How Healing Works

by Wayne Jonas

  Other studies have shown that such sharing of deep feelings about trauma and loss can also help heal specific diseases. Patients with rheumatoid arthritis report significant pain reduction after a single episode of such sharing. Patients with asthma have improved lung function—measured objectively with a spirometer—a month after a similar single sharing.

  More prolonged or repeated social and emotional exchange has profound and often permanent healing effects, especially if done in an emotionally safe environment and framed and guided in a positive direction with others to witness. An emotionally safe place is a social environment where a person can trust others to stay with them through difficult emotions, to care for and respect them, and to honor their deepest experiences as real and of value. My experience in the military, treating service members and veterans with PTSD and chronic pain, demonstrates this. For example, typical treatments for PTSD with drugs and psychotherapy have a positive but limited effect—usually helping only 20% to 30% of veterans. Exposure therapy—in which the veteran is gradually exposed to his fear triggers—can be a bit better, but it is complicated, and many veterans—especially those who have experienced sexual trauma—will not go through it. But two other approaches that tap into the meaning response have shown larger and often permanent healing.

  One approach is a therapeutic retreat, during which veterans are guided to open up to their fears, anger, anguish, and grief in the presence of other veterans who understand, accept, and love them. Dr. Joseph Bobrow describes the profound and prolonged benefit from these retreats in his book Waking Up from War. In follow-up assessments of veterans who attend such retreats, a majority experience long-term improvement and restoration in their lives. A second approach is inducing these deep meaningful experiences with hallucinogenic substances. Recent research reports that when even a single dose of such substances is administered, a majority of deeply depressed patients suffering from advanced cancer had major improvement in their mental and emotional state.

  It is important to note that the success of this approach depends on the patients being professionally selected, cared for, and guided to experience deep meaning from the episodes. Simply taking the drug by itself does not produce the healing—and in fact can cause significant harm. The drug isn’t key; the meaning is. Healing does not necessarily require a drug—hallucinogenic or not—provided the meaning response occurs. A meaningful experience often occurs spontaneously through what are called exceptional emotional experiences. These occur most often when people are suffering and open up to their emotions. Loss of a loved one—through death, divorce, or another type of separation—increases the risk for disease and death several fold. Between 30% and 50% of people who have experienced a major loss will subsequently have an exceptional experience, often described as spiritual—such as seeing or feeling a deceased person returning or seeming like a ghost, or experiencing a profound sense of the unity of all things. If those experiences are treated respectfully by others and the person is guided toward understanding and acceptance, this can be profoundly healing. If they are dismissed or treated negatively, the experience can damage a person permanently. Healing comes from how meaning is made from those experiences. It involves the social and emotional body.

  THE BEAUTY WAY

  To help my patients use their social and emotional dimensions to heal, I ask them about their social relationships during a healing-oriented visit with me.

  The purpose in exploring these elements is not to do psychotherapy or tell them how to feel. The goal is to help them learn how to use their feelings to find deeper meaning in their lives. Mabel and her family found meaning in her wisdom, love, and teaching—and arranged a way for her to express that. Susan used her social connections and her grandchild to help increase the level of social support and love in her life during a traumatic time that needed enhanced healing. My veteran patients find meaning through deep encounters with their own losses and the support of others who understand and travel with them through their anger, fear, shame, and grief. Whatever the form or method used to create this opening up to deep emotional experiences—groups, drugs, herbs, psychotherapy, energy practices, spiritual encounters, or simply spontaneous acceptance—healing comes from the way meaning is made of those experiences.

  Many cultures, both ancient and modern, use the social and emotional dimension to enhance healing capacity. I mentioned how Epidaurus—where the Hippocrates school of medicine in ancient Greece originated—had a theater at its center. In this theater, physicians helped patients learn how to deal with and heal the traumas of life by acting out the drama of emotional connections and disconnections.

  Other cultures acknowledge and use this dimension for healing. Consider, for example, the way in which the traditional Navajo culture handles mental illness. Rather than thinking of mental illness as an individual problem, the Navajo consider it a social problem, shared by the whole community. They make no distinction between individual illness and social illness. In their view, we are all swimming in the same body of social “water.” Whether we are aware of it or not, we need the water in order to survive, and a disturbance in one part of our individual world affects the world of all the community who “swim” there. The traditional Navajo treatment for mental illness involves the entire community in special healing ceremonies. One is a social ritual called “the Beauty Way,” intended to restore beauty, wholeness, and coherence to the community, tribe, and family. There are different versions of the Beauty Way ceremony, but it often consists of a combination of prayers, offerings, rituals and sweat baths, sand paintings, chants, and singing—sometimes for days. The ill person and the community are thought to have lost hózhó, the sense of beauty and integration with the universe. By surrounding the ill person with beauty, this appreciation is restored in the social environment, and the individual recovers his sense of meaning and order.

