Handbook of Mind-Body Medicine for Primary Care

Handbooks

Edited by: Donald Moss, Angele McGrady, Terence C. Davies & Ian Wickramasekera

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  • Front Matter
  • Back Matter
  • Subject Index
  • Part I: Models and Concepts for Mind-Body Medicine

    Part II: Basic Clinical Tools

    Part III: Applications to Common Disorders

    Part IV: Education for Mind-Body Medicine

  • Copyright

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    Foreword: Common Problems in Primary Care: The Need for a New Biopsychosocial and Psychophysiological Model

    Introduction

    The case for primary care as an obligation of society is derived from the special vulnerability and the universal fact of illness. This vulnerability generates a need that takes on the substance of a relative right because of the promises inherent in our social and political structures.

    We have, in a sense, all made a set of mutual promises to guarantee to each other a certain kind of society, one which is sensitive to and secures those things closest to our needs as humans. We would break our communal promise, tell a communal lie, and live an inauthentic social life if we neglected to exert every effort to assure the minimum security of access to primary care whenever it is needed. (Pellegrino & Thomasma, 1981, p. 243)

    The necessity for sick people to have access to healers is such a fundamental reality that we might wonder why it was not included within the founding fathers' Bill of Rights. In the ongoing dispute regarding government-provided universal health care, many people support the viewpoint of Pellegrino and Thomasma (1981), who maintain that primary health care services, at least, should be “the minimum security of access … whenever it is needed” (p. 243). However, this belief leaves unstated a definition of the scope and responsibility of primary health care, and in view of the currently inadequate level of support for mental health services at a primary care level (by both practicing clinicians and third-party payors), one is left to question the potential sufficiency of a future response to societal needs for mind-body treatments, even within a universally insured, primary care-oriented government health care system.

    The centrality of primary care within a well-functioning health care system is by this time indisputable. Most of the world's countries have established their health care systems around a solid core of primary care, and in a comparison of 12 different Western industrialized nations, Starfield (1994) demonstrated that countries with a stronger orientation to primary care were indeed more likely to have better health levels and lower costs. Sadly, the United States spends more money on its health care system than any other country, and yet because of the inadequacy of its primary care services, it is ranked behind many countries whose overall health care expenditures are far less (Starfield, 1994). Even within the British National Health Service, which has suffered such extremities of financial shortcoming that rationing of some specialized services became a necessity, the ready availability of general practice care has been held sacrosanct. If primary health care is destined to become a universal “right,” it is imperative that the human health problems encompassed by primary care be researched and managed to the highest degree possible so that maximum benefit can result—for optimal cost, to the greatest number. An ever increasing body of research now reveals that a majority of these health problems can be defined in terms of mind-body illness, and therefore the publication of this work, at this point in time, becomes a matter of considerable significance.

    This is an ambitious volume. It would be enough to pull together a coherent inventory of the common problems that arise at the interface between mind and body. It would be more than enough to then create a compendium of the tools that are useful against these problems. The authors have done all that and more; they have gone on to describe the use of these methods in primary care settings, where indeed they are most needed. They imply that our system of primary care should be able to accommodate these methods but that we may need to develop a new model of health care to do so. In our opinion, this is a correct interpretation, although it will not be easy. This foreword will describe a few elements of primary care—what it is, where it came from, how it fits into the larger house of medicine, what can be accomplished there—so we can understand how the principles of psychophysiological medicine can be incorporated into the primary health care of patients.

    Before proceeding further, we want to state that we will make no apology for the fact that much of this volume will be construed by many to be contentious. If the place and relevance of primary care services in the scheme of things is a matter of continued debate, then the proper role and significance of many mind-body and complementary and alternative medicine (CAM) therapies is even more controversial. Equally controversial will be many of the interpretations and philosophies associated with the practice of the clinical methods that are discussed in this volume. As commentators, we have even suggested that a more appropriate title for this book might have been A Handbook of Controversies in Mind-Body Medicine and Primary Care Practice, but this is not to detract from the timeliness and importance of this body of work. As discussed later, primary care and mental health go hand in hand; therefore, an assessment of mind-body practices within the field of primary care medicine is long overdue. But this is “cutting-edge” knowledge that often defies rigorous definition. Hence, controversy is inevitable—and in the best spirit of intellectual advancement, it should be welcomed!

    A Definition of Primary Care

    In 1996, the Institute of Medicine published the findings of its Committee on the Future of Primary Care in a volume entitled Primary Care: America's Health in a New Era (Donaldson et al., 1996). The committee recommended adoption of the following definition of primary care:

    Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (p. 1)

    The committee elaborated on this definition by describing six core attributes that characterize primary care:

    • Excellent primary care is grounded in both the biomedical and the social sciences.
    • Clinical decision making in primary care differs from that in specialty care.
    • Primary care has at its core a sustained personal relationship between patient and clinician.
    • Primary care does not consider mental health separately from physical health.
    • Important opportunities to promote health and prevent disease are intrinsic to primary care practice.
    • Primary care is information intensive.

    These six characteristics of primary care provide a frame of reference that will assist the reader in understanding this book's topic material.

    Scientific and Intellectual Basis of Primary Care

    Medical specialties have arisen because they were necessary, because they were possible, because it made sense to divide medicine's work along certain lines. Therefore, we should not demand of any medical specialty too high a standard of conceptual coherence. Primary care, which emerged just over 30 years ago as a medical specialty in the form of family practice, turns out to be extraordinarily useful to any health care system, and its shape has as much to do with what needs to be done and who is around to do it as with intellectual consistency. Since primary care has become defined as a specialty of breadth, of personal relationship, and of continuity, then it follows that certain approaches to understanding the problems and getting the work done are better suited than others. Although the reductionistic approach to scientific inquiry has catapulted medicine into an era of unprecedented progress, many clinical problems are resistant to reductionistic methods, and primary care is a clinical domain where much of this resistant material is found. Dubos (1971) has called reductionism “the doctrine of specific etiology,” but it is well recognized that chronic diseases (which now constitute over half of all illnesses) are inevitably multifactorial in origin. In addition, much of human morbidity is associated with personal and social behaviors that directly damage health; and behavior-related illness cannot be understood or managed within a reductionistic paradigm. Consequently, medicine is still only capable of curing, in a specific and permanent fashion, less than one-fifth of the total burden of human disease. Nowhere is this statistic more evident than in primary care.

