By Chuck Gebhardt MD
This is the rough draft of Part 1 of a book I am writing. I am publishing it here for anyone who might be interested in helping me improve it. This early release may also be of value to some readers even in this preliminary form. If you read this, I would greatly appreciate any comments that you are willing to share with me. I am particularly interested in hearing about anything that is confusing or in need of clarification. I would also like to hear about anything that you find particularly interesting or about which you would like to read more. My preferred way to receive these comments is by email to email@example.com. Thanks!
You may also be interested in what I am currently working on in my writing of this book:
Tentative title for the book: The Power of the Human Mind
Part 2: A Ray of Hope for the Terminally Ill
Part 3: Coping with the Loss of a Loved One
Part 4: Answers to Life’s Big Questions (These will be my answers, of course, based on the
Contents of the first 3 parts.)
(Updates will appear here as I edit or add new material. Most recent update: 5/3/23)
A word of caution: Prescription medication dosages and timing should not be changed except under the supervision of a clinician with the training and experience required to prescribe them. If the use of any of the strategies or techniques recommended here decrease the need for prescription medications, the effect will develop very slowly and will allow plenty of time to adjust dosages based on the monitoring of the responses to be expected from the medication’s use.
Over the last few decades, a body of research findings has been developed that will eventually help to greatly improve our system of healthcare. We will become much less dependent on the pharmaceutical industry to help control the many chronic diseases that develop as we age. In addition, instead of the rapid increases in healthcare costs that we have become accustomed to, we will begin to see decreases in these costs. The new understanding from this research will eventually lead to further increases in our life expectancy as we learn how to better prevent the chronic, disabling diseases which many of us now endure.
As of now, the potential for the improvements we will gain from this research initiative has yet to reach mainstream medical care. To some extent, this is because the research findings are pointing toward the need for a radical revision of the most fundamental theories on which our system of medical education and healthcare are based. Since the medical care industry is naturally very conservative, it will be slow to change. Perhaps more importantly, the changes are so radical that there is a lot of resistance to the new ideas and revised understanding that are often in conflict with what modern medical scientists still believe and teach.
Fortunately, you do not have to wait for our system of healthcare to catch up with these research findings before you can begin to take advantage of them in your life. In this article, I will provide an overview of the research findings so you can see how the claims I am making here are very strongly supported. The review of the research findings will also serve as an introduction to an expanded awareness of the root causes of chronic human diseases. For those interested in reading some of these reports, I will also be providing some of the references to the research findings I will be summarizing.
While what follows in the next section is only a brief summary of hundreds of research reports, it will still require enough time for you to carefully review it in order to gain a fairly firm understanding of the new insights that are now emerging. This time should be well spent since this understanding will be very helpful if you begin to try the strategies and techniques that will follow.
However, these strategies and techniques are simple enough and easy enough to use that you can still effectively try them without first reviewing the research on which they are based. If you want to bypass this theoretical orientation, the self-hearing strategies can be found toward the end of this article.
Research Investigating How Emotional Trauma Impacts Health
In the mid 1980’s, Vincent Felitti MD, was helping patients in an obesity treatment program for the Kaiser Permanente HMO in California. He made two important observations of the people he was treating. First, he noted that some of the most successful patients dropped out of the program, rejecting the strategies that had been effective, and regaining the weight they lost. He also noticed how many of his obese adult patients had reported being abused as children, reporting these experiences much more often than his normal weight patients. To explore the implications of these observations, he interviewed 286 of his patients in depth and these interviews supported his impression that overeating was often a partial solution to emotional problems that started when they were traumatized as children. For the successful patients that dropped out, it was often because their excessive weight gain was only a symptom of deeper problems, and weight loss did not solve them.
Then, in 1990, he presented a report on these observations at an obesity conference. After this presentation, Robert Anda MD, who had been researching the connection between depression and heart disease, suggested that they collaborate with their research. Dr. Anda proposed a formal study of Kaiser Permanente patients that would expand Dr. Felitti’s investigation to include the relationship of childhood trauma to the emergence of a much larger number of emotional and physical health problems later in life.
The research team developed a 10-question survey to measure what they called “adverse childhood experiences,” and they named it the “ACE questionnaire”. (this can be found in Appendix 2 at the end of this article) They then enrolled 9,508 Kaiser Permanente patients in their research project who had easy to access and well documented medical histories. This rich source of personal historical information allowed them to readily compare the survey results with each research subject’s adult medical history. They were very surprised to find that that not only were trauma exposures a lot more common than expected, the relationship of these traumas with illness later in life was much more powerful than they would have imagined. These findings were ground-breaking. Prior to this study, early-life traumas were not considered as potential causes for adult disease.
