Medical patients can often struggle with feeling insecure about asserting their feelings or needs to health care providers. However, when you assert yourself you feel more in control and ultimately your stress is reduced.

Keep in mind that assertiveness is not aggressiveness. Assertiveness is a balance between the extremes of aggressiveness and submissiveness. People who act in an aggressive style demand and expect others to do exactly what they want. Those who act in a submissive style give up their own beliefs, opinions, and wants to the demands of others. They feel guilty to ask for what they want as if others' needs are more important than their own. As assertive person respects others' views and feelings but also values and respects their own.

Look others directly in the eyes when talking to them and maintain an open posture. This will be easier to do if you reinforce for yourself that what you are saying is important. Don't assume a posture that says you are absolutely right---such as glaring at others when speaking, and ending your statements as if there is no questioning or doubting your words.
 
Be specific when making requests. Vague requests or comments can often be misinterpreted by others or simply ignored. If your request is very specific and direct, there is little room for confusion. For example, instead of asking for someone's help in general, specifically state what you want help with, when, and for how long.
 
Asserting your opinions, needs, concerns and questions with your healthcare providers will help you with making important decisions and assist you in your coping. Those who feel they have a voice and it matters will feel more in control and engage in a more healthy decision making.

Aches…pains…sadness…fear….insecurity…… "It's all in your head".
Have you heard this from your doctor, your spouse, a friend, or perhaps you have even said it to yourself?  Well, in part, it is true. Our thoughts exist in our head and they are very powerful tools. What we say to ourselves can lift our spirits, relax us, or give us a sense of excitement and hope. They can also make us fearful, mistrusting, and physically ill. Almost every minute of the day you are engaging in conversation with yourself. It is through this conversation that you interpret interactions with others, assess how you feel and control your physical well being.  Thoughts are very powerful but within our control. Therefore, the key to managing physical and emotional reactions is in our awareness and control of our thoughts.
Many of you have heard me say that any thought that begins with…Oh my Gosh or What if …is destined to take you to potentially some irrational thoughts and often erroneous conclusions. Our interpretation of situations is based on our past experiences, our current level of stress and is influenced by how we feel physically and emotionally. A few strategies to monitor and manage our thoughts include:

1. Avoid "all or nothing" thinking: If you are tired, overwhelmed, or physically ill and then faced with a stressful situation, your ability to cope is impaired. You are more likely to engage in all or nothing thinking. This involves using language like "always," "ought to," "need to," "never," and "must." These words set up a standard that says that if a person does not live up to an expectation then the person is terrible or the circumstance in uncontrollable. In reality, it isn't the event or person that is bad but the standard that you set. The standard is irrational because people and situations are never all good or all bad, therefore you set yourself up to feel disappointed, angry, and stressed when your expectations are not met.
2. Evaluate the evidence of your self-dialogue: Learn to distinguish your reaction from the stressful event. Many encounters that we have throughout the day have the potential to cause stress. However, it is our interpretation and our reaction that actually causes the stressful physical and emotional response. What is the evidence that you have for your thoughts and conclusions? Consider the feeling when you are stuck in traffic and late for work. Your body becomes tense, you may yell at other drivers, you may feel heart racing, experience a headache, drive more aggressively-----but did you get to work any faster? Probably not. Monitoring self-talk and reminding self that you have no control over the traffic. You have control over averting a headache or raising your blood pressure. Reminding self of your irrational thoughts and reactions will help you gain control over them.
3. Confront your worst fears: Bring your worst fears into clear focus. When you carry your irrational thoughts to the final conclusion by asking yourself and so if that does happen then what, you may find that the worst thing that could happen may not be as terrible as you think. Or appears too irrational to be realistic. Or may be a terrible outcome but one that you will learn to cope with if need be.  Simply worrying and anticipating the worst outcome only creates fear and avoidance. Confronting it helps us feel in control and ready to engage in active coping.

Depression has been found to be a significant risk factor for heart disease. So, when you are experiencing emotional pain, your heart may very well be “breaking”. The rate of depression among patients with heart disease is strikingly high, at approximately 20 to 30 percent compared to 2 percent among individuals who are not medically ill. Although many cardiac patients and, unfortunately, some of their physicians dismiss or minimize the effects of depression, it is a serious risk factor and complication for cardiac patients. Recent studies have shown that even moderate depression raised the rate of heart disease caused by obstructed coronary arteries by 60 percent and increase the rate of heart attacks by 50 percent. Although smoking, drinking, poor nutrition, and lack of exercise are important risk factors for cardiac disease, when researchers removed these factors from the equation, depression was the only remaining factor that contributed to this significant increase in heart attacks.