    George Engel (1977) introduced a concept that expanded or augmented the biomedical approach, naming it the biopsychosocial model. The biopsychosocial paradigm represents an extrapolation of the work of Ludwig von Bertalanffy, the father of general system theory. Von Bertalanffy may be one of the least appreciated intellectuals of the 20th century; although he was nominated for a Nobel Prize in 1972, he died before his nomination could be considered (Davidson, 1983). Briefly, Engel elaborated a model that conceptualized a hierarchy of factors or variables that influenced health and disease. In addition to the biomedical, with its impetus to look for explanations at progressively “lower,” or “simpler” levels of analysis—organ to tissue to cell to gene, and so on—he elaborated a set of “upward” levels—the psychological and social—that held equal sway over the course of human illness and disease. Moreover, these different levels of interaction themselves interact with one another such that psychological distress, for example, can be expected to affect endocrine function, or social isolation can be expected to affect the course of tuberculosis. This reformulation has huge implications for what becomes the legitimate business of clinicians, and nowhere has this new paradigm affected the fundamental assumptions of a clinical discipline more than in family medicine.

    Applying this contextual orientation of general systems theory to family medicine, some early advocates drew attention to the potential clinical application of Bowen's family system theory (Bowen, 1966; Christie-Seely, 1981). Use of the “relational genogram” to analyze and understand family group morbidity was promoted (Crouch & Roberts, 1987), and at least one attempt was made to link intrafamilial system developments on a time-measured scale (Rainford & Schuman, 1981). While this perspective has withstood the challenges of the past two decades, it has only gained an uneven purchase as an organizing conceptual model for medicine at large, and even the primary care disciplines have not yet evolved a particularly coherent clinical posture that follows from the biopsychosocial model. Nevertheless, it is legitimate to claim that in primary care, complex problems are not routinely dismembered to help clinicians understand them, simple technical solutions are not assumed for complex clinical problems, and clinicians generally appreciate that in many cases there is no single right answer or single cause for a problem. The reader would do well to bear this in mind while reading through the material in this volume, which is deeply concerned with associations across different levels of analysis.

    In summary, it could be said that primary care is engaged in the process of formulating an original scientific paradigm that integrates at least two existing perspectives: the ontological (or causally focused) and the holistic (which prioritizes a systems perspective). This integration is difficult and far from complete. The recent enthusiasm for “evidence-based” knowledge should guarantee that however eclectic the vision becomes, it will be grounded in validated fact.

    Managed Care

    The hand of managed care has been shaping American medicine for well over a decade now, perhaps most conspicuously in primary care. Three changes are most notable: the change in the importance of primary care, the change in function expected of primary care, and the change in incentives and resources with which to work.

    Managed care has certainly changed the centrality of primary care within the health care system. In many cases, rendering a service in a primary care setting is less expensive than rendering that same service in a specialty setting. In some cases, rendering a service in primary care is the only option, as patients will not go elsewhere for certain kinds of care. This phenomenon has been most fully characterized for certain mental health services, described in some detail later in this foreword. Early on, managed care companies figured all this out and began hiring and contracting with more primary care clinicians. This created a demand for primary care clinicians and accelerated the growth and prestige of the constituent specialties. Managed care organizations also began using contracting and other means to “push” new functions and higher levels of “productivity” into this setting. This has made it difficult to honor several of the core attributes of primary care as enumerated at the beginning of this foreword, such as establishing a personal relationship and offering comprehensive care. More recently, certain health plans have also used financial incentives, provision of additional resources, and plan-level disease management programs to add even more responsibilities. Some of this is for good reasons; for example, prevention, screening, and case finding are best done in the primary care setting and can lead to better health and less expensive health care. Sometimes the reasons have not been good and have injured primary care clinicians' ability to function therapeutically. For example, the gatekeeper role assigned to primary care clinicians was seen as a way to limit access to more expensive specialist care, thereby saving managed care companies money and sparing them the unpleasant task of denying expensive care themselves.

    As the field of clinical medicine progresses, new means of improving or protecting health are discovered. As previously noted, it often becomes evident that the best place to accomplish this work is in the primary care setting. One of the ubiquitous pressures in primary care comes from the hope and expectation from the larger house of medicine that primary care clinicians will take on these new tasks, such as screening for an ever expanding list of conditions and risk factors, managing and monitoring an ever growing list of diseases, and practicing preventive medicine. This expectation creates a set of competing demands whereby the primary care clinician must choose, from an impossibly long list of things that “should” be done, the few things that she or he will actually do on a visit. Those things rise to the top that the patient deems most important, that the clinician deems most important, that can be accomplished most easily, that the clinician is most comfortable managing, that the clinician is rewarded for doing, that resources are readily available to manage, and that the clinician is evaluated on. Many innovators in the house of medicine have been disappointed by the unwillingness or inability of the primary care system to adopt this new screening tool or that clinical intervention simply because it has been shown to be efficacious. A whole set of barriers stand between the demonstration of an efficacious intervention and its successful, enduring implementation into ordinary primary care. The concept of competing demands must be understood by anyone who hopes to introduce into primary care any new technology, pattern of care, or any other new clinical demand.

