Optimal Healing Environments: The Next Natural Step

1. Optimal Healing Environments: The Next Natural Step Wayne B. Jonas, MD President and CEO Samueli Institute 10th Annual Force Health Protection Conference Force Health Protection Through Collaboration August 9, 2007

2. Goals of this talk 1. To define healing and a healing-oriented model in health care and compare it with cure-oriented 2. To describe the components that facilitate and stimulate healing in an optimal healing environment 3. To illustrate research on healing and outline future needs for the investigation of healing environments 4. To describe approaches for the application of optimal healing environments for military experiencing medical challenges 5. Don’t lose sight of the miracle of healing.

3. The Lancet V.360 November 16, 2002

4. The Lancet V.360 November 16, 2002

5. The Lancet V.360 November 16, 2002

6. The Lancet V.360 November 16, 2002

7. The Lancet V.360 November 16, 2002

8. The Lancet V.360 November 16, 2002

9. The Success of Biomedicine 1900 Tuberculosis Pneumonia Trauma Influenza 2000 Heart disease Cancer Diabetes Arthritis Depression 2000 (developing countries) HIV Malaria Malnutrition Trauma TB 45 yr 78 yr 39 yr

10. Problems with Biomedicine • Chronic disease and aging • Depersonalization • Technology • Specialization • Cultural dis-connects • Costs • Dissatisfaction with medical care • Patients • Payers • Professional burnout

11. Cure-Oriented Model Specific Cause Paradigm Disease Illness Cause Agent Person Host Outcome Diagnostic Threshold

12. What is the contribution to the human healing process?

14. Disease and Illness InvolveMultidimensional Outcomes Social Measures Psychological & Behavioral Measures Functional & Clinical Measures Biological Measures

15. Healing-Oriented Model Whole Systems Paradigm Spiritual Psychological Social Behavioral Physical Environmental Disease Illness OE Diagnostic Threshold

16. Healing Model Whole Systems Paradigm Spirit Mind Body Spiritual Psychological Social Behavioral Physical Environmental Disease Illness OE IE Diagnostic Threshold

17. Healing Model Whole Systems Paradigm Disease Illness Spirit Mind Body Spiritual Psychological Social Behavioral Physical Environmental Depression Heart Disease Diabetes Cancer Obesity OE DIG IE Diagnostic Threshold

18. Healing Model Whole Systems Paradigm Disease Illness Spirit Mind Body Spiritual Psychological Social Behavioral Physical Environmental Depression Heart Disease Diabetes Cancer Trauma Symptoms Quality of Life Biomarkers Risk Factors OE DIG IE Diagnostic Threshold

19. Consequences of Misapplied Models (A focus on cure when healing is more appropriate) • Interactions and side effects • Lures us into complacency • Depersonalizes the interaction • Favors science over values • Objective measures [e.g. biomarkers] • over the hard to measure [e.g. hope] • Attributional evidence [e.g. RCT, Lab] • over qualitative/associative • Disempowers the patient • do to a person… • do or be with a person… • Separates prevention, treatment, rehabilitation • Encourages high cost • Late intervention • Technology/drug focus • Multiple treatments

20. Consequences of Misapplied Models (A focus on healing when cure is more appropriate) • Failure to cure the curable • Complicates the interventions • Personalizes the disease [e.g. blame] • Favors anecdotes over evidence • Wants over needs • Risks false attribution • Restricts access to care • Readiness • Behavior change • Resources • Medicalization of life [Illich] • Wastes resources/lives • Delayed intervention • Time inefficient • Needs a team approach

21. The Place of Cure and Healing in Medicine Health stimulation Illness Specific Diseases OE IE Wellness DIG Salutogenesis Pathogenesis Health support Disease treatment

24. Healing The physical, mental and spiritual processes of recovery, repair and reintegration that increase order, coherence and holism in the individual, group and environment. Healing may or may not result in cure.

25. Optimal Healing Environment A system and place comprised of people, behaviors, treatments and their psychological and physical parameters. Its purpose is to provide conditions that stimulate and support the inherent healing capacities of the participants, their relationships and their surroundings.

27. OPTIMAL HEALING ENVIRONMENTS Inner Environment (Personal) Interpersonal Environment (Social) Outer Environment (Behavioral) Cultivating Healing Relationships Developing Healing Intention Practicing Healthy Lifestyles Enhance Awareness Enhance Health Habits Enhance Caring Diet Exercise Relaxation Balance Compassion Empathy Social Support Communication Expectation Hope Understanding Belief Applying Collaborative Medicine Experiencing Personal Wholeness Creating Healing Organizations Enhance Process Enhance Integration Enhance Medical Care Leadership Mission Culture Teamwork Mind Body Spirit Energy Conventional Integrative Traditional Person-centered Building Healing Spaces Nature Color Light Artwork Architecture Aroma Music Enhance Natural & Sustainable Structures

28. 1A. Developing Healing Intention Awareness: The habitual practice of attention to the present and its full complexity. Intention: The conscious determination to improve the health of another person or oneself. Expectation: Belief and anticipation of improvement. Hope: The expectation that a desired goal can be achieved.

