Whole Health Library

• Mind and emotions play a key role in health. Research in psychoneuroimmunology, neuroplasticity, epigenetics, and the placebo effect are providing insights into the many ways in which mind and body interconnect.
• Using a combination of practices to elicit the relaxation response can be extremely beneficial.
• Options include, but are not limited to, breathing, progressive muscle relaxation, autogenic training, clinical hypnosis, imagery, biofeedback, meditation, cognitive behavioral therapy, acceptance and commitment therapy, eye movement desensitization and reprocessing, cognitive processing therapy, prolonged exposure therapy, arts therapies, and therapeutic journaling.
• Tailor choices of mind-body approaches to the specific needs and preferences of each individual patient. It can help to be familiar with the latest research for various mind-body approaches.

Matt is a 40-year-old Navy Veteran who has been struggling for the past several years with depression, unexplained bowel difficulties, headaches, and PTSD.  During his tour of duty, he suffered an injury and recovered well.  Unfortunately, a fellow soldier was killed in the same event.  On some nights, when he thinks about the past and “what he could have done,” he drinks too much alcohol.  This is occasional, however, and his wife and family are less concerned about substance abuse than they are about his nightmares, low mood, and tendency to withdraw from his family at unpredictable times.  Matt finds that he struggles with irritability when he first gets home from work.  He feels guilty and upset about his behavior, after the fact, but he has difficulty letting go of the stress he experiences during the day.

Matt’s clinic team introduced him to Whole Health, and Matt agreed to complete a Brief Personal Health Inventory (PHI).  Reviewing it helped them direct the conversation with him in several ways:

1.  On his Vitality Signs, Matt feels he is doing much better physically than emotionally and in general.

He denies suicidal ideation, but he is worried about what could happen if he cannot find better ways to cope.

2. He would benefit from being able to take a little more time to go over the Mission, Aspiration, Purpose (MAP) questions:

There is wide variation in his self-care ratings.  For some, he seems to feel he is doing very well, but for others, there is a large discrepancy between where he is and where he wants to be.  In it, he notes he is highly interested in focusing more on the Power of the Mind, as shown below.

4. Matt’s final answers provide some initial guidance about what to discuss with him first. He makes it clear Power of the Mind is his highest priority.

What can you do to support Matt with his work on Power of the Mind?  Fortunately, there are a number of options you can consider.

The idea that our mind and emotions play a critical role in our health dates back to Greek and Roman antiquity.  The Greek and Roman forefathers of Western medicine viewed the mind and body as an integral whole.  This connection was also found in Chinese and Ayurvedic medicine dating back more than 2,000 years.  Hippocrates, the father of Western medicine, believed that good health depended on a balance of mind, body, and environment.  He considered patients’ environments and attitudes in his approach to treatment.  He also believed in the body’s natural ability to re-balance itself, writing that “The natural healing force within each one of us is the greatest force in getting well.” 

In the 17th century, Descartes’ philosophy of mind-body dualism was introduced.  This model, which influenced the modern biomedical model of health and illness, emphasized the scientific study of the body in isolation, separate from the mind.  Unlike the mind-body integration that was maintained in Eastern medicine, this development in the Western world led to the separation of the physical body from the mental, emotional, and spiritual dimensions.  This resulted, in part, in a mechanistic and reductionistic orientation that continues to influence much of the modern biomedical model used today.[1]  The separation of mind from body has led to many scientific gains, such as the discoveries of bacteria and antibiotics, as well as inventions, such as the stethoscope, microscopy, blood pressure cuff, and refined surgical techniques.  Other levels of healing, however, have often gone unexamined and unaddressed.

The idea of a connection between the human mind and the physical body was first re-introduced at the end of the 19th century, as stress and mental states were increasingly considered to influence physical health.  The work of George Beard, Sigmund Freud, and Carl Jung, amongst others, introduced the concept that one’s mental life can have a profound impact upon physical health.  Carl Jung, for example, said “The separation of psychology from the premises of biology is purely artificial because the human psyche lives in indissoluble union with the body.”[2]  Interest in the power of the mind to affect physiological processes has grown during the past few decades, especially after Eastern healing approaches were introduced into Western medicine and culture.  Increased attention has been placed on mind-body techniques, such as meditation practices and the importance of controlling thinking patterns related to oneself and one’s environment.[3]  This has led to more value being placed in an individual’s active participation in his or her own healing through the development of inner resources.

Making use of the Power of the Mind requires a clinician to break out of the perspective of mind-body dualism that has been the focus of many health professionals’ training.  Perhaps it is best not to become bogged down in terms of what constitutes mental health versus what constitutes physical health; the key is Whole Health, the health of the entire individual.

Placebo effect

Research studies began demonstrating the connection between the mind and body as early as the 1940s.  Henry Beecher coined the phrase “placebo effect” after discovering in World War II that pain experienced by wounded soldiers could be controlled with saline injections.[4]  The placebo effect has been widely studied and demonstrates that factors, such as expectation and suggestion, can have specific physiological effects on the body.  Examples include intracellular repair of genetic mutations, cellular and antibody immune responses, wound healing, blood clotting, pain reduction and natural healing of infectious agents.[5]  Placebo effects have been associated with both hypnosis and psychotherapy in general.[6]  Research on the placebo effect indicates that it can be used to reduce pain, improve sleep, treat anxiety disorders [ ] such as panic [ ]  and improve ADHD symptoms [ ] and relieve depression.[7-9,207-216]  A systematic review conducted of functional neuroimaging found evidence for how several brain regions and molecular systems may be involved in placebo affects in adults with anxiety/depressive disorders.[217]. More specifically, activity in the ventral striatum, rostral anterior cingulate cortex and other default mode network regions, orbitofrontal cortex, and dorsolateral prefrontal cortex correlated with placebo antidepressant responses. Activity in regions of the default mode network, including posterior cingulate cortex, was associated with placebo anxiolysis. There was also evidence for possible involvement of the endogenous opioid, dopamine, and serotonin systems in placebo antidepressant and anxiolytic effects.

Placebo  can also ameliorate the symptoms of a wide variety of other conditions, including irritable bowel syndrome (IBS),[10] asthma,[11-13] Parkinson’s disease,[14] heart ailments,[15] such as angina pectoris, migraine and other types of headaches.[10-17,218-220]  These findings point to the importance of perception and the brain’s role in physical health. 

The National Center for Complementary and Integrative Health (NCCIH)

NCCIH’s mission is to determine, through rigorous scientific investigation, the fundamental science, usefulness and safety of complementary and integrated health approaches and their role in improving health and health care. Integrative health brings conventional and complimentary practices together in a coordinated way. Complimentary practices are classified by how the treatment is taken in or delivered.  The NCCIH classifies complementary practices in the following 4 types: 

1. Nutritional (herbs, dietary supplements, special diets, etc.)
2. Psychological (mindfulness, psychotherapy, etc.)
3. Physical (massage, spinal manipulation, chiropractic, etc.)
4. Combinations of the above: (yoga, tai chi, acupuncture, mindful eating, art therapies, etc.)
   
   

According to data from the 2022 National Health Interview Survey (NHIS) released in January 2024, over a 20 year period from 2002 to 2022, U.S. adult not only increased their overall use of complementary health approaches but were also more likely to use complementary health approaches specifically for managing pain.  The use of yoga, meditation, and massage therapy increased the most from 2002 to 2022.  In 2002, 19.2 percent of people used at least one of the following seven approaches (yoga, meditation, massage therapy, chiropractic care, acupuncture, naturopathy, and guided imagery/progressive muscle relaxation) and by 2022, 36.7 percent of the people did.

For further information on NCCIH, please refer to the NCCIH website.  For additional information on the therapies listed above, as well as many others, refer to the “Implementing Whole Health in Your Practice, Part III: Complementary and Integrative Health for Veterans” and related Whole Health tools. 

Recent advances in knowledge

Recent advances in the fields of psychoneuroimmunology, neuroplasticity, and epigenetics have provided a deeper perspective on how brains and physiology are interconnected, bi-directional, and able to change throughout life in response to experience.  The mind and thought patterns not only influence mood and behavior, but also have a direct impact on physiology.  They change neural connections in the brain, influence immune system functioning, make people more resilient to stress, and even affect the expression of genes. 

Psychoneuroimmunology (PNI)

Over the past decades, there has been extensive research demonstrating psychosocial influences on the development and course of various medical illnesses.  The work of Robert Ader and others in the field of psychoneuroimmunology (PNI) has been instrumental in showing the bi-directional interactions between brain, behavior and the immune system.  PNI represents a shift from the predominately biomedical paradigm towards establishing a biological basis for how the mind can influence the body through biological processes. 

PNI research has recognized that the nervous and immune systems communicate through a common biochemical language that involves shared neuroendocrine hormones, neurotransmitters, cytokines, and their receptors.[19]  It has been found that immune system health and physical health in general are influenced by psychological processes, including learning, psychological stress, emotions, and sensation, through neural and endocrine pathways.  The immune system can selectively up- and down-regulate its responses under different conditions.  For example, acute stress generally is associated with enhanced immunity, including increases in circulating concentrations of proinflammatory cytokines and the expression of proinflammatory genes that are driven by activation of the sympathetic nervous system.[220,221]  This is considered to be an adaptive response to the physical threats that might occur following attack, preparing the immune system to proactively address potential infection and tissue damage.[222]  On the other hand, long-term or chronic stressors are linked to suppressed immune function,[20] including increases in inflammation and decreases in antiviral and adaptive immunity.[223,224]

Emotional states can also influence immunological and inflammatory parameters. Candace Pert’s research found that neuropeptides and neurotransmitters act directly upon the immune system, suggesting a mechanism through which emotions and immunology are deeply interdependent.[21]  She asks, “Is the peptide first, or the emotion?”[21]  One study found that experimentally induced negative mood is associated with suppression of the immune system, and positive mood is associated with enhancement of chemotaxis, a measure of immune function.[22]  These relationships are especially relevant to immunologically-mediated health problems, including infectious disease, cancer, autoimmunity, allergy, and wound-healing.[23] 

Meta-analyses of cross-sectional studies comparing individuals with depression and nondepressed controls have found elevations in peripheral markers of inflammation in depressed patients, including higher levels of Interleukin 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and c-reactive protein (CRP).[225,226]  Meta-analyses of cross-sectional studies have documented elevated concentrations of IL-6, TNF-α, and CRP among individuals with posttraumatic stress disorder (PTSD) relative to healthy controls.[227,228]  However, longitudinal studies examining pretrauma inflammation have been mixed making it difficult to determine the direction of the effects.[229]  One systematic review and meta-analysis found elevations in CRP in patients with Generalized Anxiety Disorder (GAD) but not in other inflammatory markers.[230]  Results have been mixed with other anxiety disorder as another meta-analysis found no evidence of elevated inflammation in individuals with OCD, panic disorder, social anxiety, or GAD relative to healthy controls.[231]  One meta-analysis of 30 studies investigating inflammation in 1351 patients with bipolar disorder reported higher concentrations of cytokines IL-6 and TNFα as well as IL-2 soluble receptors during manic phases.[232]  There is growing evidence supports a role for inflammation in the development of schizophrenia.[233]   Meta-analyses of cross-sectional studies have documented elevated levels of CRP and IL-6 among individuals with schizophrenia.[234,235]

