Transcript Healing: The Basic Principles

Creating Stress Resilience
-as Defined by Health Outcomes
N. Lee Smith, MD
Clinical Associate Professor of Medicine
University of Utah
Director, Stress Medicine Clinic
and
Center for Interdisciplinary Medicine
HealthSouth Rehabilitation Hospital
What does stress have to do
with medical illness?
The Most Common Medical
Problems Involve Central Nervous
System Hypersensitivity:
• Irritable bowel syndrome
• Atypical chest pain (and cardiovascular disease)
• Migraine and Tension Headaches
• Fibromyalgia & Myofascial Pain Syndromes
• Anxiety disorders
• Multiple allergies (and auto-immune disorders)
Does stress reduction work?
If so, what are the keys to success?
Stress Management Quiz
Which one of the following has not yet been shown
to have improved outcome by stress management?
1. Myocardial Infarction
2. Rheumatoid arthritis
3. Metastatic breast cancer
4. Hypertension
5. Hip fracture repair
6. Obstetrical delivery
7. Psoriasis
Coronary Events (%)
Comparing Stress Reduction
and Exercise in CAD Patients
30
25
20
15
10
5
0
Usual Care
Exercise
Stress
Reduction
Intervention
Blumenthal JA, et al Arch Int Med 1997;157:2213-2223
Arthritis Outcomes with
Self-Management Training
Design:
•
•
•
•
400 patients with OA and RA
Six 2-hour Sessions
Pain 20%
°
Self
Efficacy
Medical Office Visits 43%
Costs $189 (OA)-$648 (RA)
over 4 yrs
K. Lorig, Arthritis Rheum (1985) 28:680-5.
Medical Utilization
with Depression and Anxiety
100 100
100
90
78
80
70
70
60
Percent
Depressed
or Anxious
56 56
50
40
38
42
% Depression
% Anxiety
30
20
10
0
0 to 5
11 to 20
21 to 30
6 to
10 Visits in the Past Year
Number of Medical
Smith NL, Am.
Psychosomatic
Society Annual
Meeting 1996
Behavioral Medicine Interventions:
Effects on Medical Symptoms and Costs
- High utilizers (>9 visits/yr.)
Variable
Information
Only
Physical Sx
Weekly for 6 weeks
Mindfulness
Meditation
5%
14%
Cognitive
& Experiential
35%
(of 25)
Med. Visits
(6 mo.)
3.9
4.5
( 15%)
5.4
3.8
( 30%)
5.7
1.8
( 68%)
Conclusion: To be effective, the intervention
must be experiential
CJC Hellman, Behav Med, 1990;16:165-173
(p< .001)
Control and Serotonin (5HT) Levels
UCLA Vervet Monkey study
• Dominant male 5HT levels = 2X subordinates
• Remove the dominant male:
– Submissives’ (now in control): 5HT levels rise
– Females cozy up: 5HT levels rise
• Remove the submissives:
– Dominant’s 5HT levels fall
-M. McGuire
Creating Stress Resilience
• Is stress good or bad?
• What makes the difference?
• An important key:
– How much sense of control do you feel in
dealing with it?
Animal Studies:
Cancer Cell Rejection
70
60
Percent
immune
rejection of
the cancer
cells
50
40
30
20
10
0
In Control
No Stress
Victims
-Martin Seligman,
U. of Penn
Four Principles of Stress
Resilience Clearly Related to
Improved Health Outcomes
• A sense of personal control
• A sense of connectedness
• A sense of purpose and meaning
• Hope
Karren K, Hafen B, Smith NL, Frandsen K: Mind-Body Health…
1996 (Allan & Bacon, Boston) and 2001 (Benj Cummmings, S.F.)
The Paradox of Control
• The more you try to take control of the
world out there, the more out of control it
seems
• The more you let go trying to control the
external world,
and instead, respond in a way that you
would deeply admire as wise,
the more personal control you feel
The Process of Control
1. Realize I am responsible for
a. what I give myself and my energy to
(Call it back)
b. how I think and thus respond
(“I am in charge of me.”)
The A, B, Cs of Feelings
A. The situation
(as perceived)
B. Evaluative thinking
(should, forced, threat, worth issues)
C. Response:
feelings + physiological  behavior
The A, B, Cs of Feelings
A. The situation
B. Evaluative thinking
C. Response:
If the response (C) is destructive, then
the causative thinking (B) will be found to:
1. be irrational
2. violate one’s deeper values and wisdom
Creating a Different Response
A. The situation
B’ (new)
B. Evaluative thinking
(should, forced, threat, worth issues)
C’ (new)
C. Response:
feelings + physiological
behavior
The Process of Control
1. Realize I am responsible for how I think
and thus respond
(“I am in charge of me.”)
2. So, how do I want to be?
Disengage from old thinking
(Cognitive & relaxation techniques)
Values clarification
(Meditative and reflective techniques)
3. Visualize being that way
It is as if we have
Two Minds
Operating mind
(thoughts by which to function)
Core, wise mind
(source of core values
and inner wisdom)
lift each other
safe, acceptance
caring
honest, authentic
A truly great relationship
honors needs
humor
create hope
win-win
kind
A Sense of Personal Control
has much to do with integrity to
one’s deepest, wise values
It is as if we have
Two Minds
The key:
How to
transform the
operating mind
to be one with
the wise mind
Operating mind
(thoughts by which to function)
Core, wise mind
(source of core values
and inner wisdom)
High
Sense of
Personal
Responsibility
Forgiveness
Low
= BLAME
Low
High
Negative Emotions
Positive Emotions
(fear, anger, frustration)
(confidence, love, trust)
Sense of Personal Control
Forgiveness is taking back
control of your life:
Being the way you want to be
regardless of another’s actions
A Sense of Connectedness:
• To one’s deepest self
• To other people
• To the larger sources
of one’s power
Is the way I’m handling this
situation:
Connecting us more deeply?
or
Disconnecting us?
A Sense of Purpose and Meaning
• A sense of mission: altruism
• This situation has purpose
– Loving growth
– Understanding crisis as opportunity
Creating Hope
• Visualizing (experiencing) one’s self
handling the situation well,
in accord with wisdom and deepest values
Dealing with Times of Chaos
What gives a sense of control?
–Hope
–Loving support
Stress Resilience
can be learned
It takes practicing experientially
to do so
How to Create a Sense of
Personal Control and Hope
• Conscious awareness
“I can respond as I choose.”
• Relaxation skills:
To let go and get focused
• Clarify deep values
“How do I want to be?”
• Visualizing (experiencing) responding the new way
Four Mental-Spiritual
Principles Highly Associated
with Good Health Outcomes
Summary
Resilience and Healing
has a great deal to do with:
• Empowerment & Forgiveness
(Personal control)
• Caring Love: giving and receiving (Connectedness)
• Transforming and deepening life :
-Understanding the value of its events
• Fostering Hope
(Purpose)
Summary
• Mental stress, depression and anxiety
are highly associated with the most
common medical problem
• Treating the stress issues well (both
medically and non-pharmacologically)
can significantly improve medical
outcomes and ability to function
• The principles of stress resilience and
techniques for implementing them have
been outlined