MIND-BODY TECHNIQUES Which, When, How…and a bit about language use

David Becker, MD, MPH, MA, LMFT Clinical Professor, UCSF Department of Pediatrics UCSF Osher Center for Integrative Medicine Co-Medical Director, Pediatric Pain Management Clinic

DISCLOSURES

•  Mine is one voice among many that are more accomplished, more experienced, and better communicators.

•  Personal experiences and practices

•  The complete breadth and depth of mind-body practices, language use in clinical care, and the ‘common factors’ in clinical psychology are beyond the scope of this talk.

•  I hope to bring several of these threads together to help inform clinical practice, inspire curiosity, and engage in dialog

I have no financial relationships or conflicts

of interest to disclose

OBJECTIVES

¡  Describe the similarities and differences among guided imagery, clinical hypnosis, mindfulness and others

¡  Understand how specific language influences patient experience

¡  Learn ways to apply these components to individual patients

OUTLINE

¡  Self-regulation skills vs Mind-Body techniques

¡  Characterize some differences/similarities among MB techniques

¡  Describe the common factors research and how it applies to clinical practice of mind-body modalities

¡  Summarize key factors in the clinical encounter

¡ A complex set of mental capacities that help with: ¡  Impulse control ¡  Emotion control

¡  Planning ¡  Self-reliance

¡  Socially responsible behavior

¡  Self-guidance of thought and behavior

¡  Fundamental to personality, behavioral adjustment, school readiness, and ability to cope manage stress

¡ Control over oneself, by oneself

SELF-REGULATION SKILLS

Self-regulation practices

Mind-body techniques

Routines (sleep, meals, exercise, regular activities)

Talking to someone you trust

Positive self-talk

Humor

Journaling

Yoga, Tai Chi, others

Meditation practices

Progressive relaxation/Body scan

Biofeedback

Guided imagery

Clinical Hypnosis

Autogenics

Taking a break

SELF-REGULATION VS MIND-BODY SKILLS

Techniques that facilitate one’s ability to direct behavior, modulate physiologic changes in desired directions, and control thoughts…

…so we don’t cut in line at Starbucks (self-regulation)

…for the purpose of symptom control, attaining and maintaining health and wellness, and improving functioning or enhancing performance (mind-body skills)

MIND-BODY TECHNIQUES

Guided imagery Biofeedback

Progressive relaxation/Body scan

Meditation: Clinical Hypnosis

Yoga, Tai Chi, others

Autogenics

Insight (vipassana)

Concentration (shamatha)

Transcendental

“Mindfulness”

“A good meditation practice is any one that develops awareness or mindfulness of our

body and our senses, of our mind and heart. It does not really matter which kind you

choose.”

Among the perhaps 80,000 estimated types

Jack Kornfield

MEDITATION - DEFINITION

MINDFULNESS?

“the awareness that emerges through paying attention

in a particular way, on purpose,

in the present moment, and without judgment,

to the unfolding of experience from moment to moment”

Jon Kabat-Zinn

MINDFULNESS - DEFINITION

Amy Saltzman: “Mindfulness is paying attention, here and now, with kindness and curiosity, so that we can choose our behavior”

MINDFULNESS - DEFINITION

atlasofemotions.org

MINDFULNESS ~ AWARENESS

SPECIFIC MEDITATION PRACTICES

¡ Compassion (metta) meditation:

May I be filled with loving-kindness

May I be well

May I be safe from inner and outer dangers

May I be peaceful and at ease

¡  Forgiveness meditation: For any way I have hurt myself

Through action, inaction, fear, pain or confusion

I offer myself forgiveness

To the extent I can in this moment

MEDITATION/MINDFULNESS

¡ What does it do? ¡  Improves awareness of thoughts and emotions

¡  Increases the space between stimulus and response

¡  Facilitates acceptance of what may not be under our control

¡  Trains us to choose what we attend to

PEDIATRICS Volume 1 37, number 1 , January 2016

Crum A, Langer. Psych Sci 2007

“After only 4 weeks of knowing that their work is good exercise, the subjects in the informed group lost an average of 2 pounds,6 lowered their systolic BP by 10 points,7 and were significantly healthier as measured by body-fat percentage, BMI, and WHR.”

MINDSET

¡  How is Mindset utilized? ¡  Psycho-education about various conditions

¡  Shifting attention

¡  Positive self-communication

¡  Holding alternative beliefs

¡  Pain analogies and metaphors

¡  “Hurt not harm”

¡  Yes! It feels really uncomfortable (awful, bothersome…) doesn’t it! What’s happening in that leg when you feel that sensation?

