THE HEALING FACTOR THAT CAN MAKE ALL THE DIFFERENCE
“The secret of the care of the patient is in caring for the patient.”
— FRANCIS PEABODY
I remember one day when Mom called me, complaining of severe pain in her abdomen. She had been suffering from bloating and bouts of diarrhea since Dad died, but this pain in her belly was new. Mom sounded scared. I reassured her as much as I could from 3,000 miles away.
I scrolled through the differential diagnosis in my mind. Was it her gallbladder? A bleeding ulcer? Pancreatitis? A strange presentation of appendicitis? A bowel obstruction? A hiatal hernia? Reflux?
I peppered her with the requisite questions. Did she have a fever? Had she vomited? When did she last move her bowels? Was she passing gas? Did she feel hungry?
Her answers led me to believe it was not a surgical emergency. I told her so, but still recommended that she call her primary-care doctor. A few minutes later, Mom called me back. She had paged her doctor, and her doctor had asked her to meet her at the office right away.
It was a long drive to the doctor’s office—almost an hour. Halfway through the drive, Mom called me and I asked how she was feeling. The pain had eased a bit. Fifteen minutes later, she had almost arrived at the doctor’s office when she called me and said, “Would you believe this darn pain is almost gone?”
By the time she arrived, the pain had disappeared completely.
Mom called me and said, “I swear, this happens to me all the time. I want the symptoms to be severe when I get to the doctor’s office so they can see me at my worst and help me figure out what’s wrong, but more often than not, my symptoms go away before they even call my name.”
Bingo.
My mother’s doctor never did figure out why she was having the pain, but my conversation with her led me to develop a theory. My mother trusts doctors. She believes they have the power to make her well. Many times, she has felt poorly, and after seeing doctors, she has felt better. Her mind is now firmly convinced that doctors will help her. And because she chooses her health-care providers carefully, Mom genuinely loves her physicians and feels loved by them in return.
But what if the physical improvement she experiences when she goes to the doctor is primarily the result of her mind and its effect on her body? When Mom calls the doctor and makes an appointment, what if her mind registers relaxation, hope, optimism, tenderness, and the belief that healing is on the way? Her brain lets out a huge sigh of relief. Her thoughts shut down the stress responses she experienced when she first noticed the pain, the idea of visiting the doctor elicits a relaxation response, the body rests, and her natural self-repair mechanisms get activated. Before she knows it, the body has taken care of the problem, and voilà! The symptoms are gone.
The trip to the doctor winds up getting all the credit, but the real hero is her own mind.
Of course, this not to diminish what doctors can do. When my husband cut two fingers off his hand with a table saw, and his doctor, Dr. Jonathan Jones, stitched them back on with advanced microsurgical techniques, Matt and I were in full-on worship mode. This brilliant man, who came in on his day off, used a microscope to sew back together every artery, nerve, and bone in Matt’s fingers so my husband, an artist and a writer, could still use his hands. I was so grateful to my physician colleague that I made him a painting of my own hand, as a gesture of my respect for the skill, love, commitment, and devotion he had shown to my husband.
But as much as I’m grateful to Dr. Jones, I credit Matt with much of his recovery. From the get-go, Matt held a belief that his fingers would be sewed back on and work as well as they did before he lost them. He had perfect faith in modern medicine, and even after cutting his fingers off, he looked at me with wide eyes and said, “It’s all going to be okay.” He felt no pain during the incident, probably because his body was full of pain-relieving endorphins, and when I called 911 and the paramedics arrived, Matt expressed relief. I can only imagine that his brain was spitting out healing hormones and health-inducing chemicals that aided his recovery and made Dr. Jones’s job easier, but the truth of the matter is that someone still had to sew those fingers back on. They weren’t going to replant themselves.
When doctors save us, especially when we are facing life- or limb-threatening traumas or diseases, it’s tempting to lift them up on pedestals and give them all the credit. And yes, some doctors are exceptionally gifted, and what they do speeds up the healing process so the body can go about the business of self-repair. But when the surgeon cuts out a tumor or prescribes an antibiotic or sets a broken bone, we still depend on the body’s self-repair mechanisms to finish the job. Matt’s body still had to fuse those reconnected bones and heal those cuts in his arteries and nerves. Dr. Jones made it possible for his body to do so.
I want to make it clear that, when I talk about the body’s ability to repair itself, I am in no way suggesting that we should forego the advances modern medicine now makes available to us. While I believe our bodies have a remarkable capacity for self-repair, I also believe we shouldn’t expect our bodies to do all the heavy lifting, and sometimes, the body will simply fail if we expect it to do all the work.
While my mother might not have needed her doctor’s touch to cure her belly pain, Matt clearly needed Dr. Jones. Sometimes we rely on the technology modern medicine has to offer, and sometimes we don’t. But I can promise you this: in either scenario, finding the right person to support your healing journey is crucial, and the scientific data I studied confirms this.
The Doctor as Medicine
Patients get well, at least in part, because they believe in the power of modern medicine and expect to feel relief when they see doctors and other health-care specialists they trust. My mother and Matt are not alone in placing great faith and trust in doctors. Many people experience similar conditioned responses when visiting the doctor. Patients become accustomed to going to the doctor and subsequently feeling better, so the mind may work its magic before the therapeutic encounter has actually happened, even with no direct therapeutic intervention.
