John A. Astin

Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial

The literature is replete with evidence that the stress inherent in health care negatively impacts health care professionals, leading to increased depression, decreased job satisfaction, and psychological distress. In an attempt to address this, the current study examined the effects of a short-term stress management program, mindfulness-based stress reduction (MBSR), on health care professionals. Results from this prospective randomized controlled pilot study suggest that an 8-week MBSR intervention may be effective for reducing stress and increasing quality of life and self-compassion in health care professionals. Implications for future research and practice are discussed.

The Efficacy of “Distant Healing”: A Systematic Review of Randomized Trials

The widespread use of complementary and alternative medicine (CAM), commonly defined as therapies that are neither taught widely in U.S. medical schools nor generally available in U.S. hospitals (1), is now well documented. Results of several national surveys in the United States and elsewhere suggest that up to 40% of the adult population has in the preceding year used some form of CAM to treat health-related problems (1-5). In part because of the increasing use of CAM by the public, there has been a greater sense of urgency and motivation on the part of the scientific community to study the safety and efficacy of these therapies. A belief in the role of mental and spiritual factors in health is an important predictor of CAM use (2). In a recent study of CAM in the United States (1), 7% of persons surveyed reported having tried some form of spiritual healing. This was the fifth most frequently used treatment among all CAM therapies assessed. In the same study, 35% of persons surveyed reported that they had used prayer to address their health-related problems. A national survey conducted in the United States in 1996 found that 82% of Americans believed in the healing power of prayer and 64% felt that physicians should pray with patients who request it (6). Although not without its critics (7), a growing body of evidence suggests an association between religious involvement and spirituality and positive health outcomes (8-11). Spiritual healing is a broad classification of approaches involving the intentional influence of one or more persons upon another living system without utilizing known physical means of intervention (12). Following the example of Sicher and colleagues (13), we use the term distant healing in our review. Although it does not necessarily imply any particular belief in or referral to a deity or higher power, distant (or distance) healing encompasses spiritual healing, prayer, and their various derivatives and has been defined as a conscious, dedicated act of mentation attempting to benefit another persons physical or emotional well being at a distance (13). As we define it here, distant healing includes strategies that purport to heal through some exchange or channeling of supraphysical energy. Such approaches include Therapeutic Touch, Reiki healing, and external qigong. Although they do not necessitate actual physical contact, these healing techniques usually involve close physical proximity between practitioner and patient. Distant healing also includes approaches commonly referred to as prayer. Prayer, whether directed toward health-related matters or other areas of life, includes several variants: intercessory prayer (asking God, the universe, or some higher power to intervene on behalf of an individual or patient); supplication, in which one asks for a particular outcome; and nondirected prayer, in which one does not request any specific outcome (for example, Thy will be done ). All forms of distant healing are highly controversial. Despite several positive reviews examining the research on these techniques (12-14), there continue to be conflicting claims in the literature regarding their clinical efficacy (7, 15, 16). In the absence of any plausible mechanism, skeptics are convinced that the benefits being reported are due to placebo effects at best or fraud at worst. Notwithstanding this ongoing controversy, distant healing techniques are increasing in popularity. For example, in the United Kingdom today, there are more distant healers (about 14 000) than there are therapists from any other branch of CAM. This level of popularity makes examination of the available evidence relevant. The objective of our systematic review was to summarize all available randomized clinical trials testing the efficacy of all forms of distant healing as a treatment for any medical condition. Methods A comprehensive literature search was conducted to identify studies of distant healing (spiritual healing, mental healing, faith healing, prayer, Therapeutic Touch, Reiki, distant healing, psychic healing, and external qigong). The MEDLINE, PsychLIT, EMBASE, CISCOM, and Cochrane Library databases were searched from their inception to the end of 1999. The search terms used were the above-named forms of treatment plus clinical trials, controlled clinical trials, and randomized, controlled trials. In addition, we contacted leading researchers in the fields of distant and spiritual healing to further identify studies. We also searched our own files and the reference sections of articles on distant healing that we identified. Numerous