Sotah 40a ~ Gratitude is Good for You

סוטה מ, א

בזמן ששליח צבור אומר מודים העם מה הם אומרים אמר רב מודים אנחנו לך ה' אלהינו על שאנו מודים לך 

When the chazzan says Modim, what does the congregation say? Rav said “we are grateful for the fact that that we are able to give thanks” (Sotah 40a)

Detail of cover from Thanks! How the new science of gratitude can maker you happier.  By Robert Emmons.  Houghton Mifflin Harcourt, 2007.

Much has been written in the social sciences about the effects of gratitude on a person’s physical and mental health. In the page of Talmud that will be studied tomorrow, Rav expressed a rather odd idea- that of all the things for which one could be grateful, the simple ability to be grateful was the most important of all.  Let’s turn to some of that scientific literature and evaluate Rav’s statement.

Gratitude Journals

In a review of the psychotherapeutic effects of gratitude, Robert Emmons from UC Davis and Robin Stern from the Center for Emotional Intelligence at Yale suggest that gratitude involves (a) affirming the “good things” in one’s life and (b) the recognition that the sources of this goodness lie at least partially outside the self. They note that in experimental studies, persons who were randomly assigned to keep gratitude journals on a weekly basis exercised more regularly, reported fewer physical symptoms, felt better about their lives as a whole, and were more optimistic about the upcoming week compared with those who "recorded hassles or neutral life events.” Rather than focus on complaints, they wrote, “an effective strategy for producing reliably higher levels of pleasant affect is to lead people to reflect, on a daily basis, on those aspects of their lives for which they are grateful.” The authors believe that gratitude is an effective psychotherapeutic intervention, which may "spontaneously catalyze the healing process.” 

“Clinical trials indicate that the practice of gratitude can have dramatic and lasting positive effects in a person’s life. It can lower blood pressure, improve immune function, promote happiness and well-being, and spur acts of helpfulness, generosity, and cooperation. ”

— Emmons and Stern. Gratitude as a Psychotherapeutic Intervention. J. Clin. Psychol. 2013. 69:846– 855

Letters of Gratitude

Keeping  a record of things for which you are grateful seems to have  psychological benefits. So does expressing that gratitude to others. Researchers from Kent State University studied the effects of writing letters of gratitude on three qualities of well-being: happiness, life satisfaction and depression.  They followed 219 people who agreed to write letters of gratitude for three weeks.  “Participants were…instructed to write non-trivial letters of gratitude to an individual to express appreciation for them. Participants were asked to be reflective, write expressively, and compose letters from a positive orientation while avoiding ‘‘thank you notes’’ for material gifts.  The researchers reviewed the letters “to insure the basic guidelines were followed”, and found that those in the letter-writing group had a significant improvement in their levels of happiness, which included feelings of gladness, satisfaction and fulfillment.  Compared to the non-writers, the letter writing group also showed and increased life satisfaction.  

“Gratitude appears to be a powerful and preexisting resource that when utilized can produce positive effects upon well-being.”

— Toepfer et al. Letters of Gratitude: Further Evidence for Author Benefits. J Happiness Stud (2012) 13:187–201

Finally, those in the writing group showed significant decreases in symptoms of depression over time and compared to non-writers. The authors concluded that “…writing letters of gratitude may have potential for alleviating depressive symptoms prior to more severe clinical depression. Further investigation is required before such claims can be made but the results are promising.” The study was published in the Journal of Happiness Studies. (Perhaps a subscription to this delightfully titled journal would make a good antidote to news in the papers lately. Put it on your Chanukah wish list.)

Effect of writing letters of gratitude - means for experimental and control groups on well-being variables and depressive symptoms. From Toepfer et al. Letters of Gratitude: Further Evidence for Author Benefits. J Happiness Stud (2012) 13:187–20. 

If you are looking for an entire book of the psychology of gratitude and appreciation, then you might consider reading Gratitude and the Good Life by Philip Watkins. In his review of the health benefits of gratitude, Watkins notes that “grateful people tend to be religious people.” Watkins emphasizes that religiosity is not a requirement for gratitude, and that there are many non-religious people who are very grateful. Nevertheless, “a number of religious variables show moderate to strong correlations with trait gratitude.” Which leads us to...