  Could incorporation of the social and emotional dimensions as in the Beauty Way ceremony bring healing back into modern medical care? If so, how would that affect the experience of health care and health outcomes, and how much would it cost? Dr. Don Berwick, founder of the Institute for Healthcare Improvement and former director of the Centers for Medicare and Medicaid Services (CMS), pointed me toward one system that has done just that: the Nuka System of Care, developed and run by the Southcentral Foundation (SCF) in Anchorage, Alaska. What attracted me to this system was not just Dr. Berwick’s recommendation but also the major impact that SCF produces on the people it serves. In 1982, when the SCF was first formed, the health care services for Alaskan Native peoples provided by the Indian Health Service (IHS) in Anchorage was abysmal. Their rates of alcoholism, diabetes, obesity, domestic violence, suicide, and life expectancy were some of the worst in the country. Premature births and infant mortality were similar to sub-Saharan Africa. It was not that the IHS-provided medical care was bad. In fact, state-of-the-science medical visits, prescription drugs, and specialty care were all available. IHS poured millions of dollars into providing this medical care with costs rising every year. So why was it failing its patients?

  From 1982 to 1989, SCF gradually took over health care delivery from the IHS. The results were astonishing. Twenty years after fully taking over health care delivery and after creating its own care approach, the foundation has markedly improved rates of obesity, diabetes, alcoholism, family abuse, and adverse childhood experiences. The need for costly emergency room and urgent care visits has dropped by 36%, primary care by 28%, and hospital admissions by 36%—all while improving the health of the community. Patient satisfaction rates have soared to more than 90%. Employee morale also improved, as shown by steady improvements in workforce commitment and reduction in annual staff turnover and employee satisfaction to 96%. SCF’s overall revenue has gone up and, compared to IHS days and to the rest of health care, costs per person have gone down.

  What were they doing differently? Had they found some new treatments that science had missed? How had they improved the ou
tcomes of their delivery system so dramatically? I decided to go see for myself.

  RELATIONSHIP-CENTERED CARE

  When I visited SCF’s Anchorage Native Primary Care Center and some of their more remote clinics in 2015, they were running a training program for other health systems on how to improve care and healing. I took the training; talked with employees, health care providers, and patients; and visited with system leaders. SCF had first asked to take over parts of health care for the Alaska Native people from IHS in 1982. From the very beginning, SCF set up “listening circles,” in which the people talked about their needs beyond medical care—needs in the physical, behavioral, social, and spiritual dimensions of their lives. The listening circle approach was an adaptation of an Alaskan Native process for social connection and reconciliation traditionally used by many of the tribes. SCF leaders used these circles to directly address the social and emotional dimension. One leader, an employee named Dr. Kathleen Gottlieb, opened up about the deep wounds and adverse childhood experiences in her family. Others followed, revealing the impact of illness and trauma in their lives. Soon these listening circles became Learning Circles, as participants developed deeper relationships and began to help—and challenge—each other to engage in whole-person healing, not just disease treatment. Gradually, this process was embedded into SCF, and, with Ms. Gottlieb as President/CEO, relationship-centered care became part of its standard delivery processes.

  The Learning Circle is a safe place where people can address trauma, fear, and grief and deal with their loves and losses with others’ support. In the process, they become more whole—more connected to their own social and emotional “bodies”—and healing sets in. One person I spoke with told me she grew up in a family where physical and sexual abuse, alcoholism, suicide, and obesity had been growing problems for more than four generations. By coming to a Learning Circle, she had could break that cycle and raise children who were largely freed from these adverse experiences. She did it by sharing some of the deepest traumas and losses in her own life. Others walked the healing journey with her as she learned to take these behaviors out of her own family and adopt other, healthier behaviors. For those who engaged in this process, life quality improved, and life expectancy jumped by decades—especially for their children. Over the years, this focus on relationships became a core part of the SCF health care operations. Today at SCF the patients are no longer treated as people whose medical services are delivered by strangers. Patients are now treated as customers and are owners of the company. They have continuous input on their own needs and the needs of the community. The use of the social and emotional dimension for healing was incorporated by bringing “behavioral health” into all the clinics. All employees, including physicians, are required to understand and participate in Learning Circles—through SCF’s Relationship-based Core Concepts workshop, which is now offered to other health systems.

  But I wondered: were the medical treatments provided by SCF somehow more evidence-based, more scientific or state-of-the-art than they had been before they developed the Nuka System of Care? The answer was no. Access to good, evidence-based medical treatments had been part of the IHS before SCF took over care, and that good medical practice had been continually updated for decades by IHS. Yet outcomes had continually worsened. The types of medical treatments and the agents used—drugs, surgery, counseling, emergency, and preventive care—are all part of the current Nuka System of Care and provided by IHS elsewhere. SCF had no unusual medical interventions, no better science, no more magic bullets than other systems. They still make diagnoses and deal with research and medical guidelines, insurance coding, and reimbursement. The doctors and nurses come from standard medical schools and use standard treatment tools. What has changed is relationships and customer ownership. SCF added the social and emotional dimension of healing to their delivery of health care. This allows them to tap into this previously ignored capacity for human healing.