studies have been carried out in these areasfor example, in a review of spiritual healing, Benor (12) identified 130 controlled investigations, and Rosa and colleagues [15] identified 74 quantitative studies of Therapeutic Touch. However, we included only studies that met the following criteria: 1) random assignment of study participants; 2) placebo, sham, or otherwise patient-blindable or adequate control interventions; 3) publication in peer-reviewed journals [excluding published abstracts, theses, and unpublished articles]; 4) clinical [rather than experimental] investigations; and 5) study of humans with any medical condition. We did not apply restrictions on the language of publication. The methodologic quality of studies was assessed by using the criteria outlined by Jadad and colleagues (17). In addition, we examined the extent to which studies were adequately powered, randomization was successful (that is, it resulted in homogenous study groups), baseline differences were statistically controlled for, and patients were lost to follow-up. Other predefined assessment criteria were study design, sample size, type of intervention, type of control, direction of effect (supporting or refuting the hypothesis), and type of result. Extracted data were entered into a custom-made spreadsheet. Differences between two independent assessors were settled by consensus. A meta-analytic approach was considered but was abandoned when the heterogeneity of the trials became apparent. Nevertheless, effect sizes averaged across each category of distant healing were included in an effort to provide some quantitative measure of the magnitude of clinical effects. Effect sizes were calculated by using Cohens d (18), weighted for sample size. The Hedges correction was applied to all effect sizes [19]. In studies that reported multiple outcomes, a single outcome was chosen to calculate effect size if 1) a significant change after treatment was shown for that outcome or 2) that outcome was the primary outcome measure in studies that found several or no significant treatment effects. In the few cases in which the authors did not provide sufficient information with which to calculate Cohens d, the study was not included in the overall effect size. The funding sources were not involved in the design of the study and had no role in the collection, analysis, or interpretation of the data or in the decision to submit the manuscript for publication. Data Synthesis Using our search methods, we found more than 100 clinical trials of distant healing. The principal reasons for excluding trials from our review were lack of randomization, no adequate placebo condition, use of nonhuman experimental subjects or nonclinical populations, and not being published in peer-reviewed journals. Twenty-three studies met our inclusion criteria (13, 20-41). These trials included 2774 patients, of whom 1295 received the experimental interventions being tested. Methodologic details and results of these trials are summarized in Tables 1, 2, and 3. The studies are categorized as three types: prayer, Therapeutic Touch, and other distant healing. However, these classifications are not mutually exclusive. For example, the study of distant healing by Sicher and colleagues (13) included 40 healers, some of whom would describe what they did as prayer, and the study by Miller (22) described the intervention as both prayer and remote mental healing. Table 1. Randomized, Placebo-Controlled Trials of Prayer Table 2. Randomized, Placebo-Controlled Trials of Therapeutic Touch Table 3. Randomized, Placebo-Controlled Trials of Other Distant Healing Methods Prayer Of studies that met our inclusion criteria, five specifically examined prayer as the distant healing intervention (Table 1). In all five studies, the intervention involved some version of intercessory prayer, in which a group of persons was instructed to pray for the patients (there was no way to control for whether patients prayed for themselves during the study). Qualifications for being an intercessor varied from study to study. For example, in the trial by Byrd (23), intercessors were required to have an active Christian life, daily devotional prayer, and active Christian fellowship with a local church. In the study by Harris and colleagues (39), those praying were not required to have any particular denominational affiliation, but they needed to agree with the statement I believe in God. I believe that He is personal and is concerned with individual lives. I further believe that He is responsive to prayers for healing made on behalf of the sick. In each of these studies, the intercessors did not have any physical or face-to-face contact with the persons for whom they were praying. Instructions on how the intercessors should pray were fairly open-ended in most instances. For example, in the trial by Harris and colleagues (39), intercessors were asked to pray for a speedy recovery with no complications and anything else that seemed appropriate to them (39). Two trials showed a significant treatment effect on at least one outcome in patients being prayed for (23, 39), and three showed no effect (20, 21, 24) (Table 1). The average effect size, computed for four of these studies, was 0.25 (P =0.009). Therapeutic Touch Eleven trials examined the healing technique known as noncontact Ther

The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials.

