This document summarizes a presentation on incorporating mind-body medicine techniques into clinical care for children and adolescents. It describes several techniques, including mindfulness, hypnosis, guided imagery and biofeedback. It reviews evidence that these techniques can help with conditions like irritable bowel syndrome, recurrent abdominal pain, asthma and chronic pain. It also discusses important "common factors" for effective use of these techniques, such as developing rapport, managing expectations, cultural adaptation, clinician effects, and using language strategically to create focused states and facilitate changes.

1. Mind-Body Medicine for Children
and Adolescents:
An Integrative medicine approach for
successful incorporation into clinical care
David K. Becker, MD, MA, LMFT
Clinical Professor, Department of Pediatrics
Osher Center for Integrative Medicine
Co-Director, UCSF Pain Management Clinic
University of California, San Francisco

2. Objectives
•Describe three mind-body tools appropriate for children
and adolescents
•Compare the evidence for different MBM tools for
children and understand the limitations in the data
•Describe the “common factors” applicable to
incorporating MBM tools into the encounter.

3. OUTLINE
• Self-regulation skills and Mind-body techniques
• The WHAT of mind-body techniques
• The HOW of mind-body techniques
• The “common factors”

4. I have no financial conflicts of interest to disclose

5. But I do have influences based on training and experience (biases
MD
Meditation
IM MFT
Mind-Body

7. • A complex set of mental capacities that
help with:
– Impulse control
– Emotion control
– Planning
– Self-reliance
– Socially responsible behavior
– Self-guidance of thought and behavior
• Fundamental to personality,
behavioral adjustment, school readiness,
and ability to cope & manage stress
• Control over oneself, by oneself
SELF-REGULATION SKILLS

8. Self-
regulation
practices
Mind-body
techniques
Routines (sleep,
meals, exercise,
regular activities)
Talking to
someone you
trust
Positive self-talk
Humor
Journaling
Yoga, Tai Chi, others
Meditation practice
Progressive relaxation/Body
Biofeedbac
Guided imagery
Self-hypnosi
CBT
Autogenic
Taking a break

9. Self-Regulation vs Mind-Body
Skills
Techniques that facilitate a person’s own abilities
to direct their behavior, modulate physiologic
changes in desired directions, and control their
thoughts…
…so they don’t cut in the front of the line at
Starbucks (self-regulation)
…for the purpose of symptom control, attaining
and maintaining health and wellness, and
improving functioning or enhancing performance
(mind-body skills)

10. •9 yr old boy with a cough
for 3 months
•11 yr old girl with a
cough for 3 months

11. WHAT HAPPENED?
• History
• Rapport (validation) - Attunement
• Assessment of Context, purpose, Goals, development
and competing interests (how medical do I need to be?
For whom?)
• Facilitating a Focused state of concentration
• Reframing
• Language
• Suggestion

12. MIND-BODY TECHNIQUES: Data
• Mindfulness
• Hypnosis
• Guided imagery
• Biofeedback

13. PEDIATRICS Volume 1 37, number 1 , J anuary 2016

14. • 53 patients 8-18 yrs
• FAP or IBS by Rome
II criteria for > 12 mo
• Hypnotherapy or
SMT
– Six 50-min
sessions over 3
months
• SMT: education,
dietary advice, extra
fibers, pain meds or
PPI’s. Plus 6 30-min

15. Vlieger et al. Hypnotherapy for FAP IBS: RCT.
Gastroenterology 2007.

16. Vlieger et al. Hypnotherapy for FAP IBS:
RCT. Gastroenterology 2007.

17. HYPNOSIS: Brain imaging studies
• Suggestions in trance selectively activate
specific perceptual neural systems
– Visual suggestions:
• changes in visual centers
– Altering pain suggestions:
• changes in somatosensory and ACC
• changes in subjective appraisal regions
– Post-hypnotic suggestions:
• changes in regions associated with higher
processes concerns with perception and valence
judgmentsLandry M, Raz A. Hypnosis and Imaging of the Living Human Brain. Am J Clin Hypn 2

18. • 22 children 5-18 yrs
with RAP by Rome II
criteria
• 4 weekly sessions
– Breathing exercise control
– Breathing and guided
imagery
• 70% vs. 14% ‘cured’
at 2 mo
– = < 4 pain episodes/mo with
no functional limitations

19. •Hypothesis: multi-modal psychosocial therapy
would be most efficacious.
•Strict inclusion criteria included control groups
•Neurofeedback most effective over simple
behavioral modification. Both of which
outperformed multi-modal psychosocial
interventions.

