How Healing Works

by Wayne Jonas

  She came to me because she heard I might help her enhance her own healing capacity. She had heard I had a different approach and would work to integrate it with her regular medical treatments. So we set up a HOPE visit and began to discuss the dimensions of healing in her life. We explored a list of options that science shows helps people with chronic pain heal. I asked her questions like the following:

  1. What gave her the greatest joy and well-being in her life? What was her most meaningful activity?

  2. Did she have friends and a supportive family—anyone to cry with, to love, who would nurture and support her?

  3. What was her daily behavior like? The medical treatments? Her lifestyle—diet, sleep, exercise? What did she do to relax?

  4. What was her home like—the physical environment where she spent most of her time? Did she have a special place to give her an escape from the daily chores and hubbub of the day?

  These are the main questions I go through with patients during a HOPE assessment, using a chart like the one you see here. Mandy and I made a map to help her navigate toward a healing path, showing these dimensions and the elements in them that we would explore. With patience and persistence, HOPE can often change the trajectory of illness and restore well-being—even if, as in chronic disease, cure is not possible.

  Three things emerged during my dialogue with Mandy. First, many things were right in her life and supported her healing. She had a wonderful family and some good friends. She paid close attention to the food her family ate—lots of fruits and vegetables, fish, whole grains, and minimal sugar. She tried to exercise daily—at least doing her physical therapy each day. But she had challenges in many areas—especially in rest and relaxation. Her schedule, the needs of the household, and her pain made relaxation a challenge. Five years previously, she thought she had been getting better more rapidly, but then was involved in a second car accident. In this one, she struck her head but did not lose consciousness. After evaluating her, the doctors said everything was okay. Soon after that, her crying episodes started. She could not stop thinking of both accidents and that she might never recover. That is when she was diagnosed with PTSD. This was also when the antidepressant medications and counseling were added—providing some relief in her mood but not much for the pain.

  I then asked her a question I ask most of my patients: “What do you think is going on?” The timing and setting of this question are key to getting a deep and meaningful response. The purpose of the question is to help patients search their intuition—their heart or gut or soul, depending on how they perceive it. My job is to see if I can match what comes from that intuition with reasonable scientific evidence that might be used to enhance the patient’s healing. As it turned out, Mandy’s answer held the key to her recovery.

  “Well,” she said after a slight pause, “it’s my brain—there seems to be something wrong with my brain.”

  “Why do you say that?” I probed and waited.

  “Well, I noticed that the first few times I got acupuncture, I had a big relief—like maybe 95% better. Pain down to 1 or 2. But it didn’t last. I tried it several times, but after a while it didn’t work at all. So I gave up. It was like my brain was trying to heal but could not absorb the treatments. It just wasn’t sticking. Like I said, something is wrong with my brain.” Mandy started to cry again. “Sorry, doctor.”

  Our integrative health team got together and looked at the situation. Clearly, the acupuncture was producing endogenous opioids—those internal painkillers that all our brains produce. But after the treatments, her levels of those went down and she was no longer responding. The acupuncturist suggested that she had just not had enough treatments. Repeated acupuncture will not only induce endogenous opioids, but eventually also increase the density of opioid receptors in the brain, making the person more responsive to her own brain’s painkillers and prolonging the effect. She just needed more treatments.

  The neurologist disagreed. If increases in brain receptors were the problem, they should have shown at least some evidence of effect. Mandy had first done twelve weekly acupuncture treatments, and then an additional four acupuncture treatments spaced once a month. That should have been sufficient for acupuncture to “take,” he said. Something else must be going on. He wondered if the head injury she had sustained in her second car accident had caused a problem. I mentioned that her crying episodes—a sign of possible decreased cortical inhibition of her emotions—had begun after the second car accident. This can also happen from brain injury. To see if we could find any evidence for this, we ordered a positron emission tomography (PET) scan.

  While neuroimaging technology is advancing by leaps and bounds in medicine, the interpretation of what we see in those images—especially in the brain—is still being worked out. Our interest in this for Mandy was to explore if there was any evidence of brain dysfunction in areas preventing her from responding to the acupuncture. Dr. Daniel Amen is an American psychiatrist who has the most extensive experience in the world in the use of PET scanning to refine our understanding of brain diseases; he has read over twenty-five thousand, including many looking for the effects of subtle brain injury. I had read his book Change Your Brain, Change Your Life and wondered if PET imaging would help us in working with Mandy. A PET scan is a rather crude but inexpensive way to look at metabolism in the brain. We hoped that if the PET showed clear changes in the frontal areas of her brain—especially an area of the ventro-medial frontal cortex—this might explain both the crying episodes and the failure of acupuncture to take. It was worth a shot, especially in light of Mandy’s own feeling that her brain was not functioning properly.

