statistical analysis is designed for use in blind prediction of two separately well defined entities such as DISPROF, and EMOTE. All three of these statistical procedures have been used to validate the independence of the two worlds referred to as DISPROF and EMOTE.

Factor Validity

The data contained in Table 1 describes in some detail the presence of 15 independently organised factors as contained in DISPROF. The identity loadings are generally high and conclusive (700 to 900 range); while there are a very minimum number of distracters present (factor loadings of 300 or better). Similar data contained in Table 2 depicts 14 independently organised factors contained in EMOTE.

Finally in Table 3 a principal component factor analysis was computed for DISPROF and EMOTE combined, all 98 variables. The presence of 26 independently organised factors is highly scientific evidence that DISPROF and EMOTE are assessing different phenomena. It means, of course, that we are clearly dealing with two different hidden worlds of feelings when using DISPROF and EMOTE. The more precise nature of these two hidden worlds is the further subject of this paper.

Factorial Validity

DISPROF and EMOTE each possess 49 variables representing biofeedback assessment of neural functions. Each one of these variables is ordered to a standard-like scale (all having same range) ranging from 20 to 80. This means that GSR, EMG, TEM, and PUL all range from 20 to 80, and all have a positive sign. The TEM is reversed; so that the higher the score the colder the finger. Physiologically each one of the biofeedback instruments is, of course, measuring a different and separate physical or neural function. The question posed in factorial validity is how many independently organised psychological factors are being assessed? In order to answer this question a principal components factor analysis was computed. To assure independence of organisation 0.5 eigen values were assigned. And to better understand the nature of factorial content, varimax rotations were used.

DISPROF Factors

Fifteen different independently organised factors were derived, with Factor VI and XII being bi-polar (two factors). The identity of the 15 factors showing the percentage of variance accounted for is contained in Table 1 below. Except for Factor 1 - the General PUL factor, no significant distracters were evident in either of the 15 factors (it included a GSR loading of 300 or better). The absence of distracters in the 15 factors supports the presence of psychological purity of the 14 clusters used for interpretation of DISPROF (one more factor than the earlier study) (Cassel, 1992a).

Table 1
Identity and Percent of Total Variance Accounted for
by Independently Organised DISPROF Factors
Number	Identity	%age of Variance
FACTOR I	General PUL (pulse) - positive factor.	22.094
FACTOR II	General EMG (tension) - negative factor.	21.320
FACTOR III	General TEM (sympathetic) positive factor.	24.809
FACTOR IV	Principal SEC/GSR (security/emotion) as positive factor.	2,566
FACTOR V	General GSR (emotion) as positive factor (MON, TRA, and SCH).	3,941
FACTOR VI	Bi-polar factor with HONVGSR (Home/emotion) as negative, and
FACTOR VII	HEA/GSR (health/emotion) as positive factors.	2,538
FACTOR VIII	General SUR/GSR (survival/emotion) and SCH/GSR (school/emotion) as positive factor	2,648
FACTOR IX	Principal ROM/GSR (romance/emotion) as positive factor.	2,403
FACTOR X	Principal PEL/GSR (religion/emotion) as positive factor.	2,587
FACTOR XI	Principal AES/GSR (aesthetics/emotion) as positive factor	2.185
FACTOR XII	Bi-polar factor with INIGSR (initial/emotions) as negative., and
FACTOR XIII	SO C/GSR (social/emotion) as positive factors.	2,656
FACTOR XIV	Principal SPO/GSR (sports/emotion) as positive factor.	2,356
FACTOR XV	General EMG (tension) as negative factor (SOC, REL, SUR, and HOM).	1,420

EMOTE Factors

Fourteen independently organised factors were extracted from EMOTE, with VIII being bi-polar in nature. The rather unusual aspect of this study is that 2 of the 14 factors obtained similar identity loadings as the General Pulse Factor, Ill and VII.

There was good agreement with a similar study accomplished using 230 adult persons about equally divided for sex (male and female) (Cassel, 1992b). The same number of independently organised factors were extracted as with this study, except that two of the factors were bi-polar as opposed to one for this study:
1. Six of the 14 factors extracted were precisely the same as for the earlier study, and to include the signs, except for Factor X, the INIGSR.
2. All factors in present study were accounted for in the earlier study, except they were arranged differently for the 8 other factors.

Combined Factor Structure
(DISPROF & EMOTE)

In as much as both DISPROF and EMOTE use the same 12 life space areas, and the swne biofeedback instruments, factor analysis was used to determine the overlap for kinds of feelings involved. This, of course, means both nature and intensity. It is abundantly clear from the 26 factors extracted that DISPROF and EMOTE are independently organised, and two different worlds.

