Mind-Body Medicine in Clinical Practice

Hilary McClafferty

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781498728560
• Edition: 1
• Topic: Medicine
• Subtopic: Alternative & Complementary Medicine

Consumer demand for integrative medicine has increased over recent decades, and cutting-edge research in neuroscience has identified opportunities for new treatment options. This text outlines the evidence behind mind-body medicine and provides rich case-based examples.. It is written by a clinician, for clinicians, to help practitioners stay current in this emerging field.

Including foundational chapters on the relevance of mind-body medicine, the effects of stress, communication skills, and methods for incorporating mind-body medicine into consultation, this book then introduces various mind-body therapies and considers their use in selected clinical conditions. The therapies are grouped into chapters on breath work and relaxation; hypnosis and guided imagery; meditation, mindfulness, spirituality, and compassion-based therapies; creative arts therapies; and movement therapies. Each chapter includes case studies, background and history, best use, training requirements, risks and benefits. The part focusing on specific conditions updates research and provides pediatric and adult examples in the areas of: anxiety and depression; acute and chronic pain; gastrointestinal and urologic conditions; auto-immune, inflammatory; and surgery, oncology, and other conditions.

Providing resources and practical tools to help clinicians incorporate evidence-based mind-body medicine therapies into patient care, this book is an invaluable reference for medical and nursing students, as well as for residents, fellows, nurse practitioners and physician assistants across a wide variety of specialties.

Part I

Foundations

Part I provides an introduction to the field of mind–body medicine and a brief overview of its evolution, including a high-level review of early research advances foundational to the field. The physiology and impact of chronic stress is discussed with the intent of emphasizing the value of the mind–body therapies in buffering individuals from its heavy physiologic toll. An update on the placebo–nocebo response is provided to raise awareness about its role in mind-body medicine and the potential risks of precipitating unintended negative treatment responses Clinician self-care is deliberately included early in the book with the dual goals of piquing curiosity about the potential use of mind–body therapies in day-to-day practice, and of introducing mind–body tools that may help prevent burnout and promote preventive wellness. The importance of mindful language use in the medical encounter is discussed, with emphasis on its relevance in mind–body medicine. A recurring theme in the book, this is implemented using case-based examples to help the clinician expand skills in this important area.

1	Introduction

WHAT IS MIND–BODY MEDICINE?

Mind–body medicine describes a therapeutic approach used to harness the intricate connections between an individual’s thoughts, emotions, and physiologic state. Many mind–body therapies have their origins in ancient cultures, and some, for example meditation, prayer, yoga, and imagery, are embedded in healing traditions around the world. Mind–body medicine has been accepted into modern medical practice gradually, with significant skepticism expressed by some clinicians practicing in the narrower biopsychosocial medical model, where the separation of mind and body is a central theme (Alonso 2004).

MIND–BODY THERAPIES IN MODERN MEDICINE

Seminal research by Walter B. Cannon, MD and colleagues in the early 1900s definitively established the existence of a powerful mind–body link. In 1926, Cannon coined the term homeostasis and demonstrated that challenges to the physiologic steady state resulted in activation of the sympathoadrenal axis (fight or flight response), leading to a surge in research around the stress response (Cannon 1929a, 1929b, 1939; Goldstein and Kopin 2007).

In the United States, Jon Kabat-Zinn, PhD, was the pioneer who introduced meditation into the medical mainstream through the program now known as Mindfulness-Based Stress Reduction, initially developed to help address the needs of chronic pain patients at the University of Massachusetts. Since its formation in the late 1970s, the program has evolved to include educational, training, and research initiatives housed in the Center for Mindfulness in Medicine, Health Care, and Society. Work at the Center has been instrumental in raising awareness about the field of mind–body medicine, catalyzing research, and opening doors for the introduction of other mind–body therapies into conventional practice models.

Early demonstration of the mind–body connection in children was published in Pediatrics by Olness et al. (1989) as a prospective randomized controlled study which demonstrated that salivary IgA concentrations could be acutely mediated in 57 children who received training in self-hypnosis with specific suggestions to increase salivary IgA concentrations versus a control group whose levels were unchanged (p < 0.01).

A groundbreaking study by Cohen et al. in the New England Journal of Medicine added further credibility to the field by demonstrating a correlation between a research subject’s stress levels and immune function. In this innovative study, susceptibility to the common cold induced by nasal drops was measured in 394 healthy volunteers. Results showed a statistically significant dose–response relationship between stress and infection—independent of variables, including smoking, alcohol consumption, exercise, diet and sleep quality, baseline white blood cell counts, and total immunoglobulin levels (Cohen et al. 1991). These early studies, and others, were instrumental in turning the tide of skepticism, paving the way for new research initiatives that have led to the rich collection of studies supporting this rapidly evolving field.

MASTERY OF THE RELAXATION RESPONSE

One of the overarching goals of the mind–body therapies is activation of the relaxation response, roughly the physiologic opposite of fight or flight. Typically characterized by a decrease in heart rate, respiratory rate, blood pressure, and stress hormone secretion, it has been shown to buffer physiologic wear and tear on the body associated with both acute and chronic stress. Triggering of the relaxation response is central to the effective use of the mind–body therapies and can be achieved by children and adults from a spectrum of educational and developmental backgrounds, and in a surprising range of clinical settings. All the mind–body therapies discussed in Part II involve activation of the relaxation response, reinforcing the diversity of options available to interested patients. The selected mind–body therapies covered in Part II include: breath work, autogenics, progressive muscle relaxation, biofeedback, meditation, mindfulness, compassion-based cognitive therapy, yoga, tai chi, creative arts therapies, animal-assisted therapy, hypnosis, and guided imagery.

