Stress and Health: The New "Apple a Day" Prescription
eSolutions: Stress and Health
A Conversation with Drs. Herbert Benson and Gregory Fricchione, Benson-Henry Institute for Mind-Body Medicine at Massachusetts General Hospital
The Benson-Henry Institute for Mind Body Medicine is a scientific and educational organization dedicated to research, teaching, and clinical application of mind-body medicine and its integration into all areas of health. Herbert Benson is a pioneer in mind-body medicine with a career spanning decades. BHI Director Gregory Fricchione is responsible for their clinical, educational, and research efforts. In an exclusive interview with CIHS, Drs. Benson and Fricchione explain the science of stress and how stress management improves health for people with chronic physical, mental, and addiction disorders.
CIHS: Dr. Benson, you’ve made great inroads over your career in understanding stress and illness. Can you explain your research?
Dr. Benson: I'm a cardiologist. Early in my career, I was noting that my patients often had a higher blood pressure in my office. Then I wondered whether the stress of measuring blood pressure might influence it. Years later, this was described as ‘white coat hypertension.’ But at the time, 40 years ago, that was not recognized.
I returned to Harvard Medical School, from where I had recently graduated, to see whether I could establish a model for stress-induced hypertension. We worked with squirrel monkeys, and were able to use the paradigms of reinforcement and reward, rewarding higher blood pressure. Some would die of hypertrophy, hypertension-related diseases, kidney disease, and strokes.
Then, some individuals who practiced regular meditation came to me, hearing about my work, and said, ‘Study us. We lower our blood pressure through transcendental meditation.’
We found dramatic changes in the practice of meditation ? decreased metabolism, heart rate, blood pressure, and slower brain waves. In other words, meditation brought changes opposite to those that occur during a stress response.
We looked at the basic steps of transcendental meditation and came up with two. One is repetition ? of a word, sound, prayer, phrase, or movement. The second is passively disregarding thoughts. Those two steps break the train of everyday thinking.
Using a very simple, generic technique [the relaxation response], we found that we could replicate the physiologic changes of transcendental meditation. Historically, the practice of these two steps has been going on for millennia, normally within a religious populace.
Over the next 30 years, we continued to understand and define the physiology and genomics of the relaxation response, as well as apply it to scores of stress-related diseases. Between 60 to 90% of visits to healthcare professionals are either caused or exacerbated by stress ? whether it be anxiety, depression, high blood pressure, angina pectoris, heart attacks, strokes, irritable bowel syndrome, insomnia, rheumatoid arthritis, inflammatory diseases, or infertility.
Most recently, we published that the relaxation response induces changes in energy metabolism, insulin secretion, and inflammatory pathways at the genomic level. What people have been carrying out for millennia has been given the scientific base to allow it to be more acceptable in the modern world, where measurements are often based upon scientific studies.
CIHS: Dr. Fricchione, how does stress affect health?
Dr. Fricchione: All of us are built according to the same specifications. We have certain needs and desires. The basic ones are for food, for self-preservation; sex, for species preservation; and social attachment, because we're mammals. The brain helps us attain those goals and desires. When life challenges emerge, the brain makes adjustments that are transposed into neurochemical changes transmitted via the stress response system to a body's organ. This process provides an opportunity for stress to be pathogenic [able to cause disease].
The terms to keep in mind here are stress and allostatic loading. Allostasis means maintaining stability in the face of change. It's your brain, as the master organ, doing most the work of maintaining stability in the face of environmental changes that challenge attainment of goals and desires. When your brain faces life’s daily challenges, it has to predict how much energy to produce and process to maintain your physiology within healthy range.
To give you an example, we have Mr. Jones and Mr. Smith. Mr. Jones has a secure job, a nice suburban home, and is married with two kids who are successful in school. His brain uses less energy and creates less stress than Mr. Smith, who works in a factory, has just gotten a pink slip, faces home foreclosure, and has kids who are having difficulty in school. Mr. Smith's brain has to work overtime and expend a lot of energy to keep his physiology within normative range, and that energy is processed at the cellular level by the cells' metabolic factory, the mitochondria. Thus, he has high allostatic loading, the metabolic wear and tear that comes from the struggle to maintain physiological homeostasis. Meanwhile, Mr. Jones doesn't have to work overtime to maintain his blood pressure, pulse rate, or thyroid axis; he has an easier time maintaining allostasis.
