In this blog post, you will learn (1) how we know that you can use your mind to affect your biology; (2) how doing so has been shown to improve medical outcomes and even extend life; (3) what type of stress reduction practices have been shown, by the research, to improve medical outcomes; (4) how to assess your own stress levels; (5) how to identify an intervention that can alleviate or reduce the long-term side effects of cancer treatments; (6) how to begin a very simple stress reduction practice; (7) how to ‘stomp out’ the thoughts that fuel stress; and (8) how to deepen your stress reduction practice.
Believe it or not, you CAN engage your mind in ways that affect your biology. When you work with behavioral medicine stress management techniques, you may actually affect genetic expression,. For example, in an article by Antoni, Lutgendorf and others (2012) 191 women undergoing treatment for breast cancer were randomized to either a ten week, cognitive behavioral stress reduction intervention, or to care as usual (controls).
Intervention participants successfully reduced expression of pro-inflammatory and metastasis-related genes and increased expression of interferon-related genes as compared to controls. Interferons are proteins that allow communication between cells to trigger the protective defenses of the immune system against viruses, bacteria, and most important, cancer cells. In other words, intensive mind-body, stress reduction practices can modify our bodies, right down to our cellular and genetic responses.
A groundbreaking study published in Cancer (December 15, 2008) found that breast cancer patients who participated in intensive interventions that reduce stress, improve mood, coping abilities and health behaviors had better survival rates 7 and 11 years later than did patients who did not receive such an intervention. Specifically, they found that patients in the intervention group had about half (55%) the risk of recurrence compared to the control group. In patients who did suffer recurrence, they remained cancer-free an average of six months longer than controls (45 % reduced risk).
Patients receiving the intervention also had less than half the risk (44 percent) of death from breast cancer of controls and a reduced risk of death from all causes, not just cancer. The findings from this long-term study pointed the way to the importance of providing intensive behavioral medicine programs for all patients diagnosed with cancer.
WHAT TYPES OF STRESS REDUCTION PRACTICES IMPROVE CANCER OUTCOMES?
In the Ninth International Conference for the Society of Integrative Oncology (October, 2012), Dr. Lorenzo Cohen, Director of the Integrative Medicine Program at MD Anderson Cancer Center, Houston Texas, delivered a keynote address entitled, “The Importance of Mind-Body Medicine in Cancer Care.” In his presentation, he summarized the body of research on intervention programs that significantly reduced stress and the mood state dysfunction related to stress (anxiety, depression.) The Interventions listed below were found to significantly reduce stress:
- Tai chi/Qigong
- Expressive writing
- Comprehensive programs
We know from the research that stress reduction can improve physiological variables (immune and endocrine function, blood vessel formation, DNA damage, cancer cell death and gene expression), cancer treatment response, disease progression and survival and quality of life. That is why it is important for everyone, but especially for cancer patients and survivors to assess their experience of stress and engage in practices that manage stress.
The National Comprehensive Cancer Network developed a very simple tool to assess stress and the issues causing stress for cancer patients and survivors. This tool has now become the ‘standard of care’ for oncology clinics. That is, all oncology nurses and social workers are expected to assess the stress levels of their patients on a regular basis, using this standardized instrument. In the NCCN’s Clinical Practice Guidelines for Oncology: Distress Management, oncology medical providers have access to the stress thermometer and its accompanying problem checklist. This instrument is used to identify patients and survivors in need of stress reduction assistance, and also identifies the life areas contributing to stress. You can ask your medical provider to perform this three-minute assessment with you.
How Do I Interpret My Score?
If you have a score of 3 or below, you are managing your stress fairly well. If your score is 4 or higher, it would be a good idea to incorporate stress management strategies into your lifestyle. For example, based on Dr. Cohen’s review of the research, you might find a yoga, Tai Chi, or Qigong class ‘just what the doctor ordered.’
In 2004, I received National Cancer Institute funding to create a comprehensive intervention to reduce or eliminate the late-term and long-term side effects of cancer treatment. These grant funds were made available because of the overwhelming request of patients like you.
The side effects most often reported, and those that were ‘targeted’ by the research, were (1) cognitive deficits, referred to as chemo-brain by survivors struggling with memory and recall challenges; (2) chronic unremitting fatigue, brought on by chemotherapy and other cancer treatments that disrupt our natural 24 hour cycle (circadian rhythms); (3) sleep deprivation, also related to treatment disruption of our daily cycles; and (4) anxiety, depression, stress and PTSD caused by diagnosis of, and treatment for cancer.
Between 2005 and 2011, I created and tested the intervention called “Envision the Rhythms of Life” (ERL.) This Cognitive Behavioral Medicine Intervention (CBMI) was successful in significantly reducing or eliminating these symptoms in those patients taking part in the study, and as compared to controls who did not receive the treatment.
The ERL Intervention is now available to Alaskans, in an office setting, or via telemedicine for distant patients. For those outside the state of Alaska, the ‘coaching’ model is available via telemedicine. The Intervention is covered by most insurances for persons residing in Alaska; the coaching model is a self-pay model.
An important note: The ERL intervention also produced the same changes in health behaviors and stress adaptation as the 2008 Cancer study previously cited. This suggests that those persons with a diagnosis of cancer, who take part in the ERL Intervention may also experience a survival advantage.
HOW CAN I BEGIN A VERY SIMPLE STRESS REDUCTION PRACTICE?
I will walk you through some simple ways to begin ‘mental hygiene’ stress reduction practices for improved quality of life and health outcomes. We will begin by teaching you how to “stomp your ANTS.”
WHAT DOES “A.N.T.S.” STAND FOR?
