Optimal Healing Environments: The Next Natural Step

Wayne B. Jonas, MDPresident and CEO

Samueli Institute

10th Annual Force Health Protection ConferenceForce Health Protection Through Collaboration

August 9, 2007

Goals of this talk1. 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.

The Lancet V.360 November 16, 2002

The Lancet V.360 November 16, 2002

The Lancet V.360 November 16, 2002

The Lancet V.360 November 16, 2002

The Lancet V.360 November 16, 2002

The Lancet V.360 November 16, 2002

The Success of Biomedicine

1900

TuberculosisPneumonia

TraumaInfluenza

2000

Heart diseaseCancer

DiabetesArthritis

Depression

2000(developing countries)

HIVMalaria

MalnutritionTrauma

TB

45 yr 78 yr 39 yr

• Chronic disease and aging

• DepersonalizationTechnologySpecializationCultural dis-connects

• Costs

• Dissatisfaction with medical carePatientsPayersProfessional burnout

Problems with Biomedicine

CauseAgent

PersonHost Outcome

DiagnosticThreshold

Cure-Oriented Model Specific Cause Paradigm

DiseaseIllness

What is the contribution to the human healing process?

Conditioning

Regression

Bias

Other

Treatment

Environment

Disease and Illness InvolveMultidimensional Outcomes

SocialSocialMeasuresMeasures

Functional &Functional &ClinicalClinical

MeasuresMeasures

Psychological & BehavioralPsychological & BehavioralMeasuresMeasures

Biological MeasuresBiological Measures

Healing-Oriented ModelWhole Systems Paradigm

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

DiagnosticThreshold

DiseaseIllness

OE

Spiritual

Psychological

Social

Behavioral

Physical

EnvironmentalDiagnosticThreshold

SpiritMindBody

DiseaseIllness

OE

IE

Healing ModelWhole Systems Paradigm

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Depression

Heart Disease

Diabetes

Cancer

Obesity

DiagnosticThreshold

SpiritMindBody

DiseaseIllness

OE

IE

DIG

Healing ModelWhole Systems Paradigm

Spiritual

Psychological

Social

Behavioral

Physical

Environmental

Depression

Heart Disease

Diabetes

Cancer

Trauma

Symptoms

Quality of Life

Biomarkers

Risk Factors

DiagnosticThreshold

SpiritMindBody

DiseaseIllness

OE

IE

DIG

Healing ModelWhole Systems Paradigm

1. Interactions and side effects2. Lures us into complacency3. Depersonalizes the interaction4. Favors science over values

1. Objective measures [e.g. biomarkers]over the hard to measure [e.g. hope]

2. Attributional evidence [e.g. RCT, Lab]over qualitative/associative

5. Disempowers the patient1. do to a person…2. do or be with a person…

6. Separates prevention, treatment, rehabilitation

7. Encourages high cost1. Late intervention2. Technology/drug focus3. Multiple treatments

Consequences of Misapplied Models(A focus on cure when healing is more appropriate)

1. Failure to cure the curable2. Complicates the interventions3. Personalizes the disease [e.g. blame]4. Favors anecdotes over evidence

1. Wants over needs2. Risks false attribution

5. Restricts access to care1. Readiness2. Behavior change3. Resources

6. Medicalization of life [Illich]7. Wastes resources/lives

1. Delayed intervention2. Time inefficient3. Needs a team approach

Consequences of Misapplied Models(A focus on healing when cure is more appropriate)

The Place of Cure and Healing in MedicineThe Place of Cure and Healing in Medicine

Health stimulation

Disease treatment

Health support

Salutogenesis Pathogenesis

OE IE

DIGWellness

Specific Diseases

Illness

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.

Healing

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.

Optimal Healing Environment

OPTIMAL HEALING ENVIRONMENTSInner EnvironmentInner Environment

(Personal)(Personal)Interpersonal EnvironmentInterpersonal Environment

(Social)(Social)Outer EnvironmentOuter Environment

(Behavioral)(Behavioral)

Developing Healing

Intention

Cultivating Healing

RelationshipsPracticing Healthy

LifestylesExpectation

HopeUnderstanding

Belief

Experiencing Personal Wholeness

Mind BodySpirit

Energy

Enhance

Aw

are

ness

Enhance

Inte

gra

tion

CompassionEmpathy

Social SupportCommunication

Creating Healing

OrganizationsLeadership

MissionCulture

Teamwork Enhance

Pro

cess

Enhance

Cari

ng

DietExercise

RelaxationBalance

Enhance

Healt

h H

abit

s

Applying Collaborative

Medicine

ConventionalIntegrativeTraditional

Person-centered

Enhance

Medic

al C

are

Building Healing SpacesNature Color Light Artwork Architecture Aroma Music

Enhance Natural & Sustainable Structures

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.