To carry out a systematic review of the literature examining the effectiveness of spinal manipulation for the treatment of headache disorders, computerized literature searches were carried out in Medline, Embase, Amed and CISCOM. Studies were included only if they were randomized trials of (any type of) spinal manipulation for (any type of) headache in human patients in which spinal manipulation was compared either to no treatment, usual medical care, a ‘sham’ intervention, or to some other active treatment. Two investigators independently extracted data on study design, sample size and characteristics, type of intervention, type of control/comparison, direction and nature of the outcome(s). Methodological quality of the trials was also assessed using the Jadad scale. Eight trials were identified that met our inclusion criteria. Three examined tension-type headaches, three migraine, one ‘cervicogenic’ headache, and one ‘spondylogenic’ chronic headache. In two studies, patients receiving spinal manipulation showed comparable improvements in migraine and tension headaches compared to drug treatment. In the 4 studies employing some ‘sham’ interventions (e.g. laser light therapy), results were less conclusive with 2 studies showing a benefit for manipulation and 2 studies failing to find such an effect. Considerable methodological limitations were observed in most trials, the principal one being inadequate control for nonspecific (placebo) effects. Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (e.g. of personal attention, patient expectation). Whether manipulation produces any long-term changes in these conditions is also uncertain. Future studies should address these two crucial questions and overcome the methodological limitations of previous trials.

Mindfulness goes to work: impact of an online workplace intervention.

Objective: The objective of this study was to determine whether a mindfulness program, created for the workplace, was both practical and efficacious in decreasing employee stress while enhancing resiliency and well-being. Methods: Participants (89) recruited from The Dow Chemical Company were selected and randomly assigned to an online mindfulness intervention (n = 44) or wait-list control (n = 45). Participants completed the Perceived Stress Scale, the Five Facets of Mindfulness Questionnaire, the Connor-Davidson Resiliency Scale, and the Shirom Vigor Scale at pre- and postintervention and 6-month follow-up. Results: The results indicated that the mindfulness intervention group had significant decreases in perceived stress as well as increased mindfulness, resiliency, and vigor. Conclusions: This online mindfulness intervention seems to be both practical and effective in decreasing employee stress, while improving resiliency, vigor, and work engagement, thereby enhancing overall employee well-being.

Negative Affect, Emotional Acceptance, and Smoking Cessation

Abstract This article describes recent theoretical developments and empirical findings regarding the role of negative affect (NA) and emotion regulation in nicotine dependence and smoking cessation. It begins with a review of affect-based models of addiction that address conditioning, affect motivational, and neurobiological mechanisms and then describes the role of NA and emotion regulation in the initiation and maintenance of cigarette smoking. Next, the role of emotion regulation, coping skill deficits, depression, and anxiety sensitivity in explaining the relationship between NA and smoking relapse are discussed. We then review recent models of affect regulation, including emotional intelligence, reappraisal and suppression, and emotional acceptance, and describe implications for substance abuse and smoking cessation interventions. Finally, we point out the need for further investigations of the moderating role of individual differences in response to NA in the maintenance of nicotine dependence, and controlled randomized trials testing the efficacy of acceptance-based interventions in facilitating smoking cessation and relapse prevention.

Interactive informed consent: randomized comparison with paper consents.

Informed consent is the cornerstone of human research subject protection. Many subjects sign consent documents without understanding the study purpose, procedures, risks, benefits, and their rights. Proof of comprehension is not required and rarely obtained. Understanding might improve by using an interactive system with multiple options for hearing, viewing and reading about the study and the consent form at the subject’s own pace with testing and immediate feedback. This prospective randomized study compared the IRB-approved paper ICF for an actual clinical research study with an interactive presentation of the same study and its associated consent form using an iPad device in two populations: clinical research professionals, and patients drawn from a variety of outpatient practice settings. Of the 90 participants, 69 completed the online test and survey questions the day after the session (maximum 36 hours post-session). Among research professionals (n = 14), there was a trend (p  = .07) in the direction of iPad subjects testing better on the online test (mean correct  =  77%) compared with paper subjects (mean correct  =  57%). Among patients (n = 55), iPad subjects had significantly higher test scores than standard paper consent subjects (mean correct  =  75% vs 58%, p < .001). For all subjects, the total time spent reviewing the paper consent was 13.2 minutes, significantly less than the average of 22.7 minutes total on the three components to be reviewed using the iPad (introductory video, consent form, interactive quiz). Overall satisfaction and overall enjoyment slightly favored the interactive iPad presentation. This study demonstrates that combining an introductory video, standard consent language, and an interactive quiz on a tablet-based system improves comprehension of research study procedures and risks.

