by Wayne Jonas
Healing approaches using whole systems science are just beginning to be developed in health care. As with any emerging discipline, it currently goes by many names, including the biopsychosocial model, complexity science, systems biology, systems medicine, personalized medicine, and most recently precision medicine and precision health. The NIH has recently embraced whole systems science with its Precision Medicine Initiative (PMI). PMI performs ongoing data collection on more than a million people in most of the dimensions of human functioning—from genetics to epigenetics—including behavior, medical treatment, and social interactions. Once collected, this database will become a rich source of information for better application of whole systems science and the meaning response in health care.
In the meantime, there are already examples of the power of whole systems science being applied in health care. These also go by various names, such as person-centered care, systems wellness, scientific wellness, precision wellness, functional medicine, and integrative health care. (In the second section of this book, I describe some of these systems and how you can find and use them.)
The late Professor David D. Price, a prominent research psychologist at the NIH, and world-renowned Italian neuroscientist Professor Fabrizio Benedetti analyzed all the research on how meaning and context impact chronic diseases: diseases with pain, like Norma and Bill’s; Parkinson’s disease, like Aadi’s; or depression, like Sarah’s. They and others have shown that our brains can produce large amounts of painkillers, anti-Parkinson’s neurotransmitters, anti-depression chemicals, and immune modulators—an internal pharmacy used by the meaning response to heal. These chemicals are induced in the brain through rituals and behaviors that not only influence our beliefs and expectations but also stimulate and condition our bodies to respond to those rituals and behaviors in physical ways. Often these rituals involve the use of therapeutic agents such as pills or potions, drugs or herbs, needles or knives; or sophisticated technologies such as implanted electrodes or cell transplants; or softer methods such as massages or physical therapy. From the whole systems perspective, when we set out to heal chronic diseases, the specific agent used is less important than how the treatment is administered; that is, how the ritual of healing is constructed and the meaning response is induced. Armed with an understanding from whole systems science and the power of the meaning response, I could now understand how the remarkable recoveries I had seen provided me and others with the tools and processes for making the same thing happen in others’ lives. The mystery of healing—why it happens or does not—was revealed.
BACK TO NORMA
When Norma had gotten better so dramatically from her arthritis and depression as she started taking the pills in the clinical study, I first thought she was on the active treatment, meaning I had discovered a cure for arthritis. When I found out she was on the placebo pill, I then assumed that she had gotten better because I was a good healer and she was suggestible. Her recovery and well-being must have been because I was a good communicator, I thought: I had induced in her a belief that she could get well, reinforced that belief with the treatment, and persuaded her that she could get better. Surely I was a master of biopsychosocial healing.
One of the most influential books in medicine during the last fifty years is a book called Persuasion and Healing, by psychiatrist Jerome Frank. I had read the book in medical school, and it influenced me greatly. Dr. Frank demonstrated that any type of psychotherapy has some basic features that account for its effectiveness: an emotionally charged relationship (I was Norma’s favorite doctor), a healing setting (the clinic and hospital I saw her in), and a rationale or myth explaining the symptoms and process for resolving them (my hypothesis was that the vitamin could cure arthritis).
Most doctors like to think when a patient gets better, it is because of their treatment and care. This is what keeps us going. It is self-satisfying to think that. But I soon found that the main explanation for Norma’s improvement was not the vitamin I had given her nor my miraculous persuasion powers. Norma’s recovery was a lot more mundane and less magical than that. When I revealed to Norma that she had been on the placebo, she was with her daughter. Her daughter told me that getting back to her volunteer job in the hospital was one of the most important things her mom wanted in her current stage of life. Before the study, she did not feel like going to the hospital and sat at home, remaining sedentary for long periods. This made her feel worse. Soon after starting the placebo, Norma began to tell herself she felt better and forced herself to start back at her volunteer job. Even before the treatment was supposed to kick in, her activity level increased. After she started taking the pills she began to go into the hospital regularly—at first once a week, then three times a week, then every day.
Now, we know that one of the most effective ways to prevent deterioration and even improve arthritis is to keep active. Exercise reduces pain, improves mood, and slows or reverses the decline from almost any illness—including arthritis and depression. It is one of those general healing nudges. Norma had an important purpose (her job at the hospital), and joining the study had linked that purpose to a behavior that stressed her body with exercise in a way that improved her pain and function and allowed her to nourish her soul with social contact. Her remarkable recovery had little to do with the vitamin or my powers of persuasion. It occurred because she used a compelling life purpose—meaning—to take her outside her physical comfort zone and stimulate her natural recovery capacity through exercise.
I also discovered that something else had helped induce an improvement. She was taking a pill four times a day.