This conclusion has such wide-ranging and important implications that other research teams were encouraged to begin their own independent investigations of these relationships. The findings from the ACE studies have now been well-replicated and confirmed in many other studies, including surveys in other countries and racial groups. This ongoing research has not only continued to confirm the initial reports, it has also greatly expanded our understanding of the various factors involved
Before looking at the relationships between early life trauma and problems later in life that the Adverse Childhood Experience Study found, I will briefly summarize the categories of distress the ACE questionnaire used. There were three categories of childhood abuse included: psychological abuse, physical abuse and sexual abuse. There were four categories of exposure to household dysfunction included: substance abuse, mental illness, physical violence and criminal behavior. They were all weighted the same so that the ACE score could range from zero to seven.
These research studies have shown that there is clearly something about early life distress and trauma that is carried forward into later life and continues to disrupt the comfort and peace of mind of those who have endured these experiences. The original ACE study found that these seven categories of adverse experiences were additive in their impact on later life emotional states. This additive nature of these different kinds of trauma produced what is often described as a “dose-response” relationship between the total number of different kinds of traumatic experiences and the risk of developing various kinds of chronic emotional discomfort such as depression, anxiety, insomnia, and a lack of self-confidence.
While the total number of early life trauma experiences show the same relationship with many different kinds of later emotional symptoms, I will focus here on depression as an example. As the number of ACE’s reported from the survey increased for study subjects, the likelihood of developing depression later in life increased in a graded fashion. For instance, for those with no history of abuse or distress reported in the ACE questionnaire, the risk of depression later in life was 14%. For those with a total of 4 or more categories of adverse experience reported, the risk of depression increased to 50.7%. This amounts to a 260% increase in the risk of depression for those with 4 or more ACE’s reported compared to those with none. Other research studies have not only confirmed these findings for depression, they have shown that other kinds of chronic emotional discomfort, such as anxiety and insomnia, are also strongly associated with adverse experiences in childhood.
Since the consequences of early life trauma are found decades later in adult life, they clearly have an enduring, negative impact. For many of those who have been traumatized, these effects persist across the lifespan. What is it about the experiences of trauma or prolonged emotional distress that is so likely to become embedded in the emotional make-up of the traumatized individual throughout the rest of his or her life? We can look to brain imaging studies of people with a history of ACE’s for a clue. While I will not get into the details at this point, brain imaging studies show specific changes in the structure and function of the traumatized individual’s brain that are clearly associated with these detrimental experiences. Whatever it is that is happening, it becomes recorded within the neuronal structure of the brain.
In the next step of my description of an ongoing chain of consequences from adverse early-life experiences, I will describe what the ACE studies have shown us about how adverse are often associated with self-destructive behaviors and habits. To start, consider how often the advice of health care workers, friends, and family members results in people stopping the abuse of alcohol, quitting smoking, or avoiding the use of illicit drugs? Clearly, advice is nearly useless and even the threat of going to jail or developing diseases like lung cancer or cirrhosis of the liver are rarely enough to stop these self-damaging habits. Why are people so resistant to stopping habits which have frequent, deadly consequences? The ACE study and similar research reports may be starting to provide much better answers than we have had in the past.
In a manner very similar to how the risk of emotional problems dramatically increases with a history of trauma and detrimental experiences, poor life-style decisions are also strongly associated with these adverse experiences that happened earlier in one’s life. The number of ACE’s reported in the survey were strongly associated with cigarette smoking, alcohol abuse, the use of illicit drugs, obesity, a sedentary lifestyle, and sexual promiscuity. The likelihood that someone will engage in these detrimental habits also shows the same kind of dose-response relationship as was found with chronic emotional discomfort. As the number of ACE’s increase, the likelihood of someone acquiring these detrimental habits also increases.
If we select the alcoholism as an example, those with no ACE exposures were found to have a 2.9% risk of being an alcoholic when they were surveyed as an adult. In contrast, for those with 4 or more ACE’s reported, there was a 16.1% risk. This means that someone with 4 or more ACE’s is 455% more likely to become an alcoholic than someone with no ACE’s. And, just as we found for the chronic emotional discomfort that was associated with adverse earlier experiences, all the different kinds of detrimental lifestyle choices increased with the total ACE burden.
When I first read the results of the original ACE research reports I found the strength of the associations between childhood trauma and both later emotional problems and poor life-style choices to be surprising, but they were understandable for someone raised in an environment with poor role models and parenting. It was the association between childhood trauma and adult physical disease, though, that startled me and really caught my attention. In the past, when medical scientists investigated the risk factors for physical illness, traumatic early life experiences were not something that was considered to be at all pertinent to explaining why diseases like cancer, heart disease and diabetes develop. My medical school professors never mentioned it, and even today, it is just beginning to show up in the medical literature. My careful and extensive review of the research studies that followed the original ACE study report, though, clearly confirms the ACE study findings. We now know, beyond any doubt, that emotional trauma is a potent risk factor for physical illness.
For example, In the original ACE study, 3.7% of adults with no history of childhood trauma were diagnosed with ischemic heart disease. But of the adults with 4 or more categories of trauma in childhood, 5.6% had ischemic heart disease. This means that this disease was about 50% more likely to develop in those who were very traumatized as children. Cancer, diabetes, stroke, COPD, and liver disease also showed a similar dose -response pattern between the number of trauma categories found in the survey and the risk of these diseases.
