1. Optimal Healing Environments: The Next Natural Step Wayne B. Jonas, MD President and CEO Samueli Institute 10 th Annual Force Health Protection Conference Force Health Protection Through Collaboration August 9, 2007

2. 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. Don’t lose sight of the miracle of healing.

3. The Lancet V.360 November 16, 2002

9. The Success of Biomedicine 1900 Tuberculosis Pneumonia Trauma Influenza 2000 Heart disease Cancer Diabetes Arthritis Depression 2000 (developing countries) HIV Malaria Malnutrition Trauma TB 45 yr 78 yr 39 yr

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

11. Cause Agent Person Host Outcome Diagnostic Threshold Cure-Oriented Model Specific Cause Paradigm Disease Illness

12. What is the contribution to the human healing process?

14. Disease and Illness Involve Multidimensional Outcomes SocialMeasures Functional & ClinicalMeasures Psychological & Behavioral Measures Biological Measures

15. Healing-Oriented Model Whole Systems Paradigm Spiritual Psychological Social Behavioral Physical Environmental Diagnostic Threshold Disease Illness OE

16. Spiritual Psychological Social Behavioral Physical Environmental Diagnostic Threshold Spirit Mind Body Disease Illness OE IE Healing Model Whole Systems Paradigm

17. Spiritual Psychological Social Behavioral Physical Environmental Depression Heart Disease Diabetes Cancer Obesity Diagnostic Threshold Spirit Mind Body Disease Illness OE IE DIG Healing Model Whole Systems Paradigm

18. Spiritual Psychological Social Behavioral Physical Environmental Depression Heart Disease Diabetes Cancer Trauma Symptoms Quality of Life Biomarkers Risk Factors Diagnostic Threshold Spirit Mind Body Disease Illness OE IE DIG Healing Model Whole Systems Paradigm

19. 1.Interactions and side effects 2.Lures us into complacency 3.Depersonalizes the interaction 4.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 patient 1.do to a person… 2.do or be with a person… 6.Separates prevention, treatment, rehabilitation 7.Encourages high cost 1.Late intervention 2.Technology/drug focus 3.Multiple treatments Consequences of Misapplied Models (A focus on cure when healing is more appropriate)

20. 1.Failure to cure the curable 2.Complicates the interventions 3.Personalizes the disease [e.g. blame] 4.Favors anecdotes over evidence 1.Wants over needs 2.Risks false attribution 5.Restricts access to care 1.Readiness 2.Behavior change 3.Resources 6.Medicalization of life [Illich] 7.Wastes resources/lives 1.Delayed intervention 2.Time inefficient 3.Needs a team approach Consequences of Misapplied Models (A focus on healing when cure is more appropriate)

21. The Place of Cure and Healing in Medicine Health stimulation Disease treatment Health support Salutogenesis Pathogenesis OE IE DIGWellness Specific Diseases Illness

24. 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

25. 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

27. OPTIMAL HEALING ENVIRONMENTS Inner Environment (Personal) Interpersonal Environment (Social) Outer Environment (Behavioral) Developing Healing Intention Cultivating Healing Relationships Practicing Healthy Lifestyles Expectation Hope Understanding Belief Experiencing Personal Wholeness Mind Body Spirit Energy Enhance Awareness Enhance Integration Compassion Empathy Social Support Communication Creating Healing Organizations Leadership Mission Culture Teamwork Enhance Process Enhance Caring Diet Exercise Relaxation Balance Enhance Health Habits Applying Collaborative Medicine Conventional Integrative Traditional Person-centered Enhance Medical Care Building Healing Spaces Nature Color Light Artwork Architecture Aroma Music Enhance Natural & Sustainable Structures

28. 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

29. The Washington Post, Nov 22, 2005

30. 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

31.  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.

32. 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 Wholeness Healing Presence

33. The Experience of Wholeness Mind Body Emotions Spirit Past – Traumas Present – “Why me?” Future –Hope, purpose Connectivity Coherence Control Commitment Hardiness Resilience Integration of SelfIntegration of Person

34. Effect of Structured Writing by Disease: Asthma or Rheumatoid Arthritis Asthma Rheumatoid Arthritis Asymptomatic Mild Moderate Severe Forced Expiratory Volume in 1 S, % Predicted Overall Disease Activity Smyth, J. M. et al. JAMA 1999;281:1304-1309.

