The Futurist; Washington
Jun/Jul 1999

Responsible pleasures:
A doctor's prescription for what ails you

For a longer, healthier life, physicians may increasingly prescribe "responsible pleasures" such as artistry, sexuality, and satisfying work.

Good and caring physicians have always tried to supplement their classic medical (pharmacological) prescriptions with sensible advice for living. Recently however, empirical advice has advanced this common practice to a new level of scientifically based advice, or "behavioral prescriptions." For example, behavioral prescriptions that I offer my patients include participating in the arts (such as dancing, playing an instrument, or singing), enjoying nature, doing work that is meaningful and gratifying, engaging in responsible sexuality, and encouraging specific stressreleasing physiological behaviors such as crying and laughing.

Behavioral medicine is a growing trend. About one-half of premature U.S. mortalities are directly related to individually chosen health behaviors, according to the U.S. Centers for Disease Control and Prevention. Among the common behaviors that doctors routinely warn against are the abuse of tobacco, illicit drugs, and alcohol; doctors also advise patients to balance their diets, avoid excess animal fat, take in fewer calories overall, and exercise more. But much of this advice has come in the form of finger-wagging admonitions from a domineering physician/ father figure, so it is often ignored.

Now, a new relationship is emerging between doctor and patient. As patients demand a larger role in defining good health and deciding on treatment, they want doctors who will dictate less and educate more. Fortunately, doctors are now better able-and increasingly more willing-to advise patients on what to do, not just what to avoid. In this process, they often give their patients explicit "permission" and encouragement to embrace and enjoy life in new ways, to experience pleasure, and to have fun.

Stress-Reducing Behaviors

Pleasure is healthful because it is a form of stress relief. Modern medicine is gradually beginning to accept the full value of "stress-releasing techniques" such as crying (the weep response), laughing (the mirth response), hitting or kicking exercises (the strike response), and the arts (the creativity response). I have been "prescribing" these responses to my patients since the mid-1980s.

One patient of mine, an executive we'll call "Roy," illustrates the benefits of one such prescription for stress relief. Roy was taught from a very early age that "big boys never cry" and that to do so was a sure sign of weakness, embarrassment, and shame. During the several months preceding my encounter with Roy, his mother had died, his wife was diagnosed with breast cancer, his son was suspended from high school for stealing school supplies, and it was announced that the company division he headed was being sold.

Roy reported that over the previous month he had been having daily chest pain. A previously energetic and positive man, Roy was, I sensed, overwhelmed, somewhat depressed, and in need of significant psychological and possible medical intervention. During the interview, it became obvious that he wanted to share more with me, and tears began to well up in his flushed face. While I do not generally prescribe crying at the workplace, I told him that it was okay for him to cry in the medical department setting. This precipitated a 10-minute weeping episode.

Of course, crying in itself did not solve all Roy's problems, but it surely gave him some temporary relief from his tension; it also built increasing trust, added one more coping skill to his approach to stress management, and possibly increased his energy to carry on.

The Psychology of Health

One trend contributing to the rise of behavioral medicine is what I call "the democratization of psychiatry." Examples include growing acceptance of behavioral medicine as approved treatments for addictions to alcohol, tobacco, and (more recently) food-related compulsions. Cardiologists, rheumatologists, and other traditional medical specialists are also now applying behavioral medicine principles.

Dean Ornish, considered by some to be one of the leading experts in cardiovascular disease prevention and management, promotes the medical value of not only diet, but also meditation, social bonding, and group support. [Ed. note: See "Dean Omish's Way to a Healthy Heart" by Clement Bezold in THE FUTURIST April 1999, page 33.]

Influencing behavior and enhancing lifestyle quality are also central tenets of the wellness movement, and the major pharmaceutical companies are expressing a growing interest in using behavioral change as a supplement to pharmacological interventions, thus embracing a holistic or biopsychosocial model.
Psychiatric principles are even being applied in the field of physical fitness. Many personal trainers and athletic coaches now offer support and counseling that borders on psychotherapy.

Thus, the number of behavioralmedicine techniques now being widely used in many health venues demonstrates the enormous contributions that modern psychiatry has made to the redefinition of health itself. It is time to formally recognize and integrate modern professional psychiatric principles into all healthcare endeavors and to provide appropriate training of doctors.