Research has also shown that the immune system plays a central role in how we think, feel, and behave, both in sickness and in health.[236]  For example, both preclinical and clinical studies have shown reliable effects of acute inflammation on cognitive processes, particularly psychomotor slowing and memory impairment.[237,238]

In the past several decades, the brain-gut axis has become an increasing focus of psychoneuroimmunological research.  There is a growing volume of data to indicate that the immune system is a major communication pathway between gut microbes (complex ecosystem with a diverse range of organisms and a sophisticated genomic structure) and the brain, and may play an important role in stress-related illness.[25]  Microbes are known to affect neurotransmitter modulation and synthesis, including serotonin metabolism, and can activate the central nervous system via neuroimmune and neuroendocrine pathways.[239]  Maintenance of the gastrointestinal (GI) tract's microbiome is especially important, as many microbes aid in digestive processes and curtail the proliferation of more dangerous pathogens like C. difficile.[240]

Microbiome and gut health are important for both immune and mental health.[241]   Bidirectional relationships between the immune system, nervous system, and psychological processes likely exist in certain disorders such as inflammatory bowel disease (IBD).  Stress can affect IBD, and IBD is associated with an increased risk of psychological difficulty.[27,242] Initial research has found altered composition and reduced diversity of gut microflora in autism, depression, anxiety disorders, bipolar disorder, and schizophrenia.[243,244]  Clinical depression as well as other psychiatric conditions also display evidence of disruption in the mucus and endothelial cell barrier that line the GI tract.[245]  Further understanding of the brain-gut axis has the potential to provide new areas for development for psychotropic medications.[26]

Given the detrimental effects of exaggerated or prolonged inflammation on mental health, the field of immunopsychiatry is exploring pharmacologic approaches that target inflammation and associated changes in neural function that contribute to depression and other mental disorders.[246]  Various psychological and mind–body interventions have been examined in relation to the immune system in humans. A systematic review and meta-analysis of 56 psychosocial interventions, the majority using cognitive behavioral therapy found an overall beneficial effect on immune function, including reductions in peripheral markers of inflammation.[247]  Mindfulness-based interventions have been shown to decrease inflammatory activity, particularly at the level of gene expression.[248]Both mindfulness-based and CBT approaches have led to positive changes in well-being.[249,250]  More specifically, positive affect is associated with lower levels of proinflammatory cytokines and circulating markers of inflammation, lower stimulated production of inflammatory cytokines by immune cells and reduced inflammatory reactivity to psychosocial stress.[251]  Eudaimonic well-being, which encompasses a sense of meaning and purpose in life, social connection, and the opportunity for personal growth, has also been linked to lower levels of inflammation.[252-254]

Neuroplasticity

Neuroplasticity, also known as brain plasticity, refers to the changes in neural pathways and synapses in the brain that occur throughout life as a result of changes in behavior, environment, and neural processes as well as through bodily injury.[28]  The brain is no longer believed to be a physiologically static organ.  Rather, research has shown that the brain’s physical structure (anatomy) and functional organization (physiology) alters in response to experience.  A number of factors change neuronal structures and functions, including stress, adrenal and gonadal hormones, neurotransmitters, growth factors, certain drugs, learning, environmental stimulation and aging.[29]

Growing evidence suggests that brain function cannot be considered independent from peripheral influences. The gut microbiota - an ecosystem of fungi, archaea, bacteria, and viruses that live in the gastrointestinal (GI) tract - is one such influence that has been shown to affect various aspects of human physiology, including metabolism and immune system function.[255,256]  The term “microbiota-gut-brain axis” refers precisely to the complex network of direct and indirect signaling via chemical transmitters, neuronal pathways and the immune system that creates such communication.[257]  Research has been exploring how signals from the intestinal microbiota may influence neuroplasticity and behavior.[258]

Adult neurogenesis, the generation of new neurons in adult brains, is an interesting phenomenon of neuroplasticity.  In a 2012 review article, Davidson and McEwen document how many forms of stress promote excessive growth in sectors of the amygdala, whereas effects on the hippocampus tend to be opposite.[30]  They highlight the effect of specific interventions designed to decrease stress and promote prosocial behavior and well-being on brain structure and function.  Physical exercise is effective in protecting against age‐related neurodegeneration and cognitive decline. Meta-analysis has found that physical exercise consistently results in structural and functional changes in the hippocampus/parahippocampus area and a cluster within the cerebellum, which may be crucially relevant for maintaining memory function in older adults.[259]

,Additionally, a number of studies have linked meditation practice to differences in cortical thickness or density of gray matter.  A systematic review and meta-analysis suggested the potential effects of Mindfulness Based Interventions in improving cortical thickness and connectivity in regions associated with memory and attention.[260]  Another study found that  participants trained to meditate over an 8-week period experienced increased left prefrontal cortex activation in their brain, an area associated with greater positive emotional states, deeper ability to concentrate, and stronger resilience following a stressful challenge.[31] 

Research has also examined changes in brain activity before and after receiving cognitive therapy.[32-34]  Meta-analyses have concluded that cognitive therapy for mood and anxiety disorders was associated with changes in brain regions consistent with neural models of affective regulation and self-regulation.[35-37]  This suggests that cognitive therapy alters brain functioning associated with affect regulation, problem solving, and self-referential and relational processing.  For example, Ochsner and Gross[37] found cognitive therapy to be associated with changes in regions that are involved in the regulation of negative affect, including the ventral and dorsal anterior cingulate cortex, medial prefrontal cortex, and the right ventrolateral and inferior and frontal cortices.

Refer to “Mindful Awareness” and related Whole Health tools for information on functional magnetic resonance imaging (fMRI) studies of meditation.  Refer to “Recharge” for more information on neuroplasticity.

Epigenetics

Epigenetics describes heritable alterations in gene expression that do not involve DNA sequence variation and are changeable throughout a person’s life.  Epigenetic research indicates that genes are dynamic in their expression and respond to physical stimuli such as stress, diet and exercise.[38] Epigenetic mechanisms, such as DNA methylation (DNAm), have gained increasing attention as potential biomarkers and mechanisms underlying risk for neurodevelopmental, psychiatric and other brain-based disorders.[261]  A systematic review  documented a variety of epigenetic mediators that lie on a common pathway between childhood trauma and psychiatric disorders in adulthood, such as depression.[262]  It is theorized that stressors, such as childhood maltreatment interact with the genome to produce stable changes in DNA structure and expression, and that these mechanisms may underlie the pathological behaviors observed in depressed individuals.[263]  Epigenetic modifications appear to be dynamic and may be affected by environmental factors throughout life.  A systematic review explored how undergoing psychotherapy showed detectable changes at the epigenetic level, like DNA methylation changes, associated with symptom improvement.[264]

 Social epigenetics is the subfield of genomics which asks whether and how exposures to the physical and social environment influence differential gene expression. Social epigenetics has incorporated lessons from the SDOH literature by extending inquiry into the role of economic deprivation, childhood adversities, discrimination, and place-based stressors on DNA Methylation (DNAm) in adulthood, the most pervasive marker of epigenetic alteration in current population-based research.[265]  SDOH have important biological consequences, with epigenetics potentially playing a role in linking individual and contextual factors with health outcomes across the life span.[266]  Epigenetic changes are increasingly considered a mechanism contributing to differential aging and life expectancy (Horvath, 2013), and may be one mechanism by which harmful social and economic exposures alter immune function, increase systemic inflammation, and influence other markers of complex chronic diseases with well-documented health disparities.

Epigenetics may inform why the pattern of aging is different between two genetically identical twins.  In a 2016 review on epigenetics and aging, Pal and Tyler concluded that the human life span is largely epigenetically determined rather than being genetically predetermined.  Diet and environmental influences impact life span through changing the epigenetic information.[39]  A study published in the Journal of Psychoneuroendocrinology provides evidence that developing the mindfulness skill of maintaining a non-judgmental, open presence to the present moment without being carried away by thoughts, emotions, or perceptions can potentially influence gene expression.  Kaliman and colleagues found that after eight hours of mindfulness practice, meditators showed a range of genetic and molecular differences compared to nonmeditators, including altered levels of gene-regulating machinery and reduced levels of pro-inflammatory genes, which in turn correlated with faster physical recovery from a stressful situation.[40]  Bishop and colleagues reported hypomethylation of the FKBP5 gene in Veterans with PTSD responding to the Mindfulness Based Stress Reduction (MBSR) intervention compared to non-responders who, in contrast, showed increased methylation.[265]  They speculated that FKBP5 methylation could be a predictive biomarker of the response to MBSR in PTSD.

Cross-sectional studies have shown that blood cells from long term meditators exhibit a trajectory of epigenetic ageing different from age-matched non meditator controls, with a slowdown of the epigenetic clock as the number of years of practice increases, and epigenetic changes in pathways related to common diseases and inflammatory signaling.[266,267]  Other research found a short meditation intervention in experienced meditators may rapidly influence the epigenome at sites of potential relevance for immune function.[268]  The discovery that bodies and brains change throughout life in response to mental experience suggests that positive changes can be nurtured through mental training.

Research in epigenetics neuroplasticity, and psychoneuroimmunology make it clear that our minds and our bodies are not separate from one another.  In fact, they are in a dynamic dance, constantly influencing one another.  It is because of this changeability that mind-body approaches can bring about changes for people.

The remainder of this overview focuses on Mind and Body Practices as called by the NCCIH, as well as some other well-documented interventions that also utilize the power of the mind.  Following an introduction to mind-body applications, there will be reviews of the literature on 13 different techniques as well as ways in which to incorporate them into your practice, when appropriate. The 13 techniques are divided into 2 categories: Relaxation Strategies and Emotional Healing Strategies.

It is possible to adapt, interweave, and integrate core mind-body principles and certain mind-body techniques in the course of a regular office visit.

Introduction to mind-body applications

Mind and body techniques offer patients the following:

• Greater control with their treatment
• Cost-effective therapeutic alternatives
• Effective options for managing chronic conditions and psychological disorders
• Methods for maintaining wellness.

John Astin conducted systematic reviews and meta-analyses of research on mind-body techniques and found there is considerable evidence of efficacy for several mind-body therapies in the treatment of multiple health problems.  These include coronary artery disease, headaches, insomnia, incontinence, chronic low back pain, cancer-related symptoms and cancer treatment-related complaints, as well as for improving post-surgical outcomes.[41]  Garland et al, in a systematic review and meta-analysis published in 2020, found that mind-body therapies were associated with pain reduction and reduced opioid dose. The author notes that meditation especially had a moderate to large effect on improvements in pain outcomes.[269]  Mind-body practices were also noted to improve glycemic control in patients with type 2 diabetes.[270]  Mindfulness, yoga, relaxation, and hypnosis were effective in sleep disturbance severity reduction among patients with cancer at post-intervention.  There was moderate evidence of efficacy for mind-body therapies in the area of hypertension and arthritis.[271]  Considerable evidence also exists for the effectiveness of mind-body therapies for the treatment of psychological conditions.[1]  For example, refer to the “Depression” and “Posttraumatic Stress Disorder (PTSD)” overviews.