These results tell us that emotional trauma in childhood, as measured in the ACE study survey, confers risk that adds to that of the traditional risk factors, like genetic inheritance and exposure to toxins, that medical researchers have focused on in the past. Even when statistical techniques are employed to control for these well recognized risk factors, childhood traumas still remain as potent factors helping to further explain who will eventually develop these chronic diseases. In fact, a history of emotional traumas is more powerful in predicting illnesses later in life than all of the traditional risk factors combined!
Another way to confirm these surprising findings is to look at the lifespan of the people with emotional traumas in their childhood, comparing their accumulated trauma burden to their risk of early death. When people from the original study were followed over the next ten years, the lifespan of those with no traumas was 79.1 years. In contrast, those who had reported six or more trauma categories in their childhood, on average, lived only 60.6 years. Incredibly, those with no trauma exposure reported on the ACE survey lived almost 20 years longer than people with a heavy trauma burden from their early life. This is exactly what we would expect to find if early life traumas dramatically increase the likelihood of serious medical illnesses.
Just because the ground-breaking research focused on childhood, though, does not mean this is the only period in our lives that these experiences produce long-term damage. It is now clear from the existing research literature that emotional trauma at any point in life has a negative impact on our future emotional and physical health. It is also clear that this impact is additive and cumulative. For instance, studies of soldiers who were surveyed for a history of childhood traumas prior to their wartime tours of duty found that prior trauma histories can predict which veterans are most likely to develop depression and PTSD after returning to civilian life. Further confirmation of the additive and progressive nature of the consequences of emotional trauma can be found in research studies that have looked at how the structure of the brain changes after trauma. The typical changes in certain areas of the brain that are associated with trauma in childhood not only tend to remain throughout later life, later traumatic experiences add to and increase these abnormal patterns.
It has also been found that the increased risk of long-term damage is not limited to the kinds of distress surveyed in the original ACE questionnaire. For example, studies of children who have been bullied show the same kinds of brain changes and the same kinds increased risks of emotional and physical diseases as those found in the original ACE study. Wartime traumas, the loss of loved ones, and being exposed to pervasive social prejudice have also been found to be potent risk factors for later emotional and physical illness as well as a higher risk of early death.
We can summarize these research findings by concluding that all kinds of traumatic experiences, at any time in life, can have these negative consequences for both our emotional and physical health. The more intense the distress, and the longer this stress continues, the more damage that is likely to result. This is comparatively new information that has not yet changed how the medical profession deals with chronic disease. We need an updated understanding. To help clarify the messages of this new research, I will contrast what it is telling us with what most physicians and medical scientists still believe as I write this in 2023.
Medical scientists have long viewed the human body as an amazingly complex organic machine. For several centuries now, scientists have been accumulating ever greater details about our body’s structure, its metabolic processes, and its genetic inheritance. Aa a consequence of this focus on the physical functions of human body, we have come to view human disease as predominately due to disruptions of the highly complex physical mechanisms of the body and we have catalogued and named thousands of diseases associated with these disruptions. Also, as part of this analysis of how human diseases develop, we have assumed that each of these named diseases has a unique set of physical, causative factors. Almost all modern medical research centers on investigating the physical factors that are believed to produce disease and with finding effective medications to help bring the disrupted metabolism back into balance.
While this approach to understanding human disease has been extremely effective in treating acute illness, it has left us with important unanswered questions concerning the nature of chronic, progressive illnesses. For example, there is a large explanatory gap in our ability to predict who will develop chronic disease later in life. The already identified and recognized physical factors explain less than half of the risk. In addition, the huge number of research studies to date, and the larger number of medications that have been developed, have failed to stop the progression of many of the most serious chronic illnesses we face. The strategies and the medications we empl0y do slow their progression, but the underlying disruption tends to still increase over time, often requiring ever more medications to be added to maintain reasonable control of abnormalities of levels of things like blood sugar and blood pressure.
This large gap in our ability to predict and prevent chronic disease, as well as our inability to stop their progression once they develop, are due to our failure to appreciate the true power of our mind and our emotions to either produce damage or promote healing. In the past, medical researchers have failed to realize how closely integrated our thoughts and emotions are with the metabolic processes and structural changes of our body. This body of research is showing us that while increasing our risk of developing chronic disease, emotionally distressful experiences also change the structure of the brain and the metabolic function of the body on a long-term basis. We often experience this damage as anxiety, depression, fatigue, insomnia, and other forms of chronic discomfort or distress. Eventually, the toxic effects of these emotional states and their metabolic derangements cause the body to breakdown and malfunction, resulting in chronic disease.
This leads to the key question that has motivated me to present this research and the expanded understanding of the causes of human disease that it supports: Can we reverse the damage once it has been acquired, preventing the cascade of destructive effects that usually follow?