    Mental Health Problems

    Earlier we offered a definition and a list of six core attributes of primary care tendered by the Institute of Medicine in 1996 in a volume entitled Primary Care: America's Health in a New Era (Donaldson et al., 1996). The fourth attribute, “Primary care does not consider mental health separately from physical health,” was described in some detail in that monograph by one of us (deGruy, 1996) and is particularly relevant to the business of this book. Therefore, we revisit a few highlights from that argument and update them with developments that have transpired since 1996. We organize this material under three points.

    • The Indivisibility of Mental from Physical Health. This point deserves the strongest emphasis, foremost to counteract the fundamental misconception that leads to such language as “mental health” or “physical problem.” These very notions are erroneous and incomplete and are belied by simple clinical phenomena. One can hardly find in a primary care patient evidence of psychological distress or mental symptomatology without accompanying physical symptomatology (Bridges & Goldberg, 1985; Kroenke et al., 1994). Conversely, physical—so-called medical— problems are always accompanied by psychological symptoms. It is impossible to render adequate primary care without attending to both. DeGruy (1996) has commented on the disadvantages of splitting mind and body in health care:

      Systems of care that force the separation of “mental” from “physical” problems consign the clinicians in each arm of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, undermines comprehensiveness of care, hamstrings clinicians with incomplete data, and ensures that the patient cannot be completely understood. (p. 286)

      Patients understand this concept better than clinicians, and all clinical psychophysiologists who aspire to render any care to primary care patients must fully grasp it. Primary care patients have repeatedly shown their resistance to leaving the primary care setting for special care, particularly care of a psychological nature, no matter how efficient or effective such care may in fact be (Olfson, 1991; Orleans, George, Haupt, & Brodie, 1985). Thus efforts to introduce new therapies to primary care patients are in general more likely to succeed if they can be offered within the context of ordinary primary care.

      It may be worth pointing out that mental diagnoses are themselves extremely common in primary care settings, affecting over a third of the patients seen, and that their presentation is heavily tilted toward somatic rather than psychological symptomatology. Thus somatization—the presentation of physical symptoms without a physical explanation—is an extremely prevalent and difficult problem in such settings. Moreover, many patients, somatizing patients included, may manifest insufficient psychological symptoms to meet the diagnostic criteria for a DSM mental diagnosis yet show profound functional impairment and distress. These so-called subthreshold patients clearly need help, but we have much to learn about how to help them and when our help will actually be beneficial.

    • The Inadequacy of Mental Health Care in Primary Care Settings and the Reasons for This. We seem to have settled on the understanding that under conditions of usual care, about half the primary care patients with mental disorders are recognized as such, and less than half of those patients are treated adequately. The data supporting this assertion are largely derived from depression studies, and the generalization is subject to wide variation. After a decade of miscellaneous efforts to improve the treatment of depression in primary care, the general level of recognition and management of this particular condition is probably higher, but it is probably lower for other mental conditions. Interestingly, the finding prevails even among clinicians who believe that mental disorders are important problems for their patients. Why are common, disabling conditions apparently so neglected? The reasons are more compelling and intractable than they might appear on first flush. The barriers occur at the level of the patient, the clinician, the office or clinic, and the larger health care system.

      At the level of the patient, mental disorders are perceived as stigmatizing, and a patient will sometimes avoid reporting psychological symptoms or acknowledging mental distress out of shame or a desire to keep a mental diagnosis out of his or her medical record. The fact that mental syndromes frequently manifest with physical symptomatology often leads the patient to believe that the problem itself is of a physical nature; in other words, primary care patients tend to somatize. Finally, a patient who might meet criteria for a mental diagnosis is usually not seeing a primary care clinician for that reason but for some other medical problem, and the mental symptoms are thought of as incidental or irrelevant.

      At the level of the clinician, most are not sufficiently familiar with the formal diagnostic criteria for specific mental disorders to confidently make diagnoses. Moreover, many clinicians believe that the criteria are inappropriate and result in the inclusion of patients who are not sufficiently distressed or impaired by their diagnoses to justify treatment. Just as patients somatize, so do clinicians. Our medical education has tilted us in the biomedical direction, and we tend to look for physical explanations for physical symptomatology. Many clinicians shy away from mental diagnoses, even if they suspect them, because of the amount of time it takes to deal with such problems and the havoc they wreak on tight patient care schedules. But even when the clinician is confident of the diagnosis and is ready to deal with it, she or he may avoid making and recording such a diagnosis out of consideration of the negative consequences to the patient. A mental diagnosis can sometimes find its way back to an employer, where it can adversely affect job evaluation and promotability, or to the insurer, where it can adversely affect insurability.

      At the level of the practice, mental diagnoses do not generally fare well in the competition for a clinician's precious time with a patient, particularly if a mental problem is not the reason the patient has appeared for care. Primary care practices are rarely equipped to make the case-finding efforts necessary to identify patients with mental disorders, and they rarely have the resources to treat and monitor these patients appropriately.

      At the level of the larger health care system, primary care clinicians are often not reimbursed to identify and manage mental disorders. Even in managed care plans that expect such management from the primary care clinician, rarely are the clinicians provided the proper incentive to render adequate mental health care.

    • Recent Efforts to Create a Sustainable System of Mental Health Care That Is Part of the Fabric of Primary Care. Several recent efforts are particularly relevant for the care of depressed primary care patients. Important too are the implications for those who might wish to incorporate psychophysiological interventions into primary care settings. A decade ago, we understood that most patients with mental diagnoses were appearing in primary care settings, that they were severely impaired and thus in need of help, that excellent treatments were available, and that the clinicians still were not dealing with the problems. Excellent case-finding tools, such as PRIME-MD (Primary Care-Mental Diagnoses) and its subsequent refinement, the PHQ (Primary Care Health Questionnaire), had been developed and validated. Clinicians could be persuaded to use these tools but tended to stop when the studies stopped. Even when they persisted in using them, this alone did not result in better outcomes for patients afflicted with mental disorders. Outstanding patient education and physician education programs have been developed, and these have been shown to increase both patients' and clinicians' knowledge about recognizing and treating mental disorders. Unfortunately, the programs alone have produced no corresponding improvement in patient outcomes. Improved access to mental health resources causes almost no improvements in mental health outcomes because primary care patients will not leave their primary care clinicians to access them.