In March 2011, the Defense Center of Excellence published Mind-Body Skills for Regulating the Autonomic Nervous System: Defense Centers for Psychological Health and Traumatic Brain Injury.[42]  Admiral Mike Mullen, the Chairman of the Joint Chiefs of Staff Guidance for 2011, stressed the need for a “holistic” approach to caring for service members and their families.  This report indicates that incorporating an assortment of mind-body approaches for regulating the autonomic nervous system may be more effective than just using one mind-body skill on its own.  An example of how this is being incorporated includes The Traumatic Brain Injury Center of Excellence webpage, “Healthy Sleep Following a Concussion.”  Those with insomnia are encouraged to engage in mindfulness, breathing and CBT-I practices. 

The Mind-body Skills for Regulating the Autonomic Nervous System report also highlights that an especially promising use of mind-body skills is in the area of PTSD recovery.  An important component of healing from trauma is to learn how to regulate physiological arousal in response to reminders of the trauma and ongoing life stressors, to effectively regulate affective arousal, and to learn to be more present in day-to-day experiences.  The VA-DOD Clinical Practice Guidelines for PTSD recognizes the benefit of many mind-body modalities as ways to augment other treatment approaches of PTSD symptoms, particularly with symptoms related to hyperarousal.  Mind-body Skills for Regulating the Autonomic Nervous System notes that many approaches show promise for treating a variety of disorders, including anxiety, depression, headaches, chronic pain and insomnia.[42]  It is noted that there is also substantial research indicating specifically that mindfulness meditation practices are effective for decreasing depression, anxiety, panic disorders, and substance abuse, among other problems.

Cushing and Braun conducted a systematic review for military veterans (post 9/11 operations) with combat-related PTSD.[272]  Practices were yoga that included breath work, meditation, mantra repetition or breathing exercises. Overall, the authors reported significant improvements in PTSD symptoms in those military veterans who used those mind and body practices.. Kim and colleagues also reviewed the literature earlier regarding mind-body practices for PTSD.[43]  They also included practices that are covered in this module such as meditation, deep breathing, and mindfulness-based stress reduction (MBSR).  Overall, it appears that mind-body practices are a viable intervention for improving many PTSD symptoms, including intrusive memories, high-arousal states, and avoidance.

A novel approach to providing mind-body information and skills was piloted among 55 female caregivers of military veterans.  This entailed a daily podcast series which included psychoeducation about the stress response, relaxation-response training, and self-compassion practices. From baseline to endpoint, there were significant decreases in perceived stress, depressive symptoms, somatic complaints and increase in ability to perform social roles. Further research is needed but this looks promising.[273]

Relaxation Strategies

Extensive research indicates that relaxation therapies can beneficially influence the physiology of the body, reducing stress, decreasing anxiety, improving coping with chronic pain and boosting mood.[274-277]  Strong evidence supports employing relaxation therapies to address a variety of medical and psychological difficulties.  The National Institutes of Health Consensus Development Program defined relaxation techniques as the following:[44]

…a group of behavioral therapeutic approaches that differ widely in their philosophical bases as well as in their methodologies and techniques.  Their primary objective is the achievement of nondirected relaxation, rather than direct achievement of a specific therapeutic goal.  They all share two basic components:

1. 1. Repetitive focus on a word, sound, prayer, phrase, body sensation, or muscular activity.
   2. The adoption of a passive attitude toward intruding thoughts and a return to the focus.

These techniques induce a common set of physiologic changes that is the opposite of the fight-or-flight response, which results in decreased metabolic activity, heart rate, blood pressure, respiratory rate and slowed brain waves.  Relaxation techniques may also be used in stress management (as self-regulatory techniques)

Stress and the relaxation response

“Relaxation techniques may be helpful in managing a variety of stress-related health conditions, including anxiety associated with ongoing health problems and in those who are having medical procedures. Evidence suggests that relaxation techniques may also provide some benefit for symptoms of post-traumatic stress disorder (PTSD) and may help reduce occupational stress in health care workers.”  NCCIH Clinical Digest for health professionals.(January 2024) Mind and Body Approaches for Stress and Anxiety:  What the Science Says.

 The autonomic nervous system (ANS) includes the sympathetic and the parasympathetic nervous systems.  It is responsible for the unconscious regulation of internal organs and glands.  The sympathetic branch is responsible for up- and down-regulation of many body functions.  Most notably, it mediates the fight-or-flight response, which arises when the body experiences stress (i.e. challenges or threats that lead to adaptive demands).  Hormones are released, pulse and breathing rates increase, and blood vessels narrow in the parts of the body that are not needed to take action in an emergency.  However, if the body remains in a stress state for a long time, emotional or physical damage can occur.  Parasympathetic activation (sometimes referred to as the “rest and digest” or “feed and breed” response) is used to minimize the physiological response to stress. 

Herbert Benson, a cardiologist and mind-body medicine pioneer, examined the physiological and psychological effects of Transcendental Meditation^® (TM) on TM practitioners.[45]  One of his most interesting findings was that the TM practitioners activated the parasympathetic branch of the ANS during their meditations.  He described this phenomenon as the “relaxation response.”  It is the body’s natural state of relaxation, as opposed to the state of hyperactivity of the nervous system associated with the fight-or- flight response.[46]  Benson went on to publish additional results that indicated mind-body practices such as meditation, yoga, autogenic training, and hypnosis all elicit the relaxation response.  As such, they decrease oxygen consumption, respiratory and cardiac rate, and muscle tone, while increasing alpha rhythm brain activity and skin resistance.[47]

Research has shown that regular elicitation of the relaxation response can result in the alleviation of many stress-related medical disorders.[48]  It can work to counteract the harmful effects that chronic stress can have on our bodies due to the exposure to fluctuating or heightened neural or neuroendocrine responses.  In a 2024 meta-analysis,  the researchers found evidence to suggest that stress management interventions were effective in changing cortisol (sometimes referred to as a stress hormone) levels in healthy adults.[278]  A systematic review found that one mind and body practice, relaxation, had evidence of positive effects on Immunoglobulin A, an immune system outcome.[279]  The relaxation response has been found to be effective for the following:[48,280-284]

• Anxiety, including anxiety around health conditions
• Mild and moderate depression
• Anger and hostility
• Insomnia
• High blood pressure
• Premenstrual symptoms and menstrual cramps
• Rheumatoid arthritis
• Functional bowel disorders
• Chronic pain
• Temporomandibular joint disorder.
• Reducing maternal stress, anxiety and depressive symptoms.

Eliciting the relaxation response has also been found to be effective, at least in part, in the treatment of cardiac arrhythmias,  postoperative anxiety and pain, the side effects of cancer treatment, as well as in preparation for procedures and diagnostic tests.[48]

Virtual reality (VR) has also been studied as a way to reduce stress.  Riches et al reviewed whether VR relaxation has potential to promote relaxation and reduce stress in adults with mental health conditions, especially anxiety and stress-related problems. All studies used a range of nature-based virtual environments to promote relaxation.  The authors stated that VR relaxation has potential as an intervention of low intensity to promote relaxation and reduce stress for adults with mental health conditions, especially anxiety and stress-related problems. Further research is warranted on this promising intervention.[285]

1. Breathing techniques.

2. Progressive muscle relaxation

Technique.  Progressive Muscle Relaxation (PMR) is a widely used, validated, standardized and well-established intervention aimed at reducing stress, eliciting relaxation and improving overall well-being.[291]    It was developed by Edmund Jacobson in the early 1920s to monitor and control the state of muscle tension in the body.  He wrote several books on the subject and claimed that anxiety is caused by skeletal muscle contractions.[57]  In its original form, PMR taught relaxation of approximately 30 different muscle groups.  The technique was shortened by Bernstein and Borkovec in 1973 and has been abbreviated even further today for use in clinical practice.[58]

Clinical applications.  PMR is typically taught as a two-step relaxation practice to reduce stress and build awareness of sensations of tension and deep relaxation in 14 muscle groups. 

• The first step in the PMR practice is to create tension in a specific muscle group, noticing what tension feels like in that area.
• The second step is to then release this muscle tension and begin to notice what a relaxed muscle feels like as the tension drains away.

By moving through the body, alternately tensing and relaxing different muscle groups in a certain order, one gains skill at recognizing and differentiating between the associated feelings of a tensed muscle and a completely relaxed one.  When muscle tension is reduced, stress and pain decrease.[59]  When PMR is first taught, it is often recommended to create tension and relaxation several times in the same muscle group.  With each contraction and release, muscle tension decreases further.  Body awareness is enhanced, and relaxation is deepened.  Through repetitive practice, a person can then induce physical muscular relaxation at the first signs of physical tension that accompanies stress.  After the practice, there may be one or two areas that a person finds is still tense, requiring the need to go back over that area or muscle group to tense and relax one or two more times.  Refer to “Progressive Muscle Relaxation” to learn more about this technique and how to teach it to your patients.

Evidence.  PMR was originally used to treat symptoms of anxiety and stress, but more recently it has been found to be effective for treating a wide variety of clinical conditions.[292]  It has been extensively studied for treatment of insomnia and headaches.  The American Academy of Sleep Medicine concluded, based on 17 studies, that PMR was 1 of only 3 nonpharmacologic treatments empirically supported for treatment of chronic insomnia.  It has been shown to help relax the body and mind at bedtime, allowing one to fall asleep more easily and to have a more restful night’s sleep.[60] Practice of PMR has been shown to alter sleep architecture prior to overnight sleep or naps.[293,294]  It also has been found helpful in managing chronic neck pain.[61,295]  PMR has also been found to be an effective treatment for tension, migraine headaches and tinnitus.[62,63,296] 

In addition, PMR has been found to be helpful for treating temporomandibular joint disorder (TMJ), diabetic peripheral neuropathic pain, postoperative pain, back pain and high blood pressure.[297-301]  There is also evidence that PMR is an effective treatment in improving tolerance of cancer chemotherapy and reducing cancer related pain and psychological distress in cancer patients.[64,303,304]  In addition, it has been found to improve well-being in patients with inflammatory arthritis and IBS.[65-66]  PMR was also found to be associated with a decrease in psychological strain during deployment in military personnel.

PMR can be readily adapted to minimize the risk of triggering pain in injured or painful areas.  A person can simply avoid tensing up those specific areas of the body.  Another adaptation of PMR is progressive relaxation (PR), which includes sequential relaxation of muscles, without muscle contraction.  This is helpful for individuals who find the muscle tightening process of PMR difficult due to their specific health problems, such as recent surgery, pain, fibromyalgia, etc.  PR is preferred by some people because they find it uncomfortable to contract muscles that are already tense.

Refer to “Progressive Muscle Relaxation” and “Progressive Relaxation” for more information. 

3. Autogenic Training

Technique.  Autogenic Training (AT) is a relaxation technique developed by the German psychiatrist Johannes Heinrich Schultz in 1932.  Autogenic means “generated from within.”  AT is considered a form of self-hypnosis.  It involves a series of simple, self-instructed mental exercises to increase relaxation without having to go through a hypnotic induction performed by a clinician.  It is a technique recommended when stress is a contributing factor in producing or maintaining health issues.[67]

Clinical applications.  More specifically, the practice of AT involves thinking several specific phrases to oneself to produce a relaxed feeling of warmth, heaviness, and emotional calm throughout the body.  These phrases are stated silently to oneself in a non-striving, detached way, which fosters the parasympathetic quieting of the body (the relaxation response).  At the core of AT is a set of standard exercises which focus on six physical manifestations of relaxation in the body:

1. Heaviness in the musculoskeletal system
2. Warmth in the circulatory system
3. Awareness of the heartbeat
4. Slowing down the breath
5. Relaxing the abdomen
6. Cooling the forehead

These exercises build weekly, starting first with relaxation of the peripheral extremities.  Next, regulation of the heartbeat and breathing patterns is included.  Lastly, relaxing the stomach, cooling the forehead, and feeling overall peace in the mind and body are added.  Not all individuals using AT will experience all these sensations.  Instead, they may report the overall effects of relaxation, such as reduced heart rate, lessening of muscular tension, slower breathing, reduced gastrointestinal activity, improved concentration, lessened irritability, improved sleep, and more.[68]  For some patients, coming up with and using their own autogenic phrases can be helpful in addressing their particular needs.

