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Mind-body-spirit medicine: Interventions and resources

MBS techniques can help patients who are afflicted with a wide variety of chronic conditions. This concise review helps you decide which to recommend.

Leslie Freels Lloyd, RhD, CRC, LPC; Laurie R. Dunn, MPAS, PA-C

The authors are faculty in the PA program at Southern Illinois University Carbondale. They have indicated no relationships to disclose relating to the content of this article.

It is more important to know what sort of person has a disease than to know what sort of disease a person has.
— Hippocrates

The Competencies for the Physician Assistant Profession define the professional skills needed for practice as a PA. This list of competencies includes patient-centered care, promotion of wellness, responsiveness to the needs of patients and society, and sensitivity to patients’ culture.¹ As PAs strive to meet these competencies, they should be aware of the growing use of mind-body-spirit medicine (MBSM).

Data collected from the 2002 National Health Interview Study conducted by the National Center for Health Statistics make it clear why: in this study, 75% of patients older than 18 years had utilized some form of complementary and alternative medicine (CAM).² More than 70% of patients 50 years or older use alternative treatments, including mind-body-spirit (MBS) therapies.³ Many of the average PA’s patients are probably already involved in CAM and may use MBS therapies in addition to, or instead of, allopathic treatment.

MIND-BODY-SPIRIT MEDICINE

Until approximately 300 years ago, most cultures had indigenous healers who treated the person as a whole, not separating body and mind. Treating the physical, emotional, social, and spiritual aspects of the person as one entity was standard practice until the 18th century, at which time the scientific model moved the study of medicine to separate body and mind. According to Barrows and Jacobs, “Mind-body-spirit medicine combines characteristics of ancient traditional healing systems with the modern biomedical model to create an integrated approach to health care.”⁴ Today, evidence demonstrating the effectiveness of MBS interventions is accumulating, and randomized controlled trials (RCTs) of various MBS practices are ongoing. Research is beginning to demonstrate that people can utilize mental, emotional, social, and spiritual factors to directly affect personal health.

The mind and body are increasingly considered to be a single integrated entity, called the bodymind.⁵ MBSM utilizes the conscious mind to affect the operations of the mind and subsequently the body. Dr. Herbert Benson, director emeritus of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital and Associate Professor of Medicine at Harvard Medical School, defines mind-body medicine as the integration of “modern scientific medicine, psychology, nutrition, exercise physiology, and belief to enhance the natural healing capacities of the body and mind,” of which the “end result is self-care, a complement to the conventional medical paths of surgery and pharmaceuticals.”⁶

MBSM is both art and science in pursuit of optimal health, rather than the absence of sickness. It is characterized by a philosophical commitment to whole-person care and embraces the entire individual; the mind and body are considered equally medically significant. Each person is an integration of physical, psychological, intellectual, and spiritual aspects, of which all are equally important when approaching health.⁷ As a result, MBSM draws on diverse disciplines, including neurobiology, developmental psychology, behavioral medicine, and spiritual healing. In terms of research, MBSM concepts continue to be examined through psychoneuroimmunology, the field that studies the effects of thoughts, emotions, and mental state on health.^7-9

Dr. Candace Pert, a research professor at Georgetown University’s Department of Physiology and Biophysics, is the author of Molecules of Emotion: The Science Behind Mind-Body Medicine.¹⁰ Dr. Pert’s work with neuropeptides and their receptors has allowed her to identify how the mind and body are interconnected via biochemical communications between the CNS and the immune and endocrine systems. She can identify which cells, and in which glands, emotions physically exist.^5,11 Dr. Pert has urged a fundamental reassessment of how the body works and concludes that it is now more accurate to speak of a single integrated entity, the bodymind.⁵

The mind’s role in illness The mind and the body have reciprocal relationships via biological and chemical connections. Indeed, the two are not only connected but inseparable.¹² A well known example of this inseparability is the relaxation response, as described in Benson’s 1972 and 1975 studies on the physiologic effects of stress and the use of meditation to decrease many of these effects.^13,14 Benson identified the relaxation response as a way in which the mind can be used to alter physiology. In other words, the mind can be trained to initiate the parasympathetic nervous system to begin its natural restorative processes of decreasing metabolism, heart rate, respiratory rate, BP, and muscle tension—returning these functions to normal levels. Benson concluded that the mind can alter physiology in a way that will improve health. Today, research has shown that many MBS techniques improve the body’s physiologic responses and make clinically significant differences in various medical conditions.^13-15

The MBS approach Healing is the central tenant of MBSM, and the relationship between provider and patient has educational, experiential, and collaborative features.¹⁶ Self-care is considered a necessary prerequisite to self-healing, and self-healing is espoused by many practitioners as the core of mind-body medicine. Practitioners teach specific self-healing skills, such as meditation, physical exercise, relaxation and stress reduction exercises, biofeedback, autogenics, and spirituality. The patient experiences first-hand and voluntarily the concepts of somatic and psychological awareness, the role of self-reflection, and the effect of MBS interventions, and the patient learns by doing. The practitioner and the patient have a collaborative relationship guided by principles of trust and rapport, and the provider serves as a guide or facilitator for the patient.