Unfortunately, the word depression has been overused and misused by society and therefore has lead to confusion about what it actually means. For example, it can be used to refer to mild annoyance: “I’m depressed because I can’t get tickets to the baseball game,” or to feelings that indicate major clinical depression: “There is no hope, therefore life isn’t worth living anymore”.

From a clinical standpoint, the word depression is used to describe negative emotions that can interfere with your relationships, your ability to enjoy life, and your physical health. Many people believe depression is only about feeling sad and that if they are not sad then they must not be depressed. However, you can feel irritable, anxious, or just plain disinterested with many parts of your life while suffering from depression. Many cardiac patients who are depressed admit to feeling that following their diet, taking their medication, and regularly following up with their medical appointments is not as important to them as it used to be. They appear to adopt an attitude of “Why bother?” or “What is the point?” Patients who are depressed can also experience difficulty with memory, which frequently interferes with their ability to follow the medical plans their doctors have set up for them. Therefore, one of the best things that can be done for your overall health and specifically that of your heart is to recognize signs and symptoms of depression and seek treatment.

Reforming and improving healthcare is the focus and challenge of the future. In response to some of these challenges, a holistic approach to healing has begun to spread to major universities, hospitals, healthcare agencies and medical schools.  This holistic approach, known as integrative medicine acknowledges that healing is about addressing the mind, body and spirit of the person.

Integrative medicine is a model of integrating care from the best conventional medical protocols with complimentary therapies such as acupuncture, healing touch (an evidence-based modality used by nurses to manage pain, wound/fracture healing, etc), massage and music therapy, yoga and wellness coaching for support with life style changes. The efficacy of these therapies have been widely studied with conditions ranging from gastrointestinal disorders, cancer, heart disease, stroke, Alzheimer’s disease and stress related to medical illness and surgical procedures as well as pain management post-operatively.

The American Hospital Association reports that there has been a significant increase in hospitals offering complimentary therapies with only 8.6% in 1998 to almost 25% in 2004 with an additional 24% reporting plans to add services in the future. It has been reported that patients who use integrative medicine programs in a hospital are more likely to rate their overall experience higher.

The growing trend and appeal of integrative medicine appears to be coming from the consumers dissatisfaction with the current healthcare system including feeling rushed through appointments and viewed only as their disease or illness, e.g., the breast cancer or the diseased kidney. They want to be viewed in whole as the person with the disease. Healthcare providers are also embracing integrative medicine as a way to reduce their feelings of being overwhelmed and rushed in providing care under the current healthcare system.

Diaphragmatic breathing is a process that helps people improve their ability to focus their attention on their bodies. It involves breathing from your diaphragm instead of your chest. Your diaphragm is the muscle located just below your ribs. Breathing from the diaphragm involves slow deep breaths where the diaphragm actually pulls and pushes air in and out of the lungs. Breathing from the diaphragm promotes relaxation in the body as opposed to the shallow, rapid and tense breathing that occurs in the chest when you are anxious.

Relaxation methods enable you to effectively reduce both your mental anxiety and its physical signs. As you become more relaxed, you will be able to listen better to important things you want to say to yourself regarding your health. Relaxation is a self-control technique; you are in control of your level of relaxation. Like any skill, the more you practice, the better able you will become to relax more fully and in less ideal places.

Not only does this type of breathing make relaxation on a physical level much easier to achieve, it is also more efficient and subsequently increases the oxygen supply to the heart, brain, and other organs. By using this type of breathing you can reduce your stress, reduce anxiety and improve your mental and physical well being. Practice the following exercise on a regular basis until you are able to effectively use this breathing technique as needed, particularly when you're under stressful circumstances.

