Compassionomics
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Compassionate care can raise patient self-efficacy, which is defined as a patient’s belief that their treatment will be successful and that they will, in fact, recover and achieve good health. We know from research in cancer patients that compassionate care builds patient self-efficacy, activation, and enablement (i.e., a patient’s active involvement and participation in his or her own treatment).169 Each of these things is associated with improvement in emotional distress related to having cancer.170
In cases where medications are used for treating depression, self-efficacy can even raise patients’ adherence to therapy. In a University of Colorado study supported by a grant from the National Institutes of Health (NIH), researchers studied patients newly diagnosed with depression who were prescribed antidepressant medication for the first time by a primary care provider.171
The aim of the research was to assess primary care providers’ communication and the effect of what they said on whether or not the depressed patients actually took their medicine. The researchers audio-recorded the primary care office visits, and a trained researcher coded the language of the provider (i.e., compassionate or not) using validated research techniques. The researchers also assessed adherence to antidepressant therapy by measuring the proportion of days the patients actually took the medicine over the next six months.
What they found was that, after accounting for potential confounding variables in the statistical analysis, compassionate language from the primary care clinician was independently associated with adherence to antidepressant therapy. Compassionate language was an independent predictor of whether or not the patient even went to the pharmacy to get the prescription filled in the first place!171
Compassion can also alleviate depression that comes as a result of debilitating physical health conditions. In a study that we looked at back in Chapter 3, compassion of the physician was associated with greater reduction in patients’ pain during physical rehabilitation.124 But they also measured depression symptoms in that study and found that compassion of the physician was also associated with significantly lower depression at the time of discharge from the rehabilitation program and persisting six months later.
Remember that physical therapy study from Chapter 3 that resulted from a Harvard and Stanford collaboration?129 It studied elderly patients requiring admission to the hospital. That was the study where “distancing” non-verbal communication by the physical therapist (e.g., physical distance, no eye contact or facial expressiveness) was associated with worse functional and cognitive outcomes for the elderly patients. Compassionate non-verbal communication (e.g., leaning in, closeness, eye contact, smiling) was associated with better functional and cognitive outcomes. Guess what? The researchers also measured depression. They found that therapists’ distancing behavior was also associated with the patients’ level of depression at hospital discharge. So, again, it’s not just what you say that matters.
And you do not have to be a physician or therapist to make a difference. Everyone on the care team has the opportunity to make an important positive impact on a patient with compassionate care.
In a study from the U.S. National Institute of Mental Health, researchers tested the association between the compassion of nursing home staff (specifically, nursing aides) and self-reported depression symptoms of elderly, cognitively intact nursing home residents.172
Being a resident in a nursing home can be very hard, not only physically but also emotionally and psychologically. Depression among nursing home residents is extremely common. Here’s what that study found: the compassion of the nursing aides mattered.
Compassion of the nursing aides was associated with lower depression in nursing home residents.
High compassion of the nursing aides was associated with lower depression in nursing home residents. That’s fascinating, indeed. But what was most interesting is that the results depended on the perspective of how compassion was measured.
The perspective of the nursing aides (i.e., how compassionate they thought they were) and the perspective of the nursing aide supervisors (i.e., how compassionate the supervisors thought their staff were) had no association with the nursing home residents’ depression. Only the nursing home residents’ perspective on the compassion of the nursing aides mattered.
In other words, the perspectives of the nursing aides and their supervisors did not line up with the perspectives of the nursing home residents, and only the perception of compassion from the person who received the compassion—the nursing home resident—was actually associated with relief of depression symptoms.
This has big implications on the use of compassion if the results are generalizable to other contexts. Providers may think they are providing compassionate care, but if patients do not agree (i.e., do not actually feel it), the impact on depression is not realized.
These findings underscore three important things. First, for people suffering with depression, compassion matters. Second, givers of compassion are sometimes not very good at appraising the quality of their own compassion for others. The receiver’s perspective is actually what matters.
And third, let’s remember that these were nursing aides who had the impact. When one thinks of a health care provider having a meaningful impact on patients, one typically thinks of a physician or a nurse. But here, the nursing aide wielded incredible power and had the capacity to make a meaningful difference for a patient.
The nursing aide was powerful. The power of compassion doesn’t come from the resumé of the person providing it, it comes from the person of the person providing it. The power is in the connection, not the credentials.
And this makes sense for the power of compassion: it doesn’t matter who holds the gun, it only matters if you get shot. Accordingly, anyone on the care team can make an impact by treating a patient with compassion.