Even though research reports like those based on the ACE questionnaire seem to indicate that adverse experiences and their undesirable consequences usually stay with us for the remainder of our lives, this does not necessarily mean there is nothing we can do about them. One indication is that not everyone who is exposed to childhood trauma suffers the long-term effects. There are circumstances that are somehow protective, even though exactly what they are remains to be better understood. Another indication is that there is now a large research literature that is documenting new treatment techniques which help to reverse the chronic emotional discomforts of anxiety, depression, insomnia, and fatigue, yet do not require the use of pharmaceuticals. While most of these have not yet been widely accepted and included in modern medical care, treatments that result in long lasting improvement in our emotional state are being shown to also improve our health, prevent disability, and extend our lives. See Appendix 1 for some of the references pertaining to this body of research reports.
In the remainder of this article, I will provide guidance for using some treatment techniques and strategies which have demonstrated the ability to improve the wellbeing of those that employ them while also normalizing disrupted metabolic parameters. Psychological benefits include greater peace of mind, increased energy and enthusiasm, increased self-confidence, and better sleep. Physical benefits include lower blood pressure, lower blood sugar, improved immune function, better memory, and prevention or healing of disease in general. Given these enormous potential benefits, you may be surprised by how much has been learned, by how little most clinicians know about it, and by how rarely it is being put into practice.
Using most of these strategies, though, will require a significant investment of your time and effort. Since most of them involve developing new habits that will slowly produce the benefits I am indicating, they will require patience and determination. But the improvements, once they begin, should be very long lasting.
Healing from the Disclosure and Sharing of Emotional Trauma
It is very clear from the extensive body of research already available that all kinds of emotional traumas or living through continuous distress causes damage to our sense of wellbeing and our health. This damage has also been found to be very likely to continue to accumulate for many years after these experiences. Some of the mechanisms through which this occurs are also becoming much clearer. It has been well demonstrated that the human brain structure changes in response to stressful events, and these long-standing changes stimulate the release of excessive stress hormones into the blood stream, causing disruption of the body’s protective regulatory systems. They often result in psychological problems like insomnia, anxiety and even depression. Chronic stress also raises our blood pressure, our blood sugar, and eventually greatly increases the risk that we will develop any number of serious physical ailments like heart attacks, dementia, and strokes. This cascade of damaging changes is usually unleashed by unpleasant life circumstances we all suffer from in one form or another.
Fortunately, there is also a lot of evidence showing that there are ways to prevent these harmful long-lasting injuries and to even help reverse the damage that is already in place. Very effective self-healing strategies are now readily available, and they can be used without any medical training. But, despite the availability of a lot of well-designed research studies showing the effectiveness of these strategies, very few people are aware that this research exists, and, as I write this in 2023, they are rarely being used. This does not need to be the case for you, if you are willing to seriously consider what I am saying here and give some of my suggestions a try.
I will start off by describing ways of disclosing and expressing unpleasant or distressing personal life stories that may still be impairing how well you feel and slowly but steadily impairing your health. If you ask yourself about what traumas and emotional angst you have experienced throughout your life, it should be relatively easy for you to start making a list. This is the kind of thing that the Adverse Childhood Experiences Questionnaire was targeting, as mentioned earlier. If you haven’t already, you might even take this questionnaire yourself, and use this as a starting point.
Once you have chosen an event, or a series of events to focus on, it will be helpful for you to know what to expect as you use this strategy. These events are often not disclosed to others, and we rarely give them much further thought, for a very important reason: they are usually unpleasant to think about or to discuss. This means that when you think about them, you will probably begin to feel some of the unpleasant emotions that were part of the experience when it first happened. Just be aware that these unpleasant feelings are what we are aiming to bring out and attempting to release. Just be aware that this process may bring out feelings like shame, guilt, anger, or frustration. While these feelings are just temporary, the stronger the emotions, the more important it is to begin their release. The intensity of these emotions will also serve as an important sign of your progress. If you are being successful in eliminating them, when you go back and think about the same events again, they will be less distressing, or they might even become free of the negative baggage they once held.
The process you are undertaking is designed to help you re-process destructive experiences and their meaning to you. As you have lived your life after these events, you have undoubtedly acquired many useful tools that will allow you to see what happened to you with greater understanding compared to back when they occurred. This means that it is very likely you will now have more compassion toward yourself and the others that were involved. If you have read the research findings I have provided about how the traumas we all experience are carried down through the generations, you know that it is people who are hurting that then go on to hurt others. This awareness may have given you another essential tool to assist with this process. Re-experiencing your hurtful stories in the light of greater compassion and understanding is what it is all about.
Probably the easiest, and least threatening way to begin this process, is to find fifteen or twenty minutes when you can be alone and not likely to be interrupted and begin writing about any trauma or very unpleasant experiences you have selected from your past. Once you have completed this, the research shows that you can still get lasting benefit from the process even if you just tear up and throw away what you wrote. But if you are comfortable doing so, it will be likely to be even more beneficial if you share it with someone you care about and who cares about you. That individual, or group of caring individuals, can also be an important source of valuable insights to help you in re-processing your traumas.