Try It for Yourself:  Tune in to Your Body

Try feeling each of the six Autogenic Training manifestations as you read through this.  If you have difficulty, start by just focusing on one specific part of the body, like your hands.

1. Musculoskeletal system. Allow yourself to feel heaviness in the muscles and bones.  Can you tune in to specific bones or muscles?
2. Warmth. Focus on blood flow.  It might help to focus on your hands or feet at first.  Can you make them warmer? 
3. Can you tune in to your pulse?  Where do you feel it?
4. Breathing. Note your respiratory rate.  Take a few slow deep breaths to slow it down, as you feel comfortable.
5. Imagine your abdomen softening, like melting snow.  Feel the breath in the abdomen, as you practiced in the breathing exercises, above.
6. Allow your forehead to cool down.  You might imagine an ice cube melting on it, or a gentle breeze blowing across it.

Evidence.  Empirical data supports the effectiveness of AT as a promising therapy to improve psychological well-being and quality of life in people living with chronic physical health problems[9] such as improving wellness in people living with HIV, enhancing self-control in people struggling with IBS [70], reducing symptoms associated with Parkinson’s disease.[71,305] and reducing stress and anxiety. [306]

A 2022 systematic review and meta-analysis of 13 studies found AT to yield a significant reduction in pain in individuals suffering from chronic pain.  AT’s effect on pain was found to be comparable to other psychological interventions such as progressive muscle relaxation, biofeedback or self-hypnosis but was posited to have advantages to these other methods such as  no additional muscle tension and not having to depend on experts .[307]

Regular practice of AT for headache has been shown to reduce the frequency of migraines with an observed effect on brain areas associated with aversive emotional processing, emotional stress processing and pain perception.[308]   This finding highlights how autogenic training can provide better stress regulation and address the factors that contribute to a chronic medical condition.[309]

In a meta-analysis of 60 studies, Stetter and Kupper  found significant positive effects of AT treatment when compared to controls for clinical outcomes for a number of diagnoses, including the following [67]:

• Tension headache
• Migraine
• Mild-to-moderate essential hypertension
• Coronary heart disease
• Bronchial asthma
• Somatoform pain disorder (unspecified type)
• Raynaud's disease
• Anxiety
• Mild to moderate depression
• Functional sleep disorders

A 2023 systematic review examined the impact of AT on psychological disorders.  They found the  main psychophysiological effects of AT include autonomic cardiorespiratory changes paralleled by central nervous system activity modifications and psychological outputs. This review also found medium range positive effects of AT for anxiety disorders, mild-to moderate depression/dysthymia and functional sleep disorders.[310]

Krampen demonstrated that patients receiving both AT and cognitive therapy for treatment of moderate depression showed the best outcome at follow-up.[69] Therefore, AT can be considered a helpful adjunct to other types of treatment for mood and anxiety disorders, such as Cognitive-Behavioral Therapy or psychopharmacological treatment. 

Refer to “Autogenic Training” for more information.

4. Hypnosis

Technique.  The term hypnosis comes from the Greek word hypnos which means “to sleep.”  Hypnosis has been used in medicine for millennia, with ancient texts from Egypt, China, Greece, and Rome all describing practices that are considered hypnotic.  In the late 1700s, hypnotism was led out of the realms of the occult into scientific study with the work of the Austrian physician, Franz Mesmer, to whom we owe the word “mesmerism” and its derivative “mesmerize.”  In the 20th century, Milton Erickson revolutionized the practice of hypnosis, and the vast majority of clinicians practicing hypnotherapy today use some form of the Ericksonian approach. 

Erickson viewed hypnosis as a method of calming and quieting the conscious mind so that one could access and work directly with the subconscious.  Because the body “hears” everything that enters the subconscious mind, hypnosis became viewed as a method for accessing and influencing subconscious effects on the body.[72]

Hypnotic phenomena are sometimes experienced with stage hypnosis.In contrast, a clinical hypnosis session follows a totally different format and has very different goals. In clinical hypnosis, a patient is in control throughout the whole visit and the goal is to make it easier for them to experience suggestions by helping induce trance in themselves.

Clinical applications.  Clinical hypnosis involves accessing a trance state of inner absorption, concentration, and focused attention.  This is established by using an induction procedure that usually includes instructions for relaxation to produce an altered state of consciousness.[73]  Trance is considered a naturally occurring state that is induced by mental concentration.  Attention is narrowly focused and relatively free of distractions, and the body experiences physical relaxation.  This is similar to everyday experiences such as daydreaming, losing yourself in a book or movie, or getting lost in thought while driving and missing your exit.  When a person is in a trance state, nonvoluntary and involuntary body processes become more easily controlled and changeable. 

Hypnosis uses two strategies during the trance-like state to create changes in sensations, perceptions, thoughts, feelings, and behaviors.  First, mental imagery and symbolism are used to accomplish the goal of the hypnosis session.  For example, a person with IBS may be asked to imagine what her or his abdominal pain looks like.  If the person imagines it as being a very red, pulsing object that is hot and sharp in texture, the patient may be encouraged in hypnosis to visualize this image changing, with colors and textures shifting to those that are more representative of a healthy state (perhaps a cool blue).  Other examples include preparation for surgery, such as imagining the surgery going smoothly and visualizing a successful outcome and quick recovery time.  Hypnosis can also be used as an adjunct to other treatments.  For example, a cancer patient may focus on imagery related to chemotherapy working more effectively.  This can potentially boost white blood cell production and activity. 

The second hypnotic strategy involves the use of suggestions.  The therapist and the person in the trance -like state use ideas and suggestions to support the goals of the session.  The expectation is that those suggestions can have a powerful impact on the mind and how the body and mind interact.  They are most effective when the patient is a) relaxed, receptive, and open to the suggestions, b) able to experience visual, auditory, and/or kinesthetic representations of the suggestions, c) able to anticipate and envision that these suggestions will result in future outcomes. 

Evidence.  The American Society of Clinical Hypnosis (ASCH) is the largest, multi-disciplinary, national organization dedicated to research and training in clinical hypnosis.  Members represent the disciplines of medicine, psychology, social work, and dentistry.

ASCH has compiled the research evidence for the use of hypnosis for certain conditions.[74]  (Please refer to the ASCH website for more details).  They state that there is empirical support for hypnosis being used for the following medical problems:

• Gastrointestinal disorders (ulcers, IBS, colitis, Crohn’s disease)
• Dermatologic disorders (eczema, herpes, neurodermatitis, itching, psoriasis, warts)
• Surgery/anesthesiology
• Acute and chronic pain (back pain, cancer pain, dental anesthesia, headaches, and migraines, arthritis or rheumatism)
• Burns
• Nausea and vomiting associated with chemotherapy and pregnancy
• Childbirth
• Hemophilia
• Allergies, asthma
• High blood pressure
• Raynaud’s disease
• Dentistry related conditions

ASCH also states that there is significant evidence that hypnosis may also be helpful in these psychological conditions:

• Trauma
• Anxiety and stress management
• Depression
• Bed-wetting (enuresis)
• Sports and athletic performance
• Smoking cessation
• Obesity and weight control
• Sexual dysfunctions
• Sleep disorders
• Concentration difficulties, test anxiety and learning disorders

Hypnosis tends to be very safe with minimal side effects, according to a number of meta-analyses.[311,312]  Using hypnosis to work through events in one’s past may lead to the creation of false memories and trigger strong emotional reactions.  Rarely hypnosis can cause drowsiness, headache, dizziness, and/or anxiety.  Having a clinician work closely with the Veteran during hypnosis treatment is important to mitigate any unintended side effects and receive the most benefit from the intervention.

Refer to “Clinical Hypnosis” for more information.

5. Imagery

Technique.  Imagery, also known as visualization, guided or directed imagery, or even self-hypnosis, is an ancient practice and “one of the world’s oldest healing resources.”[75]  Imagery is found across cultures, including in Native American and other indigenous traditions.  Certainly, imagery and hypnosis are related, and imagery could be considered a subunit of hypnosis.[76]

Clinical applications.  Therapeutic visualization and imagery techniques often begin by engaging in some form of relaxation.  This is followed by the development of a visual image, such as a pleasant scene that enhances the sense of relaxation.  Depending on the situation and clinical need, these images may be generated by the patient or suggested by the practitioner.  A session might include having the patient imagine coping more effectively with the stressors in his or her life.[75]

The word “imagery” suggests that the therapy relies primarily on the visual sense, but clinical imagery typically includes multiple senses.  For example, in a visualization of a relaxing place like a beach, sensory experiences might also include the warmth of the sun, the sound of the waves, the feel of the sand against bare toes, the smell of the ocean, and the feel of a pleasant breeze against the cheek.  Imagery can use emotions as well, such as imagining feeling calm and peace while enjoying the beach.  Using multiple senses is an advantage in guided imagery, as some individuals find it easier to imagine a scene using one sense compared to others.

Imagery is generally used in 3 ways as outlined by the Academy of Guided Imagery:[77]

1. Relaxation and stress reduction, which is easy to teach, easy to learn, and almost universally helpful to patients/clients. An example would be using the imagery of the beach scene described above to foster a sense of increased peace and ease.
2. Active visualization or directed imagery where the patient is encouraged to imagine desired therapeutic outcomes while in a relaxed, open state of mind. Examples include feeling more confident in a situation that is stressful, optimizing performance in some activity or sport, or visualizing a tumor shrinking.
3. Receptive or insight-oriented imagery, where images are invited to enter conscious awareness where they are interactively explored to gather more information about a symptom, illness, mood, treatment, situation or possible solution. For example, if a naturally arising image for someone’s headache is a hard, black box, the individual can begin to interact with the image—perhaps opening the black box, shrinking the black box, changing the color of the box or asking questions of the black box. 