GOALS AND OBJECTIVES

The purpose of this work is to explore the wealth of research in the field and to highlight the potential of the mind–body therapies to promote health and healing in the clinical setting. These therapies describe a new approach to the patient and are foundational to the practice of integrative medicine, an emerging field that blends evidence-based complementary and conventional approaches (Maizes et al. 2015), that has been introduced into more than 70 highly respected academic medical institutions in the United States through the Academic Consortium for Integrative Medicine and Health, which promotes initiatives in education, research, and clinical work.

RELEVANCE OF MIND–BODY THERAPIES TO CLINICAL PRACTICE

The mind–body therapies are teachable skills and represent an important facet of whole person care that ideally emphasizes preventive health and healthy lifestyle practices in the form of stress management, quality nutrition, enjoyable regular physical activity, restorative sleep, awareness of environmental exposures, and cultivation of supportive relationships.

They also provide powerful, non-pharmacologic treatment options for a wide range of physical, mental, and behavioral conditions and can be used alone or in conjunction with conventional therapies to augment treatment or to reduce side effects. They may also help the physician leverage the placebo response—an area of active study discussed in Chapter 2.

Another important benefit is their flexibility, for example, they can be used in a range of clinical settings, from outpatient clinic to critical care unit, impacting an array of physical and mental measures. Their role in facilitating increased self-efficacy, self-regulation, and sense of agency in patients facing medical challenges is a further, and often underappreciated, strength.

A survey by the American Psychological Association reported that 44% of Americans reported an increase in their stress levels over the preceding 5 years, often a factor related to a chronic illness (American Psychological Association 2012). It has been estimated that a majority of adult primary care visits have a stress-related driver (Nerurkar et al. 2013), yet few physicians receive training in addressing stress in the primary care setting (Avey et al. 2003). Children and adolescents similarly experience frequent stressors with long-lasting physical and mental sequelae as described throughout the book, highlighting the urgent need for increased awareness of the utility of the mind–body therapies in clinical practice. In some cases, the mind–body therapies may be patient-initiated, further reinforcing the importance of clinicians becoming familiar with the range and application of these therapies and the need for an open-minded approach to their patient’s curiosity about the therapies.

DEEPENING THE CLINICAL CONNECTION

Clinicians familiar with mind–body therapies also have the potential to create deeper connections with patients by exploring their experiences and strengths and helping them tap into their inner resources, reduce fear, offer hope, and reinforce realistic optimism. Use of the mind–body therapies may even indirectly benefit clinicians by adding to their available treatment options, especially in situations where conventional medicine has reached its limit of benefit, safety, or effectiveness. Evolving research around their direct use in clinician self-care is discussed in Chapter 3.

COST–BENEFITS

The ability to lower cost of treatment is an important driver in health care. Any therapy that can potentially reduce prescription drug use, decrease the post-operative length of stay, minimize pain, reduce stress-related health effects, or facilitate a successful procedure gains relevance in the business of modern health care.

POTENTIAL DOWNSIDES OF MIND–BODY THERAPIES

Potential downsides of mind–body medicine exist and include triggering or worsening of post-traumatic stress in a patient with a history of trauma of any type: physical, emotional, or sexual. This can be especially challenging if the patient has not disclosed their history, is young, or is unable to articulate their story. In a patient of any age who has experienced a trauma of any kind, or who has a diagnosis of post-traumatic stress disorder, the use of mind–body therapies should be carefully evaluated to avoid unintentional triggering of symptoms or additional distress (Section on Integrative Medicine 2016).

Ideally, these patients will already be under the care of an experienced mental health professional. Unfortunately, too often this may not be the case, and the use of mind–body therapies might precipitate unexpected emotions. In these situations, timely referral to a professional with expertise in mental health is warranted.

Other potential downsides of mind–body therapies include research gaps in some conditions, uncertainty about the best choice of therapy, and a relative paucity of trained practitioners. Unknowns in clinical outcome measurement tools and techniques are also potential downsides, although improvements in techniques, for example, use of functional magnetic resonance imaging (fMRI) has allowed significant advances in our understanding of the mechanism of action of certain therapies.

Additional potential pitfalls include unexpected worsening of a condition or symptom, inappropriate reliance on mind–body therapies as a primary treatment modality at the exclusion of proven conventional therapies in certain conditions, unrealistic expectations, resistance based on religious grounds, fear of trying something new, prohibitive cost, and lack of accessibility to therapies.

Gaps in national insurance coverage and reimbursement are further challenges, with wide variation seen in state-to-state and carrier-to-carrier coverage and a growing number of uninsured patients.

WHAT WILL NOT BE COVERED HERE

The rich philosophical debate related to the existence and nature of consciousness will not be covered here, although the topic is the focus of intense research interest. These questions are explored in a number of excellent works and lie beyond the intended scope of this book.

Some of the mind–body therapies not covered here fall into other fields, for example massage within the practice of manual medicine. Others lie outside the book’s intended focus, and although popular, lack robust supporting evidence in the clinical setting.

References

Alonso, Y. 2004. The biopsychosocial model in medical research: The evolution of the health concept over the last two decades. Patient Educ Couns 53 (2): 239–244. doi:10.1016/S0738-3991(03)00146-0.

American Psychological Association. 2012. Stress in America: Our Health at Risk. Washington, DC: American Psychological Association.

Avey, H., K. B. Matheny, A. Robbins, and T. A. Jacobson. 2003. Health care providers’ training, perceptions, and practices regarding stress and health outcomes. J Natl Med Assoc 95 (9): 833, 836–845.

Cannon,...