BIOFEEDBACK

The use of electronic equipment to measure and then feed back information about physiologic processes that can then be voluntarily modulated in a therapeutic direction.

- Tim Culbert

THE BIOFEEDBACK LOOP

Computer processes and presents back

Attend to and Modulate the process

Sensory information from patient

BIOFEEDBACK – POTENTIAL ROLES

¡  Learn how to ‘listen’ to the body

¡  Experience and See/Witness a relaxation response (or physiological change), and begin to believe in the value and possibilities… ¡  Feel (see, hear) the difference between a tense and a relaxed muscle

¡  See skin temperature increase

¡  Experience the difference between a belly and a chest breath

Guided Imagery

CLINICAL HYPNOSIS

“Hypnosis is a state of awareness, often but not always associated with relaxation, during which the participant can give [oneself] suggestions for desired changes to which [one] is more likely to respond than when in the usual state of awareness. Spontaneous self-hypnosis may happen while reading, listening to music, watching television, jogging, dancing, playing a musical instrument, doing tai chi, doing yoga, or performing similar activities.”

Olness K, Clev Clin J Med 2008

CLINICAL HYPNOSIS

¡  The utilization of an altered state of consciousness (trance, focused concentration, in the "zone“)...

¡  Usually, but not always, involving a state of relaxation (which may or may not be evident)...

¡  Facilitated by a heightened concentration on a particular image or idea...

¡  During which language, images, metaphor and/or dissociation are utilitzed...

¡  For the purpose of altering a symptom, disease or physiologic parameter…

¡  That the patient has already conceptualized and wants to happen/change.

CLINICAL HYPNOSIS: Misconceptions

¡  Patient is under the control of the hypnotherapist

¡  Patient is asleep

¡  Only a few people can be hypnotized

¡  Hypnosis masks symptoms

¡  All the psychiatric defense mechanisms of the patient are abolished in trance

¡  Therapist as coach; non-directive

¡  Children encouraged to “be the boss of their bodies”

¡  ”Hypnotists”

¡  53 patients 8-18 yrs

¡  FAP/IBS by Rome II criteria for > 12 mo

¡  Hypnotherapy or SMT ¡  Six 50-min sessions over 3 months

¡  SMT: education, dietary advice, extra fibers, pain meds or PPI’s. Plus 6 30-min counseling sessions over 3 months

Vlieger et al: Hypnotherapy for FAP/IBS – Gastroenterology 2007

Vlieger et al: Hypnotherapy for FAP/IBS – Gastroenterology 2007

•  49 of 52 original subjects surveyed 5 years after initial trial

•  Clinical remission: decrease of the PIS and PFS of > 80 % compared with baseline

•  Remission rate at 5 years:

•  SMT: 20%

•  HT: 68%

•  Larger study size

•  CD non-inferior to iHT

•  Differences: •  negative pain

beliefs •  problem-focused

coping

HYPNOSIS: Brain imaging studies

¡  Suggestions in trance selectively activate specific perceptual neural systems ¡  Visual suggestions:

¡  changes in visual centers

¡  Altering pain suggestions: ¡  changes in somatosensory and ACC

¡  changes in subjective appraisal regions

¡  Post-hypnotic suggestions: ¡  changes in regions associated with higher processes concerns

with perception and valence judgments

Landry M, Raz A. Hypnosis and Imaging of the Living Human Brain. Am J Clin Hypn 2015

FORMAL STEPS IN CLINICAL HYPNOSIS

¡  History

¡  Rapport (validation) - Attunement

¡  Assessment of Context, purpose, Goals, development and competing interests (family dynamics)

¡  Facilitating a Focused state of concentration

¡  Reframing the problem

¡  Language

¡  Suggestion/Metaphor

FORMAL STEPS IN CLINICAL HYPNOSIS: An invitation

“You’ve been so wrapped up in feeling bad, you’ve been so focused on all those things that are so hurtful to you, wouldn’t it be valuable [or, I wonder what it would be like] to be able to start to focus on other things that can help you feel better? So, to help you shift your focus and get absorbed in a different way of experiencing yourself, why not close your eyes, take in some deep, relaxing breaths, and…”

- Michael Yapko, Mindfulness and Hypnosis. 2011. p.6

AUTOGENTIC TRAINING

¡  Developed in the 1930’s through observation of the states and experiences of people in hypnosis

¡  Often taught gradually: ¡  My arms and legs are heavy and warm

¡  My heartbeat and breathing are calm and steady

¡  My belly is soft and warm

¡  My forehead is cool

¡  I feel calm and at ease

NOCEBO EFFECT

¡  Def: the occurrence of a negative outcome or symptom when the expectation of one is stated or suggested.

