Optimal Healing Environments: The Next Natural Step

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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

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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. Dont lose
sight of the miracle of healing.
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The Lancet V.360 November 16, 2002
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The Lancet V.360 November 16, 2002
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The Lancet V.360 November 16, 2002
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The Lancet V.360 November 16, 2002
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The Lancet V.360 November 16, 2002
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The Lancet V.360 November 16, 2002
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The Success of Biomedicine
1900 Tuberculosis Pneumonia Trauma Influenza
2000 Heart disease Cancer Diabetes Arthritis Depr
ession
2000 (developing countries) HIV Malaria Malnutrit
ion Trauma TB
45 yr
78 yr
39 yr
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Problems with Biomedicine

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

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Cure-Oriented Model Specific Cause Paradigm
Disease
Illness
Cause Agent
Person Host
Outcome
Diagnostic Threshold
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What is the contribution to the human healing
process?
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Disease and Illness InvolveMultidimensional
Outcomes
Social Measures
Psychological Behavioral Measures
Functional Clinical Measures
Biological Measures
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Healing-Oriented Model Whole Systems Paradigm
Spiritual Psychological Social Behavioral Phys
ical Environmental
Disease
Illness
OE
Diagnostic Threshold
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Healing Model Whole Systems Paradigm
Spirit Mind Body
Spiritual Psychological Social Behavioral Phys
ical Environmental
Disease
Illness
OE
IE
Diagnostic Threshold
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Healing Model Whole Systems Paradigm
Disease
Illness
Spirit Mind Body
Spiritual Psychological Social Behavioral Phys
ical Environmental
Depression Heart Disease Diabetes Cancer Obesi
ty
OE
DIG
IE
Diagnostic Threshold
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Healing Model Whole Systems Paradigm
Disease
Illness
Spirit Mind Body
Spiritual Psychological Social Behavioral Phys
ical Environmental
Depression Heart Disease Diabetes Cancer Traum
a
Symptoms Quality of Life Biomarkers Risk
Factors
OE
DIG
IE
Diagnostic Threshold
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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

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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

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The Place of Cure and Healing in Medicine
Health stimulation
Illness
Specific Diseases
OE
IE
DIG
Wellness
Salutogenesis
Pathogenesis
Disease treatment
Health support
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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.
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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.
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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-center
ed
Building Healing Spaces
Nature Color Light Artwork
Architecture Aroma Music
Enhance Natural Sustainable Structures
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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.
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The Washington Post, Nov 22, 2005
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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?

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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 lifes
  situations and,
• less pain

Steen e et al Patient Educ Counsel 2001 42(1)
35-46.
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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.
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The Experience of Wholeness
Integration of Self
Integration of Person

• Mind
• Body
• Emotions
• Spirit

• Past Traumas
• Present Why me?
• Future Hope, purpose

• Connectivity
• Coherence
• Control
• Commitment

Hardiness Resilience
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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 19992811304-1309.
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Positive Emotional Change Effects of
Self-forgiveness and Spirituality
Levenson MR et al. Explore 2006 2(6) 506.
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Mind-Body-Energy Practicesand the
Relaxation-Response

• Yoga
• Tai Chi
• Bioenergetics
• Cranial Sacral

• Alexander
• Johrei
• Polarity
• Reiki

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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
29448-474.
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Neural Immune Connections
Integrative Neural Immune Program http//neuralimm
une.nih.gov/index.html
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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.

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Social Support Lowers Cardiovascular Reactivity
to an Acute Stressor
Change from Baseline (mmHg)
Lepore SJ et al. Psychosomatic Med 1993 55
518-524.
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Relationship Effects
SPECIFIC Tone and affect of encounter Communicatio
n and listening Non-verbal behavior THE EFFECTS
OF OUR DOING
NON SPECIFIC Intention, attention Mindfulness Heal
ing presence THE EFFECTS OF OUR BEING
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Effect of Type of Physician Consultation
Improvement
Thomas KB. Br Med J.1987 294 1200-2.
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Physician Knowledge Affects Outcome
Gracely RH. Society for Neuroscience Abstracts.
1979 5 609.
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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

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The Therapeutic Instrument
virtually all the doctors healing power flows
from the doctors self-mastery.
Eric J. Cassell, MD, The Nature of Suffering and
the Goals of Medicine. 2nd Edition, 2004.
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2B. Creating Healing Organizations

