Compassionomics

  Psychotherapy is sometimes called “talk therapy.” In psychotherapy, a professional therapist treats individuals with psychological disorders through specific communication techniques designed to provide insight and change attitudes and behaviors, rather than by using medications. In psychotherapy, human connection matters. Big time.

  There is much to be learned about the power of empathy by studying Dr. Riess’ work. For instance, a young woman (“Jane”) came to see Dr. Riess as a patient because she needed help with weight loss.

  She was seventy pounds over her ideal body weight. For years, other weight loss methods had not worked, so she was seeing Dr. Riess on the recommendation of a nutritional counselor, in hopes that psychotherapy could help. However, the results—even after two years of therapy—were very disappointing. She just wasn’t making any progress.

  About that time, one of Riess’ students wanted to begin a research study, one that Riess now admits she wasn’t too crazy about at the time. But like a good research mentor, Riess decided to support her student’s research idea anyway.147 That decision ended up being career-changing for Dr. Riess. Literally.

  The student wanted to measure how the autonomic nervous system of the patient and the therapist mirrored each other during psychotherapy. So they elected to use measurements of skin conductance (also called electrodermal activity) where electrodes are placed on the skin.

  These generate a tracing that shows how much activation of the sympathetic nervous system and psychological or emotional distress there is at any point in time, for both the patient and the therapist. The existence of these skin changes had already been well-studied in other medical fields. This student wanted to take it to the next level to understand the response and reaction during psychotherapy specifically.147

  Jane agreed to participate in the study. After Jane’s next therapy session, the student examined the data and immediately called Dr. Riess. “You’ve gotta see this,” he said. They reviewed the data together.

  Both of them were blown away.

  If you’d been sitting in Dr. Riess’ chair, you would’ve found this to be a very calm, “vanilla,” nothing-out-of-the-ordinary psychotherapy session. But if you considered the skin conductance data, you would have found it to be anything but normal.

  While Riess’ skin conductance showed that her emotions were even-keeled throughout, Jane’s were “off the charts” at multiple times throughout the session, indicating extremely high levels of anxiety and distress.

  But here’s the thing: You wouldn’t know it. Even Dr. Riess did not detect it (and she’s a psychiatrist trained to understand the human mind who was solely focused on Jane in that session).

  Jane was a professional with a high-powered career. She appeared to be very self-confident, calm, and composed. On the outside, anyway. But on the inside, Jane was suffering from crippling anxiety. And it never fully came to the surface, even after two years of therapy. The skin conductance data uncovered that she had been suffering…in silence.

  When Riess showed Jane the tracing and explained what the data meant, Riess was shocked by Jane’s response. “I am not surprised by this at all. I live with this every day,” she said. “But no one has ever seen my pain. Until now.” This experience moved Riess to the core. Clearly, she had been missing something with Jane.

  All the research therapy sessions were videotaped, so Riess went back and watched the video again and again, examining every detail, this time as an emotion “detective.” Riess discovered that the highest peaks on Jane’s tracings, indicating the most distress, coincided with some of Jane’s very subtle motor movements like flicking her hair or looking down at the floor, or a change in tone of voice.

  Riess began to clue in to these subtleties and their significance. Dr. Riess began to meet Jane in those moments, using a tried and true intervention—empathy.

  Every psychiatrist and psychologist understands that empathy is an integral component of effective psychotherapy.148 From that point on in therapy sessions, when Riess detected Jane’s subtle outward signs of psychological pain, she responded to them consistently—with compassion—and the two would go deeper.

  For the first time, Jane unburdened herself emotionally. She let go of many painful, never-before discussed experiences from her past. And that was when everything began to change for Jane.

  She began to exercise regularly. Her eating habits changed. And the woman who had never been able to successfully lose weight actually lost nearly fifty pounds in the following year!146, 147

  Compassion changed Jane’s life. But it changed Dr. Riess’ life too. Riess learned that with careful attention to signs that people are in psychological or emotional pain—and the ability to meet people in that pain with compassionate care—it could change everything for a patient. As a result, she is now committed to advance her empathy training to reach health care providers broadly through her organization, Empathetics.149

  We will take a closer look at Riess’ research on empathy training in Chapter 9, but for now, the take-home message is this: Empathy and compassion can impact people’s psychological health. It certainly did for Jane. And it will for countless others, too.

  That brings us to a crucial message about the psychological health benefits of compassion. In contrast to the last chapter on physiological effects, where most of the data were rooted in a clinical context—and therefore mostly applicable to the relationship between a health care provider and a patient—the data we are considering now applies to everybody.