But what does the scientific data show?
I went back to the medical journals, and from what I learned, a nurturing therapeutic relationship may be responsible for a large part of the positive response patients experience when treated with placebos. Scientists postulate that it wouldn’t be enough to just imbibe placebos if they were self-administered without the participation of a physician—that to be truly powerful, someone in whom the patient places great faith must deliver them.
In an interview on NPR, Ted Kaptchuk, director of Harvard’s Program in Placebo Studies and the Therapeutic Encounter (PiPS), said, “A sugar pill doesn’t do anything. What does something is the context of healing. It’s the rituals of healing. It’s being in a healing relationship … But the placebo pill is a wonderful tool, or a saline injection is a wonderful tool, to isolate what is usually in the background, take it away from the medications and procedures that medicine does, and actually study just the act of caring. That’s, I think, what we’re measuring when we study placebo effects.”1
When Kaptchuk, who is trained as a Chinese medicine practitioner and acupuncturist, was asked how he, as a scientist, justified practicing acupuncture when most randomized, controlled clinical trials failed to demonstrate its effectiveness beyond placebo, he said, “Because I am a damn good healer. That is the difficult truth. If you needed help and you came to me, you would get better. Thousands of people have. Because, in the end, it isn’t really about the needles. It’s about the man.”2
Kaptchuk’s sentiments are affirmed in the New England Journal of Medicine article he co-wrote, which studied asthmatics. Those who reported being short of breath were treated with an albuterol inhaler (standard treatment for asthma), a sham inhaler (placebo), fake acupuncture (also placebo), and no treatment. All of the treated patients felt equally better—approximately 50 percent improvement for those treated with albuterol, the sham inhaler, and the fake acupuncture, compared to a 21 percent improvement in those receiving no treatment.
However, unlike other studies, which demonstrated physiological responses that coincided with symptomatic relief, when researchers in this study measured lung function in the asthmatics, the physiological response did not equal the patient’s subjective experience. The lung function measured in those who received fake acupuncture, a sham inhaler, and no treatment all experienced improved lung function (7 percent) but not nearly as much as those getting albuterol (20 percent).3
Why were these asthmatics feeling better, even when their bodies weren’t demonstrating physiological responses to explain the clinical improvement? Perhaps patients in the study were feeling better, not just because of the albuterol, fake acupuncture, or sham inhaler, but because somebody cared. What if the patients were treated not by the medicine itself, but by the medical care? Perhaps the treatment groups felt equally better because they received equal care, and perhaps that’s even more important than the drug or treatment they receive.
Asthma may be different from cancer. When you’re battling a life-threatening illness, it’s not so much the symptom relief you’re after; it’s the disease remission. Is the cancer gone or not? But what if symptom relief and disease remission are linked by the therapeutic experience and its relationship to the mind, the damages of the stress response, and the healing power of the relaxation response?
I suspected there was a potent link, but once again, I wanted proof.
Proof That Nurturing Care Makes a Difference
At this point in my research, I strongly suspected that a huge part of the placebo effect revolved around the delivery of nurturing care. And I had a sneaking suspicion that lack of loving care—especially with regard to medical hexing—could elicit nocebo effects. But how much of an effect did it have, and was there any evidence that the bedside manner or beliefs of the health-care provider affected health outcomes?
Dr. Lawrence Egbert conducted a study at Harvard Medical School, published in the New England Journal of Medicine, for which he randomized preoperative surgical patients into two groups. One group met with cheerful, optimistic anesthesiologists who assured them that their surgery was going to be a piece of cake, they were going to be comfortable and pain-free, and everything was going to be peachy. The other unfortunate patients (poor babies!) were attended by anesthesiologists instructed to be grumpy, rushed, and unsympathetic. (Interestingly, they were actually the same anesthesiologists wearing two different hats.) Those who got the optimistic anesthesiologists required only half the amount of painkilling medication and were discharged an average of 2.6 days earlier.4
Optimism on the part of the physician also makes a difference. Fueled by the comment, “The reason why Dr. Smith is so successful is because he’s so positive,” in 1987, Dr. K. B. Thomas was inspired to conduct a study on whether a physician’s positive attitude affects patient outcomes. His study, conducted at the University of Southampton and published in the British Medical Journal evaluated 200 of his own patients who didn’t feel well but didn’t have any apparent abnormalities on examination. The patients were randomly selected to receive one of four different types of consultations: a consultation conducted in a “positive manner,” with and without treatment, and a consultation conducted in a “non-positive manner,” with and without treatment. Sixty-four percent of those receiving a positive consultation got better, compared with 39 percent of those who received a negative consultation. The study found that patient recovery could be increased by words that suggested the patient “would be better in a few days” and, if he were given treatment, that “the treatment would certainly make him better.” On the flip side, negative words such as “I am not sure that the treatment I am going to give you will have an effect” led to longer recovery times.5 Thomas concluded, “The doctor himself is a powerful therapeutic agent; he is the placebo and his influence is felt to a greater or lesser extent at every consultation.”6
While optimism and positive words are key, trust is just as important. Nocebo effects can occur when a patient distrusts medical personnel and the therapies they implement.7 I used to work in a public health clinic in San Diego, where most of my patients were Somali refugees. Coming from a culture where medicine is practiced much differently, many of my patients were deeply distrusting of American doctors and the treatments we prescribed. In this patient population, I witnessed far more side effects resulting from common, seemingly innocuous treatments, such as prenatal vitamins, than my American patients usually reported. Although I worked hard to earn the trust of these patients, I suspect these side effects occurred because some of them genuinely believed we were trying to poison them.