Medical treatments in many systems involve taking pills and potions, whether they are drugs, herbs, vitamins, or over-the-counter liquids or tinctures. Taking a substance, especially if it is accompanied with a sense of feeling better, induces a “conditioned response” in which the act of doing something—especially something requiring a physical act or a substance with a unique smell or flavor—trains the body to respond in a way that reinforces the improvement. Like Pavlov’s dogs, which were conditioned to salivate upon the ringing of a bell, we learn to heal upon the swallowing of a pill—including a placebo pill. Our conditioned stimulus (the event that triggers the response) can be almost anything: a pill or a shot, a taste or smell, a needle, a knife or a touch; even an energy stimulus like a light, a sound, or heat or cold. The conditioned stimulus is how our belief and meaning—the reason we seek healing—gets linked to a physical response in our body in a repeated and continuous way. Dr. Kaufmann, who wrote the book on the use of niacinamide—the vitamin I was testing for arthritis—told me that it was very important that patients take frequent doses—a minimum of four times a day rather than using a more slowly absorbed version fewer times a day. His rationale was that the fluctuation of the vitamin in the blood was needed to reduce inflammation in the joints. This, as later studies showed, was not true. Still, he had tried time-released versions of the vitamin that were taken less often, and they didn’t work as well, he said. But what he had likely stumbled upon was a universal principle of healing—frequent dosing improves healing through conditioning. In fact, for some conditions, if an effective treatment has the number of pills reduced from four pills a day to two pills a day, a physician has to treat as many as twelve additional patients with the less frequent dosing in order for one patient to benefit. Statisticians call this the “number needed to treat” (NNT). This happens in other diseases also. The effect is seen not just in “soft” outcomes like pain or depression; it even results in different death rates. Several studies have shown that patients with heart disease who take all their medication have a lower death rate than those who do not take all their medications—even when that “medication” is a placebo. Like Norma, they do better if they do it more often. Norma not only took four pills a day during the study, but she was also one of my most eager and compliant patients. At least, I thought, I could take some solace that by interacting with me she had pushed through
her pain and gotten on a healing path. What actually happened is that Norma had activated her healing in each dimension of her being. She began to move more (body), she started taking more pills that both she and I believed in (behavior), she engaged with others in her volunteer work (social), and she re-established her purpose in life, which was to help others (spirit). Her healing was not from the agent she took; it was from her own agency she found.
Sergeant Martin found healing through a different path, but by using the same process of finding meaning, whole person support, and using a stimulus to heal.
BACK TO SERGEANT MARTIN
Sergeant Martin hated me. It had not always been that way. For over a year, he and I had worked together seeking the best treatment for his traumatic brain injury and PTSD by juggling various medications, counselors, and social workers. We even tried meditation and “exposure therapy”—the proven standard of care for PTSD in which a patient is gradually exposed to the very things that induce fear and nightmares in them until they learn not to react. He stopped after two sessions. “It was terrible,” he confessed to me. “Why would I want to relive that memory again?” I was sorry to see him stop, because the science said that it worked. That is when I referred him to music therapy, and he learned about Beethoven’s Ninth Symphony. The music therapist said there was something about that symphony that changed him. Perhaps he identified with the struggle the deaf Beethoven had in writing and performing it. Sergeant Martin listened to it repeatedly.
Soon after that, he and his father came in and insisted I refer him to hyperbaric oxygen treatments. It was my turn to draw the line. The science was clear—hyperbaric oxygen did not work. I wasn’t going to recommend a “quack” therapy. Both Sergeant Martin and his father left my office angry. I think their last word to me was an expletive. I was pretty sure my powers of persuasion and empathy were not working with them. It was not my finest hour as a healer.
Almost a year later, when I bumped into Sergeant Martin in the hospital hallway, he was markedly better and off medications, but hesitant to talk with me. But I was truly curious as to how he had gotten so much better, and that convinced him to talk. I wondered: had Sergeant Martin also created the fundamentals of healing—meaning, support, and stimulus—with an ineffective therapy and against my recommendations?
“To tell you the truth, Doc,” he finally confessed, “when I left your office with my father that day, I was at my wits’ end and ready to give up. I mean, I was ready to give up on everything, including my life. I wanted to commit suicide. But my dad convinced me to go to the hyperbaric clinic and said he would pay for it. I felt bad about how he cursed at you, but what could I do? You had your shot with me for over a year.”
I knew he was right. We had tried everything I knew to help him.
“When I got to the hyperbaric clinic,” Sergeant Martin continued, “I felt I had come home. There were guys there just like me claiming that they were getting better with the oxygen treatment and putting their lives back together. It was the first time I felt hopeful—that I might be able to heal, to have a seminormal life.”
What I immediately thought but did not dare voice to Sergeant Martin was that he had found something he believed in and a group to reinforce that belief. I listened instead. Sergeant Martin went on, “After my first oxygen session, I felt better. There was this rush in my ears and fresh air flowing into my lungs. When I left, my mind was clearer; I had more energy. I even mustered a small smile. And the improvements just kept on coming. Soon, I found that I was the one giving hope to other battle buddies coming in. Guys with brain injury and PTSD who came in hopeless. I told them to hang in there. Instead of me always telling my story, I found that I was listening to others tell theirs, and I could really listen now. I could help them.”