At a very basic level, when someone feels stress it’s reflected in oxidative stress, which is when mitochondria [in cells] work overtime to manage the oxygen demand and glucose processing that comes with facing challenges. Oxidative stress leads to the buildup of free radicals that are toxic to the nerves at high levels, causing damage to neural functioning. This can actually cause shrinkage in [areas of the brain] over time.
These terms - stress, resiliency, allostatis- come from engineering. Think of a bridge. It is not just a slab of concrete. It's built to be flexible because it will face challenges: hurricanes, tsunamis, earthquakes. It is built with allostasis in mind. Those terms can be adopted to humans, as well, because the human organism has to be built to withstand all kinds of daily challenges. The pathogenesis of stress-related illnesses has to do with the fact that the brain is stretched to the limit when you battle significant or severe stress.
CIHS: How is practicing relaxation response integral to health, especially for people with chronic illnesses?
Dr. Benson: When you look at how stress induces physiologic changes that are poorly treated by drugs or surgeries, one should regularly practice the relaxation response, and the more regular the practice, the more profound the changes in your genes’ activity. We believe people should evoke the relaxation response once a day for 10 to 20 minutes. The cost is only that of the time necessary, and it can treat the very disorders healthcare professionals focus on.
CIHS: Is there one relaxation technique that’s better than another?
Dr. Benson: A person has a choice of her or his technique. If you're religious, you could use a prayer. If you're secular, you could use the scores of techniques that bring forth relaxation response: yoga, tai chi, qigong, breathing exercises, or progressive muscular relaxation, for example. They all bring forth the same genomic changes. With daily practice, the technique doesn't matter.
CIHS: How can healthcare providers help the people they serve maintain allostatis?
Dr. Fricchione: At the Benson-Henry Institute, we use this equation: think of the numerator as a person's resiliency and the denominator as a person's allostatic loading, or stress level. Think about that equation when determining a person's vulnerability to illness or propensity to health. As a caregiver, once you know that equation, you can find ways to improve a person's chances of being healthy by increasing the numerator (the person's resiliency) and decreasing the denominator (the person's allostatic loading, or stress).
It doesn't matter whether a person has genetic loading or a chronic illness because the stress diathesis model allows you to understand why the external and internal environments have a role in whether you develop an illness or an episode of the ailment. Stress uncovers a person's specific vulnerabilities.
Both my parents had heart disease. I know I have loading for coronary artery disease. So, if I don't pay attention to my personal equation, if I let my allostatic loading go haywire, circumstances dictate that, or if I don't pay attention to my resiliency, then I am increasing my vulnerability for my first heart attack.
CIHS: How can individuals with chronic physical, mental, and addiction disorders develop and increase their resilience? How can their healthcare providers help?
Dr. Fricchione: Humans would not be here if we weren't resilient. Resiliency is important for our evolutionary success. One of the most important components of human resiliency is social support. There's a mountain of data to support the importance of social support in health outcomes. Human beings are examples of the mammalian line. For us to maintain our evolutionary business, we have to be socially attached. It is impossible for a human being to be healthy if he has no social attachment.
For instance, a study in the New England Journal of Medicine looked at about 2,300 men who had had a [heart attack]. The study followed these men for three years after their cardiac event. They categorized one group as having social isolation. Within those three years, their mortality rate was really high compared to those men who were not socially isolated.
View all 10 whole health and resiliency factors.
CIHS: How do you disseminate the relaxation responses? How is it used in healthcare?
Dr. Benson: I wrote a popular book in 1975 that introduced relaxation response to the public. Physicians have come to recognize the frustration they have with using just drugs and surgeries as approaches. Here now was something that could effectively treat stress.
At the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, we train all different specialties - physicians, nurses, psychologists, clergy members, social workers - from around the world through Harvard continuing education courses. With 60 to 90% of visits being in the stress realm, it's just a matter of time before relaxation responses are even more widely spread. And now with the genomic proof, you're actually changing your genes’ activity.
Learn more about stress and health and the Benson-Henry Institute trainings for health and behavioral health professionals.