    A set of progressively sophisticated care management protocols have also been developed for primary care settings, involving access to care managers, cognitive-behavioral therapists, and psychiatrists. These have resulted in definite improvements in the care process and in some instances have resulted in better health outcomes for patients, but these practice-level structural changes tend to disappear when the research support that creates them disappears. We have reached the point of realizing that a chain of conditions, each necessary but not alone sufficient, must be met to introduce into the primary care setting effective, sustainable mental health care. As of this writing, it appears that the most effective mental health care conforms to the principles of chronic disease management, such as the model developed by Wagner (Wagner, Austin, & Von Korff, 1996). Wagner's model of care generally contains elements of patient education and motivation for self-care; clinician education; easy-to-use office tools for case finding, diagnosis, tracking and monitoring, and outcomes measurement; care management; and simple guidelines or algorithms. These elements must be supported by an incentive structure that actually rewards the primary care clinician for implementing multidimensional changes in their practices.

    Future Prospects

    Many authors in this book describe innovations in clinical care that are supported by compelling evidence of their benefits. The trick will be to figure out how to get them in use and maintain their use long enough to convince everyone of their benefits. Time and progress are on our side. Increasingly sophisticated information systems make the difficult practice-level innovations, such as case-finding and tracking systems, more available and useful. The concepts of collaborative care and clinical teamwork are replacing the earlier cultural norm of the primary care clinicians as solely responsible for the health and health care of their patients. Most important, evidence is accumulating of the importance of the psychophysiological connections and the value of reaching across these connections with new therapies. This evidence will have more researchers and innovators searching for ways to bring new developments to the patients who need them, and those patients are found in primary care settings.

    References
    Bowen, M. (1966). The use of family theory in clinical practice. Comprehensive Psychiatry, 7, 345–374. http://dx.doi.org/10.1016/S0010-440X%2866%2980065-2
    Bridges, K. W., & Goldberg, D. P. (1985). Somatic presentation of DSM-III psychiatric disorders in primary care. Journal of Psychosomatic Research, 29, 563–569. http://dx.doi.org/10.1016/0022-3999%2885%2990064-9
    Christie-Seely, J. (1981). Teaching the family system concept in family medicine. Journal of Family Practice, 13(3) 391–401.
    Crouch, M., & Roberts, L. (1987). The family in medical practice: A family systems primer. New York: Springer-Verlag. http://dx.doi.org/10.1007/978-1-4612-4642-8
    Davidson, M. (1983). Uncommon sense. The life and thought of Ludwig von Bertalanffy, father of general systems theory. Los Angeles: Tarcher.
    deGruy, F. V., III (1996). Mental health care in the primary care setting. In M. S.Donaldson, K. D.Yordy, N.Lohr, & N. A.Vanselow (Eds.), Primary care: America's health in a new era (pp. 285–311). Washington, DC: National Academy Press.
    Donaldson, M. S., Yordy, K. D., Lohr, N., & Vanselow, N. A. (1996). Primary care: America's health in a new era. Washington, DC: National Academy Press.
    Dubos, R. (1971). Mirage of health. New York: Harper & Row.
    Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. http://dx.doi.org/10.1126/science.847460
    Kroenke, K., Spitzer, L. R., Williams, J. B., Linzer, M., Hahn, S. R., deGruy, F. V., III, & Brody, D. (1994). Physical symptoms in primary care: Predictors of psychiatric disorders and functional impairment. Archives of Family Medicine, 3(9) 774–779. http://dx.doi.org/10.1001/archfami.3.9.774
    Olfson, M. (1991). Primary care patients who refuse specialized mental health services. Archives of Internal Medicine, 151, 129–132. http://dx.doi.org/10.1001/archinte.1991.00400010135020
    Orleans, C, George, L., Haupt, J., & Brodie, H. (1985). How primary care physicians treat psychiatric disorders: A national survey of family practitioners. American Journal of Psychiatry, 142, 52–57.
    Pellegrino, E. D., & Thomasma, D. C. (1981). A philosophical basis of medical practice. New York: Oxford University Press.
    Rainford, G. L., & Schuman, S. H. (1981). The family in crisis. A case study of overwhelming illness and stress. Journal of the American Medical Association, 1, 246.
    Starfield, B. (1994). Primary care: Is it essential?Lancet, 344, 1129–1133. http://dx.doi.org/10.1016/S0140-6736%2894%2990634-3
    Wagner, E. H., Austin, B. J., & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly, 74(4) 511–544. http://dx.doi.org/10.2307/3350391
    Terence C.Davies, MD Professor and Chair of Family and Community Medicine, Eastern Virginia Medical School
    Frank V.deGruy, III, MD Woodward-Chisholm Professor and Chair of Family Medicine, University of Colorado School of Medicine
  • Author Index

    About the Editors

    Donald Moss, Ph.D., is a partner in West Michigan Behavioral Health Services, adjunct graduate faculty for Saybrook Graduate School, San Francisco, and mental health director for the humanitarian Trelawny Outreach Project in Western Jamaica. He is president of the Association for Applied Psychophysiology and Biofeedback, editor of Biofeedback, and consulting editor for the Journal of Neurotherapy. He serves on advisory boards for the Advanced Learning Foundation in Colorado, BioCom Technologies of Seattle, Washington, and the Behavioral Medicine Research and Training Foundation of Suquamish, Washington. Dr. Moss's third book, Humanistic and Transpersonal Psychology, was released in 1998, and he has published numerous book chapters and journal articles on humanistic psychology, philosophy of medicine, anxiety disorders, and behavioral medicine.

