The Epidaurus Project

The opening of the new Walter Reed National Military Medical Center (WRNMMC) in September 2011 marked a new era of holistic medicine in the U.S. military health system. An inspiring example of the “hospital of the future,” its whole-person approach to patient-care and state-of-the art facilities were informed by the Epidaurus Project, an initiative spearheaded by Institute Scholar Fred Foote, MD, to create a model healing environment for Wounded Warriors of the Iraq War as well as other service members. 

Envisioning a Model for Holistic Care

Launched in 2001, the Epidaurus project brought together civilian and military thought leaders to identify the core principles of patient-centered care and define the physical environment that would facilitate it.

Measuring Its Impact

A barrier to the widespread adoption of holistic or integrative medicine has been the lack of metrics to directly measure the whole-body effects of such interventions. As the Epidaurus principles were coming to life through the construction of WRNMMC, Dr. Foote turned his attention to evaluating the impact of the innovative care that Wounded Warriors and veterans would receive there.

With support from the Nova Institute (then The Institute for Integrative Health), in 2010, he convened a group of experts, including Scholar Dr. David Lary, to develop a set of scientific metrics for this purpose. Drawing on genomics, systems biology, and complex systems science, the working group developed five metrics, which Dr. Foote describes in an article published in Global Advances in Health and Medicine:

  1. The first metric (Esther Sternberg, MD, and Julian Thayer, PhD) combines heart rate variability, salivary cortisol, and neuroimmune biomarkers into a single expression to give a broader measure of allostatic load. Advanced mathematics, using successive mean difference and multilevel regression models, will be required.
  2. The second metric (Herbert Benson, MD, and colleagues) involves whole-genome transcriptional analysis to identify changes in gene expression associated with holistic therapies. In civilian populations, these investigations have shown meaningful changes in gene expression with mind-body medicine practice, including progressive activation as one moves from non-practitioner to novice to expert. Genes regulating mitochondrial energy utilization and immune processes are among the complexes involved.
  3. The third metric, Natural Language Processing (Ann Berger, MD, and Perry Skeath, PhD), uses artificial intelligence to analyze syntax and content of patient stories and self-reports to determine feeling states and propensities to action. Useful findings have been reported in various settings, including advertising and the analysis of suicide notes.
  4. The fourth metric, “star glyphs” (Jim Deleo, PhD), involves plotting patient indices as diameters on a circle, with the patient’s score represented as a dot on the line. Connecting the dots produces a geometric shape. Specific disease states may have characteristic shapes. Progression toward a “normal” shape, or fluctuation in a patient’s personal norm, can be captured by combining multiple time-sequenced glyphs into a film.
  5. The fifth metric, machine-based learning (David Lary, PhD), presents large data sets to an artificial intelligence program to identify nodes of meaning not apparent to the human observer. Our initial intent is to analyze de-identified records of patients with traumatic brain injury and post-traumatic stress disorder to establish more valid sub-groupings for these conditions. Afterward, “before/after” testing of specific holistic interventions can be pursued.

Putting the Metrics To Work

The Green Road Project is using three of the Epidaurus metrics to evaluate the healing effects of spending time in nature—specifically, on a woodland path traveled by Wounded Warriors and their families at Naval Support Activity Bethesda, home of WRNMMC. This wheelchair accessible route allows people to cross campus through a tranquil sylvan area rather than on busy roads.

The project team hopes to scientifically demonstrate the positive impact of encounters with nature on human health. Objective evidence will advance the case for increasing community green space and making exposure to nature a therapeutic mainstay.

LEARN MORE

Article: Holistic Care in the US Military I – The Epidaurus Project: An Initiative in Holistic Medicine for the Military Health System, 2001-2012. Frederick O. Foote, MD; Roger J. Bulger, MD; Susan B. Frampton; PhD, and Edmund D. Pellegrino, MD. Global Advances in Health and Medicine. May 2012.

Article (abstract): The Epidaurus Project: Holism in Department of Defense Health Facilities. Frederick O. Foote, MD. Military Medicine. January 2012.

 

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Developing safety, persistence, trust

Healing is facilitated through safety, persistence, and trust.

