How Healing Works

by Wayne Jonas

  The bedroom Susan created for herself was a simple, soothing place with natural light bathing the room in a soft, heavenly glow. A new and more comfortable bed was placed against our too exposing (for her) French doors. This allowed the light to penetrate the room indirectly from the top of the room. White opaque curtains were hung from ceiling to floor. The walls were painted a light blue-gray and kept bare except for a solitary painting placed on one wall—an abstract that almost blended into the wall. It looked like angels off in the distance emitting light—harmonizing with the feel of the room. It was painted by a good friend of hers, which further personalized its meaning. A small mobile of folded paper cranes (a Japanese symbol of healing she had come to love) hung from the ceiling. This too was personal—handmade by friends from the school her children had attended and where she had been chairman of the board after her first cancer.

  The closet was expanded to eliminate clutter in the bedroom. Every piece of clothing, every shoe, every dress and sock now had a place. If it didn’t have a place, she gave it away. A soft gray-and-white stool stood in the middle of the closet.

  When the transformation was complete, I thought the room looked as if it was already part of heaven—glowing, ethereal, simple, uncluttered, peaceful—a picture of the world to come. “Just in case I don’t end up in heaven if I die,” she humored me one day, “I want to feel a little bit of it on earth now.”

  In the corner, Susan set up a small play area for the baby and some chairs where others could sit when her grandchild was in the room. As she began to take on the weekly onslaught of chemotherapy and then after that the surgery and other medications, she spent a lot of time in that room often feeling deathly ill, but now continuously healing by sleeping, reading, listening to music, visualizing herself in a better place, and being with the baby in a way that was safe for both of them. “Just being there felt close to God,” she said, “and those I most loved, whether I was awake or asleep.” She had created her own healing space.

  More difficult, however, for Susan (and for most people) was the next dimension of healing—changing behavior and lifestyle.

  CHAPTER 6

  Acting Right

  How behavior heals.

  Seventy percent of chronic disease can be prevented or treated with a healthy lifestyle—by not smoking, consuming minimal alcohol, maintaining an improved diet, exercising, and minimizing stress. But which diet works best? A low-fat diet or low carbohydrates? Paleolithic or Mediterranean? Ornish or Atkins? With some alcohol or none? We were told for many years that we should not eat eggs or butter, but now they are okay. Coffee was bad; now it is good. Low fat was good, now it has caused the obesity epidemic. Exercise is good, but increases injuries. Stress is bad, but some stress builds resilience. It can all get rather confusing. Although there is general agreement on some harmful behaviors—smoking is definitely not good for your health, for example—science seems to flip-flop on the specifics of what is good for us. More important, even when we know what healthy behavior is, most people cannot embed those behaviors into their lives. Less than 5% of people engage in these top-five healthy behaviors. It may be good for you, but if you can’t or won’t do it, it won’t do you any good.

  What is the secret to the tapping into the 80% of our healing capacity through lifestyle? A patient named Maria taught me even as she learned it herself. The secret to healthy behavior is not willpower; it is something else.

  MARIA

  “I think we need to start you on insulin,” I said to Maria about seven seconds into our visit. “The medicines we are using now are not controlling your diabetes.”

  I was not prepared for her reaction. “No,” she said flatly, “I can’t do that.”

  There was a fire in her voice I had never heard before. Maria had always been a pleasant and cooperative patient, accepting and using all of my recommendations.

  “My father started insulin and then soon lost his legs! He went downhill from there and died. I can’t do it! I won’t do it. I am sorry, doctor.” She burst into tears.

  “But Maria”—I tried logic, even though it was clear that was not her operating mode at that moment—“it was the diabetes that caused your father’s legs to be amputated, not the insulin.”

  She was not persuaded. “I am sorry, doctor. You are a good doctor. Can’t you find me another way besides insulin? I will do anything. What about a special diet? I can go off sugar,” she implored. “I can lose weight.”

  I was skeptical. Maria was from a large Mexican family—the first child of eight. Her mother and grandmother had been her role models for domestic care and order. Maria had married an American and moved away from Mexico, but she’d brought a lot of it with her. She had six children and had created a home of her own, of which she was proud. To say that food was a major part of her home was an understatement. She loved cooking. And her family loved her cooking. She prepared it with love and from scratch, every day, three times a day, seven days a week. Often the family would invite friends to the feasts and enjoy her marvelous meals. She did it because she grew up that way, she knew how, and it made her and others happy. Maria loved food and cooking. Unfortunately, the food did not love her back—it had given her diabetes.

  Maria had been overweight most of her life; she had had diabetes for seven years and was gradually getting worse. I had referred her to the dietitian—twice—with little effect. Would she really be able to stick to a diet? The Diabetes Prevention Study, just completed, demonstrated that lifestyle modification could prevent the progression of prediabetes to diabetes better than medication. But Maria had full-blown diabetes already, and in my opinion she needed insulin. I had her on the maximum doses of an antidiabetic drug called metformin. At the time, none of the newer antidiabetic medications, such as SGLT2 and DPP-4 inhibitors were available. Insulin was the recommended next step.