20. AND OTHERS…
• Progressive relaxation/Body scan
• Autogenics
• Yoga, Tai Chi
• Journaling
• Cognitive-behavioral therapy

21. Asthma Painful procedures
Tics/Tourette’s Pruritis (itching)
Chronic pain Sleep problems
Enuresis, Encopresis Sports performance
Habit problems

22. MIND-BODY: Data in pediatric population
• Mindfulness
• Hypnosis
• Guided imagery
• Biofeedback
• Others

24. BIOFEEDBACK
The use of electronic
equipment to measure
and then feed back
information about
physiologic processes
that can then be
voluntarily modulated
in a therapeutic
direction.
- Tim Culbert

25. THE BIOFEEDBACK LOOP
Computer processes
and presents back
Attend to and
Modulate the process
Sensory information
from patient

26. Guided
Imagery

27. CLINICAL HYPNOSIS
“Hypnosis is a state of awareness, often but
not always associated with relaxation, during
which the participant can give him- or herself
suggestions for desired changes to which he
or she is more likely to respond than when in
the usual state of awareness. Spontaneous
self-hypnosis may happen while reading,
listening to music, watching television,
jogging, dancing, playing a musical
instrument, doing tai chi, doing yoga, or
performing similar activities.”Olness K, Clev Clin J Med 2008

28. CLINICAL HYPNOSIS
• An altered state of consciousness…
• Usually, but not always, involving a state
of relaxation (which may or may not be
evident)…
• Facilitated by a heightened concentration
on a particular image or idea…
• During which language, images, metaphor
and/or dissociation are utilitzed...
• For the purpose of altering a symptom,
disease or physiologic parameter.

30. What is
mindfulness?

31. “the awareness that
emerges through paying
attention
in a particular way,
on purpose,
in the present moment,
and without judgment,
to the unfolding of
experience from moment
Jon Kabat-Zinn

32. Amy Saltzman:
“Mindfulness is spaying
attention, here and
now, with kindness and
curiosity, so that we can
choose our behavior”

33. •Mindfulness: State, Trait, or Intervention?

34. •9 yr old boy with a cough
for 3 months
•11 yr old girl with a
cough for 3 months

35. • Setup:
– Rapport and Alliance
– Empathic connections
– Expectations (Goals)
– Reframing/Locus of Control
– Cultural humility
– Contextual factors (“Mindset”)
– Clinician effects: cross-training adds to skill level,
situational adaptation
– Language use
• Created a focused state of concentration
• Created a space between stimulus… and
reaction
• Use of Metaphor and Suggestion
WHAT HAPPENED?

36. atlasofemotions.org

37. atlasofemotions.org

39. tickling
Light touch
sprain
migraine
broken bone
paper cut
neuritis
active arthritis Severe burn
Physical Psychologic
Social Spiritual
bump
pinch
Sleep/fatigue
Conditioning
Inflammation
Sympathetic arousal
Peer relationships
Academic pressure
Performance pressure
Anxiety
Resilience
ACE’s
Depression
Catastrophizing
Past illness experience
Meaning of illness
Values
Religious faith
Experience of Pain
Connection Outside
of Oneself
Family dynamics

40. •Crum A, Langer. Psych Schi 2007

42. • Mindset: The lens or frame of mind that orients us to a
certain set of expectations and [assumed] associations.
- Alia Crum, PhD

44. Fig 1.
The psychological and social
forces of healing are typically
viewed as in competition with drug
effects in placebo controlled trials
(top) but in everyday practice they
underlie all treatment effects
(bottom).
•Alia J Crum et al. BMJ 2017;356:bmj.j674
• ©2017 by British Medical Journal Publishing Group

45. PSYCHOTHERAPY: The Common
Factors
• Developed from psychology
research about what works in
psychotherapy
• Psychodynamic vs CBT vs
Relational vs Brief structured vs
Gestault vs Jungian…
• No clear winner
• So what factors are important?