What your doctor believes also matters. In a study published in the Lancet, which investigated the role of endorphins in how placebos relieve pain, researchers found that, despite the use of a double-blind procedure, the expectations of the physicians still influenced how patients responded to injections of fentanyl, naloxone, or placebo.8 If the doctor doesn’t believe a certain treatment will work, the treatment may actually be less effective.
Another study conducted by the National Institute of Mental Health assessed 250 depressed patients who were randomized to one of four 16-week treatment groups: interpersonal psychotherapy, cognitive behavior therapy, the antidepressant imipramine, and placebo. As a sub-study of the larger project, researchers at Georgetown videotaped how doctors participating in this study interacted with patients and, based on these video exchanges, asked expert raters to predict who would get well and who wouldn’t.
Surprisingly, these raters were able to predict this, based on the doctor-patient relationship, regardless of which treatment the patient was given. It wasn’t just whether or not the doctor and patient connected emotionally. It turns out that what the doctor believed about the patient’s prognosis also turned out to be crucial. If a doctor believed that the patient would improve, he or she was more likely to do so than if the doctor did not radiate this type of positivity.9 These findings about physician beliefs have since been replicated in many other studies, not just in the field of mental health, but in other areas.
Not surprisingly, the personality of the physician makes a difference as well. A Harvard Medical School study published in the British Medical Journal demonstrated that the response to a placebo increased from 44 percent to 62 percent when the doctor treated the patient with “warmth, attention, and confidence.” Among a third control group of people on a waiting list who received no medical care at all, only 28 percent improved.10
The right support, combined with positive belief, can even result in inexplicable cure. In the early 1950s, Dr. Albert Mason at the Queen Victoria Hospital in London treated a teenage boy with thick, cracked leathery skin covering most of his body. His condition was believed to be a severe case of warts, and since hypnosis had previously been described as an effective treatment for warts, Dr. Mason genuinely believed hypnosis could cure the warts, even at such an advanced stage.11
Convinced of the mind’s power to induce self-repair of warts, Dr. Mason got to work. During the first session, Dr. Mason focused solely on the boy’s arm, bringing the boy into a trance state and guiding him through the process of seeing his arm as pink and healthy. After repeated treatment, the skin was nearly normal, to the shock and awe of Dr. Mason’s peers. But Dr. Mason wasn’t surprised. He had faith that the mind could heal the body, at least for a condition like severe warts.
When the boy was then seen by his surgeon, who had unsuccessfully tried to help the boy with skin grafts, the surgeon was amazed to see the boy’s healthy skin, especially because the surgeon had made a mistake. Instead of suffering from warts, the boy had been misdiagnosed. His real condition was a severe, potentially lethal genetic condition called congenital ichthyosis.
Although no evidence had ever demonstrated that the mind could cure congenital ichthyosis, both Dr. Mason and the boy believed hypnosis would work. And it did.
Word got out and others who suffered from congenital ichthyosis sought out Dr. Mason, who tried to help them. But Dr. Mason was unable to later replicate the same effect in others. He blamed his failure on his own lack of belief. While he believed hypnosis would cure warts, he doubted its efficacy for this more serious genetic condition, even though hypnosis had already cured it once.
The Ritual of Medicine
A sugar pill, while powerful, is really just a sugar pill. It’s not magic. While some treatments, like my husband’s hand surgery, repair the body in ways the body could not induce alone, other treatments merely enlist the mind’s potent power to optimize the health of the body, and the support of a caring health-care provider makes all the difference.
Some studies—like K. B. Thomas’s—go so far as to suggest that the doctor is, in fact, the placebo, that the role the physician plays, in and of itself, triggers the self-healing response.12 What we’ve learned from the placebo effect is that, as Ted Kaptchuk explains, the placebo strips away the actual treatments we assume cure us—the antibiotics, the knee surgery, the antidepressants, the painkillers, the chest surgery—distilling medicine down to something therapeutic that has less to do with pills or surgery. Without the biochemical trappings of medicine, we’re left only with medicine as it used to be back before highly effective treatments like Matt’s finger surgery existed—the ritual of medicine, the meaning we ascribe to the medical treatment, and the care of someone devoted to trying to help us get well.
Because the role of the physician in the Western world has been imbued with so much meaning in our modern culture, the support of a caring physician may carry even more weight than the same kind of support from a pastor, therapist, acupuncturist, or other loving, healing presence. Yet the same might not be true in other cultures, where the greatest healing power may lie with the shaman, the Chinese medicine doctor, or the medicine woman.