1. To begin the exercise, find a comfortable chair in a quiet room.
2. Place your hand on your abdomen below your rib cage. This where your diaphragm is located.
3. Concentrate on your breathing, taking slow, deep breaths. Breathe through your nose, inhale, and hold it.
4. Exhale slowly. You should be able to feel your stomach moving out when you inhale and in when you exhale.
5. Focus on your belly as it expands like a balloon when you inhale and deflates when you exhale.
6. Repeat several deep breaths. After you inhale, hesitate for a moment, and then slowly exhale.
7. Remember to slowly but deeply inhale and slowly but evenly exhale.
8. Avoid rapid, quick breath. This can lead to hyperventilation.
9. As you slowly blow all of the air out of your lungs, image all of the tension leaving.
10. Pause, and repeat this deep breathing until it has become a slow comfortable rhythm.
11. As you concentrate on slowing down your breathing, let your body sink into your comfortable chair. Notice how relaxed your arms feel against the chair; so do your legs, your back, and your neck. Notice that your breathing is slow, deep and regular. With each breath, you are becoming more relaxed and the tension is slowly fading.
12. You may wish to combine some imagery and positive self-statements with the breathing exercises. For example, when you exhale, imagine letting all of the tension in your body go with the breath; imagine that when you inhale, you are taking in energy and feeling stronger with every breath.          

When presented with information about their health and the changes they need to make to their lifestyles, what exactly motivates people to make these changes? Well, the fear of death is a great motivator for change. Frequently, after patients suffer a heart attack for example, they begin to make changes in their life. They may quit smoking and improve their diets. However, it’s also not uncommon for people to lose their motivation to continue these changes. They may return to smoking or gradually return to their poor eating habits. Does this sound familiar?

Are there certain factors that help people stay committed to the changes they make? There are twenty-one commonly studied theories and models that explain how certain feelings and beliefs can contribute to healthy behaviors. The following basic themes and concepts of these theories will help you identify what motivates you and how you can stay committed to healthy behaviors.

Perceived Threat

This concept refers to whether or not you believe you’re going to get sick in the first place and if you accept your diagnosis. That is, what are your beliefs about your own susceptibility to developing an illness or disease?  Do you deny the impact of your behavior (smoking, weight, stress) on worsening or contributing to your illness?

• Obtain accurate and specific information from your doctor: Often patients will claim that the doctor never specifically said that their smoking or their diet can cause damage or disease. This miscommunication may be due in part to the patients not asking direct questions because then they can assume if it wasn’t directly stated, than it must not be that serious.
• Objectively evaluate the information you are given about changes in your lifestyle: We are often very comfortable giving advice to other people we care about. We can easily say, "You really shouldn’t smoke", or 'You need to better manage your stress." However, when it comes to us, the advice is often lost. Although you may be able to say to yourself, "I really should be exercising." You may also follow-up up with excuses that gives you permission to continue with the behavior. It is important that you listen objectively to what you are saying to yourself and then correct the self talk.

Beliefs about Immediate Benefits

We are unlikely to change our behavior unless we believe that there will be an immediate benefit to our health. Telling somebody to monitor the amount of saturated fats in their diet when they are not currently experiencing any medical concerns is unlikely to yield a change in behavior. Behavior change needs to be anchored to improvements that can be experienced now.

• Visualize yourself benefiting from the changes: If you are quitting smoking or improving your diet, visualize your arteries with blood flowing freely without the clogging effects from unhealthy behaviors. Imagine your heart pumping at a regular comfortable rate without having to work so hard.
• Remind yourself that you are making the right choices: For example, tell yourself as you exercise that you are lowering your cholesterol, keeping your weight down, and improving the overall functioning of your heart.

Beliefs about the Costs of Making a Change

When we are confronted with information about our health and the changes we need to make, a couple of thoughts usually come to mind. First, we begin to weigh the benefits of eating a healthy diet versus the loss of eating whatever you want. For example somebody who perceives that the benefits of eating a healthy diet includes marginally improving heart health but the cost of changing the diet that involves depriving oneself of "good foods," is "expensive" and "an inconvenience to family" is unlikely to stay motivated. The cost of the change clearly outweighs the benefits.

How do you view changes that you need to make in your life to improve your health? Try to do a cost-benefit analysis for yourself. Notice the language that you use and then honestly assess how real you believe the health risk of is for you and what cost you perceive yourself having to pay for your health.

Self Confidence

Do you listen to a health message and find yourself acknowledging that, while it makes sense, deep inside you’re thinking, "I could never really do that."

Confidence is built when we are able to have several small measures of success in high-risk situations. So if you notice that resisting high-fat foods is particularly difficult for you when you’re dining out with friends, then small improvements will be felt as success to be built upon. This will improve your confidence and commitment to sticking with your healthy behavior.