  • Persistence: “People did not simply progress through this sequence and experience healing. The healing journey was a recursive, back and forth process. They found helpers, used the skills/resources that those helpers provided, found other helpers that provided more resources and used those skills and resources. As this process continued, people experienced a gradual amelioration of their suffering. Although many despaired at times, all demonstrated the quality of persistence—they refused to give up.”
  • Safety & Trust: “To connect to helpers, it was essential for people to feel safe in those relationships and able to trust that the person would be a helper and not a barrier to healing. Persons whose wounds included a violation of trust were especially careful about testing the safety of new relationships.”

Acquiring Resources

Resources support us as we heal. They include reframing, responsibility, and positivity. “Making connections enabled participants to acquire and refine resources and skills that were essential in their healing journey. People also brought their own personal strengths to the journey.”

  • Reframing: “A particularly important skill was the ability to reframe—that is to look at suffering through a different lens.” This does NOT mean minimizing trauma or pain, but rather it often means the opposite: understanding what happened was wrong, unfair, or uncontrollable and that we are not to blame for it.
    • “I think I kept trying to convince him I was crazy. And he kept saying, ‘No, you’re not crazy.’ […] You wouldn’t necessarily say a Vietnam Vet was crazy. You’d say they are responding like you’d expect to extraordinary circumstances.”
    • “I’m not the only one who have [sic] this problem. A lots, millions of people, you know. […] They don’t have nothing to do with that. I guess I have to live.”
  • Responsibility: While we don’t have control over what happened to us, we are the only ones who can help ourselves heal. “A third essential resource that people acquired or refined was the ability to take an appropriate amount of responsibility for their healing journeys. They participated actively in the process of healing. Once again, some participants already had developed this skill, and some acquired or refined it from their helpers.”
    “You need a lot of energy and a lot of work … it takes a lot of work. It doesn’t just happen. It’s not like a magic wand.” This patient understood that they had to actively participate in the healing process.
  • Positivity: “Another resource that people acquired or refined during their healing journey was choose to be positive—that is to have some optimism about their situation.” People have varying predispositions to positivity. In the study, positivity was important in helping people heal. This doesn’t mean a toxic positivity, but rather simply finding some good in life and feeling hopeful about our situations.

Helping Relationships

“Connection to others was an essential part of all the healing journeys.” Humans are social creatures, and even the most introverted of us need close relationships. Friends and family add meaning and value to life and help support us, in good times and bad. When we experience relational trauma, relationships can feel scary, but reestablishing safety and trust in relationships is where the healing happens. (To be clear, we do not mean reestablishing safety and trust with abusers, but rather finding other healing relationships.) “When safety and trust had been established, people were able to connect with helpers. The nature of the behaviours of helpers that fostered healing ranged from small acts of kindness to unconditional love.”

  • “Moving from being wounded, through suffering to healing, is possible. It is facilitated by developing safe, trusting relationships and by positive reframing that moves through the weight of responsibility to the ability to respond.”
  • “Relationships with health professionals were among these but were not necessarily any more important to the healing journey than other kinds of helpers, which included family members, friends, spirituality and their God, pets, support groups, administrators, case workers and supervisors.”

Healing

Healing probably means different things to different people, but one definition that emerged from the study is: “The re-establishment of a sense of integrity and wholeness.” Healing was an emergent property that resulted from each individuals’ complex healing journey, a result of bridged connections between resources and relationships. Healing, in this sense, does not mean cured—none of the study participants were cured of their ailments—”but all developed a sense of integrity and wholeness despite ongoing pain or other symptoms.” In varying degrees, “they were able to transcend their suffering and in some sense to flourish.” When we begin to heal, we find increased capacity for hope, renewed motivation to help others, and are more able to accept ourselves as we are.

Suffering

Suffering is the ongoing pain from wounding. There is debate about whether or not one actually needs to experience suffering on the path to healing.

Wounding

Wounding happens when we experience physical or emotional harm. It can stem from chronic illness or by physical or psychological trauma for which we do not have the tools to cope, or a combination of those factors. “The degree and quality of suffering experienced by each individual is framed by contextual factors that include personal characteristics, timing of their initial or ongoing wounding in the developmental life cycle and prior and current relationships.”