One doctor I interviewed—we’ll call her Dr. M—said, “I know that the most valuable thing I offer my patients is love.” She told me a story about a patient with severe nerve pain that plagued 90 percent of her body. The patient had seen dozens of physicians and quite a few alternative medicine healers, without relief. Then she saw Dr. M, who prescribed fish oil and B vitamins. Dr. M admitted to me that she prescribed the supplements mostly as a placebo, because there was no clinical evidence to support the idea that they would be effective against this nerve pain. She also spent hours listening to this patient and offering her nurturing care.
Soon afterward, the patient fell head over heels in love with a young man, and shortly thereafter, she returned to Dr. M’s office to announce that her pain was gone. She credited the B vitamins and fish oil, calling them a miracle cure.
But Dr. M told me, “I knew it wasn’t the vitamins. I believe it was the love of this young man—in combination with the care I offered—that cured her.”
The Mechanism of Nurturing Care
How can the nurturing care and positive belief of a health-care provider result in better health of the patient? It all goes back to the illness-inducing stress response and the self-repair-facilitating relaxation response. When a patient who imbues the physician with positive meaning feels tended, trusting, reassured, and nurtured, the stress response is aborted. The relaxation response is induced. The patient starts to get better right away.
Just imagine you’re diagnosed with cancer. The minute you hear the word cancer, your fight-or-flight stress responses go crazy. The adrenal gland pumps out cortisol. The sympathetic nervous system jumps to attention. The word cancer is interpreted by the mind as a deadly threat, even though the threat of death isn’t usually imminent at the time of diagnosis. In such a state of physiological stress, the body is poorly equipped to fight cancer. It’s too busy preparing to fight and flee.
Then in walks the oncologist, who is kind, nurturing, and reassuring. He holds your hand, hugs you when you cry, and assures you that he has cared for thousands of people with just such a cancer and most of them have done well. With calm words and gentle presence, the oncologist explains that no matter what happens, you will never be alone, that he will be right there by your side, doing everything in his power to help. A treatment plan is made, and he gives you a phone number you can call if you think of any more questions. He offers you another hug or gentle pat on the back. Even though you’re facing a big surgery and months of chemotherapy, you feel better already.
Why? Because the mind is soothed. The fear is alleviated. The stress response is turned off. The body relaxes. The doctor convinced your brain that all will be well, or at least that everything will be done to try to ensure that it will be. In such a relaxed state, the body can get busy doing what it does best—making efforts to heal itself.
The Absence of Nurturing Care Can Harm You
So if calming, reassuring doctors who believe all will be well can induce such positive physiological effects, we know what happens when physicians unwittingly use their superpowers in the wrong way. Although they may mean well, all too often, doctors and other health-care providers not only fail to treat their patients with nurturing care and tenderness; they may even allow themselves to get so busy, overworked, and depleted that they flat-out harm their patients.
A friend wrote to me after leaving her doctor’s office:
Lissa, if this doctor robs me as I leave the building, I won’t be able to confirm it was him, as I don’t think he looked at me once. From the nurse intake to the actual exam room, both practitioners faced AWAY from me, toward their computer terminals, while they asked me questions and clicked away at the keyboard. The computer fed him my new prescription, and he never even discussed it with me. If a computer program is all I need to monitor and refill prescriptions on my current or chronic conditions, then what am I doing spending an hour in a waiting room, waiting to look at some guy’s back? Oh, and don’t forget—the nurse clearly put a wrong code into the computer, because he came in prepared to give me a BREAST exam, rather than listening to my asthmatic CHEST. I was like, “What are you talking about, sir? You have the wrong information or else the wrong room.” Sigh. I’m so mad right now. I’m never coming here ever again.
I’ve heard this kind of feedback frequently from my online community. With many health-care providers feeling overburdened, exhausted, and unappreciated, patients sometimes wind up feeling more stressed after a doctor’s visit than they did before. If you have to sit for two hours in a crowded waiting room, only to have seven and a half minutes with an exhausted doctor who cuts you off, forgets your name, never lays a hand on you, and then scares you with a disconcerting prognosis, you can be sure your stress responses will be activated.
Nobody intends for this to happen. Health-care providers have often sacrificed so much for their patients that they stop being mindful about why they’re doing what they were called to do. They think the sacrifices demonstrate the care they have for their patients. But sacrifices are not enough. It’s time to put the care back in health care. Doctors and other health-care providers need to remember why we do what we do so we can maximize the healing effect we have on our patients. Especially when things go wrong.
How to Deliver Bad News
In 1974, Dr. Clifton Meador told his patient Sam Londe, who suffered from cancer of the esophagus, that his condition was considered fatal. After Dr. Meador broke the news about his death sentence, Sam died quickly, only weeks after his diagnosis.
But an autopsy performed after his death surprised doctors. Very little cancer was found—certainly not enough to kill him. Dr. Meador told the Discovery Health Channel, “He died with cancer, but not from cancer.” Why did he die? Perhaps the bad news triggered so much fear that stress responses wreaked havoc in his body. He died because he was told he would die and he believed he would die. His negative thoughts translated into real physiological changes.