Gratitude to God

While there are health benefits to anyone who expresses gratitude, one study looked at the effects of expressing that gratitude to God, rather than to a person, in a paper published last year in the Journal for the Scientific Study of Religion. There were four authors: two from the University of Michigan and two from the Research Services arm of the Presbyterian Church. (Interestingly no conflict of interest was declared by any of the authors. Should being a member of a Church count as a conflict?) The authors of the paper, Gratitude to God, Self-Rated Health, and Depressive Symptoms, analyzed data from the US Congregational Life Survey and wrote:

 There are three reasons why feelings of gratitude to God may affect physical and mental health. First… gratitude is a positive emotion that arises from the pleasant feelings that are associated with receiving a benefit. Viewing gratitude as a positive emotion is important because a rapidly growing body of research indicates that positive emotions are associated with a range of beneficial physiological effects, including a lower heart rate, lower blood pressure, and improved immune functioning… Second, research… reveals that positive emotions, such as gratitude, are associated with the adoption of a range of beneficial health behaviors, including exercise and medication compliance…Third, research…indicates that people who feel more grateful to God are able to cope more effectively with the deleterious effects of stress....Consistent with earlier research, the results indicate that individuals who feel more grateful to God are more likely to rate their health in a favorable manner…and they are less likely to experience symptoms of depression.

The authorship of מודים דרבנן - A meditation on Gratiude

The Talmud (Sotah 40a) cites five different versions of what should be said when the chazzan recites the Modim prayer in the repition of the Amidah. Here they are:

סוטה מ, א

אמר רב מודים אנחנו לך ה' אלהינו על שאנו מודים לך

ושמואל אמר אלהי כל בשר על שאנו מודים לך

רבי סימאי אומר יוצרנו יוצר בראשית על שאנו מודים לך

נהרדעי אמרי משמיה דרבי סימאי ברכות והודאות לשמך הגדול על שהחייתנו וקיימתנו על שאנו מודים לך

רב אחא בר יעקב מסיים בה הכי כן תחיינו ותחננו ותקבצנו ותאסוף גליותינו לחצרות קדשך לשמור חוקיך ולעשות רצונך בלבב שלם על שאנו מודים לך

1. Rav: We are grateful to you Lord our God, for the fact that that we are able to give you thanks.

2. Shmuel: The God of all flesh, for the fact that we are able to give you thanks.

3. Rav Simai: Our creator, and the one who formed creation, for the fact that we are able to give you thanks.

4. The Nehardeans say in the name of Rav Simai: Blessings and praises to your great name for your having given us life and sustained us, and for the fact that we are able to give you thanks.

5. Rav Acha bar Yaakov: So may you continue to keep us alive and find favor in us and may you bring us together and gather our exiles to the courtyards of your sanctuary to observe your decrees and to do your will with a whole heart, for the fact that we are able to give you thanks.

Unable to decide between them, (and not wanting to hurt anyone's feelings,) Rav Pappa ruled that all should be said, (אמר רב פפא הילכך נימרינהו לכולהו)  which is what is done to this day. And this is one explanation of why this prayer is called מודים דרבנן  - it is a prayer of thanks of several rabbis.

As you no doubt will have noted, the one common thread in the five versions is that they all end with the phrase “for the fact that we are able to give you thanks.” As we have seen, evidence from the social sciences suggests that there are numerous health benefits associated with expressing gratitude.  Perhaps then, acknowledging the ability to express gratitude is acknowledging that on top of everything else, we are thankful for a way of improving our well-being. Expressing gratitude isn’t just a good idea; it might also improve your mental and physical health. That sounds like something worth doing three times a day.

“I would maintain that thanks are the highest form of thought; and that gratitude is happiness doubled by wonder.”

— G.K. Chesterton. A Short History of England, chapter 6.

Sotah 31a ~ What Can a Fetus See?

