ACTIVITY DISCLOSURES

1. - • ACTIVITY DISCLOSURES • Participants must review this information prior to start of educational activity • ANCC Accreditation Statement • The Maryland Nurses Association is an accredited approver of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. • Criteria for Successful Completion • In order to successfully complete this activity and receive full contact-hour credit for this CNE activity, you must: • Attend in person and fill out the evaluation form at the end of the session and hand it in. • Conflicts of Interest • Was a conflict of interest or potential bias found for any activity planners and/or presenters of this educational activity? • þNo Yes • If yes, identify the individuals and the conflict of interest • Commercial Support • Is this activity supported by an unrestricted or in-kind donation from a commercial interest? • þNo Yes • Joint Provider • Is this activity is activity jointly-provided? • þNo Yes • Date Contact Hours for this activity will expire (for enduring activities only) • Is this an enduring/learner-paced activity? þNo Yes

2. Masters of Subjectivity

3. Vancouver General Hospital Spiritual Care & Multi-faith ServicesDoug Longstaffe .

4. SETTING THE STAGE

5. Meta Theory Base • We are not alone • “If you can grasp and maybe even feel the truth that the mind’s algorithms create all we experience, you’ll know that the same power that makes our hearts beat also animates the world. If so we’ve found our grand unified theory. Dr Robert Lanza p170 Beyond Biocentrism

6. The issue at hand There is overwhelming evidence concerning patient subjectivity as central to the degree of effectiveness related to medical interventions. There is a compelling moral imperative for intentionally assisting patients to maximize this benefit and chaplains are well equipped to address this by virtue of their role and education • .

7. Purpose of the Workshop • To improve patient outcomes. • To provide a strategy for demonstrating the worth of chaplaincy in improving all medical treatments. • To encourage the moral imperative to embrace this cause and implement strategy

8. Why Begin withFaith Hope and Love • Religion and spirituality are largely about belief and faith. Faith is living as if. Faith is belief made active. • Patients cite hope as their first need. Hope creates space for faith as does faith for hope. An attitude of expectancy. Outward focused. • Love - without it we are nothing of value. Bernie Seigle and others have written about the power of love to heal.

9. The Narrative Context • The power of the stories we tell ourselves The power of the stories that we tell others. • A story is usually told from the perspective of the teller but open to interpretation by the hearer.

10. Naming Narrative as a Pathway to the Subjective Aspect of Healing • In this way a chaplains role can be one of a powerful augment to treatment by • Working to transform negative blockages in perception of self – eg unworthy of treatment due to perceived guilt – false or real • Assisting the pt and the team to write a new story

11. The CPE tradition addressing the unconscious in healing • Dr. Gabor Mate speaks of unconscious beliefs embedded in the at the cellular level that control our behaviours no matter what we may think on the conscious level–eg seeing ourselves as all alone – or helpless as never needing help or never deserving help

12. A New Paradigm • When we treat the mind as capable of changing the brain we can treat conditions that were once considered difficult or impossible to treat’ – p150 Mario Beauregard – The Spiritual Brain

13. Or a very old paradigm?

14. The Gilgamesh Creation Epic • The story of the split

15. The Negotiation • after the acceptance of the scientific method in medicine the way potential conflict between Religion and Medicine was handled was largely to take recourse to Greek dualism, so both the church and the medical community became invested in the split between the realm of the spirit and the realm of the physical. There was the spiritual realm and the material realm. As long as each stayed on its own turf there was little problem and each could support the other

16. The Split Meant a loss • The physician provided physical treatment and the clergy provided spiritual care, not therapy. Unfortunately, this neat little division meant that despite a long history of being healers the clergy now gave this role and function over to the “physicians.” If the “doctors” were now physicians, the clergy were now spiritualists or religionists

17. . • When we think of Spiritual health, are we falling victim again to the god of the gaps theory by saying the “Spirit” is that which is immaterial, unexplainable, and unable to be examined by the physical world? The answer for a Hebrew would be unequivocally no

18. .. • If spirituality positively affects physical health, can we really define spiritual health outside of the body? Is it possible to be spiritual without the body? Do you, as the Chaplain live and practice as though the tapestry is together, or has the body gotten the short end of the stick – Longstaffe and Heyn

19. Effect of mood on health • Mortality rates are four times the normal rate in depressed persons, “not so much from suicide as from increased medical illness (63 percent of it cardiovascular disease).” Karren, Mind and Body, Ibid., 161.