Decades later, Sam Londe’s death still haunts Dr. Meador, who said, “I thought he had cancer. He thought he had cancer. Everybody around him thought he had cancer … did I remove hope in some way?”13
I suspect that this kind of thing is not uncommon. Of course, doctors never mean to harm patients. Most are motivated by the purest intentions, and we want nothing more than to help our patients heal. But I’ve heard good doctors give the bad news spiel time and time again. It often goes something like this:
DOOR #1
I’m afraid your cancer is inoperable and is not limited to the one organ we thought it was. In fact, it’s in your stomach, your colon, your lymph nodes, and dotted all over the lining of your abdomen. We haven’t done the studies yet, but it may also be in your lungs, your bones, and your brain.
If you’d like, we can give you chemotherapy, but it will just be palliative, not curative. I’m very sorry to give you this news, and of course, we’ll do everything we can to keep you comfortable. But this would be a good time to get your affairs in order. If you haven’t updated your will, you might want to do that, because only 1 in 20 people with your kind of cancer survive five years and most die within three to six months.
I’m terribly sorry to have to tell you this, and of course, we can talk further when the effects of the anesthesia have worn off and you’re a little more awake.
When bad news is delivered this way, it only triggers stress responses that make it harder for the patient’s body to repair itself and, in rare cases, may even lead to death when there is no apparent cause. It’s possible that you really can be scared to death.
I propose a new way to deliver bad news. Let’s take the same patient we described behind Door #1—the one with metastatic cancer and a 1-in-20 chance of survival. Let’s give her some time to wake up from her anesthesia. Let’s comfort her in the recovery room. Let’s tell the family we’ll have a family conference when she fully wakes up, and then let’s have this conversation instead:
DOOR #2
I have good news and bad news, so I’ll get the bad news out of the way first. I’m afraid the cancer isn’t limited to one organ, the way we hoped it would be. [Pause for a moment to give this time to sink in.]
The cancer also appears to have spread to your stomach, your colon, your lymph nodes, and the lining of your abdomen. We’ll have to do some tests to see if the cancer might have spread anywhere else, and we should be able to get that information very soon, so we can make a plan about what’s next. But I want you to know you will not go through this alone. [Pause again.]
I know that’s a lot to hear right now, but let me share with you the good news. The good news is that a percentage of people with exactly this diagnosis survive, and there are some predictors of who those people might be. The body is designed to repair itself when it gets sick, and we have clear evidence that those who nurture their bodies, minds, and spirits while staying hopeful and believing in their ability to get well are more likely to be cured. It’s important to your body that we all remain optimistic and that your mind and body stay as relaxed as possible, because only in this state of relaxation can your body fight off the cancer.
I want you to know that I believe that it’s possible for you to be cured from this cancer, and I will be here to support you every step of the way. We’ll talk tomorrow about treatment options and where we can go from here, but why don’t you get some rest first and spend some time processing this with your family. Before I go to do my next surgery, do you have any questions for me right now? [Pause and listen.]
I’ll talk to you again first thing in the morning, and if you have any urgent questions that come up between now and then, feel free to give me a call. Here’s my number in case you need me. I know this isn’t the news you wanted to hear today, but please, never give up hope. I believe in miracles, and you just might be that miracle.
Imagine how differently you would feel after each conversation. The first doctor would likely leave you feeling stressed, uncertain, and upset. The doctor behind Door #2, however, would probably make you feel supported, hopeful, and well informed, so much so that your mind and body are relaxed.
As health-care providers, I think it’s our responsibility to consider how we might facilitate the process of helping our patients hold positive beliefs and release negative ones, so we can limit stress responses and elicit relaxation responses that help the body heal itself and prevent further damage. Perhaps this act of love and service will have more profound effects than any drug or surgery. It may take a few more minutes out of our day to deliver bad news in a way that facilitates healing, but the results could be extraordinary.
Physician, Heal Thyself
When health-care professionals hold space with nurturing care, we create the ideal environment for patients to heal themselves. But all too often, we make the mistake of trying to serve those in need of healing from a place of depletion. As doctors, we are taught to sacrifice our own needs in order to serve others. We wind up severely sleep-deprived, we eat poorly, we fail to tend to our relationships, we neglect our self-care, we close our hearts to protect ourselves, and we often wind up physically, emotionally, and spiritually unhealthy. The minute a doctor or other health-care provider gives to the point of depletion, the well is dry, and true healing can no longer happen. Because we are so depleted, we feel victimized, and we wind up becoming the villains, lashing out at patients because we are running on empty.
If I could wave a magic wand and change one thing about the health-care system, I would change the insane notion that, in order to be good health-care providers, we must give at the expense of our own health. It’s impossible to be fully present for our patients, to open our hearts as widely as they must be opened, and to serve as fully as we can when we have nothing left to give. If only doctors could be models of self-care so that patients might learn by example, the whole system would undergo a radical shift. If healers could heal themselves first, we would be able to serve and love from a place of wholeness, so we could more effectively heal the world.
15 WAYS HEALERS CAN AMPLIFY THEIR ART
Healing yourself is hard work, and nobody should have to do it alone. As physicians, we can dose up life-saving treatment, but if we fail to heal ourselves so that we are full enough to sprinkle our treatments with a heaping helping of love, we limit the ability of our patients to fully and sustainably recover.