The most common way that researchers have investigated this strategy is to have their subjects write about or verbally disclose their traumas in four different 20-minute sessions. When they followed up on the effects of these disclosures by looking for helpful changes months later, they not only found very significant improvements in their subjects’ assessment of their feelings of wellbeing, they also found beneficial effects on their physical health. It is clear that the disclosures were effective since these benefits were not found in the carefully matched control groups that did not disclose their traumas. Even very objective measures of the experimental patients’ health, like blood pressure, blood sugar, and tests of immune function showed statistically significant improvements.
In many support groups, like those for people who suffer from multiple sclerosis, Lupus, or survivors of breast cancer, this kind of process of disclosure and re-processing is likely to happen naturally. Group members are very supportive of others who share their discomforts or disabilities. As you would expect, support groups, when carefully studied, also show significant in the improvements of the health of the individuals in the group when compared to those with the same illness who do not participate.
In summary of how to use these strategies, you simply write about or verbally express experiences that have been unpleasant or traumatic in your past. Just writing and not sharing is enough, but sharing with others who are non-judgmental and supportive is even better. Research has clearly demonstrated that disclosing these unpleasant experiences leads to feeling better about yourself, feeling better about the world you live in, and even improvement in objective indicators of your health.
You can review some of the scientific research on which my recommendations and conclusions are based by reading the references in Appendix 3 at the end of this article. In the next section, I will provide more simple-to-use and highly effective strategies with many of the same benefits.
Healing from Meditation and Focusing on Breathing
While there are a large number of research reports that demonstrate health benefits from engaging in a meditation practice, there are several obstacles that most people face when considering or starting to meditate. Probably the biggest problem is that meditation is often associated with specific religious and spiritual teachings that can easily be judged as conflicting with Judeo-Christian religious doctrines. While it is true that meditation started with ancient Hindu and Buddhist traditions, the research shows that the benefits that can be derived from meditation do not require accepting or believing in any religious or spiritual doctrine.
Another obstacle is the lack of training available in many areas to assist the learning of the skills needed. Much of the research that has demonstrated the healing potential of meditation strategies has involved groups led by experienced meditators. Several therapeutic strategies such as Mindfulness-Based Stress reduction and Mindfulness-Based Cognitive Therapy are becoming increasingly used, but they are still unavailable in many locations. If you are in treatment for psychological problems, and this kind of therapy is available to you, it is likely it will be of great benefit. For most readers, though, beginning meditation will likely be an individual effort.
In my experience, it is very common for people to tell me that when they have tried to meditate on their own they became frustrated and quit. Since the health benefits of meditation are so well supported by good scientific research, I have carefully explored what has been learned, searching for ways to get around the obstacles to meditation while still retaining its benefits. Here I will briefly describe what I found in a several year search for an easy to use, self-healing strategy, that also provides the benefits shown to result from more complicated meditation strategies.
In this search, I found a lot of research reports showing health improvements from what is called heart rate variability biofeedback (HRVBF). It is based on the beat-to-beat changes in heart rate which can be easily measured, analyzed, and compared to the presence or absence of disease. We are most familiar with this kind of measurement as part of the output of an electrocardiogram. In the usual EKG, though, only the average heart rate is reported, and it does not report much information about beat-to-beat changes in heart rate. But, it has been found that if you do longer measurements of the heart conduction patterns, and then do careful statistical analysis of the instantaneous beat-to-beat changes in heart rate that can be accumulated, you can then develop indices of heart rate variability (HRV) that are remarkably powerful in predicting both the presence of disease and the likelihood that disease will develop in the future.
We can measure our moment-to-moment changes in HRV with relatively inexpensive devices that provide us with indications that we are either improving and damaging our health and wellbeing. This is a form of biofeedback and the processes being developed are usually called heart rate variability biofeedback. HRVBF research has shown that techniques based on this technology can result in less anxiety, better sleep, less fatigue, and less pain. Along with these improvements in our mental state, we also find lower blood pressure, lower blood sugar, lower levels of cortisol in our bloodstream, and lower cravings for addictive substances like drugs, nicotine, and alcohol. Memory, ability to concentrate and reaction times can also improve.
Unfortunately, the use of HRVBF in clinical practice is still in its infancy and it is somewhat complicated. In order to gain the benefits from what it is showing us, I looked for ways to simplify its use. In exploring this technology, I found that using carefully controlled breathing rates provides much of the benefits the research has demonstrated. It turns out that precisely timing your rate and regularity of breathing is a very powerful way to improve your heart rate variability without the use of HRVBF devices and technology.
I have used the name “controlled breathing” for this self-help strategy Fortunately, apps that help you to precisely time and control your breathing rate are readily available for a free download on cell phones. Since there is no health risk involved, the technique does not cost anything to use, and the research clearly implies that it should be a powerful self-healing technique, I have used it extensively for myself and recommended its use to some of my patients seemed most likely to benefit. I have found its use to be remarkably effective. It may lower blood pressure and blood sugar with either less medication or no medication at all. It often helps people with insomnia. It also helps people to de-stress and calm their nerves. These are just the easy to access results that I have informally verified, but the research suggests that there are likely to be many others also.