    Angele McGrady, Ph.D., is professor of psychiatry and adjunct professor of physiology and molecular medicine at the Medical College of Ohio in Toledo. Dr. McGrady is the past president of the Association for Applied Psychophysiology and Biofeedback and is an editor of the journal Applied Psychophysiology and Biofeedback. In addition, she is a reviewer for Physiology and Behavior and Diabetes Care and the author of numerous journal articles applying physiological research methodology to chronic medical conditions, such as diabetes and hypertension.

    Terence C. Davies, MD, is professor and chair of family and community medicine at Eastern Virginia Medical School, and a practicing family physician. He is the Glennan Endowed Chair of Generalist Medicine at EVMS. Dr. Davies has a special interest in behavioral medicine interventions in primary care settings and established a division of behavioral medicine in his department three years ago.

    Ian Wickramasekera, Ph.D., ABPP, ABPH, is past president of the Association for Applied Psychophysiology and Biofeedback and was cofounder of AAPB's primary care section. Dr. Wickramasekera developed the high risk model of threat perception, an empirical approach to the diagnosis and treatment of psychophysiological disorders. He is the author of Clinical Behavioral Medicine as well as more than 80 articles and book chapters on topics ranging from hypnosis to psychophysiological psychotherapy and somatization disorder.

    About the Contributors

    Elsa Baehr, Ph.D., is a clinical associate in the Department of Psychiatry and Behavioral Science at Northwestern University Medical School. She is also a consultant to the outpatient Mental Health Clinic at the Lakeside Veterans Administration. She is the director of the NeuroQuest Clinic in Evanston, Illinois, where she shares a private practice with her husband, Dr. Rufus Baehr. She published research on brain-wave asymmetry and depression, and coauthored two chapters on depression. She has presented at professional meetings sponsored by the Association for Applied Psychophysiology and Biofeedback, the Society for Neuronal Regulation, and Future Health.

    Barbara Bailey, RN, MSN, CDE, earned her BSN in 1979 from the University of Toledo and her MSN in 1984 from the Medical College of Ohio in Toledo. She is a diabetes nurse educator for St. Vincent Mercy Medical Center in Toledo and serves as coinvestigator in several research studies about biofeedback, stress, and diabetes mellitus.

    Steven M. Baskin, Ph.D., is the director of the New England Institute for Behavioral Medicine in Stamford, Connecticut, and an attending psychologist in neurology and psychiatry at Greenwich Hospital of Yale-New Haven Health. He is currently the treasurer of the Association of Applied Psychophysiology and Biofeedback and is a former board member at large of the American Headache Society. He has authored numerous scientific papers and chapters on primary headache disorders.

    Kusum Bhat, Ph.D., is the clinical director of Cybernetix Medical Institute in Concord, California. Her doctoral thesis at the American School of Professional Psychology was titled The Role of Biofeedback Assisted Anger Control in Reversing Heart Disease. She treats coronary heart patients using cognitive behavioral methods, including biofeedback, and works as a mental health clinical specialist at Contra Costa County Hospital. She is also a certified physician assistant from the University of California at San Diego.

    Naras Bhat, MD, is a board-certified specialist in internal medicine and a certified specialist in stress management education. He is a professor of behavioral medicine at Rosebridge College of Integrative Psychology and teaches at the University of California at Berkeley. Dr. Bhat is the author of the book How to Reverse and Prevent Heart Disease and Cancer and has produced two popular videos, Uprooting Anger and Meditation Prescription.

    Raymond Bourey, MD, is a clinical assistant professor of medicine at The Medical College of Ohio. He has a background in cell biology research as well as subspecialty training in applied physiology, endocrinology, diabetes, metabolism, and sleep medicine. He has studied the basis of the metabolic syndrome and insulin resistance at the molecular level as well as in human studies. Most recently, Dr. Bourey has turned his efforts toward clarification of the impact of sleep apnea and sleep deprivation on the metabolic syndrome. He currently applies his research as an internal medicine physician in primary care.

    Cheryl Bourguignon, Ph.D., RN, is an assistant professor and a research fellow in complementary and alternative medicine at the Center for the Study of Complementary and Alternative Therapies at the University of Virginia School of Nursing. Her current studies investigate the effects of sex hormones on symptoms (pain, fatigue, sleep disturbance, mood), stress reactivity, functional status, and inflammation in pre- and postmenopausal women with rheumatoid arthritis. Dr. Bourguignon is currently expanding her research to investigating the effectiveness of relaxation, imagery, and other complementary practices and products in improving the symptoms, stress, inflammation, and functional status in women with rheumatoid arthritis.

    Patricia Carrington, Ph.D., is a clinical professor of psychiatry at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School. She has authored more than 35 research and theoretical papers in psychological and psychiatric journals on the topics of sleep and dream research, modern meditation techniques, and the new meridian-based desensitization methods. She is the author of five books: Freedom in Meditation, Releasing, The Clinically Standardized Meditation Instructors Course, The Power of Letting Go, and The Book of Meditation.

    Robert W. Collins, Ph.D., has published scientific and review articles on enuresis and encopresis. He recently published The Dry Bed Manual for bed wetters and The Clean Kid Manual for soiling children, which are available from his website at http://www.soilingsolutions.com. He has recently retired from office practice. Dr. Collins has been president of the Michigan Psychological Association and the Michigan Society of Behavioral Medicine and Biofeedback.