  Everyone knows somebody who is struggling, and some people are struggling much more than others. The scope of mental health needs (for example, anxiety and depression) in society is massive and growing.150

  Although the data in the pages to follow on the psychological health benefits of compassion are taken from clinical research in the context of clinical care by a psychiatrist or psychologist, these data are just as applicable to those who are struggling with mental health all around us: our family, friends, neighbors, classmates, and coworkers. Research shows that one in five people that we meet have some sort of mental health struggle.150

  You can have a tremendous impact on someone’s psychological health.

  So when you read the data below, please don’t think that they only apply to psychiatrists and psychologists. They do not. Even though that may be where the data come from, you don’t have to be a psychiatrist or psychologist to treat someone with compassion when they are in psychological distress. Remember: you too can have a tremendous impact on someone’s psychological health.

  It may be intuitive to you that walking with people during dark times in their life and showing them compassion can alleviate their psychological pain and suffering, at least to some extent. But is there also scientific evidence for this in the literature? The answer is yes.

  Diving in to the Data

  A recent systematic review published in the Harvard Review of Psychiatry found that compassion-based interventions in psychiatry were highly effective in the treatment of patients with psychotic disorders, eating disorders, post-traumatic stress disorder, major depression, and even patients who recently attempted suicide.151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161 One of the major mechanisms of these beneficial effects is that compassion-based interventions can reduce patients’ self-criticism and shame related to their mental health condition.

  A recent, very rigorously conducted meta-analysis of the psychology literature—a study of studies, essentially—pooled the data for 21 published randomized controlled trials (1,285 participants) of compassion-based interventions.162 Here’s what these researchers found: there was a statistically significant effect of compassion-based interventions on relief from depression, anxiety, and psychological distress, as well as an increase in well-being.

  By statistical criteria, the effect sizes were substantial and also clinically meaningful. It’s important to note that these were studies where people were trained not only to be compassionate t
o others but also to themselves (note: more to come on the topic of self-compassion in Chapter 10). Then they tested the effects of compassion interventions on their psychological health.151, 162

  This is distinctly different from a study of physician or therapist compassion towards patients and testing the impact on patients’ psychological health. Rather, it’s about the profound effect each of us can have when we treat ourselves, and those we meet in our daily lives, with compassion.

  Moreover, this research provides important context because it strongly supports the concept that compassion can heal psychological wounds and help promote psychological well-being.

  So if compassion can achieve all of that, let’s now dive into the data that demonstrates these effects, both for patients with mental health conditions as well as for patients who have psychological distress related to physical disease (e.g., depression in patients with cancer).

  You’ll also learn about the effects of compassion on depression and anxiety specifically, as well as the effects on patient-reported quality of life and well-being. But as a starting point and common thread for weaving together all the data, it is important to first establish one thing. Of all the things that can impact one’s psychological health, there is something that rises to the top as one of the most, if not the most powerful thing: human connection.

  That’s not to say pharmacotherapy (i.e., drugs) isn’t helpful. There have been monumental advances in pharmacotherapy for mental health conditions. These scientific advances have been unquestionably life-changing for millions and millions of people.

  For some people, drug therapies have been life-saving. Drug therapies can be a godsend for those struggling with mental health disorders. But there is also scientific research showing that human connection can make a meaningful difference in one’s psychological health. In battling diagnoses like major depressive disorder and generalized anxiety disorder, or in helping someone get through a period of serious psychological distress, we need all the help we can get. But what is the evidence?

  Reopening a Scientific “Cold Case”

  You have probably heard of a “cold case” before. There was even a popular television show called Cold Case that ran for seven seasons back in the 2000s. A cold case is a crime that has not yet been fully solved but is no longer the subject of an active criminal investigation.

  But if new information emerges from new witness testimony, reexamined archives, new material evidence, innovative techniques to examine retained material evidence, or fresh activities of a suspect, a cold case can be “reopened.” It’s a very real thing that occurs in law enforcement, and, consequently, it makes for great television.

  But it’s also a real thing in science.

  Sometimes study results are published in the scientific literature, but there are unsolved aspects of the problem that the researchers are studying. The data don’t totally make sense or pieces of the scientific puzzle just don’t fit together perfectly. Certain phenomena may not be fully explained by the data.

  These things can leave scientists scratching their heads, sometimes for years. Then a new scientific approach becomes available, or maybe the scientists just realize that they need to analyze the data in a different way, accounting for factors that they did not account for the first time around.

  When this becomes necessary, they go back into the cold case files—sometimes blowing the dust off of data archives that have been dormant for years and years. They reopen the investigation to take another look.

