Medical science is moving forward at breakneck speed. Advancements in stem cell research, robotics and nanotechnology promise a new era of molecularly targeted medications, replacement body parts, and regenerative treatments to combat disease and decline. But if a picture is worth a thousand words, then the footage of Jimmy Carter, looking healthy at the inauguration, his advanced melanoma now in remission, says more about our accomplishments than a year’s worth of journal articles.
As an admirer of President Carter, I am happy for him and his family, but as a psychiatrist, I have to admit I feel a little bit jealous. Those of us who treat mental illnesses — and our patients, who must live with them — are still stuck with an assortment of treatments that have improved only minimally over the past two generations. To cite just one example, the antidepressants I prescribe today are no more effective than those developed in the 1950s. Unfortunately, that is often not very effective at all. A number of meta-analyses have found that the pharmacological benefits of these medications are slight and may be, in all but the most severe cases, clinically insignificant.
Like scouts stuck in the woods, trying to start a fire by rubbing together two sticks, because of this challenging situation we need to be resourceful. What we lack in technology we must compensate for in technique. This involves making the most of two highly effective remedies that do not require prescriptions.
The first of these is hope. Merriam-Webster’s dictionary defines the word as “desire accompanied by expectation or belief in fulfillment.” This positive expectancy, to use the technical term, is the basis for the placebo effect. While long derided, the placebo effect has finally begun to receive the attention that it deserves. Recent research indicates that it plays an important role in the treatment of a wide-range of conditions. Indeed, at least half of the observed benefit of painkillers, anticonvulsants, and medications for Parkinson’s Disease is attributable to expectancy on the part of the patient.
This points toward an intriguing idea: that each of us possesses an innate capacity for healing ourselves. Functional neuroimaging studies, which allow us to observe the brain’s metabolic activity in real time, support such a contention. In patients with chronic pain, they reveal increased activation of the prefrontal cortex in placebo versus opioid-induced analgesia. This activation inhibits other, more developmentally primitive, areas of the brain — such as the amygdala and cingulate cortex — which moderate the sense of unpleasantness which accompanies pain. In this way, our thinking, human selves exert control over the reflexive, animal parts of our nature.
Seventy years ago the psychologist Carl Rogers wrote about the essential pillars of empathic understanding, unconditional positive regard, and authenticity upon which a successful therapeutic relationship is built. He argued that this relationship itself, more than anything the therapist says or does, is the critical variable responsible for improvement.
The trust that exists in such relationships is the second healing medicine. Since Roger’s time, its benefits have been demonstrated repeatedly in clinical research. One paper, from 2006, examined the degree to which so-called “psychiatrist effects” — versus pharmacological medication effects — contributed to changes in depression rating scores. It found that the difference between effective and ineffective clinicians was greater than the difference between active medication and placebo. In other words, the doctor mattered more than the pill.
While subsequent work has confirmed that the relationship between physician and patient plays an important role in the treatment of depression, the advantages of a good alliance are not limited to psychiatric conditions. In one study, irritable bowel patients who received a placebo — in this case, sham acupuncture — from an empathetic clinician who used active listening skills and communicated confidence about the treatment responded more vigorously than those who received the same intervention during a more neutral clinical encounter. Both groups fared better than waitlist controls, indicating that placebo and alliance effects are at once distinct and additive.
In medical care in general, patients who trust their doctors have consistently better outcomes than those who do not. They are more likely to cooperate with treatment and expect positive results. These hopes are more likely to be fulfilled, creating a virtuous cycle. The combination of hope and trust thus creates a positive synergy that all of us should exploit.
Why does this matter now? Because in the brave new world of 21-century medicine, we sometimes lose sight of the basics. Current systems of health care delivery, with their emphasis on volume, standardization of care, and lengthy documentation can lead to the alienation of doctor and patient alike. On one side of the stethoscope, physician burnout skyrockets, while on the other, patients express dissatisfaction with long waits, short visits, and poor provider communication. Meanwhile, our overreliance on pills has contributed to antibiotic resistance and kindled an epidemic of prescription medication abuse. Helping doctors to be healers first and foremost might not solve all these problems, but it certainly could not hurt.
David Rosenfeld is a psychiatrist.
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