Happy anniversary to Talmudology. We are now a year old, and our very first post was about the viability of an eight month fetus.  The first post of our second year is also about the fetus.  This one concerns an aggadic statement, that is to say, a homiletic teaching, that is not to be taken literally - or so one would think.  In today's daf yomi the Talmud discusses the miracles which occurred as the Children of Israel crossed through the parted waters of the Red Sea. Rabbi Meir taught that even a fetus in its mother's womb praised God, saying "This is my God and I will glorify him." Now we might have considered this a homiletic teaching that is meant to simply express a degree of amazement and thanks.  But the Talmud then asks a question that suggests Rabbi Meir meant what he said more literally:

סוטה לא, א

והא לא חזו! אמר רבי תנחום כרס נעשה להן כאספקלריא המאירה וראו

These fetuses in the womb could not see the Divine presence, so how could they sing praise? Rabbi Tanchum said: Their mother's abdomen became as clear as glass for them and they were able to see.

While Rabbi Tanchum suggested that it takes physical sight rather than emotional insight to see the divine, it turns out that the fetus can see - and hear, while still in the womb.

Increased Fetal Heart Rate in Response to Light

In 1980, two Israelis published a preliminary report on the response to light of ten fetuses between 38 and 43 weeks' gestation. They inserted an amnioscope through the cervix and shone a light into the womb for thirty seconds while monitoring the heart rate of the little fetus. They found that eight of the ten fetuses had an acceleration of their heartbeat in response to the light. That's interesting you say, but hardly what Rabbi Tanchum was describing. And you'd be correct.  So let's turn to some other studies.

Increased Fetal Brain Activity in Response to Light

A review in the European Journal of Obstetrics and Gynecology and Reproductive Biology published in 1996 was sceptical that the fetus could see much of anything while inside the womb: 

In utero visual stimulation appears to be very limited...in a dark room the amniotic cavity may be candled with a torch light, especially in the case of a polyhydramnios [an excess of amniotic fluid]. Measurements performed during rat and guinea-pig gestation have demonstrated that if only 2% of incoming light was transmitted in utero below 550 nm, this value increases with wavelength of the signal to reach 10% around 650 nm. Thus, a limited portion of external light may reach the human fetal retina when eyelids are open (this behavior starts at 20 weeks) or through the eyelids. 

But in 2003 a group of researchers from the United Kingdom (with apparently nothing else to do for amusement) built a light source from a "cardboard tube lined with non-conducting aluminised plastic, resulting in a light intensity of 1,100–1,200 Lux at the maternal abdomen as measured with a hand-held light meter." After an ultra-sound confirmed that the fetus was looking forward (really, they did this too) they turned the light on and off. And all this took place while the mother and her in-utero child were lying in a functional MRI scanner, which was used to look for activation of the little fetal brain in response to the light. Of the nine subjects they tortured in this way, one could not be analyzed due to motion, three did not show any significant activation, and five showed significant activation. Oddly, none of the fetal brains that responded showed any activation of the occipital lobe, that part of the brain in which the primary visual cortex is located and which responds to light.  Instead, it was the fetal frontal cortex showed a response to the light being shone.  Hmmm.

The Fetal Response to Sound

So much for vision. Researchers have also studied what - if anything - a fetus may be able to hear.  A group from Rambam Hospital and the Technion in Haifa studied the effect of music on fetal activity. Back in 1982 they took twenty pregnant women and played them either 25 minutes of nothing, or 25 minutes of classical or pop music through headphones. If you are wondering, the music was either a canon and songs composed by Pachelbel or "the pop-hits of the [sic] Boney-M." (Give yourself an extra point if you can recall any of the pop hits of the Boney M.) Anyway, they played the music in random sequence and monitored the fetus for breathing and body movements.  They found that compared to no music, when music was piped into the mothers' ears there was a significant increase in the breathing movements of the fetus, but there was no difference between classical and pop music.  

“..it seems that the fetus moves into a more active state when music is played to the mother.”

— Zimmer, EZ. et al. Maternal Exposure to music and fetal activity. Europ. J. Obstet. Gyec. Reprod. Biol. 1982 (13) 210.

And remember the experiments with cardboard tubes shining light into the womb of forward facing fetuses? Well that same group also performed functional MRI scanning of the brains of a group of fetuses but this time they strapped "an MRI compatible headphone" to the maternal abdomen (or the maternal ears, as a control) and played 15 seconds of music. (The paper does not specify the kind of music that was chosen. I do hope it wasn't the Boney-M.) Five of the twelve fetuses that had music piped into their mother's abdomen showed activation of the temporal lobes, but despite this low number the authors enthusiastically concluded that their study showed "...that brain activity can be detected in response to stimulation prenatally..." 