Norman Cousins, author of Anatomy of an Illness, knows this well. Cousins had been diagnosed with the degenerative collagen disorder ankylosing spondylitis, and he believed he would be able to arrest his condition if he were discharged from the hospital and treated with high doses of vitamin C and daily laughter instead of anti-inflammatory drugs, painkillers, and tranquilizers. Fortunately, his doctor, with whom Cousins enjoyed a collaborative partnership based on mutual respect, supported his decision.
In Anatomy of an Illness, Cousins wrote, “I would say that the principal contribution made by my doctor to the taming, and possibly the conquest, of my illness was that he encouraged me to believe I was a respected partner with him in the total undertaking.”
The Placebo Effect in Complementary and Alternative Medicine
Nurturing care explains why many patients often experience remarkable results when treated by complementary and alternative medicine (CAM) treatments, which include such therapies as acupuncture, Chinese medicine, homeopathy, Reiki, herbal medicine, energy medicine, craniosacral therapy, chiropractic medicine, and other such modalities. Yet CAM treatments are often shown to be “ineffective” according to evidence-based medicine principles—in other words, they’re considered no more effective than placebos. I believe the reason many of these treatments have not stood up to placebo-controlled trials is because sham acupuncture, delivered with nurturing care, is as effective as real acupuncture, delivered with nurturing care. Both work equally because, as Kaptchuk stated earlier, it isn’t “about the needles.” Both trigger relaxation and reduce stress in the body. And this is a good thing, not something CAM healers need to get defensive about!
What if much of what we offer in Western medicine works in the same way? In many cases, especially when it comes to the treatment of “chronic” disease, the care and reassurance we offer is perhaps as valuable to the physiology of the body as the pills and injections.
Please understand, I’m not here to argue whether CAM methods of healing are “effective” or not. If your illness mysteriously vaporized after you took a homeopathic remedy, or if you’re an energy healer who has witnessed spontaneous remissions happening to your patients, I do not doubt the efficacy of such treatments. In fact, I fully believe that unexplainable things happen in the hands of trained professionals practicing forms of medicine that scientific data has yet to verify.
Instead of dismissing such treatments, I’d like to make the argument that perhaps nontraditional healing modalities work not so much because of the modality being practiced as because of the potent combination of positive belief in the healing method, the nurturing care offered by the practitioner, and the relaxation responses these treatments induce. Perhaps these modalities are, in fact, highly effective—but not via the means we might expect.
What I’m suggesting is that all interventions aimed at facilitating health and healing—whether conventional drugs and surgeries or CAM treatments—may work primarily through the power of the mind. We’ve already demonstrated that many conventional medical treatments fare no better than placebo, while others have been proven to be more effective than placebo. This suggests that some conventional treatments really do offer benefit beyond what positive belief and nurturing care can facilitate. Most CAM treatments, however, seem to offer most, if not all, of their benefit because of positive belief, nurturing care, and the positive physiological responses they trigger.
Is It the Treatment or the Relaxation Response?
The evidence suggests that real acupuncture may be no more effective than sham acupuncture. A few acupuncture trials demonstrate efficacy beyond sham acupuncture,14 but the majority do not. When patients were randomized to receive either real acupuncture (inserting needles along energetic meridians as taught in acupuncture school) versus sham acupuncture (inserting needles willy-nilly or poking the skin with fake needles but not sticking them all the way in), many of the people getting real acupuncture got better. But so did the people getting sham acupuncture.15 Although many people believe it’s all about the appropriate needle placement, what if it has more to do with the acupuncturist than the acupuncture technique?
The same is likely true for Reiki, a Japanese form of energy healing typified by laying on hands or waving the hands over the body to move life-force energy through “stuck” places in the body. Studies such as the one conducted at Sonoma State University and published in Oncology Nursing Forum examined patients getting chemotherapy and found that those getting Reiki were more likely to experience positive health outcomes than those getting standard treatment alone, but those getting sham Reiki were equally likely to experience a benefit.16 Again, this doesn’t surprise me. As someone who has practiced Reiki myself, I can attest to the fact that Reiki is profoundly relaxing, especially when it’s delivered by someone who really cares. But sham Reiki would be too. No wonder people enjoy it!
Studies also suggest that homeopathy, a CAM therapy based on the hypothesis that a substance that causes the symptoms of a disease in healthy people will cure that disease in sick people when administered in very small doses, may be no more effective than placebo, though the data is conflicting. One meta-analysis of 107 homeopathy trials, conducted at the University of Limburg in The Netherlands and published in the British Medical Journal, suggested a trend toward clinical efficacy, implying that homeopathy may be more effective than placebo and deserves further study.17 However, a larger, more carefully designed meta-analysis of the data, published in the Lancet, evaluated 110 homoeopathy trials and 110 matched conventional-medicine trials and focused on ferreting out study biases. This study, conducted at the University of Bern in Switzerland, demonstrated little to no efficacy of homeopathy beyond placebo.18 I would argue that perhaps it’s not the homeopathic remedies that heal; it’s the homeopath.