  The PET scan seemed to confirm her feelings and our hypothesis. It demonstrated a reduction in glucose metabolism in the left frontal lobe, not exactly where we had hypothesized, but in an area where some of the executive functions and inhibitory pathways to pain and emotional control might have been damaged. We had no way to know whether this was caused by the car accident or if this explained her ongoing pain and temporary response to opioids and acupuncture. But it seemed to confirm our belief that Mandy needed to try to regrow those areas of the brain. More important, the scan energized Mandy to want to reengage in her own self-care—something she had neglected over the years. The simplest way to regrow the brain is to exercise it. We suggested either biofeedback or an intensive set of relaxation response exercises. Mandy liked that idea, so our next task was to find a method that she enjoyed and could maintain long enough to enhance function in that part of her brain. Mandy decided to try mindfulness meditation.

  MIND-BRAIN-BODY

  Most of modern biomedicine focuses on treating diseases of the mind—mental and psychosomatic illnesses—by manipulating the brain. But the reverse is also possible. The brain and the rest of the body can be treated through the mind. Mandy needed a way to regrow a part of her brain that had become injured and dysfunctional, even possibly atrophied, by years of pain and treatments to alleviate it. While someday we may be able to regrow parts of brains using stem cells or direct electrical stimulation, those days are not here yet. Our experience with drug and herbal treatments also shows that those methods provide only partial relief in a few and risk producing side effects in many. In the meantime, there are methods to regrow the brain through behavior, social learning, and mind-body practices. Physical exercise can increase neural growth generally. Mandy did some exercise but could not engage in intensive physical training. Also, we could not use exercise to grow the specific areas that seemed to be problematic for her. Biofeedback of brain waves can growth brain areas—often in specific areas. That approach required multiple visits and sophisticated equipment. Virtual reality is another method but is generally not viable for chronic pain. These also cost money and are not easy to incorporate into self-care. We needed an approach Mandy could bring into her daily life. The one that seemed the most practical and meaningful for Mandy was mindfulness meditation training.

  For Mandy, this meant
creating a process for her to do deep relaxation every day for at least eight weeks. I knew about the research showing that patients who engage in at least eight weeks of mind-body practices such as mindfulness or meditation for thirty minutes a day can grow areas of the frontal lobe that Mandy had lost. She was excited to try this. She had previously tried meditation and found it helped her feel better, and have less anxiety, but she had not kept it up. The challenge now would be integrating it into her daily life. For this, the behavioral medicine and health coach on the team came into play. They worked with her to design—with her family—a process allowing her to engage in thirty minutes of mindfulness meditation every day. She preferred this over the visualization that Jake had done, or heart-rate variability biofeedback—another evidence-based option. The first attempt failed because as long as she was in her house, she felt overwhelmed by responsibilities for her family. She had no place in her house that she could fully relax.

  The behaviorist and health coach helped her organize that special place in her house. It turned out to be in her bedroom, where she constructed her own little nurturing corner. The family cooperated to ensure that this place was isolated and not invaded by the rest of them. In her own little corner, she placed some of her favorite sacred symbols and family mementos that she enjoyed. She decorated it with soft cloth and low light. A CD player was set up to deliver favorite music or nature sounds. It was her own optimal healing environment. A set of reminders to both the family members and herself, sent simultaneously through a cell phone app, allowed her to engage in over thirty minutes of mindfulness and breathing practice every day for more than two months. At that point, a repeat PET scan showed improved neurological function in the frontal lobe. This encouraged her to continue. She also noted that her sleep had improved and her pain had dropped from the usual 5 to 7 on a scale of 1 to 10, to a 4 or 5. It was now time to try acupuncture again.

  Research shows that it takes between eight and twelve weeks of acupuncture for opioid receptor density to change in the brain. But this had not previously worked for Mandy. We hoped that now that she had the right neurological foundation, the acupuncture would take. Mandy had used her mind to change her brain. So she began a series of twenty acupuncture treatments using a combination of body and ear points. Gradually, over the next two months, the rebound of pain she had previously experienced after acupuncture began to diminish. Within three months, her pain levels were down to 1 or 2 out of 10, and she could scale back her acupuncture to once every month and eventually once every three months. More important, her quality of life, functional capacity, and ability to tap her own healing capacity increased. She learned that when her pain began to increase, it was often because she had not engaged in sufficient self-care, either by not getting enough sleep or by skipping her mindfulness practices or ignoring increased stress in her life. Her medications were now only a low-dose antidepressant, which, along with her restored frontal lobe, prevented most of the crying, and acetaminophen for an occasional pain flare.

  Mandy was the beneficiary of integrative health.

  I use the term “integrative medicine” in reference to the merger of conventional medicine—as I was trained in—and complementary and alternative medicine, such as acupuncture, chiropractic, or massage. The term “lifestyle medicine” is used in reference to the merger of conventional medicine and behavior in the form of self-care, such as nutrition, exercise, and stress management. “Integrative health” is at the intersection of all three of these fields with good scientific evidence and patient-centered care as the driving principles for its application. This is what Mandy had at her disposal. This is the future of health care for chronic disease.