“A ray of hope flitters in the sky
A tiny star lights up way up high
All across the land dawns a brand new morn
This comes to pass when a child is born”

— Boney M. When a Child is Born, 1981.

Giving Thanks - Thanksgiving

The Talmud describes how the Crossing of the Red Sea was a miracle of such extraordinary nature that even in-utero fetuses joined in singing a prayer of thanks with the Children of Israel. In his famous introduction to the tenth chapter of Sanhedrin, Maimonides describes how aggadah should not be taken literally. Instead, a deeper message should be sought. And so for our American readers, who celebrate Thanksgiving today, Talmudology leaves you with this question: what are you thankful for? For what blessings in your life might a fetus open its eyes and see, or say thanks while still in its mother's  womb? Now that I think of it, that's a question that everyone should answer.

Happy Thanksgiving.

“Human fetuses are, to a certain extent, able to memorize certain sensory properties...Despite the fact that they have only very short periods of wakefulness and that their brain is not mature enough to integrate sensory experiences, several experiments suggest that this does not prevent pre- and perinatal learning.”

— Lecanuet, J, Schaal B. Fetal Sensory Competencies. European Jopurnal of Obstetrics and Gynecology and Reproductive Biology 1996. 68: 1-23

Sotah 20b ~ Queen Esther, Mood, and Menstruation

There is a great deal of scientific work investigating the effect of the menstrual cycle on a women's mood. There has been less examination of the effect of mood (or stress) on the cycle.  In today's page of Talmud, there is a digression into gynecology and psychology, and specifically the role of psychological stress on menstruation.  

Queen Esther's Stress

סוטה כ, א

למימרא דבעיתותא מרפיא אין דכתיב ותתחלחל המלכה מאד ואמר רב שפירסה נדה והא אנן תנן חרדה מסלקת דמים פחדא צמית ביעתותא מרפיא

Does fright loosen the womb [and causes a woman to menstruate]? Yes, as the verse states (Esther 4:4) "...and the Queen [Esther] became very afraid" about which Rav explained:" she began to menstruate."

But haven't we learned elsewhere in a Mishnah (Niddah 39a) that fear suspends the discharge of menstrual blood? In fact, fear that is not sudden contracts [the womb and prevents bleeding], but sudden fear loosens [the womb and causes early menstrual bleeding].

Here are some of the things that the rabbis of the Talmud believed could induce menstruation:

1. Carrying a heavy load (Tosefta Niddah 9:1)

2. Jumping (ibid)

3. Sudden fright (Niddah 71a, and Niddah 39a)

4. Yearning for intercourse (Niddah 20b)

5. Garlic, onions and peppers (Niddah 63b)

In today's daf, Rav opined that fear can induce menstruation. Let's take a look at the medical literature and see whether or not it supports his assertion.

“Data from both animal and human research indicate that psychological stress is associated with altered menstrual function.”

— Barsom S, et al. Association between psychological stress and menstrual cycle characteristics in perimenopausal women. Women’s Health Issues 14 (2004) 235-241

The Effect of Stress on Menstrual Function

In a review from the Department of Biological Sciences at Ohio University, researchers acknowledged that stress is difficult to define. However, one final common pathway of stressors is the low availability of dietary energy. Ovulation - which is the first part of the cascade that leads to menstruation - has been blocked in hamsters "by food restriction, pharmacological blockers of carbohydrate and fat metabolism, insulin administration (which shunts metabolic fuels into storage), and cold exposure (which consumes metabolic fuels in thermogenesis)." Women athletes frequently experience a lack of menstruation, which is found in up to 65% of competitive young runners. But what about psychogenic causes of a disturbed menstrual cycle - after all, Rav taught that it was fear that caused Esther's presumably early onset of menstruation? While not adressing this directly, the Ohio University researchers had this to say about the relationship between psychological stressors and amenorrhea (the lack of menstruation. Remember that word - it will come up again):

Associations between psychological disturbances and amenorrhea or infertility have long been interpreted as a causal relationship, but prospective studies demonstrating that psychogenic factors contribute to reproductive dysfunction in women are almost completely lacking . Early psychoanalytic conclusions that psychological conditions underlie involuntary infertility in women have been criticized recently on several grounds: first, the same psychological conditions have been found in analyses of fertile women; second, other women with very serious psychic problems conceive with ease; and third, couples with an unfulfilled desire for a child do not show psychological disorders any more frequently than do couples without fertility disorders. Even the direction of causality is questionable, because there are grounds for believing that infertility and its medical treatment cause the depression and anxiety observed in some infertility patients. These findings have led to the recommendation that the term ‘psychogenic infertility’ should be withdrawn from use because it is simplistic and anachronistic.