As I have been using this controlled breathing technique, it has occurred to me that it is actually a simple kind of meditation that makes use of a continuous focus on the depth and duration of the breathing process. It provides many of the health benefits that have been found with other kinds of meditation while bypassing some of the biggest obstacles that can prevent people from adopting a meditation practice. Becoming comfortable with the use of this technique could also serve as a very useful introduction to meditation in general. Its only drawback is that it may take several weeks of its use to clearly see its benefits.
In summary to this section, if you already have an established meditation practice, or access to meditation training, there is strong research support for its health benefits. Otherwise, you might want to give controlled breathing an adequate trial since it provides many of the same benefits. Appendix 4 contains references for both the meditation and HRVBF research. You can find my guide to using a simplified Controlled Breathing strategy in Appendix 5.
Appendix 1: References for Research Investigating How Emotional Trauma Impacts Health
This is the original “Adverse Childhood Experiences” research report:
Felitti VJ, Anda RF, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Prev Med 1998; 14:245-258
Here are a couple large surveys that confirmed the original ACE report in other populations:
Bellis MA, Hughes K, et al. Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey. J Public Health 2015; 37:445-454
Llabre MM, Schneiderman N, et al. Childhood trauma and adult risk factors and disease in Hispanics/Latinos in the US: results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study. Psychosom Med 2017; 79:172-180
This research report, published in 2006, includes an excellent survey of what was known about the effect of traumatic experiences on changes in brain structure. In 2006 it was already conclusively demonstrated that traumatic experience is associated with long term detrimental changes in brain structure and function:
Anda RF, Felitti VJ, et al. The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci 2006; 256:174-186
This research study used a different survey to measure childhood sources of distress than was used in the ACE study, included a different population, and confirmed the dramatic psychological problems that were found in the ACE study:
McCauley J, Kern DE, et al. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 1997; 277:1362-1368
This research report uses the same database as the original ACE study, but goes into much more detail about the increased risk of ischemic heart disease and mortality form adverse early life experiences:
Dong M, Wayne GH, et al. Insights into causal pathways for ischemic heart disease: Adverse Childhood Experiences Study. Circulation 2004; 110:1761-1766
The ACE questionnaire covered many of the most common causes of early life trauma but not all. This report adds the damage caused by being bullied as one example of other traumas that impact health and well-being in adults:
Copeland WE, Wolke D, et al. Adult psychiatric and suicide outcomes of bullying and being bullied by peers in childhood and adolescence. JAMA Psychiatry 2013; 70:419-426
Appendix 2: The “Adverse Childhood Experience” questionnaire from the original research report
Finding your ACE Score
While you were growing up, during your first 18 years of life:
- Did a parent or other adult in the household often …
Swear at you, insult you, put you down, or humiliate you?
Act in a way that made you afraid that you might be physically hurt?
Yes No If yes enter 1 ———
- Did a parent or other adult in the household often … Push, grab, slap, or throw something at you?
Ever hit you so hard that you had marks or were injured?
Yes No If yes enter 1 ———-
- Did an adult or person at least 5 years older than you ever…
Touch or fondle you or have you touch their body in a sexual way?
Try to or actually have oral, anal, or vaginal sex with you?
Yes No If yes enter 1 ———-
- Did you often feel that …
No one in your family loved you or thought you were important or special?
Your family didn’t look out for each other, feel close to each other, or support each other?
Yes No If yes enter 1 ———-
- Did you often feel that …
You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?
Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes No If yes enter 1 ———-
- Were your parents ever separated or divorced?
Yes No If yes enter 1 ———-
- Was your mother or stepmother:
Often pushed, grabbed, slapped, or had something thrown at her?
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes No If yes enter 1 ———-
- Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No If yes enter 1 ———-
- Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No If yes enter 1 ————
- Did a household member go to prison?