Evidence-based medicine The RCT is considered the gold standard for evaluating medical interventions.⁸ Although RCTs for CAM and MBS interventions are still limited, the number is increasing and several systematic reviews are available.^4,17 PAs should note that evidence-based medicine is not defined solely by use of the RCT; it is rather the integration of clinical expertise with the best evidence available to the clinician.

MIND-BODY-SPIRIT THERAPIES

Meditation has so far been studied primarily as part of a program of combined interventions. Toobert and colleagues conducted a prospective RCT investigating a comprehensive lifestyle management program in women with coronary heart disease.¹⁸ Meditation was part of a program that included exercise, diet, and group support. The authors found that scores on the Perceived Stress Scale and Ways of Coping Scale were not significantly changed at a 4-month follow-up and were not significantly changed on the Perceived Stress Scale at a 12-month follow-up. At the 12-month follow-up, however, the Ways of Coping Scale indicated a significant overall effect (P = .012), which appeared to be a result of the increased number and quality of the strategies employed. The obvious problem with a study of this sort is that it cannot reveal the impact of meditation alone, without the influence of the other interventions.

Dr. Dean Ornish and colleagues conducted a prospective RCT to determine the effect of comprehensive lifestyle changes on coronary atherosclerosis.¹⁵ This study employed meditation as part of a multicomponent intervention that also included a low-fat vegetarian diet, smoking cessation, stress management training (including meditation), and exercise. The experimental group received only the lifestyle change intervention, whereas the control group received “usual care.” As measured by percent diameter stenosis, 82% of the experimental group had an average change toward regression of coronary artery disease (CAD). The average percent diameter stenosed regressed from 40.0% (standard deviation [SD] 16.9) to 37.8% (SD 16.5) in the experimental group, whereas the average for the control group progressed from 42.7% stenosed (SD 15.5) to 46.1% stenosed (SD 18.5). In lesions with greater than 50% stenosis, regression from an average percentage diameter of 61.1% (SD 8.8) to 55.8% (SD 11.0) was seen in the experimental group, and progression from 61.7% (SD 9.5) to 64.4% (SD 16.3) occurred in the control group. These were statistically significant at both the 1-year and 5-year follow-ups (P = .02 and P = .001, respectively). The Ornish team concluded that comprehensive lifestyle changes may bring about regression of severe CAD. As with the Toobert study, however, the specific role played by meditation is unclear.

Exercise and body therapies have well known benefits, both physical and mental. The recent popularity of tai chi and qigong has led researchers to look at the benefits of these therapies in particular. Tai chi, the most popular form of exercise in China, developed into a martial art in the 1200s.⁸ It consists of a series of flowing movements in which physical and mental balance are the focus for maintaining chi, or vital energy. Similarly, qigong is another ancient Chinese exercise, using physical movements and breathing to circulate chi. Both tai chi and qigong are used in the practice of traditional Chinese medicine.

In an RCT of 95 elderly patients with CAD, Stenlund and colleagues found that qigong and group discussions resulted in the following: self-estimated level of physical activity was increased (P = .011), and coordination (P = .021), performance in a one-leg stance test (P = .029), and performance in a box-climbing test (P = .035) improved.¹⁹ A pilot study by Lee and colleagues using qigong in controlling BP showed significant reduction in diastolic and systolic measurements.²⁰ Additionally, an RCT study of 36 college-age women with premenstrual syndrome (PMS) tested the effects of qigong on PMS. Results demonstrated noteworthy reductions in pain and total PMS symptomatology, with statistically significant reductions reported in water retention and negative feelings (P ≤ .001).²¹ Tai chi has been used to improve cardiovascular function in older adults²² and holds promise for increasing immunity to varicella-zoster virus.²³

Autogenic training is the use of autosuggestion to help the body and mind return to their normal states. It is typically used to foster relaxation and is characterized by themes of heaviness; warmth; cardiac, respiratory, and abdominal activity; and blood flow to the head.²⁴ Phrases such as “My arms are heavy and warm. I am at peace,” and “My heartbeat is calm and regular,” are repeated to enhance their effectiveness. Autogenics is one of the most convenient and easy-to-use MBS therapies and may benefit patients with muscle tension, hypertension, GI problems, racing/irregular heartbeat, headaches, hyperventilation, asthma, anxiety, irritability, or fatigue.