Menstruation and Incarceration

Some of the rabbis viewed Esther's association with King Achashverosh as being coerced: she was brought to his palace against her will, and remained there in a similar state. So with only a bit of a stretch, we might turn to a 2007 paper published in Women's Health Issues which addressed the influence of stress on the menstrual cycle among newly incarcerated women.  Researchers analyzed 446 non-pregnant women who answered a number of detailed questions about their menstrual cycles.  They found that 9% reported amenorrhea (I told you what that meant two paragraphs ago) and that a third reported menstrual irregularities.  

“Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.”

— Allsworth J. et al. The influence of stress on the menstrual cycle among newly incarcerated women. Women's Helath Issues 2007; (17) 202-209.

As might be expected, the stressors of the incarcerated women in this study included drug and alcohol problems and sexual abuse. These are not the same stressors that faced Queen Esther - who was held in such esteem by her kingly husband that he promised her (Esther 5:6) "up to half of the kingdom."  But this work does show how stress may impact the menstrual cycle.  

A Longitudinal Study of Psychological Stress and Menstruation

The final study we will review comes from a cohort of predominantly white, well educated married women of whom 505 were "invited to participate join a special survey focusing on midlife and menopause." Rather than ask about stress and current menstruation, the researchers performed a two-year analysis. Here's what they found:

In analyzing stress levels and cycle characteristics across 2 years...women with marked increases in their level of stress (n 􏰸=30) are shown to have decreased length (􏰿0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (􏰿0.1 day/cycle) compared with increases in these measures (􏱀2.9 days/cycle for cycle interval; 􏱀0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n 􏰸=103); t-tests indicate that these differences are significant (p < .05).

Some of the differences that the researchers found in this group were really small - "0.3 days/cycle for duration of bleeding" but if you are into statistics this difference can be significant (that's what those t-tests are all about). But these statistical associations were not powerful, and the researchers concluded that "the results of this investigation...suggest that, in the long term, stressful life events have little relationship to the length of menstrual cycle intervals and the duration of menstrual bleeding in perimenopausal women."

The three studies we've reviewed (even that last one with its weak findings) all suggest that there is indeed some relationship between psychological stress and menstruation.  Generally, the effect of stress is to increase the length of the menstrual cycle which may result in amenorrhea.  But according to Rav, stress caused Esther to menstruate sooner - the opposite of most modern research findings.  Single events should be used with caution when trying to build a general explanatory model, but Rav, and the other rabbis of the Talmud were onto something when they noted that both acute and chronic fear (which is of course just one type of stress) -  can effect a women's menstrual cycle.  

Sotah 14b ~ Visiting the Sick

סוטה יד, א

ואמר רבי חמא ברבי חנינא מאי דכתיב אחרי ה' אלהיכם תלכו וכי אפשר לו לאדם להלך אחר שכינה והלא כבר נאמר כי ה' אלהיך אש אוכלה הוא אלא להלך אחר מדותיו של הקב"ה מה הוא מלביש ערומים דכתיב ויעש ה' אלהים לאדם ולאשתו כתנות עור וילבישם אף אתה הלבש ערומים הקב"ה ביקר חולים דכתיב וירא אליו ה' באלוני ממרא אף אתה בקר חולים

Rabbi Chama the son of Rabbi Chanina said: What is the meaning of the verse (Deut 13:5) "You should follow the Lord your God"? Is it possible for a human to follow the Divine?...The verse mean that you should emulate God's attributes. Just as he clothed the naked...you should clothe the naked. Just as Holy One, Blessed be He visited the sick...you too should visit the sick...