  THE FACE OF LOVE

  Most of the medical community ignores this data, just as I had. Most physicians and scientists think these dimensions are too intangible, so they seek more material ways to treat illness—preferring to lower cholesterol rather than increase love; to raise brain serotonin rather than deal with grief. Not that lowering cholesterol or raising serotonin are bad things—but they are only a small part of what humans need to heal. Love may be a many-splendored thing—the stuff of poets and songs and mystics—but that splendor does not pay off like a drug or supplement. So, nothing further was ever done with the rabbit data on petting and heart disease, yet we have a multibillion-dollar drug and supplement industry selling you a way to lower cholesterol. Little has been done with the data showing reduced mortality with reduced loneliness, yet we have a multibillion-dollar drug industry to increase serotonin so you can worry less about your loneliness.

  After I flew back from Alaska, where I had seen relationship-centered care in full operation, I could not find a health system in our area that integrated this into the care for my own family. When Susan got cancer again, we needed such a system so we had to figure out how build one on our own. Fortunately, we had the awareness and social networks to do so.

  After six months of chemotherapy, Susan now faced another, even more traumatic event—the surgery. A double mastectomy and simultaneous DIEP flap reconstruction (deep inferior epigastric perforators, named for the associated blood vessels) this meant a twelve-hour operation involving three surgeons, two anesthesiologists, and four nurses. She would be cut from neck to pelvis, with the top part removed and the bottom part shifted up to the top—her body reorganized. Thank science for anesthesia and antiseptics! The recovery would be long and painful; the physical loss alone would be large. The surgeon said she would bounce back in no time—two weeks. The nurse indicated that she should not lift the grandbaby or even have him on her lap for eight weeks. The risk of suffering would be great; the possibility of falling into sadness and depression was present every day. While Susan had difficulty with the behavioral dimensions of healing that could prepare her for this onslaught—exercise, improved diet and supplements, meditation and visualization—she was good at relationships. During her first cancer she had sought divine love through prayer and meditation and a spiritual meaning for her illness. This time she looked again for love, but not the divine kind of love that spiritual healers describe. This time she sought a different kind of love—the common love of ordinary humans. It was a love that emerged largely from the females in our family, at least in acts and presence. Those who showed up at the door to sit with Susan when she couldn’t move were people like our next-door neighbor, Rose Ellen. Rose Ellen doesn’t cook, so she didn’t bring any meals; she said she couldn’t help with the grandchild because she wasn’t good with babies. But she came over anyway and said she would be available for anything Susan needed any time, day or night—just let her know. Rose Ellen isn’t a romantic type of person, nor is she particularly spiritual or complicated in how she lives her life—but she offered true caring and presence on an as-needed basis.

  Others came, too. Susan’s friend from college, who’d had a similar procedure a few months before, showed up and stayed for several days cooking, cleaning, and making conversation. Our two daughters came. One, a chaplain—the “analytical one” of the family, who had worked for over a year as a hospital chaplain ministering to the depths of suffering—knew exactly how to be, from lying down in bed with her mother to setting up an online meal chain system that brought food from friends on an organized schedule. Our younger daughter is a singer and teacher, the “creative one” in the family. She recorded a special set of songs for each phase of recovery and brought humor and laughter into the house—sustenance for the soul. Through both chemotherapy and surgery, one person after another showed up—all people Susan had loved and served in her life. Some we had not known well before. Some we had. Our niece from California flew out for ten days to help with the grandbaby and to cook. My sister followed her an
d did the same thing. I realized from watching this parade of faces—all bringing their physical bodies and human love to our house—that this was also the way that divine love leaked in. No special spiritual healers or waving of hands needed. The support we got from this network of other human beings allowed me to spend time sitting with Susan, helping her to the bathroom and the shower, sleeping next to her when she slept, bringing our new grandbaby up the steps into her room—and going to work. I took periodic breaks to take care of myself, and so I could, with this help from others, be present for her in the long run. We may not have had a Nuka-like health system to deliver relationship-centered care, but Susan used a network of friends and family to bolster the social and emotional dimension of healing on her own. And it worked. Her white count stayed up, her surgery recovery was like clockwork, and the grandbaby brought us joy and thrived. Eight weeks after the end of chemo and surgery not only could Susan lift the grandbaby, but she also had planned a trip for the extended family to Florida during the holiday season. The medical treatments for her cancer may have added only an 7% chance to her ten-year survival, but the quality added to all our lives by the social and emotional dimension of healing was immeasurable. We had found our own Beauty Way.

  GLORIA

  Not everyone has the network Susan does to tap the social and emotional dimensions of healing. However, that does not mean this dimension can’t be used effectively by everyone. Gloria demonstrated that to me. She had retired three years earlier from her job making omelets and doing kitchen work at a local golf club. The club, an old one with an established staff, had been her home for forty years. She started working there when she was twenty-five. It paid reasonably and provided benefits, so she stayed. With that income and her husband’s, they raised three children—two of whom had gone to college—something she was very proud of because she had not finished high school. She had retired at age sixty-five, and soon after that, her fatigue and muscle pains became progressively worse. She was diagnosed with fibromyalgia and chronic musculoskeletal back pain. She was told to exercise and rest, given painkillers to take “as needed,” and sent to physical therapy and acupuncture. These helped some, but her pain levels hovered “around four to five out of ten all the time,” she told me on our first visit, “especially in the morning.”