    Margaret Davies, MD, is a professor of family and community medicine at Eastern Virginia Medical School. She is assistant dean of student affairs at EVMS and pioneered an innovative student wellness program that has received national attention. Dr. Davies is a practicing family physician and has special interests in family issues and in training medical students, medical residents, and physicians to address psychosocial problems that affect the health and well-being of primary care patients.

    Frank V. deGruy, III, MD, is the Woodward-Chisholm Professor and chair of the Department of Family Medicine at the University of Colorado School of Medicine. He has been researching and writing about mind-body problems, particularly mental health problems in the primary care setting, for 20 years. Dr. deGruy has been funded by the National Institute of Mental Health to study somatization in primary care and has served as a grant reviewer for the NIMH's Services Research Grant Review Group. Currently, he is chair of the National Advisory Committee of the Robert Wood Johnson Depression in Primary Care Program.

    C. C. Stuart Donaldson, Ph.D., is a psychologist in private practice in Calgary, Alberta, Canada. He is the director of a multidisciplinary pain treatment and rehabilitation center and a pioneer in the field of surface EMG and chronic pain. His recent work has involved the integration of SEMG, quantitative EEG, and chronic pain. Dr. Donaldson has published extensively on biofeedback and chronic pain.

    Jonathan M. Feldman, MS, is currently pursuing his Ph.D. in clinical psychology at Rutgers University and completing a predoctoral internship in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. Mr. Feldman has been conducting research on comorbidity between psychiatric disease and asthma as well as identifying behavioral factors that can complicate asthma self-management. He is the principal investigator on a National Institute of Mental Health predoctoral fellowship examining the impact of panic disorder on asthma. His clinical expertise is in cognitive-behavioral treatment for anxiety and mood disorders.

    Annabaker Garber, Ph.D., R.N., is currently an associate editor with Milliman Care Guidelines, a division of Milliman USA. Her background includes a Ph.D. in physiological psychology and a master's in psychosocial nursing. Her career includes research faculty experience working on three grants, including one as a coprincipal investigator at the University of Washington School of Nursing. Dr. Garber has developed and taught professional training programs in psychophysiology, had a private practice, and, as the clinical director for a medical device manufacturer, designed and published psychophysiology treatment protocols. Her areas of expertise are behavioral treatment for stress-related disorders and psychophysiology.

    Richard Gevirtz, Ph.D., is a professor in the health psychology program at the California School of Professional Psychology, Alliant International University, San Diego. He has been involved in research and clinical work in applied psychophysiology for the last 25 years, with primary interests in understanding the physiological and psychological mediators involved in disorders such as chronic muscle pain, gastrointestinal pain, fibromyalgia, chronic fatigue syndrome, panic disorder, and functional cardiac disorder. Dr. Gevirtz is the author of many journal articles and chapters on these topics.

    Nicholas Giardino, Ph.D., is a postdoctoral fellow in the Department of Rehabilitation Medicine at the University of Washington School of Medicine. His research focuses on respiratory psychophysiology in chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease, and functional somatic syndromes, such as chronic fatigue syndrome and chemical intolerance. Dr. Giardino also performs clinical and epidemiological research in the area of comorbid psychological and chronic respiratory disorders. His clinical work focuses on behavioral and psychophysiological interventions for chronic respiratory disease and pain.

    Christopher D. Gilbert, Ph.D., is a licensed psychologist who since 1974 has used biofeedback as an aid in treating psychophysiological and anxiety disorders. He received his doctorate in psychology from Michigan State University and until recently taught psychology at Ramapo College of New Jersey. He is coauthor of Multidisciplinary Approaches to Breathing Pattern Disorders, is on the international advisory board of the Journal of Bodywork and Movement Therapies, has written several articles on hyperventilation, and edits the newsletter of the International Society for the Advancement of Respiratory Psychophysiology. Dr. Gilbert is now associated with the chronic pain management program of the Kaiser Permanente Medical Center in San Francisco.

    Alan G. Glaros, Ph.D., is the Beulah McCollum Professor of Dentistry at the University of Missouri-Kansas City in the Department of Dental Public Health and Behavioral Science. He has held positions in the Department of Psychology at Wayne State University and the Department of Clinical and Health Psychology at the University of Florida. Dr. Glaros maintains an active clinical and research program in temporomandibular disorders.

    Robert W. Jarski, Ph.D., PA-C, is the founder and director of the complementary medicine and wellness program at Oakland University in Rochester, Michigan. Dr. Jarski completed specialized training in behavioral medicine at the Harvard Medical School and is formally trained in interactive guided imagery and mindfulness meditation. He received a major research grant from the Michigan Department of Public Health to study stress management and has served as a grant project reviewer for the National Institutes of Health National Center for Complementary and Alternative Medicine. Dr. Jarski is a referee and editorial board member of several professional journals, has published numerous articles in scientific journals and books, and is a hospice volunteer. His expertise lies in education for health and healing from the curricular level, where students consciously learn, to the cellular level, where the body learns to heal itself.

    Stanley Krippner, Ph.D., is professor of psychology at Saybrook Graduate School, San Francisco. He is a fellow of the American Psychological Association, the American Psychological Society, the American Society of Clinical Hypnosis, and the International Society for Clinical and Experimental Hypnosis, and past president of two divisions of the American Psychological Association. Dr. Krippner is coauthor of The Mythic Path, editor of Dreamtime and Dreamwork, and coeditor of Varieties of Anomalous Experience, recently published by the American Psychological Association.

    James Lake, MD, is a board-certified psychiatrist with long-standing interests in the interface between mental health and culture and in the philosophical and scientific perspectives of different systems of medicine as they pertain to diagnosis and treatment of psychiatric disorders. Presently, he is in private practice in Pacific Grove, California, where he integrates conventional biomedical therapies and evidence-based alternative therapies for adult psychiatric disorders. Dr. Lake was recently selected to create and chair a committee on complementary and integrative medicine at a private hospital in Monterey with the goal of introducing complementary and integrative treatments into the hospital setting and affiliated clinics. From 1999 through 2000, he was an attending physician at Stanford University Hospital, where he consulted on psychiatric cases in the Complementary Medicine Clinic.