29. The Washington Post, Nov 22, 2005

30. The Sick Role and Healing • The sick role = dis-empowered • Belief • expectancy in healing • management of intention • Hope • confidence, competence • belief congruency – listening • Meaning • of illness and suffering • what does it mean to recover?

31. From Pain to Self-Awareness • Population was 60 patients with chronic, refractory pain. • A 12-week group program designed to change perception: • the body ‘as a talking subject’ rather than focusing on pain; • the wholeness of participants’ situation rather than pain as either physical or psychological; • using everyday language and ways of expressing themselves; • respecting, seeing, listening and trusting the group participants; • challenging the participants to evoke their internal control rather than use the health care personnel. • A year later the participants had: • an increased awareness of self, • more constructive ways of handling life’s situations; and, • less pain Steen e et al Patient Educ Counsel 2001; 42(1): 35-46.

32. 2B. Experiencing Wholeness Healing Presence A deep emotional presence that enhances recovery and the experience of wholeness. West: the physical and emotional wholeness from which deep personal engagement, caring and communication emerge. East: sometimes conceptualized as “bioenergy”, and is said to be accumulated, stored and transmitted between healer and healee.

33. The Experience of Wholeness Integration of Person Integration of Self • Mind • Body • Emotions • Spirit • Past – Traumas • Present – “Why me?” • Future –Hope, purpose • Connectivity • Coherence • Control • Commitment Hardiness Resilience

34. Effect of Structured Writing by Disease: Asthma or Rheumatoid Arthritis Asthma Forced Expiratory Volume in 1 S, % Predicted Rheumatoid Arthritis Asymptomatic Mild Moderate Severe Overall Disease Activity Smyth, J. M. et al. JAMA 1999;281:1304-1309.

35. Positive Emotional Change: Effects of Self-forgiveness and Spirituality Levenson MR et al. Explore 2006; 2(6): 506.

37. Mind-Body-Energy Practicesand the Relaxation-Response • Yoga • Tai Chi • Bioenergetics • Cranial Sacral • Alexander • Johrei • Polarity • Reiki

38. Mindfulness-Based Stress Reduction Meditation for Early Stage Breast and Prostate Cancer Patients 59 patients with breast cancer and 10 with prostate cancer enrolled in 8-week program that incorporated relaxation, meditation, gentle yoga and daily home practice • Significant improvements in overall quality of life, • Side effects included reduced stress symptoms, improved sleep quality and beneficial changes in hypothalamic-pituitary-adrenal axis functioning • Was this due to increased time and attention? Carlson LE, et al. Psychoneuroendocrinology 2004; 29:448-474.

39. Neural Immune Connections Integrative Neural Immune Program http://neuralimmune.nih.gov/index.html

42. 2A. Cultivating Healing Relationships • Consist of two domains that involve those designated clinical or socio-cultural. • Primary domain is social support and service for the household, family, friends, support groups and community. • Therapeutic alliance: the embodied social and psychological interactions between healer and healee that facilitate healing.

43. Social Support Lowers Cardiovascular Reactivity to an Acute Stressor Change from Baseline (mmHg) Lepore SJ et al. Psychosomatic Med 1993; 55: 518-524.

44. Relationship Effects SPECIFIC Tone and affect of encounter Communication and listening Non-verbal behavior THE EFFECTS OF OUR DOING NON SPECIFIC Intention, attention Mindfulness Healing presence THE EFFECTS OF OUR BEING

45. Effect of Type of Physician Consultation Improvement Thomas KB. Br Med J.1987; 294: 1200-2.

46. Physician Knowledge Affects Outcome Gracely RH. Society for Neuroscience Abstracts. 1979; 5: 609.

47. Developing a Healing Alliance • Self-care – “in a good space” • Compassion and caring skills • Communication skills • Listening, feedback, language, culture • Partnerships and continuity • Person-centered • Relationship-centered

48. The Therapeutic Instrument “… virtually all the doctor’s healing power flows from the doctor’s self-mastery.” Eric J. Cassell, MD, The Nature of Suffering and the Goals of Medicine. 2nd Edition, 2004.

49. 2B. Creating Healing Organizations • Leadership, staff, vision, mission • Organization, team building, payment

50. The Washington Post Health Section 12.12.06