Evidence.  There are studies suggesting that imagery or guided imagery can be helpful in a variety of situations and conditions including stress management, preparation for surgery or procedures, pre-operative pain, anxiety, depression, cancer, fatigue, childbirth, improving athletic performance, managing chronic illness, positive health behaviors, nightmares, etc.[78,79,313,314]  In one systematic review focused on arthritis and other rheumatic diseases, improvement was found in pain and function across studies reviewed.[80]  In systematic reviews addressing musculoskeletal pain and non-musculoskeletal pain and imagery, Posadzki and colleagues concluded that the data is encouraging but not conclusive.[81,82]  One challenge in the research is that imagery is often combined with relaxation, and it is difficult to separate their effects.  Studies might evaluate imagery in combination with other mind-body techniques.  Over the years, research on imagery has found that it does indeed reduce stress and affect the immune system; this includes improving white blood cell counts.[83-88]

Mental rehearsal of single or complex motor acts, not accompanied by actual movement, is called kinesthetic imagery or sometimes motor imagery.  Research has explored the benefits to performance when rehearsal of physical activity is performed by the self rather than merely observing someone else doing that activity in imagination.  Several recent meta-analyses[89,90] have focused on whether this type of imagery could improve athletic performance.  When a program includes both mental rehearsal of motor acts, as well as physical practice itself, performance does appear to be improved.  This type of kinesthetic imagery has been used successfully to assist with physical performance across a broad range of areas, including teaching laparoscopic techniques to surgeons, playing piano, and improving soccer performance.[91-93] Interestingly, one meta-analysis found that motor imagery practice increased actual  motor strength, even without physical practice, when compared to a control group of healthy adults.[315]  Another found the use of motor imagery helpful for upper extremity motor rehabilitation after stroke.[94]

A 2023 meta-analysis addressed the efficacy of Imagery Rescripting (ImRs), which is often used to treat psychological complaints related to aversive memories.[316]  In ImRs, patients are instructed to first imagine the beginning of a difficult memory including sensory impressions, body sensations, thoughts and emotions; then they are guided to imagine changing how the events proceeded that would satisfy current “basic needs”.  The results suggests that imagery rescripting does address aversive memories, is effective in treating a variety of mental health disorders, and similarly effective as exposure, cognitive restructuring or EMDR.

It is possible for nearly anyone to use imagery.  Some individuals may prefer the assistance of a trained professional to help guide them in the use of imagery for their concern.  Many psychotherapists, psychologists and sometimes other trained professionals can assist patients with using imagery for themselves.  Those who might be especially skilled would be providers who are trained specifically in imagery or clinical hypnosis.  Other providers who may incorporate imagery into their work include physical/occupational therapists, psychiatrists, nurses, and integrative medicine clinicians.  Two well-known organizations providing training are the Academy for Guided Imagery and the American Society of Clinical Hypnosis.  In addition, there are many imagery recordings available both in retail stores and on the Internet for a variety of health and wellness concerns.

Contraindicated imagery.  It is not advised to use guided imagery with individuals who

• Are actively psychotic
• Experience hallucinations, delusions, delirium, dementia, or have difficulty separating fantasy from reality
• Feel that imagery would be in conflict with religious or spiritual beliefs
• Have a history of unprocessed trauma (which can arise suddenly during a session)

It is always important for the clinician considering using imagery to know the individual well. 

Refer to “Guided Imagery” for more information.

Try It for Yourself:  The Power of Imagery

Note: Only do these exercises if you do not have any of the contraindications listed above. 

1. Imagine that you are holding half of a lemon in your hand.
2. Make use of all your senses. Feel its weight in your hand.  Note the bright yellow color.  Smell it.  Does it make any sounds? 
3. Now taste it. Lick the exposed surface of the fruit.  Take a bite.  How does it taste?

Note your body’s response.  Did you pucker up?  Did your mouth water?

7. Meditation

Technique.  The history of meditation is a very rich one, with the earliest written records of its use found 2,500 hundred years ago in the Hindu Vedantism culture of India.  One of the most famous meditation teachers, Siddhartha, also known today as the Buddha, lived from 563 to 483 BC, according to tradition.  Forms of meditation have arisen in many cultures and geographic locations, and while methods and practices vary they share certain underlying principles.  For example, there are meditation practices within Judaism, Islam, and Christianity, among others.  Yoga practices are often included under the rubric of meditation.

Although ancient, meditation is subject to a great deal of current interest.  Thousands of research studies have been conducted on both the physiological and psychological effects of meditation practice.  Meditation is often classed as a mind-body technique and listed as a complementary approach.  Research in meditation has increased dramatically with the coming of age of mindfulness meditation in the past few decades.

Defining—and therefore studying—meditation is difficult, given the broad scope of meditation types, lineages, styles, and goals.  “Meditation” can be considered an “umbrella” term that includes a wide diversity of practices.  Meditation comes from the Latin “meditari” meaning to engage in contemplation or reflection.  Generally, in psychology, meditation refers to a practice in which the mind is trained to maintain focused attention for any number of reasons, including to enhance relaxation or develop positive psychological states.

Clinical applications.  More recently, some researchers and writers have conceptualized meditation research as being two-pronged:

• Types of meditation that are more focused on concentration practices, such as Transcendental Meditation^® (TM) or the relaxation response
• Those that are based in mindfulness practice, such as Zen meditation and Vipassana

TM was brought to the United States in the 1960s by Maharishi Mahesh Yogi of India and was studied by Herbert Benson, a cardiologist who did pioneering research in the field of mind-body medicine.[45]  Examining the physiological and psychological effects of meditation, he described the common features of concentration practices.  He found that these practices led to the relaxation response, a quieting of the sympathetic nervous system.  He distilled these commonalities of concentration practices to 4 components: 

 

1. A mental device on which to focus attention (e.g., a mantra or the breath, etc.)
2. A passive attitude toward distracting thoughts (i.e. thoughts will arise but rather than repressing or following them, allowing them to pass away)
3. Decreased muscle tone (i.e. settling into a comfortable position to minimize muscular effort)
4. A quiet environment (limiting distractions in the place of meditation, etc.).

The most common application of mindfulness in use in health care settings today is the popular 8-week mindfulness-based stress reduction program (MBSR).  Informed by Vipassana meditation, MBSR was designed to be a secular practice.  Mindfulness Meditation encourages present-moment awareness; self-regulation is enhanced by having a person focus on immediate experience.  In addition, it is characterized by a nonjudgmental awareness.  People are encouraged to be curious, open and accepting as they focus their sensation on the breath, parts of the body, or a simple task like eating or walking.  Mindfulness-based cognitive therapy (MBCT) is an adaptation of the MBSR program; it is used for prevention of relapses of depression.

For further information on mindfulness training, please refer to “Bringing Mindful Awareness into Clinical Work,” “Mindful Awareness Practice in Daily Living,” “Practicing Mindful Awareness with Patients,” and “Going Nowhere: Keys to Present Moment Awareness.”

Evidence.  Generally, meditation has been researched and clinically applied to many different types of problems, including medical and psychological conditions.  A number of studies have focused on stress.  In a meta-analysis on meditation and its impact on medical illness, Arias and colleagues,[101] states that

…the strongest and most beneficial effects of meditative practices occur in the domain of psychological health/functioning, as well as in the physical parameters of disease conditions that are strongly influenced by emotional distress and where the physical symptoms can perpetuate emotional distress.  These findings support the hypothesis that meditative treatments have a multifaceted effect on psychologic as well as biologic function, and that secondary physical benefits may occur via alterations in psychoneuroendocrine/immune and autonomic nervous system pathways.[101]

In a systematic review and meta-analysis, meditation programs were found to be helpful for psychological stress and well-being.[102,103]  Researchers found that meditation programs can result in small to moderate reductions of some of the negative dimensions of psychological stress.  They can improve symptoms of anxiety[  ] and depression[104-106,319,320] and MBCT has been shown to assist with prevention of relapse of depression.[107,108]  Anxiety and depression are common problems of Veterans and comorbidities with substance use and PTSD.  Researchers also conducted a systematic review of the literature on schizophrenia spectrum disorders (SSD) and mindfulness-based interventions (MBI).  They noted that MBIs for SSDs shows promise in reducing negative, depressive symptoms and preventing relapse.[321]  In a systematic review, mindfulness was noted to have had an impact on violence and aggression.[322]

In the results from a national survey (published in 2019), 18% of Veterans reported using mindfulness meditation in the previous year.  They rated mindfulness with a mean score of 3.18 out of 5 in terms of effectiveness with a response “somewhat helpful” to “moderately helpful” range.[323]  Also pertinent about this national survey was that 78% of those who used mindfulness reported its use developed outside of the VHA and most noted was the lack of awareness that the VHA offered mindfulness.

Addressing Veterans’ PTSD symptoms through meditation, aggregate analysis from a multi-site evaluation found medium effect sizes when compared to treatment as usual for PTSD severity.  Veterans also showed increases in overall mindfulness and nonreactivity to inner experiences.[109,324]  Other reviews and meta-analyses of non-Veterans support that meditation appears to be effective for PTSD.[325,326]

The impact of meditation on cognitive functioning has also been studied including attention, executive functioning, and working memory.  Mindfulness-based programs improved executive functioning, working memory and attention in healthy adults.  It was also shown to outperform its comparators.[327,328]  In adults diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) there was an improvement in symptoms including executive functioning and emotional dysregulation.[329]

 It also appears that mindfulness-based interventions may be helpful for chronic pain management.[110-112,330-332]  In systematic reviews and meta-analyses, Impact included having a beneficial effect on pain intensity, depression and quality of life.

There is mixed evidence regarding whether mindfulness meditation may also assist with improving insomnia, delivered through either MBSR or Mindfulness Based Treatment for Insomnia (MBTI) a meditation-based program for individuals suffering from chronic sleep disturbance.[113,333]  More recently, several systematic reviews and meta-analyses found that MBSR did not improve objective or subjective sleep quality in patients with chronic insomnia and cancers nor did MBI, when combined with CBT-I, positively impact chronic insomnia disorder.[334-336]

Research of mindfulness practices has been applied to many health problems such as cancer.  For cancer patients, it has been found that there is an improvement in mental health and stress [114-116].  To date, meditation appears to be helpful for chronic disease symptoms in epilepsy, tinnitus, peripheral neuropathy, Irritable Bowel Syndrome and multiple sclerosis.[118,337]  A systematic review  found a positive trend in favor of the benefits of mindfulness interventions across a range of psychological, physiological, and psychosocial outcomes including anxiety, depression, mental fatigue, blood pressure, perceived health, and quality of life post transient ischemic attack and stroke.[124]

In another meta-analysis on standardized mindfulness interventions in healthcare, the authors concluded, “The evidence supports the use of MBSR and MBCT to alleviate symptoms, both mental and physical, in the adjunct treatment of cancer, cardiovascular disease, chronic pain, depression, anxiety disorders and in prevention in healthy adults and children.”[119]  Katterman and colleagues, in a systematic review,  found that mindfulness meditation was helpful in decreasing binge eating and emotional eating, in individuals with those problems.[120]. In a systematic review, the authors noted that MBI’s could be helpful in addressing eating disorders, as well as promoting weight loss among bariatric individuals.[338]

Studies have explored the biochemical correlates to meditation, especially looking at MBSR intervention.  Several meta-analyses have shown a positive impact on increased telomerase activity[121], and  brain changes including functional MRI and  EEG studies.[122,339,340]  More recently, however, there are findings suggesting otherwise.  Two recent high-level combined randomized controlled trials were published in Science Advances (Kral, Davis et al., 2022).[341]  The authors note that they failed to replicate prior findings and found no evidence that MBSR produced neuroplastic changes compared to control groups, either at the whole-brain level or in regions of note in previous studies.

Loving-kindness practice, or Metta meditation, is often used as a part of meditation programs.  It has been shown to have a positive impact on mental health including compassion, positive affect, negative affect, psychological symptoms, when compared to passive control groups.[342]

The concentration meditation practice of Transcendental Meditation (TM)  was reviewed and several meta-analyses found that it was helpful in reducing both  systolic and diastolic blood pressure as well as anxiety.[123,343,344] 

Try It for Yourself:  Meditation

As you may have already noted, this curriculum has many different Mindful Awareness moments, and most of them are intended to elicit the relaxation response and heighten awareness.  For this exercise, try a simple challenge. 