In this daf, Rabbi Chama teaches that visiting the sick should be performed because it's the right thing to do: after all, God himself is said to have visited Abraham as he was recovering from circumcision. But as we noted when studying the tractate Nedarim,  elsewhere the rabbis of the Talmud taught that visiting the sick actually aided in their recovery.  Here's a reminder:

נדרים לט, ב - מ, א

תניא ביקור חולים אין לה שיעור ... אמר אביי: אפי' גדול אצל קטן רבא אמר אפי' מאה פעמים ביום אמר רבי אחא בר חנינא כל המבקר חולה נוטל אחד מששים בצערו

יצא ר' עקיבא ודרש: כל מי שאין מבקר חולים כאילו שופך דמים. כי אתא רב דימי אמר: כל המבקר את החולה גורם לו שיחיה וכל שאינו מבקר את החולה גורם לו שימות

Visiting the sick is a mitzvah that has no limit... Abaye said that even an important person must visit a lesser person who is ill...Rava said: [you must visit a sick person] even one hundred times a day...Rabbi Acha bar China said: "Whoever visits a sick person takes away one-sixtieth of his suffering...

Rabbi Akiva expounded and said: "Whoever does not visit the sick, it is as if he sheds blood." When Rav Dimi came [from Israel to Babylon] he said: "Whoever visits the sick causes the person to live, and whoever does not visit the sick, causes the person to die." (Nedarim 39b-40a)

Visiting the Sick in the Modern Intensive Care Unit

Many years ago I visited the famous Grady Memorial Hospital in Atlanta, and was privileged to be given a tour of their new Neurocritical Care Unit, part of the Marcus Stroke and Neuroscience Center (and thank you, Bernie "Home Depot" Marcus).   While the unit has all the fancy equipment you'd expect, what impressed me the most was a feature I had not seen in any other intensive care unit (ICU): every patient room has an adjoining suite where a family member can eat, sleep, shower and wait (and there is a lot of waiting in ICUs). There are no visiting hours; the family member literally lives in the ICU with their loved one.  My tour guide explained that the unit sees the presence of  visitors as a way of offering the best care to the patient. It is a wonderful approach to the care of the sick - but it wasn't always like that.

A HISTORY OF VISITING THE SICK - IN HOSPITALS

Visiting times in hospitals still vary greatly, and many have an open door policy. But not too long ago, you might only be able to visit a patient in a hospital for a couple of hours each week. In the 1870s, Doncaster Royal Infirmary in Britain limited visiting to three afternoons a week - which was a more generous policy than that of the Royal Berkshire Hospital, which allowed only one 15 minute visits twice a week. In a survey of over 400 British hospitals conducted in 1988, over a quarter of those which replied allowed visiting for no more than two hours a day. Perhaps these restrictive policies were in response to some visitors who abused the generosity of Britain's glorious National Health Service. 

“[A more open visiting policy] proved to be a disaster, primarily because of abuse of the system by visitors. Many would arrive promptly at 8 am and stay all day. They would bring sandwiches and flasks . . . and camp out by their relative’s bed . . . Others would eat patients’ food, [and] ask for extra cups of tea...there was even a threat of violence from a visitor asked to leave temporarily...”

— Alderman B. Hospital visiting hours. BMJ 1988;296:1798-9.

HELP PATIENTS GET WELL SOONER - BY VISITING THEM

In 2006 an Italian group reported the results of a study on the effects of hospital visitors on patient outcomes in its small intensive care unit.  The ICU changed its visiting policy from a restricted one (one visitor twice a day for thirty minutes) to an unrestricted one every two months.  After two years of this alternating policy, the authors compared the outcomes of their 226 patients. Despite significantly higher environmental microbial contamination during the unrestricted visiting periods, septic complications were similar. But the risk of cardiocirculatory complications was twice as high in the restricted visiting periods, which were also associated with a (non-significantly) higher mortality rate. The unrestricted group was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. The authors concluded that "liberalizing the visiting hours seems to be more protective because it is associated with a reduction in severe cardiovascular complications."

Incidence, with Odds Ratio and 95% Confidence Intervals, of septic and major cardiovascular complications in patients enrolled during the restricted (RVP) and unrestricted visiting periods (UVP) adjusted for age, gender, and time of enrollment. RR indicates relative risk; UT, urinary tract; pul., pulmonary; and CV compl., cardiovascular complication. From Fumagalli et al. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit Results From a Pilot, Randomized Trial. Circulation. 2006;113:946-952.