  That’s what happened with the Treatment of Depression Collaborative Research Program (TDCRP) study that was first commissioned by the National Institute of Mental Health (part of the NIH) way back in 1985.163 One of the aims of the research was to compare the effectiveness of different approaches to psychotherapy in treating patients with depression.

  But another aim of the research was to compare the effectiveness of psychotherapy to the effectiveness of a drug therapy already known to be effective: specifically imipramine hydrochloride, a drug that is still on the market today. Ultimately, the TDCRP researchers concluded that, compared to psychotherapy, the biggest effects on depression came from the drug.164

  But that conclusion did not sit well with a group of researchers from the University of Wisconsin-Madison (UW-Madison). Why? Because the original TDCRP researchers ignored the potential effect that individual psychiatrists can have on eventual patient outcomes. The research assumed (mistakenly, as postulated by the UW-Madison researchers) that all psychiatrists are equally effective at treating depression with psychotherapy.

  So, nearly twenty years later, the researchers got access to the original TDCRP data and reopened the cold case.165 They analyzed the same data, but in a different way. There were multiple different psychiatrists providing care to the patients in the TDCRP study. The UW-Madison researchers factored into the data who the psychiatrist was (i.e., the person of the psychiatrist himself or herself) while assessing the treatment outcomes of the patients.

  In doing this, they saw—for the first time—an unmistakable pattern in the data. The original TDCRP researchers missed it.

  Although the variation in depression scores for patients in the study was affected by the drug (imipramine hydrochloride), the variation in depression scores was explained even more by which psychiatrist the patients saw. The individual psychiatrist’s effects were actually greater than the drug’s effects!

  By reopening this cold case, the researchers learned that both individual psychiatrists and drugs contribute to outcomes in treating depression. And they concluded that effective psychiatrists can actually increase the effects of drug therapy.

  The person of the psychiatrist matters—in a major way.

  Here’s a quote from the conclusion section of the cold case study:

  “The most effective psychiatrists augment the neurochemical effects of the drug. Based on these findings, it can be concluded that the person of the psychiatrist makes a difference in the response to antidepressant medication. Therefore, the health care community would be wise to consider the psychiatrist not only as a provider of treatment, but also as a means of treatment.”165

  But what was it about the psychiatrist that made him or her more or less effective than other psychiatrists? Could it be…wait for it…their compassion?

  Compassion for Others Can Alleviate Depression

  The UW-Madison study was not the only scientific cold case investigation of the TDCRP data archives. There was another—this time by researchers from Yale University.166 It offers insights into what it was about individual psychiatrists that made them more or less effective in treating patients with depression.

  As part of all the research activity in the original TDCRP study, one thing that they measured was called a “relationship inventory” from the patients’ perspective. This is the piece of data that the Yale researchers went back and focused on.

  It was a survey that measured the patients’ assessment of therapists’ (1) compassionate understanding, (2) “congruence” (i.e., whether or not the therapist made an authentic connection with the patient), and (3) “unconditional positive regard” (i.e., genuine caring about the patient). Using the patient ratings on the relationship inventory, the Yale researchers found that a compassionate connection from the therapist was a major factor in depressed patients’ response to therapy! Makes sense, right?

  Here’s another interesting finding: A University of Pennsylvania study of 185 patients undergoing cognitive-behavioral therapy for depression tested the relationship between therapist compassion and recovery from depression.167 The researchers used a well-validated compassion scale (i.e., research survey) that allowed patients to rate how warm, caring, and compassionate their therapist was.

  They also used a well-validated scale for measuring the severity of depression symptoms. The researchers were very rigorous in the analytical approach—controlling for the initial severity of depression and even accounting for the fact that severe depressi
on could make a patient less likely to judge their therapist as compassionate—to ensure that neither of these things was a factor in the results.

  Therapist compassion had a moderate to large effect on reducing depression symptoms.

  What they found was a robust, statistically significant association between high therapist compassion and recovery from depression. Based on the magnitude of the associations observed, the researchers concluded that therapist compassion had a moderate to large effect on reducing depression symptoms.

  So this was the effect of the therapist themselves (and specifically the effect of the therapist’s compassion), not the cognitive-behavioral therapy techniques that were employed. This result is not about the treatment protocol, it was how the protocol was applied (i.e., with or without a compassionate, caring approach).

  But how? How does compassion impact depression?

  Scientists from Duke University have found that compassion can reduce feelings of hopelessness, combating demoralization.168 People who suffer from depression often perceive an inability to extricate themselves from the distressing condition, and compassionate care can help build positive expectancies for recovery.

  Accordingly, it has been said that compassion can help alleviate a patient’s “depression about depression.” In Chapter 5, you’ll learn more about how compassion can motivate patients to take better care of themselves, and depression is a prime example.