1A. Developing Healing Intention

The Washington Post, Nov 22, 2005

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?

The Sick Role and Healing

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

From Pain to Self-Awareness

Steen e et al Patient Educ Counsel 2001; 42(1): 35-46.

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.

2B. Experiencing WholenessHealing Presence

The Experience of WholenessThe Experience of Wholeness

•Mind•Body•Emotions•Spirit

•Past – Traumas•Present – “Why me?”•Future –Hope, purpose

•Connectivity•Coherence•Control•Commitment

HardinessResilience

Integration of SelfIntegration of Person

Effect of Structured Writing by Disease: Asthma or Rheumatoid Arthritis

55

60

65

70

75

80

85

Baseline 4- mo Follow- up

ControlExperimental

Asthma

Baseline 4- mo Follow- up

ControlExperimental

Rheumatoid ArthritisAsymptomatic

Mild

Moderate

Severe

For

ced

Exp

irat

ory

Vol

ume

in

1 S

, % P

redi

cted

Ove

rall

Dis

ease

Act

ivit

y

Smyth, J. M. et al. JAMA 1999;281:1304-1309.

Levenson MR et al. Explore 2006; 2(6): 506.

Positive Emotional Change: Effects of Self-forgiveness and Spirituality

Mind-Body-Energy PracticesMind-Body-Energy Practicesand the Relaxation-Responseand the Relaxation-Response

• Yoga• Tai Chi• Bioenergetics• Cranial Sacral

• Alexander• Johrei• Polarity• Reiki

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.

Integrative Neural Immune Programhttp://neuralimmune.nih.gov/index.html

Neural Immune Connections

2A. Cultivating Healing Relationships2A. Cultivating Healing Relationships

Consist of two domains that involve those designated clinical or socio-cultural.

1. Primary domain is social support and service for the household, family, friends, support groups and community.

2. Therapeutic alliance: the embodied social and psychological interactions between healer and healee that facilitate healing.

Social Support Lowers Cardiovascular Reactivity to an Acute Stressor

0

5

10

15

20

25

30

Systolic BP

No SupportAloneSupport

Cha

nge

from

Bas

elin

e (m

mH

g)

Lepore SJ et al. Psychosomatic Med 1993; 55: 518-524.

Relationship EffectsRelationship Effects

SPECIFICTone and affect of encounterCommunication and listeningNon-verbal behavior

THE EFFECTS OF OUR DOING

NON SPECIFICIntention, attentionMindfulnessHealing presence

THE EFFECTS OF OUR BEING

0%

10%

20%

30%

40%

50%

60%

70%

Positive Consultation Negative Consultation

Effect of Type of Physician Consultation

Thomas KB. Br Med J.1987; 294: 1200-2.

Imp

rove

men

t

-4

-2

0

2

4

6

8

-10 0 10 20 30 40 50 60

Placebo (PNF)Placebo (PN)

Physician Knowledge Affects Outcome

Gracely RH. Society for Neuroscience Abstracts. 1979; 5: 609.

Developing a Healing AllianceDeveloping 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

The Therapeutic Instrument

“… virtually all the doctor’s healing power

flows from the doctor’s self-mastery.”

Eric J. Cassell, MD, Eric J. Cassell, MD, The Nature of Suffering and the Goals of MedicineThe Nature of Suffering and the Goals of Medicine . . 22ndnd Edition, 2004. Edition, 2004.

• Leadership, staff, vision, mission

• Organization, team building, payment

2B. Creating Healing Organizations

The Washington Post Health Section 12.12.06

Healing Relationships as the Healing Relationships as the Core of Health Care QualityCore of Health Care Quality

The call for “providing patients with appropriate services … with good communication, shared decision making, and with cultural sensitivity” ...

Crossing the Quality Chasm: A New Health System for the 21st Century Institute of Medicine 2001

A Model of Relationship-Centered Organizations

Safran DG, et al. J Gen Intern Med 2006; 21: S9-S15.

Effect of Teamwork on Mortality Risk

• Teamwork model included:• a structured collaborative communication protocol,• daily rounds attended by every team member, • the patient and available family members.