35. Levenson MR et al. Explore 2006; 2(6): 506. Positive Emotional Change: Effects of Self-forgiveness and Spirituality

37. Mind-Body-Energy Practices and the Relaxation-Response Yoga Tai Chi Bioenergetics Cranial Sacral Alexander Johrei Polarity Reiki

38. 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.

39. Integrative Neural Immune Program http://neuralimmune.nih.gov/index.html Neural Immune Connections

42. 2A. 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.

43. Social Support Lowers Cardiovascular Reactivity to an Acute Stressor Change from Baseline (mmHg) Lepore SJ et al. Psychosomatic Med 1993; 55: 518-524.

44. Relationship Effects SPECIFIC Tone and affect of encounter Communication and listening Non-verbal behavior THE EFFECTS OF OUR DOING NON SPECIFIC Intention, attention Mindfulness Healing presence THE EFFECTS OF OUR BEING

45. Effect of Type of Physician Consultation Thomas KB. Br Med J.1987; 294: 1200-2. Improvement

46. Physician Knowledge Affects Outcome Gracely RH. Society for Neuroscience Abstracts. 1979; 5: 609.

47. 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

48. The Therapeutic Instrument “… virtually all the doctor’s healing power flows from the doctor’s self-mastery.” Eric J. Cassell, MD, The Nature of Suffering and the Goals of Medicine. 2 nd Edition, 2004.

49. Leadership, staff, vision, mission Organization, team building, payment 2B. Creating Healing Organizations

50. The Washington Post Health Section 12.12.06

51. 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 21 st Century Institute of Medicine 2001

52. A Model of Relationship-Centered Organizations Safran DG, et al. J Gen Intern Med 2006; 21: S9-S15.

53. 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.

54. 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.

57. 3A. Practicing Healthy Lifestyles ( Behavioral Medicine) The employment of adequate amounts and types of exercise, diet, relaxation, creative outlets, and balancing work and leisure.

58. Health Promotion Behavioral 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

59. Behavioral Medicine Success at Lifestyle Change: Clinical Requires special training Family and social aspects Public health Worksites/schools Homes/places of worship Commercial pressures

60. Workplace Program Reduces Illness & Healthcare Utilization Rahe RH et al Psychosomatic Med 2002; 64(2): 278-286.

61. 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

62. 3B. Applying Collaborative Medicine (Integrative Medicine) Conventional Medical Care Person-centered Health Care Complementary Medicine Traditional and Folk Medicine

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

65. CAM: American Use Interventions: 1.Prayer by others 2.Prayer for self 3.Natural products 4.Breathing exercises 5.Prayer groups 6.Meditation 7.Chiropractic care 8.Yoga 9.Massage 10.Diet therapies 11.Progressive relaxation 12.Guided imagery 13.Homeopathic treatment 14.Tai chi 15.Acupuncture 16.Energy healing/Reiki 17.Naturopathy 18.Biofeedback NHIS: 2002

66. 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

68. Herbs and Drugs Interact Anticoagulant and coagulant* activity: alfalfafeverfewpoplar angelicafucusprickly ash aniseedgarlicquassia asafoetidagingerred clover celeryginsengwillow bark chamomilehorse-chestnuts agrimony* clovehorseradishgoldenseal* enugreeklicoricemistletoe* feverfewmeadowsweetyarrow* Newall, 1996

69. Quality of Supplements % of Label 1 2 3 4 5 6 7 8 9 10 140 120 100 80 60 40 20 0

72. Cochrane Collaboration

74. 4. Building Healing Spaces Light, air, nature, color, art, music Function, flow, privacy and community

76. 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.

77. 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.

78. Designing the Outer with the Inner and the Inter in Mind

79. Healing Environments in Military Operations

80. 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

81. 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 Examples of OHE Domains in the Military

82. 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

83. 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

84. Experiencing Personal Wholeness Yoga as an Adjunctive Therapy for Post-Traumatic Stress Disorder: A Feasibility Study Walter Reed Army Medical Center

85. Ear Acupuncture for Acute Pain in the ER 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

86. 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

87. Partnership Opportunities AHA Health Forum April 10-14, 2007 San Diego, California “Evaluating Optimal Healing Environments” Contact Information Barb Findlay, RN, BSN Vice President, OHE SM Program Samueli Institute bfindlay@siib.org 703-299-4800

88. 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

89. What is the contribution to the human healing process?

93. 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