Critics challenged the results of studies like the homeopathy meta-analysis, that led the Lancet to announce “the end of homeopathy” and the “growth of truth.”19 Yet I want to point out that those criticizing the study cited it as an example of conventional medicine twisting the data to discriminate against alternative medicine.20 If we’re going to use evidence-based medicine to evaluate treatments that don’t easily lend themselves to such analysis, we must be open-minded in our interpretation of results that affirm healing methods we don’t fully understand. Applying negative bias to this kind of data just because we can’t conjure up a biochemical explanation is unscientific.
Keep in mind that many of these studies are far from perfect. The problem with the way some of them are conducted is that it’s hard to blind both the patient and the practitioner. Though some sham acupuncture studies use dummy “needles” that are able to fake out even the acupuncturist, others blind the patient only.
This fudges things up. Studies demonstrate that when clinicians know which treatment patients are getting, they inadvertently communicate this nonverbally to the patient, which is why most conventional medical trials are double-blinded, so both the researcher and the patient are in the dark about whether they’re being treated with a placebo. This distinction makes clinical research into many CAM treatments fraught with bias.
The Real Goal of Treatment
Let’s not get sidetracked by poor data here. Although scientists may not be able to physiologically explain the science of many CAM treatments, is this really necessary when we already have a biochemical explanation for such treatments? We know that lying on an exam table with a caring practitioner in a relaxing environment focused on the intention of healing may abort the stress responses so many of us walk around with on a daily basis, especially when we’re sick. We also know that eliciting relaxation responses is known to induce positive hormonal changes and return the body to its natural state of homeostasis, which can induce self-repair of the body. Need we know more?
In conventional medical wisdom, we call anything that doesn’t outperform placebo “quackery.” But haven’t we lost sight of the real goal? I suggest we reconsider our evaluation standards regarding the efficacy of medical treatments. If the patient is getting better, does it really matter whether the treatment is better than placebo? Is resolution of symptoms and cure of disease not the ultimate goal? Does it really matter how we achieve such a goal?
I know it’s a radical concept. But I’m not the only one considering such notions.
In an editorial in the British Medical Journal, Yale professor Dr. David Spiegel chided skeptics for implying that, if most of the benefit of CAM therapies comes from the placebo effect, they should be consigned to the realm of quackery. He posed this question: “Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor—patient interactions that the rest of medicine might do well to hear?”21
The Placebo Effect in Psychotherapy
It’s not just CAM treatments whose positive effects may stem more from positive belief, nurturing care, and the relaxation responses they induce than from the treatment itself. Studies show that psychotherapy may benefit patients in the same way. Certainly, data supports the notion that those getting psychotherapy fare better than those not getting it.22 But is it really the psychotherapy, or could it be that psychotherapy induces relaxation responses due to the combination of the patient’s positive belief and the loving support of a caring therapist? Are the mind and body not more likely to heal when relaxed?
In a landmark experiment conducted at Vanderbilt University and published in the Archives of General Psychiatry, highly experienced psychotherapists treated 15 college students who suffered from anxiety and depression, while a comparable patient group was treated by college professors who were not therapists. Patients treated by the unskilled professors showed as much improvement as patients treated by the professional therapists.23
Medical anthropologist Dr. Arthur Kleinman believes that attributing psychotherapy’s successes to the placebo effect need not dismiss its benefits. He sees it as more of a complement. “Psychotherapy may very well be a way of maximizing placebo responses … but if so, it should be applauded, rather than condemned, for exploiting a useful therapeutic process which is underutilized in general health care.”24
The Placebo Effect in Faith Healing
Though there is less clinical data in the arena of faith healing, we might argue that the same dynamic could be at play with faith healers. Think about it. People come from far and wide to be in the presence of someone they believe will heal them. Add to that other people in need of healing who have made a pilgrimage and who share the same positive belief. Throw in rituals and practices that reinforce the belief—the loving hug, the laying on of hands, the meditation, the herbs, the holy water—and you’ve got a recipe for elicitation of relaxation responses and self-healing that scientists would dub “the mega-placebo effect.”25
Let’s look at the healing waters of Lourdes as an example of this mega-placebo effect. Lourdes offers the perfect opportunity for self-healing. People set out on a pilgrimage and are often exhausted when they arrive, meaning they’re mentally in a state of increased receptivity. The shrine at Lourdes involves multiple sacred symbols of healing and many opportunities for healing rituals, as well as the company of other pilgrims who have made the journey. Collectively, those who go are often infected with contagious emotion and collective hope. This alone—the belief that the healing waters will cure disease—may be enough to activate the relaxation responses that are necessary for the body to heal itself.
The Catholic Church is aware of this and has worked hard to rule out any healings that might be deemed “hysteria.” Their aim is to make sure the cures are actual miracles of a divine nature, rather than the result of self-healing caused by the power of the mind. To ensure this, the Church employs physicians to verify whether a spontaneous healing “counts” as a true “sign of God.” Since 1858, only 68 have met their stringent criteria.