46. World Psychiatry 2015;14:270–277

47. PSYCHOTHERAPY: The Common
Factors
Alliance: the bond, agreement about the goals and the tasks (of
therapy)
Empathy: identifying with the other by adopting his or her
perspective
Expectations: through explanation of the patient’s disorder,
presenting the rationale for the treatment, and participating in the
therapeutic actions.
Cultural adaptation: the explanation given for the patient’s
distress and the therapy actions must be acceptable to the patient.
‘Clinician’ effects: does is matter who the clinician is?
Treatment Differences: when empathy, structure and alliance
are there, it doesn’t matter what the modality is.
Adherence and competence: adherence to the protocol and

48. PSYCHOTHERAPY: The Common
Factors
• Alliance/Rapport
• Empathy
• Expectations
• Cultural adaptation
• Clinician effects
• Treatment differences
• Adherence and
competence
Larger effect sizes: Smaller effect sizes:

49. EMPATHY
• The complex process by which an individual can be
affected by and share the emotional state of another,
assess the reasons for another’s state, and identify with
the other by adopting his or her perspective
• Which is thought to be necessary for the cooperation,
goal sharing, and regulation of social interaction

52. EXPECTATIONS
• “In medicine, expectations can be induced verbally and then
physicochemical agents or procedures can be administered or not,
making the two components (creation of expectations and the
treatment) independent.
• In psychotherapy, creating the expectations, through explanation of
the patient’s disorder, presenting the rationale for the treatment, and
participating in the therapeutic actions, is part of therapy.”
• In MBM, context creates an opportunity for a focused state of
concentration, during which shifts in awareness, mindset, and
biological functions are possible.
World Psychiatry 2015;14:270–277

53. THERAPIST EFFECTS
• “Studies have shown that effective therapists (vis-a-vis
less effective therapists) are able to form stronger
alliances across a range of patients, have a greater level
of facilitative interpersonal skills, express more
professional self-doubt, and engage in more time outside
of the actual therapy practicing various therapy skills.”
World Psychiatry 2015;14:270–277

55. TREATMENT DIFFERENCES
• When empathy, structure and alliance are there, it
doesn’t matter what the modality is.
• “All therapies with structure, given by empathic and
caring therapists, and which facilitate the patient’s
engagement in behaviors that are salubrious, will have
approximately equal effects.”
World Psychiatry 2015;14:270–277

56. ADHERENCE AND COMPETENCE
• “It would seem logical theoretically that adherence to the
protocol and competence would be related to outcome.
That is, for cases where the therapist followed the
protocol and did so skillfully, there should be better
outcomes.
• However, this is not the case.”
World Psychiatry 2015;14:270–277

57. World Psychiatry 2015;14:270–277

58. The Common Factors: What’s
missing?
• Focused state of concentration
• Trance
• Mindfulness state
• Suggestion
• Guided meditation
• Language

59. How we talk reflects how we think,
what we believe, how we teach and
what we come to expect. -
Dan Kohen

60. The use of language
“Words are, in my not-so-humble opinion, our
most inexhaustible source of magic…
Capable of both inflicting injury, and
remedying it.”

61. THE THERAPEUTIC USE OF LANGUAGE
• Direct suggestions (softened):
– As you slow down the breathing, notice
how the calm feelings help you feel safe
and comfortable
• “You may want to start by relaxing the
muscles on your nose OR your toes OR
only you who knows!”
• Child: “I’m really scared!”
– “Yes, AND, you can start to…turn down your
scared dial as low as you want to go”
• Child: “I can’t do that!”
– “Yet!”

63. HOW DOES THIS APPLY TO MIND-BODY
TECHNIQUES?

64. The ‘Common factors’ of Mind-Body
Medicine
• Context:
– Attunement: Rapport and Alliance/Empathic
connections
• Cultural humility
– Expectations (Goals)
– Reframing/Locus of Control
– “Mindset”
– Clinician effects: cross-training adds to skill
level, situational adaptation
– Language use
• Creating a focused state of concentration
• Creating a space between stimulus… and
response
• Individualized use of Metaphor and

66. Healing “consists only in…
allowing, causing, or bringing
to bear those things or forces
for getting better (whatever
they may be) that already exist
in the patient.”
- Cassell, “The nature of suffering and the goals of
medicine”