In another study of nursing aides in nursing homes from the University of Utah, researchers found that compassionate care by nursing aides was effective in counteracting one of the most extreme manifestations of depression among elderly nursing home residents: learned helplessness.173
For people suffering from depression, compassion is definitely powerful. Anyone has the power to make a meaningful difference. Please don’t misunderstand the message here. People who have serious mental health conditions, including depression, should be under the care of an appropriately trained and credentialed professional. That’s a given. Compassion is not a substitute for quality care.
The message here is different. The message is that in addition to the care of those professionals in a formal role, the rest of us also have a tremendous opportunity to impact one’s psychological health. And the data backs that up.
Think of the most severe—the most lethal—manifestation of depression: suicide. Now think back to the story from Chapter 1 about the suicidal man walking to the bridge. In his suicide note, he said that if just one person, any person, would show him compassion with nothing more than a smile, he would not go through with it. He would not jump. Again, this was what it said in his suicide note:
“I’m going to walk to the bridge. If one person smiles at me on the way, I will not jump.”52
It didn’t have to be a licensed psychiatrist or other mental health professional that saved him with an act of compassion, it could have been anyone. When it comes to the suffering of depression, anyone (and everyone) has the power to change a life.
Compassion Can Alleviate Anxiety
“…and as I left his offıce, he said, ‘You know, you have a very bad disease, but we are going to take care of you.’ The doctor-patient relationship was incredibly therapeutic and reassuring. I had no qualms, no doubts with putting my life in his hands. I had full confidence in his expertise, his concern and emotional support.”
—Breast cancer survivor97
In Chapter 3, you learned how a giver of compassion can harness the autonomic nervous system of the receiver of compassion, activating a receiver’s parasympathetic nervous
system, and therefore inducing a calming effect.102, 103, 105 But those were experimental studies in healthy volunteers.
What is the evidence that compassion reduces anxiety in patients?
Researchers from Johns Hopkins University studied this phenomenon through a randomized controlled trial in 210 women, the majority of whom were breast cancer survivors.97 The study participants were given a consultation from an oncologist. Then the researchers used a validated scale of patient anxiety as their main outcome measure. (If you’ve ever had a cancer diagnosis—or known someone who has—you’ll understand why that’s a pretty important outcome measure.)
The researchers wanted to be extremely rigorous about the research, so they made sure that all the research participants were receiving the exact same intervention (i.e., a standardized consultation from an oncologist). They scripted an informational consultation session with an oncologist and videotaped the oncologist presenting the information.
The information the oncologist shared was about metastatic breast cancer and included a discussion of what it means to go on chemotherapy treatment: reviewing its risks and benefits, the probabilities of short- and long-term survival, and the probability of side effects. It was just the facts—all business. No emotional support component. No compassion. That is the video that the control group (i.e., “standard care” group) watched.
But then they scripted and videotaped a consultation session—with the same oncologist who shared the exact same information—that was also infused with compassionate language, interspersed before and after all the technical information. That’s the video that the intervention group (i.e., the “enhanced compassion” group) watched. The researchers measured the study subjects’ anxiety levels before and after the consultations and then compared the effects of standard care versus enhanced compassion.
The first finding from this study was that the women who participated had a huge amount of anxiety inside them, no matter how calm they may have appeared on the outside. In fact, 57 percent of study subjects enrolled in this research scored above the 75th percentile for anxiety (compared to the general population), and 18 percent of them scored in the 99th percentile. Understandable, of course, given what a patient with breast cancer goes through.
As expected, participants in the enhanced compassion group were more likely to believe that the oncologist cared deeply. But here is the more noteworthy finding: at the end of the videotaped consultation, the participants randomized to the enhanced compassion group were measurably and statistically significantly less anxious than those in the standard care group!
There are other fascinating findings from this study that we’ll share later, but for now it’s important to understand that compassionate statements from a health care provider can reduce patient anxiety in not only meaningful, but measurable ways. Numerous other studies consistently support this, including studies in physical medicine and rehabilitation, studies on breaking bad news to patients, and studies in primary care.124, 174, 175, 176
One study calculated the cumulative value of every single compassionate statement from the physician in terms of impact on patient anxiety.48 It was a NIH-sponsored study from the University of California San Francisco.
The patients in this study had been admitted to the hospital and were under the care of a hospitalist (i.e., a physician who specializes in hospital medicine). Using a validated scale to measure patient anxiety and a validated methodology for measuring the number of compassionate statements to patients by the physician, what they found was eye-opening.
First of all, the anxiety level for patients admitted to the hospital was very high, which is not at all unexpected. Regardless of how much anxiety they were exhibiting on the outside, they were definitely feeling it on the inside.