Sergeant Martin went on to explain how the hyperbaric oxygen worked—an explanation that has been disproven. He explained to me that there were areas of his brain from the injury that could not effectively use oxygen, and when it was forced into his system under pressure, those brain areas “woke up” and began to function again. I say this has been disproven because good studies have shown that breathing even room air—without high oxygen—and at a low pressure also can also improve function. No more oxygen than usual was getting to the brain in those cases, but people got better anyway. In fact, other studies showed that small doses of ischemia—low oxygen—can also induce healing responses in the brain. It was the small physiological stress that stimulated healing. Professor Benedetti, whose research on placebo, pain, and performance I described previously, has demonstrated that many of the physiological and functional effects of 100% oxygen can be produced by room air in people working at high altitude when they collectively believe they are getting 100% oxygen and that they will benefit from it.
While Sergeant Martin believed in his own explanation—that more oxygen was penetrating his brain—what he was actually experiencing was a mild stressful stimulus to his body in a positive environment that, as happened to Norma, that conditioned him to improve. But unlike Norma, whose stimulus involved working through the pain of exercise because of an inert pill, Sergeant Martin got an abnormal physiological jolt of a mild toxin—high oxygen—that his body responded to by rallying a repair reaction. Getting high oxygen may seem counterintuitive. After all, isn’t oxygen good for you? Sergeant Martin believed (and his practitioners said) that his brain was getting the oxygen it needed. However, the normal concentration of oxygen in the air and the amount the body is used to is about 20%. Oxygen at 100% delivered under high pressure (as Sergeant Martin received) is actually slightly toxic to the body. This induces the body to protect itself by increasing antioxidant production and other repair processes and accelerates healing. The same healing reaction can be induced with no increase in oxygen or even with low oxygen—or other stressors.
I will describe the ritual he did in more detail in a later chapter, but at this point I had learned that Sergeant Martin found, like Norma, a meaningful way to heal himself by helping other service members with brain injury and PTSD. While his condition and treatments were completely different from Norma’s, the healing processes he used were the same. He had lined up a meaningful therapy he believed in, done it in a supportive environment, and used high oxygen as a physical stimulus to condition a recovery response that working with me had not.
BACK TO BILL
This world we live in is a relentless place. Often it seems that traumas and stresses come at us continuously, wearing us down, only to hit us with even more difficult ones. Sometimes, they seem to come all at once—a death of a loved one, loss of a job, a car accident, a serious disease. Other times, it is more like water torture—drip, drip, dripping small and continuous stresses that will not let up and have no end in sight. Regardless of which way life brings us traumas, no amount of treatment or therapy will wipe away suffering unless we also build our resilience and recovery capacity. There is no magic cure for suffering, but there is an ability to recover and be happy—if we are willing to walk the labyrinth of healing and use the tools at our disposal to help. Whole systems science and the meaning response teach us that we have a smorgasbord of healing options—proven and unproven—if we adhere to a few basic principles.
Bill showed me, more than any other patient, how to walk that labyrinth. Unlike Norma, Bill was not a believer in any treatment. Nor was I his favorite physician. Unlike Sergeant Martin, he was not antagonistic toward me. Nor was he looking for any particular type of therapy—alternative or conventional. Of course, he wanted the scientifically best treatments for his back pain, if possible, but even more than that, he just wanted to get better. He had tried so many milder treatments that he wanted something “stronger,” as he put it. One might think that having a family member with strong beliefs—like his wife, with her belief in acupuncture, might strengthen one’s personal beliefs and help with healing. But this is not always the case. Family members, like physicians, are often trying to “fix” a person
with chronic illness—getting them to see the doctor, try new treatments, and change behaviors. This pressure can sometimes backfire, however, making the person resistant to those suggestions, or worse, when the treatments fail, reinforcing their despair that recovery from their illness is hopeless. Over the years, Bill had been to the best pain centers in the world—Walter Reed, Johns Hopkins, and veterans’ hospitals. He had told his back pain history hundreds of times, and each time someone had tried to help him with one or more treatments. Gradually, as Bill told me when he came in for his pre-op evaluation, he needed something stronger because over the years, he had “become” his back pain. It dominated his life. Others helped reinforce that with all their treatments. He had finally stopped seeing doctors until his wife recommended acupuncture. But, like the other treatments, it had only a mild effect. Surgery was his best hope. He wanted to “cut out the pain,” he said.
And it worked for a while. Bill got rapid relief from the surgery. It lasted nine months. Then it came back.
Why did it work? Why did it come back? Bill believed in surgery. So did his doctors. Modern cultures generally believe in surgery. It helped him to do what was most important and meaningful to him—to be with his grandkids. But back surgery of the type Bill had is actually not effective when tested in rigorous research—sham surgery works just as well. Still, surgery can be an excellent stimulus for self-healing. Like other treatments, it can work well when the components of healing—meaning, support, and stimulus—are aligned. However, unlike the four pills a day and regular exercise Norma did or the repeated oxygen and social reinforcement of Sergeant Martin, Bill could not repeat the stimulus. Surgery is usually done only once or twice.