  “Well,” I said, unable to conceal my hesitancy, “there are some major dietary and lifestyle changes that might control your diabetes. But you don’t have lot of time to show improvement. We could give it a month—two at the most.”

  Maria looked eager to hear more. So, with little hope and even less thought, I wrote down the names of two books that had reported rapid improvement in diabetes patients who use them. Both involved very low fat, no sugar, and an organic vegan diet. No meat, no processed or packaged foods, no added anything.

  “See what you think of these,” I said, “and come see me in about two weeks and we will see if these make sense for you.”

  Despite my lack of enthusiasm, Maria was overjoyed. “Thank you, doctor. I will cure my diabetes. You will see.” She left with vigor in her step. False hope, I thought.

  She didn’t return for six weeks. I had just asked my nurse to give her a call and ask her to come back in when I saw her name on my schedule.

  She looked much different. “I did it!” were the first words out of her mouth. “I cured my diabetes with your diet.”

  Maria had lost fifteen pounds, and a check of her short-term blood sugar was normal. I was still skeptical, but pleased. “That is great, Maria,” I said. “Let’s check your long-term sugar.”

  That too showed improvement. It was still abnormal, but better. I was impressed and a bit more hopeful.

  “How are you feeling?” I asked.

  “Just fine, doctor. Can I avoid insulin now?”

  I agreed to have her continue and check back with me monthly. Each month we checked her weight and the long-term blood sugar marker called HbA1c. Over the next five months, her weight largely stayed the same, but her blood sugar remained stable and continued to improve. But something else was happening to her that I couldn’t quite put my finger on. Her moods had changed. Instead of the cheerful, agreeable Maria I had known, she seemed sad. I wondered if something stressful was going on at home. Had someone died? Were she and her husband not getting along? It took a few more visits for her to finally tell me.

  “Doctor,” she said flatly, tears now running down
her cheeks, “I didn’t want to admit this, but I cannot do the diet anymore. At first it was okay—new and different. But over the last several months I have become very sad. My family hates the food I prepare now, so I cook two meals, one for me and one for them. But, frankly, I hate the food, too. We no longer have friends over for dinner. When my family visits from Mexico, they want someone else to cook. I have lost energy for the kitchen. I cannot care for them like this. I can’t care for myself like this. I have failed. Put me on insulin. I will lose my legs and life rather than my family.”

  Now I had tears running down my cheeks. Maria sounded despondent. She had been so afraid of insulin and so determined to cure herself with the new diet that she had gutted her primary identity as a cook and homemaker. She was afraid to talk with me about it because she thought I would confirm that she had failed and put her on insulin—a death sentence in her mind. In the process, she had also likely reduced her fat intake so drastically that it was affecting her neurotransmitters and contributing to her mood problems. But the main problem was that she had tried to make a lifestyle change that she was not ready for, a change that removed joy from her family and her life. Like many who try to make a radical behavior change without linking it to the central purpose and meaning in their life, it could not be sustained.

  “Maria,” I said gently, “you have not failed. You have succeeded. Your blood sugars are much better, and you don’t need insulin. But for this to last, you will need to find a way to balance this diet change with your love for food and meals that you and your family have always had. Let’s work together to figure out a way to do that.” She agreed.

  We also agreed to take up the conversation in full at another visit. But I actually hadn’t the foggiest idea of how to help Maria. In the meantime, she would make herself and her family a wonderful Mexican meal to celebrate her success—and not worry about what was in it.

  The next time I saw her, the old sparkle had returned in her eyes. Her blood sugar had also risen a bit. We would work out a plan with her that was better than the last one, I promised. I suspected it would require we bring in not just another dietician, but a chef to help her take her favorite recipes and make them healthier, and a health coach to help her move her goals forward in a more incremental and meaningful manner. I knew that part of Maria’s improvement had to do with the lower sugar content in her diet. But part of the improvement was also the partial starvation she induced in herself by such a radical shift in protein and calories. Like Aadi, she had induced her body to begin healing through a physical stress response. But the process could not be maintained if it removed something so important in her life.

  LIFESTYLE MEDICINE

  Every year, nearly a million people in the United States die prematurely because of unhealthy behaviors. And chronic lifestyle-related diseases are rapidly becoming the major causes of death worldwide—and soon will surpass infectious disease and malnutrition. Behavior is the primary contributor to the six leading causes of death—heart disease, cancer, stroke, respiratory diseases, accidents, and diabetes. These collectively account for almost 75% of all deaths. And they are all largely preventable. Lifestyle also contributes to diseases of the brain, such as depression and Alzheimer’s. Even more disturbing is a new trend: the recent increase in adult-onset (type 2) diabetes in children and teens, which is caused by obesity, lack of exercise, and environmental toxicity. The behaviors that can prevent these premature deaths and diseases are fairly simple—no tobacco and minimal alcohol and drug use; maintenance of proper weight; consumption of nutritious, unprocessed food; clean air and water; physical activity; social support; and good stress management. Most people know this. Shelves of popular books are written about this. Multiple national scientific bodies make recommendations on this. Governments try to regulate behavior for this. Yet despite these efforts, less than 5% of people engage in all of these basic behaviors. And, in an ironic alignment of numbers, less than 5% of medical funding is spent on primary prevention—supporting efforts to help people make these behavior changes. We get what we pay for. Willpower is not the solution to this dilemma. Maria had great willpower yet ran into common social and personal obstacles to using behavior as a path to healing. When left to our own devices, often we can’t do what’s necessary—or we do it wrong.