Environmental Cues

Many of the motivating factors we’ve talked about so far involve changes that you need to make inside yourself. There are also environmental changes you can make to support your efforts to change unhealthy behaviors. Surrounding yourself with cues to remind you of our commitment to change and help you sustain changes can be quite useful.

• Surround yourself with supportive people who share your commitment to a healthy lifestyle.
• Keep healthy foods readily available to you.
• Establish an exercise routine with a partner.
• Keep a list of your priorities and the amount time committed to each task as a reminder of your improve time management techniques.

Humor can be one of the best stress relievers. Scientifically, laughter has been shown to release endorphins---the body’s own natural pain killer and feel-good chemical. From a physical standpoint, laughing is like an aerobic exercise. Researchers have shown that one-hundred good belly laughs have the same health benefits as fifteen minutes on a stationary bicycle. Laughter has also been shown to strengthen the immune system so it can fight off viral and bacterial infections. Good, solid laughter can even increase the natural killer cells of the body that destroy abnormal precancerous cells. Laughter really is good medicine.

From an emotional standpoint, using humor can be a good coping strategy. When you laugh about something, you can momentarily forget your tension, and your body automatically relaxes. Humor can also give you a fresh approach to life’s daily stressors.  It can help you keep a sense of proportion and perspective about situations in which you find yourself. After all, there will be many things—other people’s action or life events---that will be out of our control.

Humor can bring enjoyment to life and dramatically interferes with thoughts and feelings of depression and anxiety. Have you ever noticed that when you are laughing the tension of anxiety fades and levels of sadness can be lifted? 

People who laugh often are usually more social, pleasant to be around and report feeling less physical and emotional tension. Patients who use humor to cope with medical conditions report that it feels like taking a break from worry, pain and fear. This distancing can help you take a break from your current distress while at the same time mobilizing your coping resources for your future coping needs.

Managing stress is critical to your health.  Stress has been shown to be an independent risk factor for heart disease and it reduces the effectiveness of the body’s immune system. This compromised immune function puts you at risk for developing numerous chronic diseases.

So, take care of your health and go ahead and laugh.

Lori Stevic-Rust, PhD

Medical Director, Lake Health’s Integrative Medicine Program

Reforming and improving healthcare is the focus and challenge of the future. In response to some of these challenges, a holistic approach to healing has begun to spread to major universities, hospitals, healthcare agencies and medical schools.This holistic approach, known as integrative medicine acknowledges that healing is about addressing the mind, body and spirit of the person.

Integrative medicine is a model of integrating care from the best conventional medical protocols with complimentary therapies such as acupuncture, healing touch (an evidence-based modality used by nurses to manage pain, wound/fracture healing, etc), massage and music therapy, yoga and wellness coaching for support with life style changes. The efficacy of these therapies have been widely studied with conditions ranging from gastrointestinal disorders, cancer, heart disease, stroke, Alzheimer’s disease and stress related to medical illness and surgical procedures as well as pain management post-operatively.

The American Hospital Association reports that there has been a significant increase in hospitals offering complimentary therapies with only 8.6% in 1998 to almost 25% in 2004 with an additional 24% reporting plans to add services in the future. It has been reported that patients who use integrative medicine programs in a hospital are more likely to rate their overall experience higher.

The growing trend and appeal of integrative medicine appears to be coming from the consumers dissatisfaction with the current healthcare system including feeling rushed through appointments and viewed only as their disease or illness, e.g., the breast cancer or the diseased kidney. They want to be viewed in whole as the person with the disease. Healthcare providers are also embracing integrative medicine as a way to reduce their feelings of being overwhelmed and rushed in providing care under the current healthcare system.

At Lake Hospital System, we are committed to a holistic approach to healing. Subsequently, we have introduced integrative medicine services to our existing hospitals with plans for expansion to the new Tripoint Medical Center, which opens October 21, 2009. We are committed to providing a healing experience from the calm color choices, soft lighting in the rooms and hallways to the music and massage therapy that is offered as a complimentary service. In addition, our nursing staff is being trained in healing touch, an energy-based approach that uses the hands with gentle touch to enhance the caring and healing experience. Acupuncture, yoga, dietary counseling, massage and stress management will be offered in our new outpatient facility that will open with Tripoint.