20. ENTER STAGE RIGHT • THE PLACEBO

21. What is a placebo ? • Placebo means to please: definition -substance or procedures without specific activity against the condition being evaluated - Karren 487 • What the placebo suggests to us is that we may be able to change what takes place in our bodies by changing our state of mind p486 in Karren

22. Placebo as an agent • A placebo does not usually promise an outcome. It promises to be an effective agent in treating a disease

23. AND NOW FOR A WORD FROM NOT OUR SPONSOR -THE FDA • The more you BELIEVE you’re going to benefit from a treatment, the more likely it is that you WILL experience a benefit. Robert De Lap – head of one of the Food and Drug Administration’s Offices of Drug Evaluation for the USA – quoted from Keith J Karren et al – Mind Body Health p489

24. Is Faith a placebo ? • What then is the healing relationship between faith and a placebo? • Different kinds of healings – some related to medicine some to G-d and some to faith – faith can be in the doctor or in medicine or in ones self or in faith itself. • Doctors regularly ask – will the pt let the medicine work

25. . • Herbert Benson in 1970s after reviewing the literature concluded that the placebo effect was “ closer to 70-90% of the total treatment effect in many cases – total is likely at least around 40% of most treatment and when done in trial the placebos are about 40 -50% effective on average but it depends on many factors such as the type of diSease the type of person etc

26. . • Given mounting evidence that the placebo effect works for some conditions—notably chronic pain and inflammation—researchers and funding agencies are seeking to unravel the mechanisms behind the phenomenon to determine how best to exploit it clinically. The US National Institutes of Health (Bethesda, MD, USA), for example, has made it a priority to identify placebo effects and how they work. - Hunter

27. Neuron Activity • Benedetti and colleagues have also shown that placebos can induce changes in single neurons in the basal ganglia, which stimulate the release of dopamine and thus relieve symptoms of Parkinson disease (Benedetti et al, 2004) in Philip Hunter – A question of Faith. Embo reorts Feb 2007

28. Famous Placebo case • The famous Dr. Bruno Klopfer case –skin lymphoma dissappered twice and returned twice due to the newspaper accounts - p 483 Karren • In some trials even the people who knew they were getting a placebo benefitted

29. Conditioning or Expectation • placebo effects are mediated by expectations when conscious physiological functions, like pain and motor performance, are involved, whereas they are mediated by conditioning when unconscious physiological processes, such as hormone secretion, come into play, said Benedetti

30. Blocking Nocebos • When the Amygdala gets triggered it floods the body with stress hormones that prepare it for emergency – even seeing TV show about a domineering mother can prime your own subjugation schema - - PRIMING MAY BE THE WAY WE EXPEREINCE SCHMAS MOST OF THE TIME - Emotional Alchemy Tara Bennet- Goleman - So chaplain need to ask what may be triggering our patient schemas - others may not notice – we need to lead the way

31. Why clinical placebo trials trump lab trials • Meprobamate drug experiment – one enthusiastic doctor and one skeptic - each totally unaware of which pills were placebos - Meprobamate proved significantly more powerful than the placebo – but only for the who believed in it. There was no drug effect for the skeptical physicians patients. Dossey pp134 -135

32. Different strokes for different folks • Reducers and amplifiers respond differently Karren

33. THE CATALYTIC

34. The Catalytic • It is through the most central aspect of work ie PRESENCE or MUTUAL MINDFULNESS that we offer something different than most if not all of the team. • When combined with our “priestly” role and our ability to ritualize we have a powerful synergistic combination. • Granted, G-d Heals but we need to get the patient’s mind and body receptive to its own healing power and the power of G-d.