Count 10 long, slow abdominal breaths without your mind wandering away from the task.

If you notice your mind wandering gently bring your awareness back.  If you have lost count, simply start again.  Many people find it hard even to focus for 3 full breaths without distraction.  Remember though, that the ability to catch your mind wandering and gently bring it back is a key component of meditation practice.

Don’t judge.  Don’t strive.  Just stop, observe, let it go, and return, as often as needed.

In summary, meditation is considered a safe and potentially efficacious complementary method for treating certain illnesses, stress-related difficulties, and non-psychotic mood and anxiety disorders.  Refer to “Meditation” for more additional information and more detailed reviews of research related to mindful awareness training.

Seven different Power of the Mind tools are featured above, and there are many more.  Find out which ones are available where you work.  If interested, choose a few techniques (breathing is a popular one) you can offer yourself.  There is an increasing body of research supporting the use of these approaches.

Emotional Healing Strategies

Henry Maudsley said, “The sorrow that hath no vent in tears may make other organs weep.”  Healing emotionally upsetting experiences through the use of specific therapeutic techniques improves physical and mental health, enhances immune function, and results in fewer visits to medical practitioners.[125]  This section focuses on clinical techniques to use the power of the mind to heal traumatic and stressful experiences and better manage negative emotional states that may be negatively affecting health.  This is of particular importance in the Veteran population, where there is a high prevalence of PTSD, depression, and other mental health issues.

Cognitive Behavioral Therapy

In recent decades, there has been a growing recognition that the mind has a powerful influence over emotional and physiological states.  The development of CBT in the mid-1950s by Albert Ellis and Aaron Beck was built on the principle that thinking patterns, not just external events and people, influence a person’s feelings and behaviors.  Extensive research involving CBT has shown that maladaptive thoughts are causally linked to emotional distress and problematic behaviors.  It is the most widely studied form of psychotherapy.

CBT emphasizes developing the capacity to analyze one’s thinking, identifying patterns of thought that cause suffering and distress and modifying these thoughts to create more realistic and positive ways of thinking that foster a greater sense of well-being and happiness.  The field of CBT is widely used within the VA. 

Techniques used in CBT include writing down negative feelings, thoughts, behaviors, and beliefs in a thought record.  The goal of this tool is to help people develop the ability to notice and observe automatic thoughts about themselves, other people, and life events.  Through this observation, a person can begin to identify and evaluate inaccurate, negative, or maladaptive thoughts that can lead to dysfunctional behaviors.  A person can then choose to replace these negative thoughts with adaptive thoughts that are more helpful, a technique known as cognitive restructuring.  These techniques are practiced by the patients themselves under the supervision of a therapist.

Many disorders are associated with common dysfunctional thought patterns.  Depression is linked to negative beliefs and thoughts of hopelessness and helplessness.  Anxiety disorders are linked to maladaptive cognitions related to future possibility of danger or threat.  Panic disorder misinterprets the physical symptoms associated with anxiety as harmful.  Social anxiety is associated with fear of embarrassment and humiliation, while generalized anxiety disorder and obsessive-compulsive disorder are characterized by excessive obsessions, worry about future undesirable events or the consequences of worry itself.

Cognitive behavioral therapy is widely available in the VA and has strong research supporting its use for many challenging-to-treat conditions.

Distorted thinking can precipitate and maintain psychopathology and can be associated with poorer coping with chronic medical issues.  Many psychological disorders can be treated and prevented through examining thought patterns and restructuring to be more accurate.  Cognitive distortions, patterns of exaggerated or irrational thought, are believed to perpetuate the effects of psychopathological states, especially depression and anxiety.  Burns identified a list of main cognitive distortions.  They include the following [126]:

• All or nothing thinking
• Overgeneralization
• Filtering
• Disqualifying the positive
• Jumping to conclusions
• Magnification and minimization
• Emotional reasoning
• Should statements
• Labeling
• Personalization
• Blame

For further descriptions of these cognitive distortions, refer to “Working with Our Thinking.”

CBT also involves efforts to change behavioral patterns.  These strategies might include facing one’s fears instead of avoiding them, behavioral activation and approaching versus avoiding activity, using role playing to prepare for potentially stressful interactions with others and learning to calm one’s mind and relax one’s body.  Maladaptive behaviors are identified and skills are learned that focus on active coping. This is associated with more adaptive adjustment versus passive coping which leads to poorer outcomes. 

Evidence.  Hofmann et al. conducted a comprehensive meta-analytic study of CBT.[127]  They identified 269 meta-analytic reviews that examined CBT for a variety of problems.  They found that the efficacy of CBT for anxiety disorders was consistently strong.  Large effect sizes were reported for the treatment of obsessive-compulsive disorder, and at least medium effect sizes for social anxiety disorder, panic disorder, and post-traumatic stress disorder.  Medium to large CBT treatment effects were reported for somatoform disorders, including hypochondriasis and body dysmorphic disorder.  They found strong support for CBT of bulimia and anger control problems.  As a stress management intervention, CBT was more effective at reducing general stress than other treatments.  CBT was found to demonstrate superior efficacy as compared to other interventions for treating insomnia.  In fact, Cognitive Behavioral Therapy for Insomnia (CBT-I) was developed as a first line treatment for insomnia and sleep difficulties. CBT-I. It has been found to be effective across a range of populations and delivery.  Treatment aims to identify and address the underlying psychological, behavioral and physiological mechanisms that maintain insomnia.[345]

CBT is recommended as first-line treatment for depression and meta-analysis including 409 RCTs (518 comparison) with 52,702 patients found its efficacy to be documented across different formats, ages, target groups and settings with a moderate to large effect size.[346]  Comparative trials suggest that CBT is significantly more effective than other psychotherapies, but the difference is small.  CBT appears to be as effective as pharmacotherapies at the short term, but more effective at the longer term for treatment of depression.  A meta-analysis has also found cognitive behavioral therapy for anxiety-related disorders to be associated with improved outcomes compared with control conditions.  These effects lasted as long as 12 months after treatment completion at which point effects were small to medium for generalized anxiety disorder and social anxiety disorder, large for PTSD, and not significant or not available for other disorders.[347]

In short, all of these common mental health conditions are characterized by thought patterns that are unhelpful and potentially modifiable through CBT.

The Veteran’s Administration and National Institute on Drug Abuse (NIDA; National Institute on Drug Abuse, 2018) both recommend CBT for substance use disorders (SUD) as an evidence-based approach to addiction treatment. A systematic review found CBT produced small to moderate effects on substance use when compared with inactive treatment and was most effective at early follow-up (1–6 months posttreatment) compared with late follow-up (8+ months posttreatment).[348]

For treatment of psychotic disorders and schizophrenia, CBT is recommended as an adjunctive to antipsychotic medications.  

According to a 2021 review, CBT is especially effective in treating the positive symptoms of schizophrenia, which are those that a person experiences in addition to reality. These symptoms appear after a person develops the condition and include delusions, hallucinations, and disorganized behavior.[349]  They found that CBT may be more effective for people who have flexible beliefs, good insight and a shorter duration of illness.  The results of a 2018 review suggest that CBT may help reduce cognitive impairments, disorganized behavior, and depression. This treatment approach may also alleviate positive symptoms, negative symptoms, social anxiety and substance abuse.[350-352]

CBT was found to be less effective than family intervention or psychopharmacology for chronic symptoms or relapse prevention. [127] A systematic review and meta-analysis found CBT could prevent or delay the onset of psychosis by 12 to 24 months suggesting it is a promising intervention at the preventative stage. [353]

CBT has also been found to be helpful in the management of various medical conditions.  A systematic review with a meta-analysis observed that CBT had an effect on reducing blood pressure and BMI in hypertensive adults.[354]  It was also found to be an effective intervention for weight loss in obesity treatment and considered a useful option for improving the glycemic control of diabetic patients undergoing long term treatment.[355,356]  It is effective for treating a wide various of pain conditions, such as improving pain, disability, fear avoidance and self-efficacy in chronic back pain patients and improving quality of life and reducing depressive symptoms in patients with diabetic peripheral neuropathy.[357,358]  CBT is effective in improving the Quality of Life of breast cancer patients [ ] and reducing levels of anxiety and depression and relieving fatigue symptoms in rheumatoid arthritis patients.[359,360]  It has also been found to be an effective treatment for improving depression, anxiety and social integration in individuals with traumatic brain injury and post-concussion syndrome.[361]

2. Acceptance and Commitment Therapy

In recent years, cognitive behavioral therapies have been deeply influenced by the rise of acceptance and mindfulness-based interventions.  Steven Hayes, a main researcher in this area, has reflected that these therapies focus on changing the function of psychological events that people experience, rather than changing or modifying the events themselves.[105]  One of these interventions is Acceptance and Commitment Therapy (ACT).

ACT uses acceptance, mindfulness techniques, commitment to values, and behavior activation techniques to produce psychological flexibility.  ACT was developed in the 1980s by Hayes, Wilson and Strosahl.  A cardinal feature of ACT is its differing approach towards negative thoughts.  Rather than directly changing the content (e.g., accuracy) of negative thoughts, ACT methods emphasize changing the function of thoughts by encouraging patients to adopt a different awareness of and relationship to their thoughts.[132]  This altered relationship focuses on neutralizing (defusing) thoughts with a variety of techniques rather than repressing or changing them.  Various “cognitive diffusion” techniques help patients to see the “…bad thought as a thought, no more, no less…”[133] and no longer have their behavior driven by experiential avoidance or dysfunctional behavior.  Other cardinal features of ACT are values and committed action encouraging the engagement in actions to live a purposeful, intentional life that is guided by one’s deepest values. 

ACT has been effectively implemented across a broad range of therapeutic settings, including mental health, primary care, and specialty medical clinics. It can be delivered in a variety of formats, including 1-day group workshops, online and smartphone applications, and telehealth.[362]

A systematic review highlights that ACT is a promising intervention for Veterans across a wide variety of presenting problems as well as intervention delivery (in-person and telehealth) and type (group and individual therapy).  In particular, ACT showed clinically significant improvements in depression, anxiety, PTSD symptoms, chronic pain and substance use in Veterans.  Additionally, ACT was found to improve quality of life specifically through reductions in maladaptive behaviors and increase in adaptive behaviors.[363]

Recent literature mainly agrees on the small to moderate effect sizes of ACT on depression and anxiety symptoms in different populations, including OCD.[365,366]  A systematic review of randomized controlled trials  found evidence that ACT is effective on depression, anxiety and hallucinations seen in psychotic disorders.[367]   ACT has shown promise for improving functioning, quality of life and distress across various chronic health conditions, including HIV, diabetes, cancer, epilepsy, obesity, chronic pain,[134,135], cardiovascular disease [ ] and insomnia.[368,369]  Evidence is promising for ACT in the treatment of chronic pain.[370]  An overview of systematic reviews with meta-analysis of randomized clinical trials found that ACT can improve outcomes related to chronic pain, such as improving pain-related functioning, psychological flexibility, pain acceptance and quality of life and reducing psychological inflexibility, pain catastrophizing, depression and anxiety symptoms.[371]

Refer to “Working with Our Thinking” for more information.