ANTS stands for “Automatic Negative Thoughts” and describes those little ‘stories’ we are telling ourselves, every day, twenty-four hours a day. What we want to do, to improve quality of life and health outcomes, is to identify and then transform the ANTS in our mind so they no longer cause us so much distress.
The FIRST STEP is to identify them. Pay attention, throughout the day, to your mood state. Are you feeling anxious? Afraid? Angry? Hopeless? Depressed? If the answer to any of these is yes, become still for a moment, and listen to the story that is playing in the background of your mind—the story you are telling yourself that is feeding the emotional response.
- FIRST: Label the emotion, as you experience and feel it. Are you feeling anxious? Depressed? Fearful? Label the emotion and describe it.
- SECOND: Pay attention to where you feel the discomfort in your body. Do you feel like there is an empty pit in your stomach? Are your shoulders tight and tense? Does your heart ache? How are you expressing this emotion in your body?
- THIRD: Listen to the story, with all its richness, that feeds the emotion and write the story down. For example, one cancer patient was suffering from unremitting fatigue that had prevented her from caring for her children the way she did before treatment. She had not been taking them to all the numerous activities she had once insisted they take part in, and felt very guilty about this. In her story, her children resented her for her failure to take part in all these activities. As her story continued, she envisioned her children becoming socially inept because they did not participate in as many community events. The spiral of worry continued downward, with her viewing herself as a bad mother, and her children eventually failing to become competent members of society—and all because, according to the story line, she had no energy and had failed them as a mother. The guilt, worry and self-denigration only made her more tired. However, after she ‘checked out’ her story with her family, she learned that her children had actually felt frustrated by having insufficient down time to just relax or spend one-on-one time with their friends.
It is quite common, once we evaluate our interpretation of our ‘stories,’ to discover that we have created unnecessary suffering for ourselves—and oftentimes, for others as well. So, assessing our ongoing ‘stories,’ and acting on what we learn can have health promoting benefits for us, and for those around us.
Now that you have fully identified the Automatic Negative Thought in full story form, answer, in written form, and as completely as possible, these four questions.
- Is this story true?
- Is this story ABSOLUTELY true?
- What would your life be like if it wasn’t true?
- What would your life be like if the exact opposite were true?
Simply asking these questions ‘transforms’ your thought processes from a rigid state to one that is more opened minded and more flexible. Often, this can lead to creative breakthroughs in thinking, helping to resolve the problem at hand, and contributing significantly to a more positive mood state.
Once you have identified your ANT theme, written the story, and asked the four questions, you ‘seal the deal’ of mind-body change by doing the benefit-finding exercise.
WHAT IS BENEFIT FINDING?
In any situation, no matter how difficult, there is always some benefit that can be found. Terminally ill persons say that the one benefit end of life brings to them is a profound appreciation for every moment of beauty, sharing and support that they experience in the final weeks and days of life. Because life will soon end, it may be experienced with a richness and depth that had eluded them in their previously busy life.
Losing a job may mean you have an opportunity to find a livelihood that is even more fulfilling than what you did before. Living with illness or disability may deepen your sense of compassion and understanding for others who have suffered similar fates. Realizing that every moment in life brings an opportunity for growth and understanding is called ‘benefit finding.’
Now you know the basic practice:
- Identify the ANTS
- Evaluate the ANTS; and
- Find the Benefit.
Now, to embed your practice, ‘check in’ with yourself throughout the day; identify troubling emotions; and work through the process as part of your day.
Some persons add an image to grab their attention to the emotional response that needs attention. For example, one patient says each time she finds herself feeling upset, she says, to herself, STOP! and in her mind’s eye, holds up a very large, red stop sign. She then attends to the ANT that has been disturbing her by walking her way through the process described in this segment, and “Stomping the ANT” that has been troubling her. She reports that she feels a great sense of self-satisfaction in how she is now able to control her thoughts in constructive ways, and finds that her perception of events, her mood state, and her energy levels are much improved.
In future blog posts, we will discuss other simple stress reduction strategies the reader can engage for improved health outcomes. Since the first step is to identify and confront the major ‘story themes’ causing the stress, you will be able to lay the foundation for improvement by putting into practice what has been discussed in the current blog.
- Andersen, B.L, Yang HC, Farrar WB, Golden-Kreutz, DM, et al. Psychological intervention improves survival for breast cancer patients: A randomized clinical trial. Cancer; Published Online: November 17, 2008 (DOI: 10.1002/cncr.23969); Print Issue Date: December 15, 2008.
- Antoni MH, Lutgendorf SK, Cole SW et al. (2006) The influence of bio-behavioural factors on tumour biology: pathways and mechanisms. National Review of Cancer, 6 (3), 240-248.
- Antoni MH, Lutgendorf SK, Blomberg B, et al. (2012). Cognitive-behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics. Biological Psychiatry, 2 (71), 366-372.
- Freeman, LW & Dirks L. (2006). Mind-Body Imagery Practice Among Alaska Breast cancer Patients: A Case Study. Alaska Medicine, 48 (3), 74-84.
- Freeman, L.W., Cohen, L., Stewart, M., White, R., Link, J., Palmer, J.L., Welton, D.L., McBride, L., & Hild, C. (2008). Qualitative Analysis of Breast Cancer Survivor Imagery: Themes Leading to Improved Quality of Life. Oncology Nursing Forum.
- Freeman, L.W., Cohen, L., Stewart, M., White, R., Link, J., Palmer, J.L., & Welton, D.L. (2008). An Imagery Intervention for Recovering Breast Cancer Patients: A Phase I Clinical Trial of Safety and Efficacy Journal of the Society for Integrative Oncology.6 (2), 67-75.
- Wein, H. (2010). Stress hormone causes epigenetic changes. http://www.nih.gov/researchmatters/september 2010/09272010stress.htm