• 56% reduction in risk-adjusted mortality among cardiac surgery patients after introduction of a new “interdisciplinary care team” model

Uhlig PN et al. Joint Comm J Qual Improv 2002; 28: 666-72.

Organizational Dimensions of Relationship-Centered Care

Has an Effect on:

• Reduced mortality• Improved functional health outcomes• Shorter length of stay• Workforce morale and turnover

Safran DG, et al. J Gen Intern Med 2006; 21: S9-S15.

3A. Practicing Healthy Lifestyles 3A. Practicing Healthy Lifestyles ((Behavioral Medicine)Behavioral Medicine)

The employment of adequate amounts and types of exercise, diet, relaxation,

creative outlets, and balancing work and leisure.

Health PromotionHealth PromotionBehavioral MedicineBehavioral Medicine

The Healthy Lifestyle: • Addiction management

• Smoking, alcohol, food, drugs, sex, violence

• Exercise• 30 minutes aerobic 3 X week; strength; balance

• Diet content and amount •Low fat, high-fiber, 5 fruits and vegetable-a-day diet

• Stress management and life balance• work/school-personal life balance • relaxation response for 20 minutes, 1-2 X day

Behavioral MedicineBehavioral Medicine

Success at Lifestyle Change:

Clinical• Requires special training • Family and social aspects

Public health• Worksites/schools• Homes/places of worship• Commercial pressures

Workplace Program Reduces Illness & Healthcare Utilization

Rahe RH et al Psychosomatic Med 2002; 64(2): 278-286.

Health Promotion Health Promotion at the Worksiteat the Worksite

Return on Investment

Comprehensive Programs $3-8 ROIDisease management $7-10 ROIRisk Management $4-5 ROI

Participation?Disease Treatment?

RW Whitmer, et al., JOEM. 45: 2003RW Whitmer, et al., JOEM. 45: 2003

3B. Applying Collaborative Medicine3B. Applying Collaborative Medicine (Integrative Medicine)(Integrative Medicine)

• Conventional Medical Care

• Person-centered Health Care

• Complementary Medicine

• Traditional and Folk Medicine

75%

62%

71%

59%

50%

36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Age-adjusted Percent of U.S. Adults Who Have Used Complementary and Alternative Medicine

NHIS 2002

Ever Used Used in the past 12 months

Any CAM CAM (excluding megavitamins)

CAM (excluding prayer)

Barnes, P.M. et al. Advance Data from Vital Health Statistics. Number 343, May 27, 2004. CDC p.4

CAM: American Use

Interventions:1. Prayer by others2. Prayer for self3. Natural products 4. Breathing exercises5. Prayer groups6. Meditation7. Chiropractic care8. Yoga 9. Massage

10. Diet therapies11. Progressive relaxation12. Guided imagery13. Homeopathic treatment14. Tai chi15. Acupuncture16. Energy healing/Reiki17. Naturopathy18. Biofeedback

NHIS: 2002

Non-mainstream Medicine

• Popular (1997 and 2002)

• 80 % use world wide (WHO)

• 40% of Americans use (50% of women)

• 50-75% of cancer patients; AIDS users

• Paid - $24 Billion out-of-pocket in 1997

• Concealed - 72% don't talk about it to doctor

• Combined - 83% used conventional treatment

Herbs and Drugs Interact

• Anticoagulant and coagulant* activity:alfalfa feverfew poplarangelica fucus prickly ashaniseed garlic quassiaasafoetida ginger red clovercelery ginseng willow barkchamomile horse-chestnuts agrimony*clove horseradish goldenseal*enugreek licorice mistletoe*feverfew meadowsweet yarrow*

Newall, 1996

Quality of Supplements

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10

% o

f Lab

el

1 2 3 4 5 6 7 8 9 10

140

120

100

80

60

40

20

0

Cochrane Collaboration

4. Building Healing Spaces

• Light, air, nature, color, art, music

• Function, flow, privacy and community

Sunny Hospital Rooms Expedite Recovery

In an inpatient psychiatric unit:• Those in sunny rooms had an average stay of 16.9

days compared to 19.5 days for those in dull rooms, a difference of 2.6 days (15%): P < 0.05

In post-operative recovery:• Rooms with windows decrease length of stay by 1

day. (p<0.05)

Beauchemin KM et al. J Affective Dis 1996; 40: 49-51.