Writing in The Journal of the American Medical Association in 2004, Donald Berwick and Meeta Kotogal called for a change in the policy of restricted visiting hours in intensive care units.  They noted three areas which are often of concern to ICU staff when considering the question of visiting hours.  They also noted that although these concerns seem reasonable, the scientific literature tells "quite a different story."

Physiologic Stress for the Patient: "The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients’ stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress." 

Barriers to the Provision of Care: "The second concern is that the unrestricted presence of loved ones at the bedside will make it more difficult for nurses and physicians to do their jobs and may interfere with the delivery of care. The evidence suggests, however, that the family more often serves as a helpful support structure, increasing opportunities for patient and family education, and facilitating communication between the patient and clinicians." 

Exhaustion of Family and Friends: "The third concern is that constant visiting with the patient may prove exhausting for family and friends who fail to recognize the need to pace themselves. While that does sometimes happen, it is also true that open visiting hours help alleviate the anxiety of family and friends, allowing them to spend time with the patient when they want and to feel more secure and relaxed during the time they are not with the patient. One study found that open visitation had a beneficial effect on 88% of families and decreased anxiety in 65% of families."

A review of visitation policies in ICUs produced by the American College of Critical Care Medicine Task Force went one step further and found "no evidence that pets that are clean and properly immunized should be restricted from the ICU environment." So don't forget to bring the dog next time you visit a family member or friend in the ICU (or anywhere else for that matter). 

““...the preponderance of the literature supports greater flexibility in ICU visitation policies. Descriptive studies of the physiologic effects of visiting on mental status, intracranial pressure, heart rate, and ectopy demonstrated no physiologic rationale for restricting visiting. In fact, in seven of 24 patients with neurologic injuries, family visits produced a significant positive effect, measured by decrease in intracranial pressure.
”

— Davidson et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Critical Care Medicine 2007; 35 (2): 612.

HOW TO VISIT A FRIEND WHO'S SICK - THEN, AND NOW

Most of the evidence about the benefits of visiting the sick that we've been discussing have centered on the ICU- because that's where most of the research has been done. But for most of the time, an ill friend will not be in the ICU, or even in the hospital. Instead they will be at home, and so that is where the visit will occur.  Sadly, the ability to be a friend to a friend who is sick does not come easy to all of us.  Here's what Letty Pogrebin noted, in her recent book How to be a Friend to a Friend Who's Sick:

It's not uncommon for people to freeze or panic in the company of misery, botch gestures that were meant to ease, attempt to problem-solve when we have no idea what we're talking about, say the wrong thing, talk too much, fidget in the sick room, sit too close to the patient or stand too far away. Some of us don't visit our sick friends at all...

The Talmud sensed that visitors need some guidelines as to how to behave, and Rav Shisha suggested the following rule (Nedarim 40): "One should not visit a sick person in the first three hours of the day or in the last three hours of the day." In addition, the Talmud notes that "one who goes to visit the sick should not sit on the bed nor on a bench or a chair, but instead should wrap himself up in his cloak and sit on the ground, because the divine presence rests above the bed of a sick person." While we may no-longer follow this advice, the suggestion that we take our visits to the sick seriously is one that we should heed. Let's close with some more advice, updated for the modern era, from Pogrebin's 2013 handbook (p86-86):

1. Ask the patient to be honest with you and all their friends.

2. Be honest with yourself about your attitude toward the visit.

3. Think through your role in the visit.

4. Don't visit if you can't abide silence.

5. Be prepared to respond without flinching to whatever scene or circumstances greet you during your visit.

6. Be sensitive to your friend's losses.

7. Talk honestly with your children about the demands illness makes on friendship and how important it is to visit people who want company.

““What is the reward given for visiting the sick in this world? “God will guard him and restore him to life and he will be fortunate on earth, and You will not give him over to the desire of his foes.” [Ps 41:3.]:
”God will guard him” - from the evil inclination.
”And restore him to life” - from his suffering.
”And he will be fortunate on earth”- in that everyone will take pride in him.
”And You will not give him over to the desire of his foes”- for he will have good friends... ”

— TB Nedarim 40a.

[Repost from Nedarim 39b]