  A SHIFT TOWARD HOLISM

  There is a story that around the year 500 BCE, an enlightened ruler in Tibet did a remarkable thing. He invited master healers from all the major healing traditions of the world to a yearlong conference of learning. Physicians came from corners of the known world, including Greece and the Middle East, North Africa, China, and India. Their purpose was to share the best of their craft and synthesize the most effective treatments known to humanity—in other words, to create a truly integrative approach from the world’s healing traditions of the time. What emerged was a remarkable system that informed and infused medical thinking for over a thousand years. It was the integrative medicine of its day.

  We need a similar effort to integrate the best healing traditions from around the world today. In an age of instant information and global interaction, patients are already exposed to and using practices from multiple healing traditions and nonconventional systems. In 1993, Dr. David Eisenberg of Harvard published a study in the Journal of the American Medical Association showing that over one-third of people in the United States regularly sought out so-called complementary and alternative medicine (CAM) practices and visited alternative healers. A decade later, that number was 40% and climbing. The use of so-called complementary and alternative medicine is even higher in Europe, South America, and Eurasia and up to 80% in the populations of non-Western countries. But rarely do conventional doctors know about these practices. Rarely do patients tell doctors when they are using them, and rarely do doctors ask about or offer them. The gap between curing, healing, and self-care is greater than ever. Patients are the ones saddled with trying to do the proper integration that the profession should be doing. The consequences of this gap can be tragic when people like Trevor, struggling with high blood pressure and eventual kidney failure, seek out more holistic practices but without appropriate scientific input. We need another concerted effort today—like what was done in Tibet a thousand years ago—with the help of modern science and information technology.

  Fortunately, there is a shift toward more integration in health care today. The effort is occurring—but with difficulty. In 1948, the WHO came out with a controversial definition of health. The WHO defined health as more than just curing physical disease, but “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It declared that this definition should be the goal of all health care. However, most of modern medicine went on its reductionist way—looking for finer and finer divisions of the body into the small and particular. The study of DNA was under intense research when WHO published its definition, with the Watson and Crick discovery of its structure published in 1953. The first randomized clinical trial (RCT)—done in the same year as the WHO definition—launched the role of reductionism onto the stage of human testing for medical decision making. As we’ve discussed, the RCT has become the primary tool for deciding what is good evidence in health care. For the last five decades, this science of the small and particular has continued to dominate biomedical research and clinical practice—being applied everywhere and to everything.

  Then, gradually, international groups began to respond to our need for rebalance and more whole person care. In 2001, a landmark report from the Institute of Medicine (now National Academy of Medicine) called Crossing the Quality Chasm laid out ten principles for the redesign of health care to provide more patient-centered, holistic care in medicine. The first three recommendations were as follows:

  1. Care is based on continuous healing relationships.

  2. Care is customized according to patient needs and values.

  3. The patient is the source of control.

  The report also called for good evidence, shared information, better safety, anticipation of (not just reaction to) patient needs, prevention, and cooperation among clinicians. In other words, team care. In a major effort to live up to these principles, four main primary care associations in the United States—in pediatrics, family medicine, internal medicine, and obstetrics-gynecology—published a joint set of guidelines for the Patient Centered Medical Home in 2007. The idea behind this was to provide care that is the following:

  • Patient-centered: takes into account the needs and preferences of the patient and family

  • Comprehensive: cover
s the whole person, including their physical, mental, prevention, wellness, acute and chronic care

  • Coordinated: is organized to integrate all elements of health care delivery

  • Accessible: includes 24/7 care, with telephone and IT communications

  • Committed to quality and safety: ensured thorough continuous improvement

  In other words, the call was for medicine to be more responsive to the whole person, be more integrated, and be more focused on prevention and health promotion than our current system. Echoes of Crossing the Quality Chasm reverberated throughout the mainstream.

  Other groups and other countries too have pushed for more integrative and holistic care. In 2008, the international Institute for Healthcare Improvement (IHI) defined and began to support training for achieving the “Triple Aim” of health care worldwide: (1) improving the patient experience, (2) improving the health of populations, and (3) reducing the per-person cost of health care. The concept of pay for value (rather than for procedure or treatment) emerged from these efforts. The goal was described clearly by visionary leaders such as IHI founder Dr. Don Berwick, who called for an “integrator”—an organization that accepts responsibility for all three aims. Dr. Berwick went on to create the Center for Medicare and Medicaid Innovation, which funded and tested new models of health care, demonstrating how to implement pay for value. Pay for value efforts were already under way in England, Europe, Australia, Singapore, Japan, and other countries. These innovative models are gradually moving more fully toward the type of integrative health care that people like Trevor need to prevent disease and stay healthy, and that Mandy used to heal herself from chronic pain.