Yes No If yes enter 1 ———-
Now add up your “Yes” answers: This is your ACE Score
Appendix 3: References for Healing from the Disclosure and Sharing of Emotional Trauma
These reports are just a few of the many research studies demonstrating the healing effect of disclosing traumas:
Smyth JM, Written emotional expression: effect sizes, outcome types, and moderating Variables. J Consult Clin Psychol 1998; 66:174-184
Radcliffe AM, Lumley MA, et al. Written emotional disclosure: testing whether social disclosure matters. J Soc Clin Psychol; 2010; 26:362-384
Smyth JM, Stone AA, et al, Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis. JAMA 1999; 281:1304-1309
Here are the two research reports about the benefits of group therapy, one concerning cancer and another concerning coronary heart disease:
Spiegel D, Bloom JR, et al. Effect of psychosocial treatment on survival of patients withMetastatic breast cancer. Lancet 1989; 334: 888-891
Ornish D, Scherwitz LW, et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998; 280:2001-2007
Appendix 4: References for Healing from Meditation and Focusing on Breathing
This is a review article that analyses the results of a large number of research studies showing that mindfulness-based meditations can improve depression, anxiety and other mood disorders:
Hofmann SG, Sawyer AT, et al, The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review. Journal of Consulting and Clinical Psychology 2010; 78: 169-183
This is another review article analyzing studies of mindfulness-based meditation to successfully treat substance abuse disorders:
Li W, Howard MO, et al, Mindfulness Treatment for substance abuse: A systematic review and meta-analysis. Journal of Substance Abuse Treatment 2017; 75: 62-96
Here are two studies selected from a large number of research reports showing that mindfulness-based meditation improves blood pressure at least as well as standard blood pressure medications:
Hughes JW, Fresco DM, et al, Randomized Controlled Trial of Mindfulness-Based Stress Reduction for Prehypertension. Psychsom Med 2013; 75: 721-728
Nejati S, Zahiroddin A, et al, Effect of Group Mindfulness-Based Stress-Reduction Program and Conscious Yoga on Lifestyle, Coping Strategies, and Systolic and Diastolic Blood Pressures in Patients with Hypertension. J Tehran Heart Cent 2015; 10: 140-148
Here are two studies showing that mindfulness-based meditation can improve blood sugar:
Kian AA, Vahdani B, et al, The Impact of Mindfulness-Based Stress Reduction on Emotional Wellbeing and Glycemic Control of Patients with Type 2 Diabetes Mellitus. Journal of Diabetes Research 2018; 45: 1-6
Rosenweig, S, Reibel DK, et al, Mindfulness-Based Stress Reductionis Associated with Improved Glycemic Control in Type 2 Diabetes Mellitus: A Pilot Study. Alternative Therapies 2007; 13: 36-38
Here are two review articles that analyze the results of a large number of research studies showing heart rate variability biofeedback and slow breathing strategies can improve anxiety, depression and insomnia:
Lehrer P, Kaur K, et al, Heart rate variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis. Appl Psychophysiol Biofeedback 2020; 45: 109-129
Zaccaro A, Piarulli A, et al, How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Frontiers in Human Neuroscience 2018; 12; 1-18
Here are two articles demonstrating objective improvement in lung function using heart rate variability biofeedback:
Lehrer PM, Vaschillo E, et al, Biofeedback Treatment for Asthma. Chest 2004; 126: 352-361
Lehrer PM, Vaschillo E, et al, Heart Rate Variability Biofeedback Increases Baroreflex Gain and Peak Expiratory Flow. Psychosomatic Medicine 2003; 65: 795-805
This is a research study showing that routine use of slow and regular breathing can decrease blood pressure and reduce the need for medications for this purpose:
Grossman E, Grossman A, et al, Breathing-control lowers blood pressure. Journal of Human Hypertension 2001; 15: 263-269
Appendix 5: Using the Controlled Breathing Strategy
“Controlled Breathing” is a name I adopted for my version of a very easy to learn and use, self-healing technique. It is based on research that has demonstrated a powerful healing effect from the use of heart rate variability biofeedback devices. Through careful review of a large number of these research reports, and my own experimentation, I discovered that a much simpler version of this strategy can be very practical for almost anyone to use, and this simplification retains almost all the benefits of the much more complex and sophisticated heart rate variability biofeedback techniques.
Well-designed scientific research studies have shown that repeatedly using breathing sessions during which you precisely control your rate of breathing can lessen anxiety, improve depression, and may improve or eliminate insomnia. The research also shows that its extended use may even lower blood pressure, lower blood sugar, improve breathing for those with asthma, and decrease joint pain for those with arthritis.
Why is precise timing so important? The researchers who have explored this question have found that certain very regular breathing rates resonate with various neurological and metabolic processes in your body. They have found that controlled breathing calms your nervous system by downregulating the sympathetic “fight or flight” system and lowering stress hormones. These beneficial effects are most potent during the breathing sessions, but they also carry over somewhat into the rest of your day. These sessions will be most useful if used for a few minutes every day, and with continued use the beneficial effects should slowly increase over time. While you might be able to see or feel some benefits immediately, to be able to clearly decide if these sessions are helping may require at least several weeks of continued use.
The most readily available way to use this technique is to download a free app on a smartphone that can be used to guide you to breathe at a precise, pre-selected breathing pattern. An app called “iBreathe” works well if you have an iPhone, and “Breathly” for an android phone. Once you have a good app downloaded, you should find the “custom settings” screen to set the inhale and exhale timing as well as any holds. It is the total duration of each breath that determines the important frequency of the session you are preparing to do. For example, you might set 5 seconds for inhale, 2 seconds hold between your inhale and exhale, and 5 seconds for exhale. The key number would then be a total of 12 seconds per breath. Most apps also allow you to pre-set the total duration of your breathing session. I recommend starting at about 5 minutes per session, but longer is probably even better, if this is practical. Once you start a session, each device will give you a shape, figure or cursor to guide you in precisely timing each phase of your breathing, and will stop the session when your selected total time is up.