A New Medical Paradigm: Optimism, Not Fear

Long-term behavioral change is likely to occur among individuals only after fundamental attitudinal shifts about oneself and personal growth have taken place. Thus, selfesteem, self-discovery, and personal growth also become extremely important. A fundamental shift needs to take place personally and culturally in regard to what I call "the paradigm of medical optimism."

Essentially, this paradigm is based on love of life, self-determination, and responsibility. By contrast, the traditional predominant medical paradigm of pathology and paternalism is based on a fear of death and a clinging to dependency and victimhood.

The paradigm of medical optimism views human beings as fundamentally good and recognizes that pleasure is not inherently "wrong" or "harmful." On the contrary, given basic emotional balance, human beings can-and should-engage in responsible pleasures that do not harm others or society. One new role of the physician is to give patients permission and encouragement to enjoy the bounties and beauties of life without guilt. Doctors must not fear writing these behavioral prescriptions, for they are very much a part of the emerging new role of health-care providers as educators, coaches, and counselors.

Rx: Pleasure

The paradigm of medical optimism requires including pleasureand its first cousin, creativity-into life as a prescription for total health.

Humans are blessed with an abundance of responsible pleasures, including touching, hugging, giving and receiving love and friendship, sleeping, engaging in responsible sexual activity, experiencing the beauty of nature and the arts, savoring wonderful smells and tastes, eating, participating in athletics, dancing, bathing and swimming, dreaming and daydreaming, experiencing the joy of childbirth, meditating and praying, engaging in intellectual pleasures, reading, being creative, solving problems, playing games, gardening, being appreciated, appreciating others, and many more that you could think of. I don't think any single one of these is harmful to you or to others unless it is engaged in excessively, and most of these cost very little money. Let's focus on just four specific responsible pleasures: laughter, the arts, sexuality, and work.

Rx Laughter: A Dose Of Daffiness?

Laughter, or what some call the mirth response, was popularized in the 1970s by a nonphysician, the late journalist Norman Cousins, author of Anatomy of an Illness. The book described his experience using laughter as an analgesic for ankylosing spondylitis.

Thanks to Cousins and a very few others who study the physiology of human laughter, we now have some data to cite. Most notable among the serious researchers in this field is Stanford University psychiatrist William Fry, who has studied the physiology of laughter, including its impact on blood pressure, neuroendocrine response, and respiratory effects. Other studies have looked at stress hormone changes during mirthful laughter and at the possibility of a positive relationship between humor appreciation and longevity. The recent Robin Williams film Patch Adams showed the positive impacts of a doctor literally clowning with his patients.

I suggest that the medical profession take laughter very seriously and that doctors not hesitate to prescribe its appropriate frequent use by their patients. Doctors could teach patients techniques that stimulate laughter, induce full-blown mirth responses, and measure the impact of laughter on health and longevity.

Rx Arts: Creativity and Enjoyment

The second responsible pleasure that I would like to address is the arts.

One female patient of mine, "Bonnie," was an overworked manager who was juggling the daunting challenges of a full-time corporate position requiring extensive travel with raising young children. During our medical interview, Bonnie said she had wanted to learn to play the cello-a lifelong dream. But she worried that this activity would represent yet another obligation to an already busy schedule rather than help her reduce stress. After reviewing her obligations to her work and her family, I felt that this activity would represent something she could do for herself and that engaging in the arts would be a relaxing and useful stress-management tool.

After a year of lessons and practice, Bonnie reported that her "cello time" had become a "lifesaver" to which she looked forward at least twice a week. When she chose to transfer to another company, her colleagues raised money for a "new cello" fund because they observed how much playing the cello meant to her and noticed her improved well-being since she began.

Some persistent clinicians and basic researchers in the creative-artstherapy movement have been exploring the arts' therapeutic capacity pioneering what some have now begun to call arts-medicine. Do aesthetic stimuli-sound, melody, rhythm, light, color, form, dance, words-have an impact on human physiology or longevity? Certainly, we all intuitively believe that engaging in the arts (either actively or passively) has an impact on the quality of life. Science is now validating our long-held beliefs.

While some studies are being conducted in all of the arts, the most mature of these sciences is musicmedicine. In more than 22 years of research at the International Society for Music in Medicine, studies of over 80,000 surgical patients have unequivocally demonstrated music's capacity to reduce anxiety and pain.