Music as a Healing Space• Music can

• promote a sense of well-being and distract patients from pain

• improve mood and decrease anxiety, pain in acute and chronic conditions

• Music may • help premature babies to gain weight• improve depression in the elderly• enhance care-giving behavior

Kemper, K. et al. South Med J 2005; 98(3): 282-288.

Designing the Outer with the Inner and the Inter in Mind

Healing Environmentsin Military Operations

OHE in the Military Setting

• There are no universal metrics for OHE assessment used in the military

• The delivery of OHE in a military settings is likely no better or worse than in a civilian settings. • Recent Walter Reed situation• VA/DoD and PTSD syndrome management

• Outside of the health care system programs for delivery of human optimal performance is active in the military

INTERNAL 1. Mind – Mission and meaning, spiritual care

2. Experience – little formal focus

3. Relationships – Camaraderie and community

EXTERNAL4. Lifestyle - Health Promotion, addiction Rx

5. Treatments – Collaborative, little Integrative

6. Spaces and 7. Places – mission oriented

Examples of OHE Domainsin the Military

Integrative Medicine Emerges in the Military

• CIM, WBAMC, Ft. Bliss

• Chiropractic in VA and Military

• MIL-CAM, VET-HEAL – Samueli Institute

• DARPA, Persistence in Combat

• MIL-PIM – University of Arizona

• Acupuncture

• PMR Departments

• Naval Medical Center, San Diego

• VA – Integrative Medicine Unit, SLC

• DOD-FDA Dietary Supplement Committee

Cultivating Healing Relationships

• Development of a Pilot Study to Develop and Test Improved Communication Training Strategies in the Care of Military Populations• Walter Reed Army Medical Center• Jeffrey Jackson, MD, PhD

• Development of a Military Empowerment Program- a program that would empower families by teaching mind/body practices that could be shared with returning loved ones (injured soldiers) while residing at the Fisher House.  • Walter Reed Army Medical Center• National Naval Medical Center• Mark Chapin, MD

Experiencing Personal Wholeness

• Yoga as an Adjunctive Therapy for Post-Traumatic Stress Disorder: A Feasibility Study • Walter Reed Army Medical Center

Ear Acupuncture for Acute Pain in the ER

0

0.5

1

1.5

2

2.5

3

3.5

Difference in pain betweenpre- and post-ER

Difference in pain betweenpre-ER and 24-hr. follow-up

Acupuncture + standard care Standard care only

Goertz, CM et al. Auricular Acupuncture in the Treatment of Acute Pain Syndromes: A Pilot Study. Military Medicine, 2006;171(10):1010-1014.

P<0.001

P=0.503

Samueli Institute OHE Program(Current Activities)

1. In-depth case studies of eight hospitals and their experiences implementing ‘healing initiatives’

2. Systematic review of the ‘healing-oriented’ literature, looking specifically for cost-value data

3. Environmental scan of hospitals across the country (electronic survey n=2000)

4. “Living Laboratories.” Collaborative relationships with healthcare systems to access and assess health services that measure clinical, professional and economic outcomes of OHE components

Partnership OpportunitiesAHA Health Forum

April 10-14, 2007San Diego, California

“Evaluating Optimal Healing Environments”

Contact InformationBarb Findlay, RN, BSN

Vice President, OHESM ProgramSamueli Institutebfindlay@siib.org

703-299-4800

Organizations with Health Care Quality Initiatives

• The Samueli Institute• The Picker Institute• The Institute for Health Care Improvement• Corporate Health Improvement Program• Robert Wood Johnson Foundation• Bayer Foundation• Commonwealth Fund• The Fetzer Institute• Pew Trust• Planetree• The American Hospital Association• Centers for Medicaid and Medicare Services • The “Medical Home” concept in Primary Care Medicine• “TransforMED” of the AAFP• The Institute for Patient and Family Centered Care • The Agency for Healthcare Research and Quality• The Veterans Health Administration

What is the contribution to the human healing process?

Conditioning

Regression

Bias

Other

The HealingEnvironment

Treatment

AcknowledgementsBarbara Findlay, R.N.

Sita Ananth, Ph.D.

Ian Coulter, Ph.D.

Mike Finch, Ph.D.

Kelly Gourdin

Katherine Smith

William Beckner, M.S.Ronald A. Chez, M.D.

Christine Choate, D.C, Ph.D.

And the innovative leaders of the patient-centered

healing-oriented initiatives