After you have selected your custom settings on your app, you should select a time and location for your sessions. Most likely, you will want a private location and a time when it will be unlikely that you will be interrupted. I find that a reasonable way to start is to plan on a 5-minute session twice a day. I also recommend starting with 5 seconds inhale and 5 seconds exhale. In general, slower breathing rates are more potent, so you might want to add a second to your breathing settings every few days. As I mentioned earlier, it is the total duration of each breath that sets up the frequency to which the rest of your body responds, and it is the key number for determining the benefits, so add the longer time to either the inhale, the exhale or to the holds as you find is most comfortable and natural for you.
If you have trouble following the app timer when you first try it, it is likely that you are inhaling or exhaling too quickly. To get over this problem, you might want to try using what has been called “pursed lips” breathing. This means you will breathe through your mouth and close your lips down like when you blow out a candle. You can slow both your rate of inhaling and exhaling this way, and once you get used to slow breathing you may no longer need to use pursed lips. I find, though, that when I attempt very slow breathing rates, it is easiest for me to go back to the pursed lips method for a while until I get used to the slower rate.
Using controlled breathing for better sleep: If you consistently use this strategy for several weeks, you should find it easier to fall asleep and stay asleep. The longer you use it the better it should work. If practical, try to do your last session of the day just prior to sleep, so you are more relaxed and the session will shut your thinking off for at least a few minutes. Once you are well practiced with the technique, you can also use it without the app if you awaken in the middle of the night by counting the seconds to yourself silently (e.g.: one thousand one, one thousand two, etc.). When I wake up at night and have difficulty going back to sleep, I find I often fall back to sleep after about my third or fourth breath while using this slow breathing method.
Using controlled breathing to de-stress: To maximize the relaxing effect of this technique, you should aim to get used to breathing as slowly as possible (as long as the rate you are using is comfortable). Concentrating on very slow breathing usually stops you from thinking about other things while you are doing your sessions. Much of our habitual thinking is actually motivated by stress and worries, and this kind of thinking stimulates the release of stress hormones in our body. We feel anxious and our body is being slowly damaged by these stressful thought patterns. Using slow breathing sessions usually shuts off stressful thinking, calms your mind and heals your body. If you are often very anxious, try using 10 minutes of controlled breathing twice a day, for a few weeks, to be better able to clearly experience the benefits.
If you find yourself getting stressed by events at work or during a busy day and it is not practical to use the app, you might try just silently counting your breathing to yourself. People who do this after stressful events report feeling calmer very quickly. Correctional officers have reported great benefit when they face high levels of stress during their work in our prisons. Special forces soldiers, who also routinely face high levels of stress, have reported great benefit when using this kind of strategy to quickly recover their mental balance.
Using controlled breathing to lower your blood pressure: You could use the same approach that I recommended above (to de-stress) if you are trying to lower your blood pressure. About a year ago, my blood pressure was averaging about 152 over 95 and I was going to start blood pressure medicine. But after I read the research about how effective using heart rate variability biofeedback was for lowering blood pressure, I decided to try controlled breathing first. When I checked my blood pressure before and after doing 10-minute controlled breathing sessions, I found a significant and repeatable drop in my blood pressure. Over the next few months my average blood pressure slowly dropped. My blood pressure is now averaging about 112 over 70, without medications. To be safe, if you are on prescription blood pressure medicines, you should not adjust these without consulting your prescribing physician first.
Using controlled breathing to lower blood sugar: In a manner just like I suggested for managing stress and lowering blood pressure, you can try using controlled breathing to lower your blood sugar. Just like the improvements seen for insomnia, anxiety and blood pressure, there are also research reports showing that heart rate variability biofeedback lowers average blood sugar with continued use. In addition, people who have told me that they checked their blood sugar before and after doing controlled breathing sessions have reported the sessions produce drops in their readings. Although I do not yet have much data to demonstrate this, I suspect that continued use of carefully timed controlled breathing sessions will be likely to lower the medication requirements for those with diabetes. Again, to be safe, do not adjust diabetes medications on your own.
If you decide to give controlled breathing a try, here are several things to keep in mind. Since using some method to precisely guide the timing of your breathing is very important, use a smartphone app or a similar timing device whenever possible. And, while slower breathing rates are usually better and more effective, the research reports also indicate that it is possible that you might find a specific rate that does better than others that are either a little slower or a little faster. Pay attention to which rates feel best. Also, the longer you use this strategy, the more the benefits should accrue over time.
There are other ways to improve the effectiveness of controlled breathing sessions. One is to become skilled at very slow breathing rates. What I have found while exploring slower rates is that certain very slow rates (especially in the range of 18 to 20 seconds per breath) have much higher resonance with my heart’s beat-to-beat variability (as measured by heart rare variability biofeedback devices). This would suggest that the usual rates used by researchers, often about 10 seconds per breath, while very effective, may not actually be the most optimal.
Finally, there are research studies that indicate that including any statement that is positive, and feels good, will increase the healing effect of the sessions. One way is to add a brief affirmation about health or healing to be stated silently in your mind while doing each breath and following the timer on the app. Another is to use a favorite prayer statement or phrase from the Bible, or other sacred text, as an alternative to using affirmations.