Stress Management Central to Wellness
At NorthCare Community Mental Health Center in Oklahoma, “Peer support specialists are the cornerstone of our wellness program,” explained Nancy Reed, Project Director for NorthCare’s PBHCI grant program. The Center offers an array of wellness activities, including: the SAMHSA-HRSA Center for Integrated Health Solutions program, WHAM (Whole Health Action Management); NEW-R (Nutrition and Exercise through Wellness and Recovery); tobacco cessation; an exercise program in partnership with the YMCA; and numerous other educational classes.
At the pinnacle of their wellness activities is stress management, a critical skill for whole health and recovery. In addition to a class devoted to the subject, stress management is woven into every wellness activity. Janette McKeever, C-PRSS, a certified recovery support specialist at NorthCare, truly embraces the value of stress management. Janette used to receive NorthCare services, and manage stress was one of the most important skills she learned. “The daily action plan saved my life,” remarked Ms. McKeever. Using an action plan enabled Ms. McKeever to be more mindful of her life and feelings. “I write down what I need to do to take care of myself and a major part of that is managing my stress and saying no to people.” Ms. McKeever explained that the inability to say no to people is common among people with behavioral health conditions, whom she says tend to want to please people. But, if we you take on too much and become stressed, mental and physical health can take a hit.
In addition to using her daily action plan, Ms. McKeever practices the relaxation response every night before bed by using a CD with a guided imagery. The elicitation of the relaxation response has allowed her to stop taking her once-necessary nighttime medication.
Ms. McKeever’s work with stress management extends beyond her personal life. As a facilitator of WHAM, Wellness Recovery Action Plan (WRAP), and Living Longer, Living Stronger, she regularly teaches and demonstrates common stress management activities. Ms. McKeever shows a demonstration video and has participants practice yoga and uses a guided imagery CD to take participants through and familiarize them with the relaxation response. “We really do talk about how important it is to remember that if we get stressed out, it affects our whole being.”
Ms. McKeever reinforces to her peers that stress management activities can come in many forms, including taking a walk, talking to a friend, and of course, the relaxation response. “When you start working with folks to reduce and stabilize things like blood pressure it opens a whole new area of thought on how we can help consumers get healthier and happier,” Ms. Reed explained. “This was totally outside of our conscious thought prior to the PBHCI grant. It has changed our thinking to focus more on wellness and whole health, rather than just treatment and recovery from mental health issues.”
Learn more about NorthCare and the SAMHSA PBHCI program.
The Relaxation Response was created and researched by Dr. Herbert Benson of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital. Dr. Benson pioneered mind-body medicine by linking stress to health, and found that people can decrease their metabolism, rate of breathing and heart rate, and brain waves to counteract the commonly known “fight or flight” response, or stress response. He named this activity the “relaxation response.”
- Sit quietly in a comfortable position.
- Close your eyes.
- Deeply relax all your muscles, beginning at your feet and progressing up to your face. Keep them relaxed.
- Breathe through your nose.
- Become aware of your breathing.
- As you breathe out, say the word, "one"* silently to yourself. For example, breathe in…out, "one"; breath in…out, "one," etc.
- Breathe easily and naturally.
- Continue for 10 to 20 minutes.
- You may open your eyes to check the time, but do not use an alarm.
- When you finish, sit quietly for several minutes, at first with your eyes closed, and then with your eyes opened. Do not stand up for a few minutes.
Do not worry about whether you successful achieve deep relaxation. Maintain a passive attitude and allow relaxation to occur at its own pace. When distracting thoughts occur, try to ignore them by not dwelling upon them and return to repeating "one."
With practice, the response should come with little effort. Practice the technique once or twice daily, but not within two hours after any meal since the digestive processes may interfere with the elicitation of the relaxation response.
*or any soothing, mellifluous sound, preferably with no meaning or association to avoid stimulation of unnecessary thoughts.
Learn more about the relaxation response and the science behind it.
WHAM (Whole Health Action Management) is a training program and peer support group model developed by CIHS to encourage increased resiliency, wellness, and self-management of health and behavioral health among people with mental illnesses and addictions. WHAM uses some of the key concepts developed by the Benson-Henry Institute for Mind-Body Medicine, including the 10 resiliency factors and the relaxation response.
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