¡  Examples: ¡  This medication can cause nausea, headache, rash, glaucoma, etc…

¡  Knowledge of receipt of pain/anxiety medication augments efficacy (placebo)

¡  Knowledge of discontinuation of pain/anxiety medication reduces duration of efficacy (nocebo)

Science. 2017 October 06; 358(6359)

JUST BREATHE NORMALLY…

“This will hurt a bit! There will be a little poke!”

“Little sting here!—Little sting here again!”

“You shouldn’t feel anything sharp”

Can words hurt? Pain 114 (2005) 303–309

“Let us know if you feel pain”

“OK! It’s going to be really hot!” “It will feel like a bee sting”

“Are you uncomfortable? This isn’t ideal, I know. If you’re not comfortable, you let me know.”

NOCEBO EFFECTS: Context Matters

Rossettini et al. BMC Musculoskeletal Disorders (2018) 19:27

How we talk reflects how we think, what we believe, how we teach and what we come to expect.

- Dan Kohen

tickling

Light touch sprain

migraine

broken bone

paper cut neuritis

active arthritis

Severe burn

Physical Psychological

Social Spiritual

bump

pinch

Sleep/fatigue

Conditioning

Inflammation

Sympathetic arousal

Peer relationships Academic pressure

Performance pressure

Anxiety

Resilience ACE’s

Depression

Catastrophizing

Past illness experience

Meaning of illness

Values

Religious faith

Experience of Pain

Connection Outside of Oneself

Family dynamics

PSYCHOTHERAPY: The Common Factors

•  Developed from psychology research about what works in psychotherapy

•  Psychodynamic vs CBT vs Relational vs Brief structured vs Gestault vs Jungian…

•  No clear winner

•  So what factors are important?

World Psychiatry 2015;14:270–277

Alliance: the bond, agreement about the goals and the tasks (of therapy)

Empathy: identifying with the other by adopting his or her perspective

Expectations: through explanation of the patient’s disorder, presenting the rationale for the treatment, and participating in the therapeutic actions.

Cultural adaptation: the explanation given for the patient’s distress and the therapy actions must be acceptable to the patient. ‘Clinician’ effects: does is matter who the clinician is? Treatment Differences: when empathy, structure and alliance are there, it doesn’t matter what the modality is (maybe). Adherence and competence: adherence to the protocol and competence is not significantly related to outcome.

PSYCHOTHERAPY: The Common Factors

Alliance/Rapport

Empathy

Expectations

Cultural adaptation

Clinician effects

Treatment differences

Adherence and competence

Larger effect sizes: Smaller effect sizes:

PSYCHOTHERAPY: The Common Factors

EXPECTATIONS

¡  “In medicine, expectations can be induced verbally and then physiochemical agents or procedures can be administered or not, making the two components (creation of expectations and the treatment) independent…

¡  …In psychotherapy, creating the expectations, through explanation of the patient’s disorder, presenting the rationale for the treatment, and participating in the therapeutic actions, is part of therapy.”

¡  In clinical care (and formal MBM), context creates an opportunity for a focused state of concentration, during which shifts in awareness, mindset, and biological functions are possible.

World Psychiatry 2015;14:270–277

THERAPIST EFFECTS

¡  “Studies have shown that effective therapists (vis-a-vis less effective therapists) are able to form stronger alliances across a range of patients, have a greater level of facilitative interpersonal skills, express more professional self-doubt, and engage in more time outside of the actual therapy practicing various therapy skills.”

World Psychiatry 2015;14:270–277

TREATMENT DIFFERENCES

¡  When empathy, structure and alliance are there, it doesn’t matter what the modality is.

¡  “All therapies with structure, given by empathic and caring therapists, and which facilitate the patient’s engagement in behaviors that are salubrious, will have approximately equal effects.”

World Psychiatry 2015;14:270–277

The ‘Common factors’ of Mind-Body Medicine

¡  Context: ¡  Attunement: Rapport and Alliance/Empathic connections

¡  Cultural humility ¡  Expectations (Goals) ¡  Reframing/Locus of Control ¡  “Mindset” ¡  Clinician effects: cross-training adds to skill level, situational adaptation ¡  Language use

¡  Facilitating a focused state of concentration

¡  Creating a space between stimulus… and response

¡  Individualized use of Metaphor and Suggestion

“Words are, in my not-so-humble opinion, our most inexhaustible source of magic… Capable of both inflicting injury, and remedying it.”

- Albus Dumbledore

Healing “consists only in… allowing, causing, or bringing to bear those things or forces for getting better (whatever they may be) that already exist in the patient.” - Cassell, “The nature of suffering and the goals of medicine”