3. Eye Movement Desensitization and Reprocessing

Technique.  Eye Movement Desensitization and Reprocessing (EMDR) was introduced by Dr.  Francine Shapiro in 1989.  It was presented as a new treatment for traumatic memories and PTSD, with later expansion to other anxiety disorders and phobias.  EMDR is generally a multi-session intervention which uses bilateral stimulation, often in the form of eye movements, taps, or sound, with the goal of processing distressing memories, reducing symptoms, and enabling patients to develop more adaptive coping mechanisms.  There is an 8-step protocol that includes having patients recall distressing images while receiving one of several types of bilateral sensory input, including side-to-side eye movements.  Initially used for adults, EMDR has been found to be useful with children as well. 

Evidence.  One controversy about EMDR is whether the bilateral stimulation (e.g., eye movements, etc.) adds a specific benefit to the treatment.  A recent meta-analysis of just this issue found that in both clinical and laboratory settings, eye movements (compared to no eye movements) had a medium effect size, which suggests an advantage for using eye movements over not doing so.[136]  The exact psychophysiology of bilateral stimulation is still largely unknown.

Another controversy is whether EMDR is better than other treatments for decreasing distressing memories, PTSD or anxiety.  To date, studies show that when EMDR is compared to no treatment, patients are better off with EMDR treatment than without.  When compared to no treatment or to nonspecific therapies, EMDR is again shown to have positive effects.  Results have been consistent across studies that use different measures, and focus on a variety of complaints.[137,138,372]  Research suggests that EMDR is of similar efficacy to other exposure therapies and more effective than medication alone or treatment as usual.[139-142] [143]A meta-analysis compared CBT to EMDR and EMDR treatment appeared slightly superior to CBT [144]  but not in studies with low risk of bias.[373]

In a recent meta-analysis on EMDR and substance use disorder (SUD), EMDR was noted to be effective in a variety of outcomes such as treatment engagement and severity, reducing comorbid posttraumatic and depressive symptoms, but not for the reduction of cravings.[374]  Strong conclusions are cautioned given the number and quality of studies, heterogeneity of methods and other factors.

Authors of a 2021 meta-analysis and literature review reported that EMDR is an effective treatment for adults with depression, regardless of age, sex or subtype (primary or secondary).[375,376]  Looking at adults diagnosed with Major Depression Disorder (MDD), another meta-analysis found that EMDR was more effective than no treatment in reducing depressive symptoms and out-performed Cognitive Behavioral Therapy (CBT), especially in those with traumatic experience. The authors caution that these results be considered in light of small sample sizes and low quality of trials.[377]

In the VA/DoD Clinical Practice Guidelines (updated January 9, 2017) for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder, it is stated that recommendation is strong for: individualized treatment with EMDR, as well as Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE).[378]

There is also some suggestion that EMDR might be effective in reducing pain including postoperative pain, and chronic nonspecific back pain when accompanied by trauma.[138,145] However, these results are from single randomized controlled studies and further research is needed.

4. Cognitive Processing Therapy and Prolonged Exposure Therapy

Cognitive Processing Therapy (CPT)[146] and Prolonged Exposure Therapy (PE)[147] are trauma-focused evidence-based psychotherapies that are strongly recommended by the American Psychological Association (APA) and the Departments of Veterans Affairs and Defense (VA/DoD) as first-line treatments for posttraumatic stress disorder (PTSD).[379,380]  They are two of the most widely studied psychological treatments for PTSD. Both CPT and PE have been found to produce clinically significant improvement in PTSD symptoms in multiple randomized controlled trials.[148,149,381]  Although these treatments share many common factors, the focus of CPT is on changing maladaptive thoughts, while the main mechanism of PE is exposure exercises. 

CPT is a manualized therapy developed by Patricia Resick that is based on cognitive theory.  It typically involves 12 60-90 minute sessions once or twice a week. More recently it has been administered over a variable number of sessions determined by the patient’s needs, based on research indicating this yielded better outcomes.[382]

CPT works by directly challenging and modifying maladaptive thoughts and changing upsetting feelings that have developed following the traumatic incident, such as those about safety, trust, control, self-esteem, other people, and relationships.  More specifically, CPT helps patients create new understandings and reconceptualization of their trauma by modifying maladaptive appraisals or “stuck points” through cognitive restructuring to form a more accurate, balanced and healthy interpretation of what happened, oneself, and the world. 

CPT can be administered in individual, group or combined formats with individual appearing to be the most effective.[383]  The original CPT protocol included a detailed written account of the traumatic event, but later research suggested that this aspect of the treatment was not necessary for it to be effective.[384]

Meta-analytic findings indicate that CPT yields large effect size reductions in PTSD symptoms and loss of diagnosis with lasting benefits across a range of outcomes.[385-387]  It has been found effective in patients with complicated presentations, co-occurring conditions and comorbid personality disorders, such as depression, suicidal ideation, sleep, traumatic brain injury, and borderline personality disorder.[388-392]

Several studies examined CPT for treating PTSD in Veterans and service members and found it yielded significantly more improvement in PTSD symptoms, depression, anxiety, guilt and social adjustment, [ ] including in Veterans who had experienced military sexual trauma.[393-395]  One study found forty percent of Veterans who received CPT no longer had PTSD by the end of treatment.  Other research demonstrated that CPT could be delivered to Veterans via tele-videoconferencing.[396,397]  In comparison, PE, was developed by Edna Foa and is based on emotional processing theory.  It involves 8-15 90-minute sessions usually weekly during which a patient talks through the traumatic memory by doing repeated imagined exposure exercises.  PE targets avoidance as the symptom that prevents recovery, through helping the patient engage in activities they have been avoiding because of trauma.  It also provides repeated exposure to traumatic memories through teaching how to gradually approach these trauma-related memories, feelings and situations that have been avoided since the trauma.  The patient does in vivo exposure exercises, to activate the fear associated with the trauma and provide a corrective experience.  Over time, this exposure leads to the habituation/extinction of conditioned fear responses.

The exposure component and verbal retelling of the trauma can be challenging. Drop out rates from PE tend to be higher than that of other more cognitively-focused therapies such as CPT and EMDR. Several studies have explored alternative models of providing PE, including massed PE (10 sessions over a 2-week period) and a shorter PE protocol for primary care both show promising results.[398-399]

PE has been found to be effective for use across diverse patient presentations. across survivors, in different cultures and countries, regardless of the length of time since traumatization or the number of previous traumatic events.[400]  PE has the strongest recommendation as a treatment for PTSD in every clinical practice guideline and has been found to be effective for patients with complicated presentations, including those with comorbidities such as substance use disorder.[401]

PE integrated with or offered concurrently with substance use treatment has been found to be more effective for reducing PTSD symptoms and in some studies substance use, than substance use only treatment.[402,403]  A meta-analysis found the average PE-treated patient fared better than 86% of patients in control conditions on PTSD symptoms at the end of treatment. PE has been found to reduce anger, guilt, negative health perceptions and depression.[151,404]  Randomized clinical trials have demonstrated PE to be effective in reducing PTSD symptoms in U.S. military personnel and US Veterans.[405-407]

In 2006 and 2007, the Veterans Health Administration (VHA) launched system-wide efforts to implement both CPT and PE.[408]  These efforts included specialized trainings, mandated access to CPT or PE for all Veterans with PTSD, and creation of the national PTSD Mentoring Program to assist PTSD clinics in several efforts including ways to bolster CPT/PE delivery and establishment of an Evidence-Based Psychotherapy Coordinator at each medical center to promote these therapies.  To date, thousands of VHA clinicians have been trained in CPT and PE increasing the VHA’s capacity to provide evidence-based care to Veterans with PTSD.[152,153]  

Research has demonstrated the effectiveness of CPT and PE in Veteran populations that are diverse with respect to gender, service era, traumatic type and psychiatric comorbidities.[149,154-156] Results suggest that Caucasian veterans, African American veterans and Hispanic veterans all experience similar rates of improvement in their PTSD symptoms.[409]  The PE and CPT therapist manuals suggest that these treatments are not appropriate for all patients with PTSD, such as those engaging in self-harming behavior, and may be useful for patients without a full PTSD diagnosis.[157]  More information about these treatments is available at the VA’s PTSD: National Center for PTSD website; refer to Cognitive Processing Therapy for PTSD and Prolonged Exposure Therapy.

5. Creative Arts Therapies

Expressive therapies, more recently referred to as creative arts therapies (CATs), are often included under the auspices of complementary medicine.  Generally, other complementary therapies have received more attention and research over the years than the expressive therapies.  With individuals choosing more complementary approaches, however, the creative arts therapies are worthy of inclusion here.

Techniques and resources.  Listed below are some of the most well-known CATs and associated websites for further exploration including the umbrella organization of the National Coalition of Creative Arts Therapies Associations (NCCATA).[158]

Art therapy

Art therapy is a mental health approach in which clients, facilitated by the art therapist, use art media, the creative process, and the resulting artwork to explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem.  A goal in art therapy is to improve or restore a client’s functioning and his or her sense of personal well-being.  Art therapy practice requires knowledge of visual art (drawing, painting, sculpture, and other art forms) and the creative process, as well as of human development, and psychological and counseling theories and techniques.  The field of art therapy has only existed in the West since the 1940s, but it is likely that art has been used therapeutically throughout history.[159]

Music therapy

Music therapy is an established therapy in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals.  After assessing the strengths and needs of each client, the qualified music therapist provides the indicated treatment including creating, singing, moving to, and/or listening to music.  Through musical involvement in the therapeutic context, clients' abilities are strengthened and transferred to other areas of their lives.  Music therapy also provides avenues for communication that can be helpful to those who find it difficult to express themselves in words.[160]  The earliest known music therapy intervention occurred in 1789.

Drama therapy

Drama therapy  and Psychodrama is an active, experiential approach to facilitating change.  Through storytelling, projective play, purposeful improvisation, and performance, participants are invited to rehearse desired behaviors, practice being in relationship, expand and find flexibility between life roles, and perform the change they wish to be and see in the world.  Modern drama therapy began with Jacob Moreno’s development of psychodrama in the early 20th century.[161]  Refer to the National Drama Therapy Association website for more information.

Dance therapy/movement therapy

Dance therapy or movement therapy is focused on movement behavior as it emerges in the therapeutic relationship.  Expressive, communicative, and adaptive behaviors are all considered for group and individual treatment.  Body movement, as the core component of dance, simultaneously provides the means of assessment and the mode of intervention for dance/movement therapy.  The roots of dance therapy can be traced to the early 20th century and the work of modern dancer and pioneer, Marian Chace.  She was able to bring her work into hospital settings, where the news of her therapeutic intervention spread.[162]

Evidence.  What do we know about general efficacy of creative arts therapies to date?  In reviews regarding the use of these therapies on psychological symptoms and quality of life in individuals with cancer, there appeared to be a variety of beneficial effects.[163,164]  Utilization of CATs during cancer treatment improved anxiety and depression, coping and stress, as well as measures of quality of life.  Pain was reduced as well, although fatigue was not.

