California Pacific Currents 2003
An Abiding Interest in How the Mind Affects the Health of the Body: The Work of John A. Astin, PhD
Acupuncture. Distant Healing. Massage. Guided Imagery. Meditation. These and other complementary and alternative medicine (CAM) therapies are not common in the curricula of US medical schools or generally available to patients in US hospitals. They are, however, widely utilized by the American public. Despite a lack of easy access or ready reimbursement from third-party insurers, the Journal of the American Medical Association (JAMA) reported that the number of visits to CAM providers in 1998 was greater than the number of visits to all primary care physicians, and there is no reason to doubt that this trend has changed significantly in the new millennium.
Many Things to Many People
CAM represents a wide array of modalities and is not easily defined. Some CAM therapies—and there are hundreds of them—are supported by a growing body of literature determining their effectiveness. Other alternative therapies cannot claim the same positive clinical outcomes. Researchers are now conducting sound, scientifically robust studies to assess the effectiveness of CAM. John A. Astin, PhD, is involved in just such an effort with distant healing and AIDS patients in addition to several other avenues of investigation.
Dr. Astin’s research and clinical work—characterized overall by an abiding interest in how our mind and its attendant thoughts, feelings, psychological constructs, and level of stress affect our physical health—has focused on several related areas:
- Psychosocial factors that create barriers to the use of CAM;
- Use of mind-body therapies, particularly mindfulness meditation, to treat various health-related problems;
- The role of spirituality in health care;
- The psychological construct of control and its relationship to mental and physical health.
Dr. Astin, whose research has been published in many major medical journals including JAMA, the Annals of Internal Medicine, and the Archives of Internal Medicine, received his PhD in Health Psychology from the University of California, Irvine. In addition to his publishing credits in the mainstream medical literature, he is coauthor of the book, Control Therapy: An Integrated Approach to Psychotherapy, Health, and Healing. He has been a research fellow in the Complementary and Alternative Medicine Program at the Stanford University School of Medicine, as well as assistant professor and director of mind-body research at the Program in Complementary Medicine, University of Maryland School of Medicine. He joined California Pacific Medical Center Research Institute in July of 2002.
Barriers to the Use of Mind-Body Therapies
“My primary research at California Pacific currently centers around a large NIH grant. I’ve been working on this project for a couple of years. It focuses on understanding why many physicians have been slow to adopt a more ‘whole-person’ perspective that recognizes the importance of psychosocial factors in physical health and well being,” comments Dr. Astin. Understanding barriers to the use of evidence-based mind-body therapies seems particularly important because there is growing scientific evidence underscoring the contribution of psychological, spiritual, and social factors in an individual’s health status and functionality. And while medicine purports to be evidence-based, studies indicate that these psychosocial factors are given insufficient attention in education and clinical practice.
Surveys suggest that what physicians most desire before they will adopt any new therapy is evidence of efficacy, primarily from randomized controlled trials or systematic reviews. A substantial body of research suggests that an array of “mind-body” interventions (e.g., meditation, guided imagery, relaxation, and biofeedback) can be effective adjunctive therapies for several health-related problems, including insomnia, chronic pain, tension and migraine headaches, mood disorders, preparation for surgery, cardiac rehabilitation, and symptom management in cancer. These therapies have, however, remained largely at the margins of mainstream, conventional medical education and practice.
Some studies are attempting to document the effectiveness of mind-body interventions. For example, in addition to his own research projects, Dr. Astin has become, after the untimely death of California Pacific’s Elisabeth Targ, MD, the primary investigator on a project designed to investigate the effects of prayer and distant healing on AIDs patients. Currently, this study is in the data-collection phase.
Evidence of a therapy’s effectiveness frequently does not result in a change in clinical practice. The barriers to incorporating new therapeutic approaches are varied and complex. Therefore, in order to develop intervention strategies to facilitate the integration of demonstrably effective mind-body therapies into the mainstream of health care, it is vital that the specific barriers and obstacles to such integration be identified and examined. “The goal of our research will be to identify factors that might account for differences in the extent to which physicians recognize the importance of nonphysical factors (e.g., stress) in health and are open to using mind-body approaches in clinical practice.”
The specific aims of Dr. Astin’s current study are to:
- Identify personal, demographic, and social-environmental factors that facilitate or inhibit physicians’ use of mind-body therapies in clinical practice;
- Examine personal, demographic, and social-environmental factors that might account for greater openness to mind-body principles and practices among physicians and physicians-in-training.