In 1962, Vittorio Micheli was admitted to a Verona hospital with a large cancerous tumor on his left hip. Within ten months, his hip had almost completely disintegrated, leaving his bone floating in a mass of soft tissue that required a cast to keep his leg attached. As a last resort, he took a trip to Lourdes, where he bathed several times. Each time, he described a feeling of heat moving through his body. Over the next month, he experienced renewed energy, and his doctors repeated his X-rays, finding a much smaller tumor mass. The doctors were so intrigued that they documented every step of his recovery. Soon afterward, Micheli’s tumor disappeared, and the bone began regenerating. Within two months, he was walking again.26
Anna Santaniello’s miracle, the second-to-last one recorded at Lourdes, occurred after she had developed severe heart disease following acute rheumatic arthritis. She suffered from severe shortness of breath, as well as Bouillaud’s disease, which made it difficult for her to speak and impossible for her to walk. She also had severe asthma attacks, cyanosis (blueness caused by lack of oxygen) of her face and lips, and lower limb swelling. After volunteers lowered her into the healing waters, her symptoms disappeared, and a doctor confirmed her cure.
Most recently, in March of 2011, 56-year-old Serge François was pronounced the latest miracle. After complications of a herniated disc left him with almost no mobility in his left leg, he made a pilgrimage to the sacred shrine in 2002 and experienced a rapid increase in mobility. He’s still doing well ten years later.
In Anatomy of an Illness, Norman Cousins wrote, “The vaunted ‘miracle cures’ that abound in the literature of all the great religions … all say something about the ability of the patient, properly motivated and stimulated, to participate actively in extraordinary reversals of disease and disability.”
Reclaiming the Heart of Medicine
As health-care providers, we are blessed with a sacred opportunity. We have the power to encourage relaxation responses in our patients and, in so doing, be part of the healing process in more ways than just drugs or surgeries. In my opinion, if we fail to optimize the self-healing mechanisms of our patients, we do them—and ourselves—a huge disservice. And if we step up to the plate and do our job well, our role in the healing process may mean the difference between life and death for the patient.
I often joke that I practice love, with a little medicine on the side. Yet, all too often, technological advances have so distanced us from our patients that the love seems to have gotten lost in the process. Whereas a physician used to do house calls, sit at the bedside, and touch the patient, we now offer 13-minute patient visits in a sterile white room where lab tests may take the place of a thorough patient history and radiological studies may even replace the hands-on physical exam. Without the healing power of listening, loving touch, nurturing care, and healing intention, what are we offering patients beyond straight technology?
When you’re facing a health crisis, make sure you find the nurturing care you need. It’s not enough to seek out the best surgeon or the most famous university doctor who specializes in your specific illness. Though specialized skills certainly come in handy, if you want to optimize your body’s chance of cure, you’ll also want to ensure that your health-care providers genuinely care. You may need more than just one person as you navigate the course of your treatment. You may need a whole team believing in you, offering you tools from their various toolboxes, and helping you make the body ripe for miracles. As you gather your team, you’ll also need the members of that team to cooperate with one another.
Acupuncturist Susan Fox calls such a team of collaborative practitioners “the healing round table.” The healing round table is a collaborative process in which all health-care practitioners involved in the care of the patient are equal players whose opinions matter. At the healing round table, the patient, not the doctor, presides as the utmost authority. While physicians might be invited to the healing round table, the invitation to be present does not grant doctors the right to give orders, negate the advice of others, disrespect others at the table, or, most importantly, disregard the patient’s wishes.
While I understand the need to have a physician calling out orders during a trauma situation in the emergency room, the same does not apply to those caring for someone with a chronic illness. I once heard a respected physician (albeit a tired one) say to a brilliant nurse, “Let’s play a little game. I’ll play doctor. You play nurse. I’ll give the orders, and you follow them.” This kind of dynamic serves neither the health-care provider nor the patient.
I’ve also heard doctors ridicule patients for seeking out alternative or homeopathic treatments, disrespecting both the patient and the CAM practitioner. These kinds of adversarial relationships trouble me deeply, because they speak to a much greater dysfunction within our health-care system. This dictatorial, condescending, hierarchical mind-set is more militaristic than the way I believe health-care systems should be. And while doctors in the trenches may feel they are at war against disease, replicating warlike methods of communication within hospitals and patient exam rooms doesn’t help people heal. It only triggers stress responses. Health care functions much more effectively when teams work as a unit committed to serving the patient first and foremost, without ego, competition, and unnecessary power plays.
In my online community, I’ve been recruiting health-care revolutionaries—health-care providers and patients who are committed to bringing the care back to health care. If you’re nodding your head and wondering where the rest of us are, don’t despair. We’re here, an increasingly organized and vocal population of change agents who know we must reclaim the heart of medicine and are committed to seeing change happen. Keep the faith. We need you now more than ever.
As mind-body medicine pioneer Dr. Larry Dossey wrote to me, “We really do constitute a kind of parallel medical world that exists alongside the conventional kind. We focus on what [the conventional world] knows, and we honor it, but more besides: spirituality, meaning, purpose, consciousness, compassion, empathy, love … And guess what? We are going to win the competition. It’s really only a matter of time. But we need to dance as fast as we can, because time is not on our side. The urgency is real. So welcome to the dance!”
The time is now. Are you ready?