Other arts-medicine studies have explored such issues as immune functions and stress among musicians, the impact of music on weight gain of premature infants, improving patients' convalescence by enhancing the visual environment of healthcare facilities (the "room with a view" study), using creative writing to relieve the pain of upsetting personal events, and using dance or movement therapy for patients with cystic fibrosis.

Regrettably, little research has yet been done on the effect of the creative process or the arts on longevity. Needless to say, this new field of arts-medicine represents enormous opportunities to study the impact of aesthetic stimuli and artistic activities on human health and well-being.

Rx Sex: Ecstasy vs. Agony

The third responsible pleasure that I would like to discuss is sexuality, especially the experience of orgasm-undoubtedly one of the most pleasurable experiences in human existence. This is not surprising from an evolutionary perspective, given that the fundamental biological purpose for sex is to perpetuate the species. There is also evidence that sex is beneficial to our general health.

"Victor," another executive patient of mine, was highly energetic, successful, and motivated; he reported that his tennis game had improved significantly since he started letting out a grunt each time he hit the ball-a behavior observed among highly successful tennis professionals such as Monica Seles and Andre Agassi.

After congratulating him, I moved the discussion toward Victor's sexual satisfaction, which he reported had been less than ideal due to his own and his wife's fear that the four children in the house would detect the noises of lovemaking. Since the last of the four children had just gone off to college, I asked Victor to consider transferring his successful grunting techniques in tennis to lovemaking, in keeping with the natural desire to express great pleasure. Victor reported several months later that he felt more full of life and was eternally grateful for this very practical advice.

While no one has studied specifically the benefits of noisemaking during sex, a study published in the prestigious British Medical Journal in late 1997 found that men who had sex twice a week or more (i.e., "high orgasmic frequency") had a 50% lower mortality rate than men who had sex less than once a month.
Thanks to such courageous research pioneers as Alfred Kinsey, William Masters, Virginia Johnson, and others, human sexuality is now accepted as a subject of serious scientific inquiry capable of being mainstreamed into modern medical practice. The physiology of arousal, orgasm, and post-orgasm as it affects blood pressure, peripheral vasculature, heart and respiratory rate, endocrine response, and skeletal muscles is now well understood.

Among women, for example, it has been found that those who have at least weekly sexual behavior have estrogen levels about twice as high as their less sexually active contemporaries. Perimenopausal women (average age 49) with "weekly sexual behavior" were found to have fewer "hot flashes" and tended to age more slowly. And studies of arthritis and migraine headaches have demonstrated hours of pain relief after the relaxation and release associated with sexual activity and orgasm.

Within the bounds of responsible behavior, including an emphasis on a loving, monogamous relationship, if possible, I believe that many more physicians should be counseling and encouraging their patients to engage in more-frequent, responsible sexual behaviors. I am convinced of its health-giving properties.

Rx Work: A Meaningful Life

The final and probably most important responsible pleasure is work. Some people might find that to be an unusual choice for pleasure since many think of work as drudgery. As an occupational physician, however, I have found that those who are fortunate enough to achieve gratifying and meaningful work are probably experiencing a major health and longevity benefit. We already know the opposite-that acute and chronic work stress can negatively impact health, such as contributing to heart disease.

One classic American Psychological Association study that examined social factors in predicting life expectancy found that work satisfaction had the highest correlation with longevity. Based on my 22 years' experience in occupational medicine, I am convinced that those individuals who have achieved job satisfaction and meaning in their daily working lives and long-term careers fare significantly better from a health perspective than those who view work as mindless drudgery to be endured as a means to an income only.

It is incumbent upon all doctors to better understand issues relating to work satisfaction, then help people to redesign their individual and institutional lives. This could also ensure a healthier and more-productive future work force.

Making Life Worth Living

Given the now widely recognized profound impact of behaviors and attitudes on health outcomes, the future of behavioral medicine appears bright. Already, we are seeing creative changes in medical advice, such as taking "news holidays"-i.e., not watching the news-prescribed by noted alternative-medicine expert Andrew Weil.

Eventually, the central role of incorporating responsible pleasures into our lives will finally receive the recognition and further study it deserves. And we can all look forward to an exciting new era in health care in which a prescription of pleasure is as common, safe, and effective as a prescription for a bottle of pills.

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