A secondary aim of this research will be to examine the extent to which medical education affects future physicians’ attitudes toward adoption of mind-body principles and practices. “For purposes of our research project, mind-body principles are defined as the recognition of the influence of nonphysical factors—including psychological, social, environmental, interpersonal, cultural, and spiritual—on health and well being. Following the lead of the NIH’s National Center for Complementary and Alternative Medicine, we define mind-body practices as interventions that employ a variety of techniques designed to facilitate the mind’s capacity to affect bodily function and symptoms,” says Dr. Astin. And this subtle, difficult-to-measure ability of the mind to affect numerous and varied body functions is just what attracts Dr. Astin and his group of fellow researchers.
Preliminary Focus–Group Data
Findings from the focus-group portion of the barriers to the integration of mind-body medicine study identified several factors as potentially important:
- Physicians sometimes believe they are unqualified to employ mind-body strategies in clinical practice or are unaware of referrals and/or resources available to them in these areas;
- Lack of sufficient time (spending the time necessary to talk to patients about psychosocial issues is not financially practical);
- Inadequate third-party reimbursement for addressing psychosocial factors in clinical practice;
- Inability to control larger social forces that affect patients’ lives (e.g., family difficulties contributing to stress);
- Belief that patients are either not interested in or are resistant to addressing psychosocial and/or mind-body issues.
These focus-group findings will be integrated into results from the two national surveys mentioned earlier that Dr. Astin and his associates have nearly completed: the first directed to practicing physicians (primary care and specialty) and physician educators, and the second designed for physicians-in-training (medical students and residents). Following these surveys, in-depth interviews will be carried out with a smaller subset of respondents to identify specifically how medical education contributes in positive or negative ways to incorporating mind-body principles and practices into health care. Mindfulness Meditation and Prevention of Substance Abuse Relapse The philosophical roots of “mindfulness” can be traced to both eastern and western contemplative practices, most notable among these being Buddhist meditation (Vipassana or insight meditation). Mindfulness principles and practices have begun to be integrated into a variety of behavioral medicine and clinical psychology settings with promising results.
“Just off the drawing board is a project designed to study the potential applications of mindfulness meditation in medicine. My Research Institute colleague, Cassie Vieten, PhD, and I recently submitted a proposal to the NIH to develop an intervention based on mindfulness meditation to prevent relapse from substance abuse,” says Dr. Astin. The proposal is based on research indicating that difficulty managing negative affective states, such as depression, anxiety, anger, and stress, is a strong predictor of relapse among individuals recovering from substance abuse. “We are proposing to develop and pilot test a therapeutic intervention called Mindfulness-Based Addiction Treatment that is specifically focused on preventing relapse by enhancing recovering addicts’ capacity to regulate and tolerate negative affect through the use of mindfulness-based strategies.”
Mindfulness involves the cultivation of moment-to-moment, non-judgmental awareness of one’s present experience. The goal of this practice is to cultivate a stable and non-reactive awareness of one’s internal (cognitive-affective-sensory) and external (social-environmental) experiences. This skill enables one to respond to life consciously (mindfully) in contrast to the tendency to react reflexively to the myriad situations and experiences encountered in daily life. “When the going gets tough, people often resort to using alcohol and other drugs as a way of self-medicating. This habitual response, though effective in the short term for relieving emotional distress and managing stressful situations, usually has long-term, negative consequences,” notes Astin. “We believe that an intervention incorporating techniques that enhance the skills of mindfulness and self-awareness will be particularly well suited to helping patients with histories of substance abuse to better control their response to challenging internal and external stimuli and thus be in a stronger emotional and psychological position to resist future relapse.”
An Initial Glimpse at the Effects of Spirituality on Heath
As part of his commitment to helping move medicine beyond its sometimes overly narrow focus on biomedical causes and cures, Dr. Astin plans to continue exploring his interests in the relationship between spirituality and mental and physical health. In this respect, he is currently serving as a consultant on a large, prospective study funded by the John Templeton Foundation to investigate the inner religious/spiritual life of college students and examine, among other things, the degree to which students’ spiritual beliefs, values, and experiences are related to a number of variables including academic performance, interests, mental and physical health, and well being.
Along with completion of the above–mentioned projects, Astin’s future research plans at California Pacific include studying the potential applications of mindfulness-based interventions for smoking cessation as well as to improve outcomes in pregnancy and childbirth, both of which are known to be adversely affected by psychosocial stress.
“The mind affects the body in potentially countless ways, some of which we are just
beginning to understand. A goal of my work will be to better define and document the mechanics of that subtle, yet profound, and multifaceted interaction. I do hope that with greater scientific evidence at hand, we will begin to see a much wider adoption of mind-body therapies in medical training as well as in practice.”