• Leadership, staff, vision, mission
• Organization, team building, payment

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The Washington Post Health Section 12.12.06
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Healing Relationships as the Core 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
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A Model of Relationship-Centered Organizations
Safran DG, et al. J Gen Intern Med 2006 21
S9-S15.
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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.
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Organizational Dimensions of Relationship-Centere
d 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.
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3A. Practicing Healthy Lifestyles (Behavioral
Medicine)
The employment of adequate amounts and types
of exercise, diet, relaxation, creative outlets,
and balancing work and leisure.
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Health PromotionBehavioral 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

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Behavioral Medicine

• Success at Lifestyle Change
• Clinical
• Requires special training
• Family and social aspects
• Public health
• Worksites/schools
• Homes/places of worship
• Commercial pressures

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Workplace Program Reduces Illness Healthcare
Utilization
Rahe RH et al Psychosomatic Med 2002 64(2)
278-286.
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Health Promotion at the Worksite
Return on Investment Comprehensive Programs
3-8 ROI Disease management 7-10 ROI Risk
Management 4-5 ROI Participation? Disease
Treatment?
RW Whitmer, et al., JOEM. 45 2003
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3B. Applying Collaborative Medicine (Integrative
Medicine)

• Conventional Medical Care
• Person-centered Health Care
• Complementary Medicine
• Traditional and Folk Medicine

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CAM (excluding prayer)
Any CAM
CAM (excluding megavitamins)
Barnes, P.M. et al. Advance Data from Vital
Health Statistics. Number 343, May 27, 2004. CDC
p.4
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CAM American Use
NHIS 2002

• Interventions
• Prayer by others
• Prayer for self
• Natural products
• Breathing exercises
• Prayer groups
• Meditation
• Chiropractic care
• Yoga
• Massage

• Diet therapies
• Progressive relaxation
• Guided imagery
• Homeopathic treatment
• Tai chi
• Acupuncture
• Energy healing/Reiki
• Naturopathy
• Biofeedback

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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

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Herbs and Drugs Interact

• Anticoagulant and coagulant activity
• alfalfa feverfew poplar
• angelica fucus prickly ash
• aniseed garlic quassia
• asafoetida ginger red clover
• celery ginseng willow bark
• chamomile horse-chestnuts agrimony
• clove horseradish goldenseal
• enugreek licorice mistletoe
• feverfew meadowsweet yarrow
• Newall, 1996

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Quality of Supplements
140 120 100 80 60 40 20 0
of Label
1 2 3 4 5 6 7
8 9 10
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Cochrane Collaboration
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4. Building Healing Spaces

• Light, air, nature, color, art, music
• Function, flow, privacy and community

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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
• In post-operative recovery
• Rooms with windows decrease length of stay by 1
  day. (p

Beauchemin KM et al. J Affective Dis 1996 40
49-51.
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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.
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Designing the Outer with the Inner and the Inter
in Mind
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Healing Environments in Military Operations
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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

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Examples of OHE Domains in the Military
INTERNAL 1. Mind Mission and meaning,
spiritual care 2. Experience little formal
focus 3. Relationships Camaraderie and
community EXTERNAL 4. Lifestyle - Health
Promotion, addiction Rx 5. Treatments
Collaborative, little Integrative 6. Spaces and
7. Places mission oriented
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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

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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

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Experiencing Personal Wholeness

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

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Ear Acupuncture for Acute Pain in the ER
P0.503
P
Goertz, CM et al. Auricular Acupuncture in the
Treatment of Acute Pain Syndromes A Pilot Study.
Military Medicine, 2006171(10)1010-1014.
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Samueli Institute OHE Program(Current Activities)

• In-depth case studies of eight hospitals and
  their experiences implementing healing
  initiatives
• Systematic review of the healing-oriented
  literature, looking specifically for cost-value
  data
• Environmental scan of hospitals across the
  country (electronic survey n2000)
• Living Laboratories. Collaborative
  relationships with healthcare systems to access
  and assess health services that measure clinical,
  professional and economic outcomes of OHE
  components

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Partnership Opportunities
AHA Health Forum April 10-14, 2007 San Diego,
California Evaluating Optimal Healing
Environments Contact Information Barb Findlay,
RN, BSN Vice President, OHESM Program Samueli
Institute bfindlay_at_siib.org 703-299-4800
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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

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What is the contribution to the human healing
process?
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Acknowledgements
Barbara 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