Discerning Validity Statistics

An evaluative instrument is valid to the degree to which the scores discern between variously defined populations. It is clear that the sex (male/female) of individuals represents such a well and acceptably defined group of individuals. A t-statistics was computed for each of the many scores contained in the data bank involved in the study. The principal elements contained in that data bank, of course, are the 49 scores for DISPROF and EMOTE separately and collectively.

Male and Female Differences for DISPROF

The significant differences between male and female individuals of the study based on a t-statistics between the means on each of the scores for DISPROF are as follows:
1. More males married than females 0.0 1 8.
2. Females greater SURVIVAL-GSR-DISPROF 0.012 (more concerned about survival)
3. Females greater on EMG-DISPROF at 0.05 10/12 times; Sign Test favours females 12/ 12 and is significant 0.01 level (females display greater EMG)
4. Males favour TEM-DISPROF on Sign Test 12/12 -significant 0.0 1 level (males display greater TEM).
5. Males favour PUL-DISPROF on sign test 11/12 - significant 0.002 level (males display greater PUL).
6. Females favour greater INIGSRDISPROF at 0.000 level (females enter activity with higher GSR).
7. Females have greater number of CLUSTERS-DISPROF with significance at the 0.025 level.

Male and Female differences for EMOTE

The significant differences between male and female individuals of the study based on a t-statistic between the means on each of the scores for EMOTE are as follows:
1. Males have greater concern about health on GSR-EMOTE with significance at 0.002 level.
2. Females have greater concern about survival on GSR-EMOTE with significance at 0.003 level.
3. Females have greater EMG-EMOTE levels at 0.05 level or better 11/12, and Sign Test favouring females is 12/12 times with significance at 0.001 level.
4. Males have greater TEM-EMOTE at 0.000 level 12/12 times (males have greater TEM-EMOTE than females).
5. Males have greater PUL-EMOTE at 0.01 level 5/12 times, and Sign Test on PULEMOTE 12/12 times with Significance at 0.001 level (males greater PUL-EMOTE than females).
6. Females have greater INIGSR-EMOTE with significance at 0.000 level.
7. Females have greater number of CLUSTERS-EMOTE with a significance at 0.0 1 level.

Married and Not Married for DISPROF

There were 46 persons in the 110 members that were married, and 64 who were not married. A t-statistic was computed for means of each of the scores between DISPROF and EMOTE with significant findings as follows:
1. More of the 110 were not married than married - 64 were not married, and 46 were married.
2. Not married had significant higher AESTHETIC-GSR score than married - 0.042.
3. Married had significantly higher MONEY-GSR scores than the not married 0.001.
4. Not married had significantly higher SURVIVAL-GSR scores than married 0.007.
5. Based on the Sign Test 11 / 12 means for TEM favoured not married individuals - 0.003.

Married and Not Married Differences for EMOTE

Mean scores that were statistically significantly different between not married and married persons for EMOTE are as follows:
1. Four of the GSR-EMOTE scores were statistically significantly different between married and not married, at the 0.05 level or better; all were higher for married persons in SOC (social), SEC (security), SCH (school), and MON (money).
2. Based on the Sign Test 11/12 of the GSR scores favoured the married persons; so GSR is statistically significant in EMOTE for married folks - 0.003.
3. Based on the Sign Test 12/12 EMG scores favoured married persons with statistical significance at 0.00 1 level of confidence.
4. Based on the Sign Test 11/12 TEM scores favoured non married persons - 0.003.
5. Married persons tended to have a significantly greater number of clusters than non married ones - 0.0 1 8.

Independence of DISPROF and EMOTE

A t-statistic was computed between each pair of scores for DISPROF and EMOTE to establish further their independence of organisation. The data contained in Table 4 below is a summary of those findings. The findings suggest the following:
1. DISPROF tends to have significantly higher GSR scores for HOM (borne), MON (money), SUR (survival), and INIGSR (initial GSR).
2. EMOTE tends to have significantly higher GSR scores for TPA (travel).
3. EMOTE tends to have significantly higher EMG scores in 9 of the 12 life space areas, but all EMG scores are higher than corresponding DISPROF ones, 12/12 Based on the sign test, EMG scores are significantly higher than corresponding scores on DISPROF.
4. DISPROF has no TEM scores that are statistically different from corresponding EMOTE scores, but all 12 DISPROF scores are higher than corresponding EMOTE scores. Based on the sign test of 12/12 DISPROF TEM scores are significantly higher than corresponding EMOTE scores.
5. DISPROF has all PUL scores for the 12 life space area significantly higher than for corresponding EMOTE scores. Therefore, DISPROF tends to have significantly higher PUL scores than EMOTE.

Blind Prediction using Discriminant Function

A statistical discriminant function was accomplished for purposes of predicting blindly the DISPROF and EMOTE scores for the 110 members involved in the study. The data contained in Table 5 displays the success of the blind predictions and is highly statistically significant.

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