  Behavioral change is difficult for us, not because we are “weak,” but because we are unaware of how our environments and experiences—the health care system, our culture, our past personal history, and the media—are influencing us. When we have this awareness, we can create personal environments where healing behavior easily occurs. We do not have to struggle. We can create a new reality, as one of my other patients showed me.

  JEFF

  Jeff’s dad had died short of age sixty-five of a massive heart attack. Jeff, also a smoker, worried this would happen to him, and he hated the coughing and the smell and the cost of his smoking, but he just could not stop. He had tried nicotine patches, smoking cessation classes, vaping, hypnosis, and acupuncture, but nothing worked for more than a few weeks. He was chemically and psychologically addicted. Then he asked me for help. We did a healing-oriented evaluation (a HOPE assessment, which I will describe later), during which I asked him questions about the dimensions of healing in his life—his external environment, his behavior, his relationships, and his inner life. Surprisingly, what emerged from our discussion was the idea of running. He enjoyed running for short distances; it made him feel better, and he loved both being outdoors and the rhythmic, almost meditative movement; he even liked the soreness he felt after a workout. He had played basketball in high school but hadn’t been to the gym since he graduated. Despite liking running, he had never run more than one mile at a time. “I don’t think I could do more than that,” he noted. “Especially since I started smoking.”

  If Maria had been a ten on the “I can do it” scale, Jeff fell closer to a one or a two.

  I heard about a program that offered marathon training for people who had never run before. I suggested that he stop worrying about trying to quit smoking and sign up for this program instead.

  “I can’t do a marathon, doctor,” he scoffed. “I can barely run a mile.” But he agreed to check out the program anyway. Neither of us expected what followed.

  At the first meeting of the group, the leader asked people to take off their watches and pedometers and just follow him on a short, easy run. They could stop any time during the run and walk instead, if they wanted. They set off at a moderate pace and ran a flat or downhill route.

  Jeff had no problem with the run. In fact, he loved it, especially running with others, which he had not done before. When they stopped, he was shocked to learn that he had just run four miles, something he thought he was incapable of doing. He had broken through a mental barrier.

  Over the next few weeks, he started making friends with his fellow runners, enjoying both the social contact, being outdoors, and the discipline of the training. He also noticed that he was smoking less and less, even though he had not made any conscious decision to quit. He was simply not craving cigarettes so much anymore. He was craving running instead.

  There are biological explanations for Jeff’s response. When you smoke, your body is stimulated to produce neurotransmitters such as dopamine, serotonin, and norepinephrine. These transmit messages to receptors in your brain that make you feel good—just as a nicotine high does. This is the reward that smokers are addicted to. When the nicotine is removed, they feel bad. But other behaviors, such as vigorous exercise, switch on some of the same brain receptors stimulated by nicotine. Many runners, myself included, experience this feeling as a runner’s high. By stimulating his brain’s reward system with running, Jeff was simply substituting running for cigarettes to satisfy his brain’s craving and to get the reward. By the time he ran his first half marathon a year later, he had not smoked a cigarette in three months. Rather than futile battles to overcome a negative addiction—smoking—Jeff had a new ritual that be
came a positive addiction—a healthy one. This method of change can work for many behaviors and negative addictions, including overeating, alcohol, and drugs, by developing a healthy behavior in a manner that feels equally rewarding. A year later, he was still running—and not smoking.

  Jeff did that successfully. Maria did not. She and I still needed to figure out how changes in her food behavior could become more rewarding. We had to connect her behavior change more deeply to what she valued in life.

  THE PLACEBO LIFESTYLE

  Even healthy behaviors can produce both benefits and harms, depending on how we view them and use them. Maria’s healthy diet improved her diabetes but harmed her mental well-being and family life. Current biomedical science attempts to tease out what produces the benefit of specific behavior changes by using the science of the small and particular. This type of science approaches behavior, such as eating, as it does drugs, herbs, and other treatments. We examine the content of certain diets and try and separate out the effects of their content—low or high fat, low or high carbohydrate, low or high protein, and so on. We dissect different types of exercise, such as running, walking, swimming, weight lifting, yoga, tai chi, or gardening. When we investigate methods for stress management, we scrutinize various approaches, such as meditation, visualization, music, mindfulness, biofeedback, and intentional breathing. This is all well and good, except that the more rigorously we do these studies—with better controls, larger sample sizes, more accurate measurement methods—the smaller the effect from the specific behavior is—just like with drugs and herbs.