    Charles W. Lapp, MD, is director of the Hunter-Hopkins Center and assistant consulting professor in community and family medicine at Duke University. He is a diplomate of the American Boards of Internal Medicine, Pediatrics, and Independent Medical Examiners, and is a fellow of the American Academies of Pediatrics, Family Physicians, and Disability Evaluating Physicians. Dr. Lapp has published extensively on the neurobiology, assessment, and treatment of chronic fatigue syndrome.

    Mark A. Lau, Ph.D., is a psychologist at the Cognitive Behaviour Therapy Unit at the Centre for Addiction and Mental Health in Toronto and is an assistant professor in the Department of Psychiatry at the University of Toronto. He has an active interest in cognitive-behavioral therapy training and supervision and a nationally funded program of research interests investigating the role played by inhibitory deficits in depressive thinking styles. Dr. Lau is a founding fellow of the Academy of Cognitive therapy.

    Leonard Lausten, DDS, is an associate professor in the Department of Dental Public Health and Behavioral Science and director of the Special Patient Care Center at the University of Missouri-Kansas City School of Dentistry. He has served on the faculty at Marquette University, where he also directed the advanced education program in general dentistry and taught in the oral medicine program. Dr. Lausten maintains a clinical practice serving patients with temporomandibular disorders and those who are medically compromised or have dental fears.

    Theodore J. La Vaque, Ph.D., has graduate and postgraduate education in both physiological psychology and clinical psychology. He was a research associate in behavioral neuroendocrinology at the West Side Veterans Administration Hospital in Chicago and assistant professor in the Department of Psychiatry at Abraham Lincoln School of Medicine, University of Illinois. Dr. La Vaque has been in private practice since 1975 and is currently the director of the Clinical Psychophysiology Center, Rogers Memorial Hospital, Milwaukee, Wisconsin. He is also an associate editor of Biofeedback, the newsmagazine of the Association of Applied Psychophysiology and Biofeedback.

    Debra E. Lyon, RN, Ph.D., is an assistant professor in the School of Nursing and a postdoctoral fellow in the CAM Research Training Program in the Center for the Study of Complementary and Alternative Therapies at the University of Virginia. Her scholarly articles have appeared in several journals, including Journal of the Association of Nurses in AIDS Care, Journal of School Nursing, Issues in Mental Health, Applied Nursing Research, and Journal of Nursing Scholarship. Dr. Lyon has also written book chapters, including one on women as individuals in Women's Health: A Relational Perspective Across the Lifespan.

    Paul Lehrer, Ph.D., is a clinical psychologist and professor of psychiatry, at the University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, where he directs the Center for Stress Management and Behavioral Medicine. He also is professor of psychology at Rutgers University, where he teaches in the graduate clinical psychology program. His research interests are in respiratory psychophysiology, cardiovascular variability, and the interrelationships among anxiety disorders, disordered breathing, and somatization disorder. He has published more than a hundred scientific papers on these topics and is senior editor of the book Principles and Practice of Stress Management, which is now in its second edition. He is president-elect of the Association for Applied Psychophysiology and Feedback.

    Joel F. Lubar, Ph.D., is professor of psychology at the University of Tennessee. He has published more than a hundred papers, many book chapters, and eight books in the areas of neuroscience and applied psychophysiology. He is president of the EEG division of the Association for Applied Psychophysiology and Biofeedback and was the president of AAPB in 1995–1996. He was responsible for developing the use of EEG biofeedback (neurofeedback) as a treatment modality for children, adolescents, and adults with attention deficit hyperactivity disorder, starting with controlled studies in the mid-1970s. Dr. Lubar is currently developing databases for the assessment of individuals with ADD/HD and is the scientific advisor and developer for several controlled multicenter studies evaluating the effectiveness of neurofeedback.

    Olafur S. Palsson, Psy.D., is a licensed clinical psychologist. He completed a twoyear postdoctoral fellowship in behavioral medicine at the University of North Carolina at Chapel Hill. From 1996 to 2000, Dr. Palsson was director of behavioral medicine and assistant professor of psychiatry and family medicine at Eastern Virginia Medical School, where he conducted clinical work and research in mind-body medicine and taught medical students and family medicine residents. He is currently a research associate in the division of digestive diseases and nutrition at UNC-Chapel Hill, treats patients with psychophysiological disorders, and conducts research on functional gastrointestinal disorders.

    J. Peter Rosenfeld, Ph.D., is a professor of psychology, neurobiology, and physiology at Northwestern University and is past president of the Association for Applied Psychophysiology and Biofeedback. He serves on the editorial board for the journals Applied Psychophysiology and Biofeedback and International Journal of Rehabilitation and Health and has served as consulting editor for numerous scientific journals. His research has recently focused on the detection of brain signatures for false memories, the detection of deception and malingering through patterns in event-related brain-wave amplitudes, and the asymmetry protocol for the neurofeedback treatment of depression.

    Zindel V. Segal, Ph.D., is head of the Cognitive Behaviour Therapy Unit at the Centre for Addiction and Mental Health in Toronto. At the University of Toronto, he is a professor in the Departments of Psychiatry and Psychology and head of psychotherapy research for the psychotherapy program in the Department of Psychiatry. He holds the Morgan Firestone Chair in Psychotherapy. Dr. Segal is a founding fellow of the Academy of Cognitive Therapy and is an associate editor for Cognitive Therapy and Research.