Biofeedback uses technology to provide the user with information on physiologic states such as muscle tension, galvanic skin temperature, and brain waves so that the user can manipulate them by conscious mental control. The disadvantages of biofeedback include the need for equipment and a trainer to teach the method, but research suggests it is one of the most promising interventions and insurance providers increasingly will pay for it. Dr. David Shapiro is one of the early biofeedback pioneers and began studying the effects of biofeedback on BP and heart rate in the 1970s.^25,26 It has also been compared to relaxation methods, transcutaneous electrical nerve stimulation, electrical neurotransmitter modulation, and combinations of these interventions in patients with headache.²⁷ All these treatments reduced the frequency and severity of headaches, but in the biofeedback group, time with headache decreased the most, from 31.1 hours per week to 1.3 hours per week, on average.²⁷ There was no statistically significant difference in the degree of pain between the interventions, although the biofeedback group reported the lowest level of pain of all the groups at the end of the study (mild pain as opposed to moderate pain).²⁷

Relaxation and stress reduction have long been associated with maintaining good health. Recent studies have begun to look at the effectiveness of relaxation and stress reduction techniques when used in combination with other interventions, such as meditation, imagery, or spirituality. For example, mindfulness meditation combined with stress reduction has been found to effectively reduce nurse burnout.²⁸

Guided imagery involves using images, smell, touch, hearing, and taste to stimulate a flow of thoughts with sensory qualities. Imagery has been used for diagnostic purposes by asking a patient to describe his or her problem. Additionally, imagery has been used in psychological rehearsal, such as preparing a patient for a medical procedure or to endure side effects.⁸ This technique is also used to treat chronic diseases and conditions, to deal with pain and stress, to alter behavior, and to improve immune response and overall health.

Spirituality as defined by a group of 60 medical researchers, scientists, and experts in psychology and the neurosciences is the “personal quest for understanding answers to ultimate questions about life, meaning, and relationship to the sacred or transcendent.”²⁹ Spirituality includes prayer, which Hood and colleagues describe as being conversational, petitional, ritualistic, or meditative.³⁰ Spirituality and prayer have been associated with healing for centuries, with early medical practices (and the first hospitals) closely tied to religion. Although the influence of religious groups on medical practice has since diminished, recently there has been a reappearance of interest in the medical humanities, in the connection between spirituality and medicine, and in scientifically based research into the mind-body-spirit connection. In the Handbook of Religion and Health, Koenig and colleagues review more than 1,200 studies conducted in the 20th century that have examined the relationship between religiosity/spirituality and health.³¹ The majority of these studies demonstrate that religiosity/spirituality has a positive effect on health, but clinicians should bear in mind that some religious coping methods can be deleterious. Examples include the conviction that illness is a punishment for wrongdoing or a sign of possession by demons. Religious beliefs may also lead patients to stop taking or refuse to take medications, fail to seek timely medical care, refuse lifesaving or preventive treatments, and avoid traditional mental health care.³¹

Journaling involves writing down ones’ thoughts and feelings for therapeutic purposes. It has most frequently been used to assist patients in dealing with stress or trauma. However, journaling can also be used to address specific life problems and symptomology, as with cancer patients.^32,33

THERAPEUTIC IMPLICATIONS OF THE EVIDENCE

MBS techniques may allow patients to alter or control autonomic functions associated with stress reactivity, alter muscular and motor activity, and modulate immune function.^34-36 MBS techniques may be particularly helpful for patients with headaches, hypertension, anxiety, insomnia, irritable bowel syndrome, skin disorders, dyspepsia, fibromyalgia, chronic fatigue syndrome, autoimmune disease, CAD, chronic low back pain, symptoms related to cancer and its treatment, and arthritis.¹⁷ “Table. Mind-body-spirit interventions” (in the online version of this article) provides a summary of selected therapies, and Table 1 lists some resources for more information.

MBSM can be utilized in virtually any practice setting. Pelletier has noted that it is effective in ambulatory care,³⁷ and Dr. James Gordon, founder and director of the Center for Mind Body Medicine in Washington, DC, has used it in quite different circumstances. Dr. Gordon, a psychiatrist and 30-year veteran of MBM, and his healing team used these techniques with postwar Kosovo high school students in the treatment of posttraumatic stress disorder.³⁸ Although MBS techniques can help most patients, those with debilitating mood disorders, personality dysfunction, relationship conflict, and psychological trauma should initially be referred to a psychologist or psychiatrist for assessment prior to use of mind body interventions.¹⁶

Dr. Naomi Remen, physician, author, and pioneer in mind-body medicine, stated in a July 1999 interview in Shambhala Sun magazine that MBSM “hopes to synthesize the best from alternative and conventional approaches [and] actually goes far beyond these techniques to recognize the potential for wholeness in everyone.” Dr. Remen calls on all health professionals to commit to strengthening the wholeness in their patients by all means possible. With the emergence of evidence-based research demonstrating the effectiveness of MBSM, PAs can now explore more ways to provide high-quality care for patients.

REFERENCES

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