35. Why is the transformative encounter important to Faith acting effectively as a placebo? • There is some evidence to suggest that those who are engaged affectively not just cognitively do better with placebos. Karren p424 • The mirroring of PRESENCE or Mutual mindfulness is in itself a healing force.

36. Faith

37. Why talk about placebos?Why not just faith? • Because the placebo effect is accepted as a well documented phenomenon of tremendous healing value • Its acceptance can be a gateway for acceptance of faith as having intrinsic healing power. • We can learn about how faith works from placebo studies.

38. .FAITH IS ALREADY OPERATING AND RITUAL IS ALREADY BEING CONDUCTED

39. Medical Ritual • Dr John Welch has written convincingly of modern medical doctors as equivalent to the ancient healing priests, with clinics as minor shrines– hospitals as major temples. • He documents everything from the clothing worn to the procedures in his comparison. He believes it all creates the context for the placebo effect.

40. How The Doctor Matters • The doctor need to believe in the cure even if it is believing in the placebo. • The doctor needs to relate as a human being who is also in need of healing and forgiveness.

41. For good or for ill • - Dr. Larry Dossey writes of prayer as intrinsically powerful for the good but also potentially a harmful – eg some Voodoo

42. The doctors words • Does he or she have a desire to get better? A will to live? Although it is essential to ask these questions the beliefs of the patient are only one side of the coin. The physician beliefs also shape the outcome of therapy, so it is also vital to examine them in any treatment situation. P 134 Dossey Healing Words

43. THE ETHICS OF IT ALL

44. Two Ethical Considerations • Are we in some way disparaging the power of G-d as healer? • Are we seeking to fool people?

45. ETHICS of NOCEBO • – In principle it is right and proper to give the patient all the relevant information. But a nocebo effect may be accidentally triggered if a patient interprets a long list of possible complications from a treatment as evidence that things are likely to go wrong p 146 -147 Mario Beauregard and Denyse Oleary The spiritual Brain

46. Integrity or Deception • Placebos administered without deception may be an effective treatment for IBS Dr. Ted Kaptchuk Placebos Without Deception et al 2010

47. Integrative Ethics • Principle-ism uses non maleficence , beneficence, autonomy and justice in the context of a reductionist “objective” frame of reference but from a complementary alternative medical perspective autonomy may be overriding other spiritual values – When the whole person is being treated elevating autonomy may make no sense- see Davis E Guinn PhD Ethics and Integrative Medicine – Moving Beyond The Biomedical Model in Alternative Therapies 2001 vol 7 no 6

48. , • This raises the ethical dilemma of whether it is appropriate to lie to patients—either tacitly or explicitly—about the nature of their treatment. It seems that for the placebo effect to work, patients need to believe in the treatment. However, their relationship with the doctor is also critical—if patients have faith in the doctor, then even knowingly taking a placebo could be effective., - Hunter

49. . • perhaps the greatest impact in medical practice will not be in misleading patients with the prescription of inert pills, but through greater transparency, with doctors only administering treatment in which they have sufficient confidence. This, in itself, might generate a placebo effect.- Hunter • RELATES TO THE NEED FOR CHAPLAINS TO BE CONFIDENT IN POWER OF FAITH – WITHOUT THIS MEANING EXACT OUTCOMES – IE THE EXPEREINCE OF THE ILLNESS CAN DEFINITELY BE ALTERED EVEN WHEN THE ACTUAL ILLNESS IS NOT CHANGED - DL

50. The relationship may be everything in some cases • One study titled, Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome found there were no differences between the healing effects of knowing or not knowing the pill was a placebo.