    Gabriel E. Sella, MD, is a physician specializing in family and preventive medicine as well as occupational disability and pain management. His research and teaching focus on muscle physiology, electromyographic assessment, and biofeedback. He has published 10 textbooks and more than 80 articles and has given over 250 professional presentations and seminars nationally and internationally. Dr. Sella is a board member of the SEMG Society of North America and the American Academy of Pain Management and has seven fellowships and three board certifications. He is particularly interested in the subject of myofascial pain and its treatment, with special emphasis on EMG assessment and neuromuscular reeducation.

    Mahmood Siddique, DO, FACP, FCCP, is a clinical assistant professor of medicine in the division of pulmonary and critical care medicine at University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School. He is in private practice in Hamilton, New Jersey. Dr. Siddique completed residency in internal medicine at the Robert Wood Johnson Medical School and a fellowship in pulmonary and critical care medicine at Case Western Reserve University. He is board certified in internal medicine, and pulmonary and critical care medicine and specializes in sleep medicine. He is currently an advisory committee member of the Global Initiative for Asthma.

    Emanuel Stein, MD, is professor of family and community medicine and internal medicine at Eastern Virginia Medical School. He is a diplomate of the American Board of Internal Medicine, a diplomate of the subspecialty Board of Cardiovascular Disease, and a fellow of the American College of Physicians, the American College of Chest Physicians, and the American College of Cardiology. Dr. Stein also holds a master's degree in public health from Columbia University and has served as clinical cardiologist, educator, researcher, and administrator. His books have been translated into French, German, Indonesian, Italian, Japanese, and Spanish. Dr. Stein is licensed to practice acupuncture in Virginia.

    Sebastian Striefel, Ph.D., became a professor emeritus in the Department of Psychology at Utah State University in September 2000. For 26 years, he taught graduate-level courses in ethics and professional conduct, clinical applications of biofeedback, clinical applications of relaxation training, and behavior therapy. As the director of the division of services at the Center for Persons with Disabilities at Utah State University, Dr. Striefel managed a variety of programs, including an outpatient clinic, a biofeedback lab, and an early intervention program. He is past president of the Association of Applied Psychophysiology and Biofeedback, current president of the neurofeedback division of AAPB, and secretary/treasurer of the international section of AAPB. In addition, he writes an ongoing ethics column and conducts workshops on ethics, standards, and professional conduct.

    Diana Taibi, MSN, RN, is a doctoral student in nursing at the University of Virginia. As a research assistant, she works closely with Dr. Cheryl Bourguignon on research investigating changes in pain, sleep, mood, and fatigue over the menstrual cycle in women with rheumatoid arthritis. Ms. Taibi will continue to focus on pain and symptom management in rheumatoid arthritis as a doctoral student and predoctoral trainee at the Center for the Study of Complementary and Alternative Therapies at the University of Virginia School of Nursing.

    Ann Gill Taylor, MS, Ed.D., FAAN, is the Betty Norman Norris Professor of Nursing and director of the Center for the Study of Complementary and Alternative Therapies at the University of Virginia. As part of her 30-year focus on academic nursing, she developed the critical care master's program in nursing at the University of Virginia. Dr. Taylor has published numerous journal articles and book chapters on complementary and alternative therapies, therapeutic touch, and pain management. Her current research is investigating links among the musculoskeletal, vascular, neuroendocrine, and central nervous systems in fibromyalgia.

    Sharon Williams Utz, Ph.D., RN, is associate professor and chair of the division of acute and speciality care of adults at the University of Virginia School of Nursing. Educated and experienced in the care of adults with cardiovascular conditions, she has held positions in hospitals, rehabilitation centers, and university schools of nursing. Her current research and teaching focus is on care of chronically ill adults, with a focus on self-care and cultural competence among health care providers. Awards include appointment as a University of Virginia Shannon Scholar, a scholar of the American Nurses Foundation, and two citations for papers presented at annual conferences of the Association for Applied Psychophysiology and Biofeedback. Relevant publications include articles and book chapters on care of patients with hypertension and heart attack, use of biofeedback, the self-care model, and the case-management model of care.

    Randall E. Weeks, Ph.D., is a clinical psychologist specializing in behavioral medicine and neuropsychology. He is director of the New England Institute for Behavioral Medicine and clinical program director of the New England Heachache Treatment Program. Dr. Weeks has numerous publications in headache classification and treatment with an emphasis on the role of analgesic overuse in headache maintenance.

    Suzanne Woodward, Ph.D., is an assistant professor of psychiatry at Wayne State University School of Medicine in Detroit. Her research interests have concentrated on sleep in women during menopause, and she is a nationally recognized expert and invited speaker in this area. She has published numerous articles and chapters on sleep in women. Dr. Woodward is a charter member of the North American Menopause Society as well as a member of the Association of Professional Sleep Societies. She has been a member of the Association for Applied Psychophysiology and Biofeedback since 1980 and has served on the board of AAPB. She is a concerned proponent of the integration of behavioral medicine into traditional medical education programs.

    Ari E. Zaretsky, MD, received his medical degree from the University of Toronto and then completed a psychiatry residency there. He pursued a fellowship in cognitive therapy both at the Centre for Addiction and Mental Health in Toronto and Massachusetts General Hospital in Boston. Dr. Zaretsky is Head of the Cognitive Behaviour Therapy Clinic at Sunnybrook & Women's College Health Sciences Centre, and an assistant professor in the Department of Psychiatry, University of Toronto. He is a Founding Fellow of the Academy of Cognitive Therapy and has a national reputation as a teacher of cognitive therapy. He has published on supervision in cognitive therapy and on cognitive therapy for bipolar disorder and has received peer-reviewed funding from CIHR and NARSAD. His current research activities include CBT for bipolar disorder, prophylactic CBT for women at risk for postpartum depression, and CBT for HIV+ individuals.


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