Integration of the biopsychosocial model: Perspectives of medical students and residents

Purpose To examine residents’ and medical students’ attitudes toward the incorporation of psychosocial factors in diagnosis and treatment and to identify barriers to the integration of evidence-based, mind–body methods. Method A random sample of third- and fourth-year medical students and residents was drawn from the Masterfiles of the American Medical Association. A total of 661 medical students and 550 residents completed a survey, assessing attitudes toward the role of psychosocial factors and the clinical application of behavioral/mind–body methods. Results The response rate was 40%. Whereas a majority of students and residents seem to recognize the need to address psychosocial factors, 30%–40% believe that addressing such factors leads to minimal or no improvements in outcomes. The majority of students and residents reports that their training in these areas was ineffective, yet relatively few indicate interest in receiving further training. Females are more likely to believe in the need to address psychosocial factors. Additional factors associated with greater openness to addressing psychosocial factors include (1) the perception that training in these areas was helpful, and (2) personal use of behavioral/mind–body methods to care for one’s own health. Conclusions There is a need for more comprehensive training during medical school and residency regarding both the role of psychosocial factors in health and the application of evidence-based, behavioral/mind–body methods. The current health care structure—particularly insufficient time and inadequate reimbursement for addressing psychosocial factors—may be undermining efforts to improve patient care through inconsistent or nonexistent application of the biopsychosocial model.

Sense of Control and Adjustment to Breast Cancer: The Importance of Balancing Control Coping Styles

The relationship of modes of control and desire for control to psychosocial adjustment in women with breast cancer was examined. Fifty-eight women with stage I or stage II breast cancer were surveyed shortly after their diagnosis and again 4 and 8 months later. The authors hypothesized that a control profile in which individuals use a positive yielding (i.e., accepting) mode of control in conjunction with an assertive mode results in better adjustment than relying exclusively or primarily on an assertive mode. Results lend preliminary support to this hypothesis. At 8-month follow-up, those women who had a high desire for control and were low in positive yielding control showed the poorest adjustment, whereas those high in desire and the positive yielding mode showed the best psychosocial adjustment. The findings suggest that balanced use of active and yielding control efforts may lead to optimal psychosocial adjustment and quality of life in the face of life-threatening illnesses.

Development of an Acceptance-Based Coping Intervention for Alcohol Dependence Relapse Prevention

Both psychological and neurobiological findings lend support to the long-standing clinical observation that negative affect is involved in the development and maintenance of alcohol dependence, and difficulty coping with negative affect is a common precipitant of relapse after treatment. Although many current approaches to relapse prevention emphasize change-based strategies for managing negative cognitions and affect, acceptance-based strategies for preventing relapse to alcohol use are intended to provide methods for coping with distress that are fundamentally different from, though in theory complementary to, approaches that emphasize control and change. This paper describes the development of Acceptance-Based Coping for Relapse Prevention (ABCRP), a new intervention for alcohol-dependent individuals who are within 6 months of having quit drinking. Results of preliminary testing indicate that the intervention is feasible with this population; and a small uncontrolled pilot study (N = 23) showed significant (P < .01) improvements in self-reported negative affect, emotional reactivity, perceived stress, positive affect, psychological well-being, and mindfulness level, as well as a trend (P = .06) toward reduction in craving severity between pre- and postintervention assessments. The authors conclude that this acceptance-based intervention seems feasible and holds promise for improving affect and reducing relapse in alcohol-dependent individuals, warranting further research.

Coping with loss of control in the practice of medicine.

Although the quest for active control and mastery can be seen as a central thread that ties together important aspects of human experience, we are frequently confronted with the reality that much of what is encountered in life lies outside our active instrumental control. Control must involve finding healthy and life-affirming ways to exercise personal mastery, and identifying constructive ways to respond to the lack of control that pervades the human condition. In this article we explore a number of professional areas in which physicians may experience significant feelings of loss or lack of personal control-difficult encounters with patients, dealing with patient nonadherence, end-of-life care, confronting the uncertainty and ambiguity that are frequently a part of illness, as well as institutional and systemic factors that can result in loss of various forms of autonomy and control over decision-making. We then consider maladaptive ways in which physicians sometimes attempt to address such losses of control and suggest that personal stress and burnout and difficulty developing effective therapeutic relationships with patients may be the consequence, in part, of these efforts. Finally, we discuss an empirically derived, multidimensional theoretical model for better understanding control dynamics, and identifying more optimal strategies physicians can employ in their efforts to gain and regain a sense of control in caring for patients.