Dance therapy research has increased and interventions have been applied to Parkinson’s disease, among others.  Improved scores for balance were attained in this population using dance therapy with improvements in gait, balance, executive functioning, mental health and dual tasking.[165,166,410-412]  This result was found for the healthy elderly, as well.[167,168]  A meta-analysis showed a positive effect of dance therapy on exercise capacity and reductions of systolic and diastolic blood pressure in individuals with hypertension.[169,413]  In patients with chronic heart failure, dance therapy improved health-related quality of life and exercise capacity.[170]. In patients with mild cognitive dysfunction, a meta-analysis found that dance therapy significantly improved global cognitive function, memory, executive function, attention, language and depression.   Longer dance interventions (greater than 3 months) were shown to improve global cognition more than shorter interventions.[414]  Dance movement therapy has also been noted to decrease depression and anxiety and improve quality of life.[415]

Music therapy has received more focus as well.  Several recent meta-analyses found that music therapy was helpful in decreasing disruptive behaviors, anxiety and depression in those individuals with dementia and in improving systolic blood pressure.[171,172,416,417]

The use of music therapy has been related to improved sleep quality, reduced anxiety for individuals receiving hemodialysis and reductions in pain scores for acute postoperative pain, as well as during endoscopic procedures.[173-178]  This appeared true when it was used as an adjunct to conventional cancer therapy.[418]  Depression scores improved with listening to music daily over a 2-3 week period.[179]  Physical activity accompanied by music appeared to improve physical performance for the elderly and individuals with COPD.[180,181]  Music therapy may improve functioning in those with schizophrenia or schizophrenic-like disorders.[182]

Art therapy was the focus of a systematic review and the researchers found that there may be benefit to this intervention in reducing scores on assessment measures of trauma.[183]  There is also suggestion that art therapy may be helpful to individuals with non-psychotic mental health difficulties such as depression and anxiety.[184] Art therapy appeared to improve overall quality of life, as well as anxiety and depression, in women with cancer.[419]

The least studied to date is drama therapy. However, in a 2023 systematic review and meta-analysis, authors Orkorbi et al., found that both drama therapy and Psychodrama contributed to improving client’s mental health.[420]

More and higher quality  research on CATs is needed. 

6. Therapeutic journaling

Technique.  Socrates said that “The unexamined life is not worth living.”[421]  Therapeutic journaling connects thoughts, feelings, and actions through inner written reflection, provides a creative way to process difficult life events and increases self-awareness and self-understanding.”[422-429]   Robust evidence has shown that journaling can be an important tool for mental and physical health The benefits of writing include self-regulation, clarifying life goals, gaining insight, finding meaning and exploring different points of view.[430]  Writing can also foster positive emotions as putting feelings and thoughts into words widens one’s scope of attention, sparks the search for solutions and allows the mind to be more flexible.[431]

There are several forms of journaling used in psychotherapy.[432]  Writing can be used to build personal identity and meaning through the use of autobiographical writing.[433]  A gratitude journal, on the other hand, is used to reflect  and focus attention on what one is grateful for and the positive aspects of one’s life. Therapeutic journaling, on the other hand, typically involves keeping a regular journal to write about events that bring up anger, grief, anxiety, or joy that occur in daily life.   For specific upsetting, stressful, or traumatic life events a particular therapeutic journaling protocol is recommended.  This involves journaling for three to four daily sessions for 20 minutes per session writing about one’s deepest thoughts and feelings about the upsetting or difficult event or experiences.[434]  

This practice of putting emotional upheaval down on paper has been found to improve physical and mental health.  Dr. James Pennebaker, one of the first researchers in this area, found that this writing protocol was associated with both short-term improvements in physiological arousal and long-term decreases in health problems.  Pennebaker and Beall conducted the first expressive writing research study showing that participants who used the writing protocol had better health outcomes four months later than participants in three other writing groups.[185]

Written Exposure Therapy (WET) is another brief treatment for PTSD that is offered at many VA’s.  This manualized treatment helps to find new ways to think about traumatic experiences and its meaning through engaging in written assignments that are completed during a brief five-session therapy.  A systematic review indicates that WET is an efficacious and effective treatment for PTSD symptoms across a variety of samples, settings and counties.  Important to note that dropout rates for WET were generally low and less when compared with other trauma-focused treatments.[435]  One study found WET to be a promising treatment option for Veteran patients in VA clinical care settings whether delivered in-person or via telehealth.[436] 

Research on the psychological mechanisms that underlie these writing protocol suggest that expressive writing leads people to create narratives that explain their feelings and gives them a self-distanced perspective.  This involves seeing themselves in the difficult event from afar and feeling more removed.  From this different vantage point , individuals can create meaning and reduce negative emotions which contribute to feeling better.[186,187]  This alternate perspective may encourage cognitive restructuring that leads to beneficial outcomes.[188,189]  It may also bring about benefits through desensitization towards negative events, a broadened attentional focus, self-affirmation and a greater sense of mastery over events.[190-192]  Importantly, this writing practice can also generate forgiveness in interpersonal conflict and can promote feelings of wisdom and hope in difficult situations through working through  distress to reaching more positive perspectives.[437,438]  

Refer to the “Forgiveness” tool.

Evidence.  Smyth and colleagues studied patients with asthma or rheumatoid arthritis and had them do therapeutic journaling for just 20 minutes over 3 consecutive days about the most stressful event of their lives (versus daily events for the control group).  They found that 4 months after journaling, the asthmatic patients in the treatment group had a 20% improvement in lung function and the patients with rheumatoid arthritis showed a 28% reduction in disease severity.  Banburey found that writing about emotional events resulted in quicker wound healing than writing about trivial topics.[193]  Halpert and colleagues found that patients with IBS who did 4 days of therapeutic journaling about their deepest thoughts, emotions, and beliefs regarding their disease had improved disease severity and fewer negative thoughts about their symptoms.[194] 

Expressive writing has been found to produce significant health benefits, including the following: 

• Improved lung functioning in asthma[195]
• Decreased disease severity in rheumatoid arthritis[195]
• Reduced pain and improved overall physical health in cancer[195]
• Improved immune response in HIV infection[195]
• Decreased hospitalizations for cystic fibrosis[195]
• Reduced pain intensity in women with chronic pelvic pain[195]
• Improved sleep-onset latency in poor sleepers[195]
• Less complicated postoperative course[195]
• Overall immune system functioning improves as well[196]

In addition, it has been utilized for assistance with specific life circumstances, including the following:

• Break-up with life partner[197]
• Death of loved one[198]
• Unemployment[199]
• Natural disaster[200]

General stressful events [201]

Smyth’s review suggests that the effects of written emotional expression are substantial and similar in magnitude to the effects of other psychological interventions, many of which can be time-consuming and expensive.[203]

Sohan et al. conducted a meta-analysis of 20 journaling intervention studies and their findings support the wide use of journaling in many forms of psychotherapy for a broad range of mental illnesses.  They found an average of 5% statistically significant reduction in patient scores on mental health measures compared with control groups, with a greater benefit in anxiety and PTSD symptoms, and a lesser benefit in depression.[439]

Emmerik, Reijntyes, and Kamphuis conducted a meta-analysis investigating the efficacy of expressive writing for treatment of posttraumatic stress conditions (e.g., acute stress disorder and PTSD) and comorbid depressive symptoms.[202]  The writing protocol resulted in significant and substantial short-term reductions in posttraumatic stress and depressive symptoms.  There was no difference in efficacy between writing therapy and trauma-focused CBT.  Another meta-analysis by Pavlacic et al., provided additional insight that expressive writing produced a small overall effect size for posttraumatic stress but negligible to small effect sizes for posttraumatic growth and quality of life.[440] 

Expressive writing has been found to be beneficial also as a “stand alone” technique for the treatment of depressive, anxious and post-traumatic stress disorder symptoms.[441]  In a 2021 study, it was found that enhanced expressive writing (i.e., writing with scheduled contacts with a therapist) was as effective as traditional psychotherapy for the treatment of traumatized patients. Expressive writing without additional talking with a therapist was found to be only slightly inferior suggesting that expressive writing could provide a useful tool to promote mental health with only minimal contact with therapist.[442]

Expressive writing may also hold promise as a nonstigmatizing, accessible, resource-efficient intervention for some veterans. One study found that non-therapist-assisted expressive writing may be most suitable for Veterans experiencing reintegration issues who had subclinical PTSD symptoms, higher levels of social support and below average combat exposure.[443]

Expressive writing can therefore be considered an evidence-based treatment for posttraumatic stress and constitutes a useful treatment alternative for patients who do not respond to other evidence-based treatments.  When prescribing therapeutic journaling, giving instruction on how to journal is essential in ensuring proper utility of the tool and instilling self-efficacy in the patient.[444]  Journaling may be a particularly powerful intervention when access to conventional therapeutic services is constrained such as in times of crisis and in resource-limited settings.[445]  It may be especially useful for reaching trauma survivors in need of effective mental health care who live in remote areas.  It can also be a way to reach people who are unwilling or unable to engage in psychotherapy.  Expressive writing may be contraindicated for individuals who do not typically express emotions or who have severe trauma histories or psychiatric disorders.[204-206]  

Refer to “Therapeutic Journaling” for more information.

In the Whole Health visit with Matt, his team learns that he has a good deal of social support, including his wife, his parents, and a brother, as well as a few good friends.  He was previously invited but declined participating in a support group.  He is given information on therapeutic journaling and breathing exercises and is referred to a therapist to address some of his chronic issues. 

In a follow up visit, he notes he has been talking about his struggles with his therapist and has worked on telling his story through therapeutic journaling.  Although this helped his PTSD, it did not resolve all his symptoms.  His therapist went on to use EMDR, and he is doing much better with his trauma-related nightmares and alcohol use.  His symptoms have improved over a period of months, and he is feeling more hopeful.

Matt continues to work with his therapist on learning and incorporating other mind-body skills for his concerns.  He addresses the irritability with his family by learning a combination of relaxation and imagery.  Prior to getting out of the car to go into his home, he now practices slow, deep breathing for 5-10 minutes and invokes a calming image of himself relaxed at his hunting cabin.  He then imagines taking that calm into his home, with the intention of enjoying the noise, love, and chaos of his small children clamoring to spend time with him.  He extends his imagery to see himself maintaining the calm throughout the entire evening and feeling good about how he is with his family.

Matt is fortunate that his therapist is also competent in hypnosis and has been utilizing evidence-based, gut-centered hypnosis and CBT with him.  His diarrhea has improved, and he is feeling calmer overall.  He is practicing the skills he learned during his hypnosis session by using a recording at home.  He is monitoring stressful thoughts with CBT worksheets.  At times, he can become aware of and dispute the unhelpful thoughts he has, including, “I can’t handle this.”  He changes this thought to, “This isn’t easy, but I can deal with it.”  He is focused now on letting his thoughts support the positive actions he is trying to take in moving on with his life.

His therapist and physician were concerned about his continuing headaches.  His physician referred him to a health psychologist who specializes in biofeedback.  Matt engaged in six treatment sessions before the headaches lessened.  The biofeedback therapist reinforced the breathing skills learned from his original provider.  The biofeedback intervention included surface electromyographic (EMG) training to decrease muscular contraction, especially in his jaw and neck, as well thermal biofeedback, which focuses attention on body temperature.

Matt found that using the power of his mind led him to feel more in control of his life and his symptoms.  He maintains an ongoing practice of the imagery, relaxation, and cognitive strategies, as he finds them helpful in his work and family life.  

“Power of the Mind” was written by Shilagh A. Mirgain, PhD and by Janice Singles, PsyD. (2014, updated 2024).

This Whole Health overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.