But second, and most importantly, the researchers found that for each compassionate statement from the hospitalist to patients, the patients’ level of anxiety decreased by 4.2 percent. So, for example, if a hospitalist made three compassionate statements to a hospitalized patient, the patient’s anxiety level (on average) decreased by 12.6 percent. Therefore, every statement of compassion can have a measurable, incremental effect.
The power of compassion is not a binary thing; the power of compassion is cumulative.
The research shows that the power of compassion is not a binary thing; the power of compassion is cumulative! More compassion equals more power.
Compassion Can Alleviate Distress and Improve Quality of Life
If you are a patient with cancer, not only can compassion reduce anxiety in measurable ways, as we saw in the Johns Hopkins randomized trial that was focused on breast cancer patients, but it can also alleviate patients’ psychological distress. Unfortunately, in some cancer patients who have a poor prognosis for survival, this may be the only outcome they can hope to improve.
In research studies, there are validated survey instruments to measure the amount of psychological distress that a patient is experiencing. In a study of 454 cancer patients receiving treatment in an outpatient oncology practice, researchers found that higher physician scores for compassion during the consultation (as rated by patients) were associated with lower patient emotional distress following the consultation.170
A 2012 systematic review of 39 studies in cancer patients found that high clinician compassion was associated with lower psychological distress, and one of the mechanisms for lower psychological distress was better psychological adjustment to a cancer diagnosis.177, 178, 179
Psychological adjustment (or adaptation) to cancer has been defined as an ongoing process in which the patient tries to manage emotional distress, solve specific cancer-related problems, and gain mastery or control over cancer-related life events. Adjustment to cancer is not a single event, but rather a series of ongoing coping responses to the multiple tasks associated with living with cancer.180
A compassionate physician-patient relationship is known to be an important factor in a patient’s adjustment to a cancer diagnosis, and subsequently this is associated with less psychological distress. 170, 177, 178, 179, 181 This improved psychological adjustment can also result in improved emotional quality of life.181
Another study in cancer patients found that out of all aspects of the doctor-patient relationship, the patients’ quality of life was most clearly predicted by the “affective” (i.e., emotional) quality of the relationship with the physician.182 A German study of 710 cancer patients also found the same thing; physician compassion (as rated by the patients) was associated with less depression and improved psychological quality of life for patients with cancer.169
The effect of caregiver compassion on quality of life in cancer patients perhaps should not be surprising, in light of the decades of available data on the effects of patient support groups (i.e., supportive-expressive therapy that takes place in a group). Researchers from Stanford University who have published extensively on this topic have found that support groups result in improved mood and better coping, which are two of the major factors that make up psychological well-being and improved quality of life.183 If compassionate relationships with peers in patient support groups make a difference for cancer patients, it is logical that compassionate relationships with health care providers over time could make a difference too.
But these patterns in the data are not just limited to patients with cancer. Compassionate communication by clinicians has been associated with lower emotional distress in patients in primary care as well.184, 185
For example, in a randomized trial from Johns Hopkins University that was conducted in 69 primary care physicians and 648 of their patients, researchers randomized physicians to an education program of “emotion handling” communication skills versus no education (control). They found that patients of physicians randomized to enhanced emotion handling had significantly lower emotional distress that was sustained out to six months.185
In a U.K. study of patients with low socioeconomic status in a primary care clinic, t
he researchers found that primary care physician compassion (as rated by patients) was associated with improved patient well-being up to one month following the visit.186 There are very few medications and treatments that remain effective for so long after just one dose!
What about Post-Traumatic Stress Disorder (PTSD)?
Here’s a thought: could compassion also be an effective way of preventing post-traumatic stress disorder (PTSD)? While this idea has not yet been proven, it is currently being investigated in promising new research.
PTSD is a relatively common psychiatric disorder characterized by distressing re-experiencing symptoms, effortful avoidance of trauma reminders, and physiological hyperarousal diagnosed in individuals who have been exposed to a traumatic event. It takes an enormous toll on sufferers. It is not only associated with reduced quality of life but also the development of additional serious health conditions over time.187
Furthermore, it is associated with greater health care costs and an inability to return to work. Accordingly, the World Health Organization has raised awareness of the clinical, social, and economic toll of PTSD and has called for innovative approaches to prevent it. In short, PTSD is a serious public health problem.
Historically, PTSD was described in soldiers exposed to the trauma of combat. They would come back from war with deep psychological wounds that would manifest with a myriad of symptoms including behavioral changes (e.g., agitation, irritability, hostility, hypervigilance, self-destructive behavior, or social isolation), psychological changes (e.g., flashbacks, fear, or severe anxiety), mood changes (e.g., loss of interest or pleasure in activities, depression, or loneliness), sleep disturbances, unwanted thoughts, or emotional detachment.