How Healing Works

by Wayne Jonas

  Two weeks later, the patients were asked by someone new (not the doctor) if they were better and if they needed more treatment. The results showed that 64% of patients who got a positive consultation were better, compared to only 39% of those who got the negative consultation. About 50% in either the placebo or nontreated groups reported being better. In other words, the coincidental healing rate (the “regression to the mean”) was about 50%. But a simple shift in the belief and expectations of patients induced by the language and attitude of the doctor could either increase that healing rate by 28% or decrease it by 22%—a total difference of another 50% from the baseline healing rate. The difference in healing rates between those who got a pill and those who did not was only 6%. The shared mind space between doctor and patient significantly enhanced or interfered with the patient’s own healing processes—even from a single encounter.

  This dance between minds making meaning does not require the doctor to say anything or that it even be consciously perceived by the patient. The late NIH researcher Dr. David D. Price, whose work on placebo I described in chapter 4 (see this page), demonstrated in several studies that a doctor’s belief influences a treatment’s effectiveness—even when the patient does not know of that belief. Oral surgeons who had extracted third molars (wisdom teeth) were told that after the extraction their patients would get either a pain killer, a placebo, or naloxone. Naloxone, a drug used to combat narcotic overdose, could increase their pain. The patients were told nothing, but later asked to rate their pain and need for medications. Patients whose surgeons thought their patients had received an effective painkiller reported less pain and had less need for medications, compared to those patients whose surgeons thought their patients had not received an effective pain treatment—either placebo or naloxone. In fact, all patients got placebo. Without any verbal exchanges, patients seemed to read the surgeon’s expectations. People surpass rats or rabbits in reading subtle signals and infusing meaning into those signals—even when they don’t know they have done so.

  This and similar research makes me wonder if it is truly possible to withhold or hide information from a patient or if they read the situation and react on some level no matter what the doctor attempts to do. Indeed, the dance of the mind behaves more like the ebb and flow of energy and information between people and things. Even if we cannot measure it directly, its impact on healing is profound.

  NOCEBO

  For the most part, patients and physicians are largely oblivious to the healing and the harm that arise from the mind and spiritual dimension. Like the other dimensions of healing, our health care system seems to mostly miss this. We attribute improvements to the specific treatments given rather than to the context and meaning created during the delivery of those treatments. But we do this at our peril. By not acknowledging the more nonlocal view of the human mind described by Dr. Siegel and others, our health care system not only misses a key dimension for healing, but it may be harming us as well. This is seen most clearly in what is called the “nocebo” effect—the negative impact of ritual and belief on health and healing.

  For every ritual, belief, conditioning, or social learning process that improves healing, there is the potential for those same processes to harm. In the 1987 study by Dr. Thomas described earlier, patients’ recovery rate was cut almost in half by a single negative encounter with their physician. Dr. Price showed how physicians’ subtle nonverbal expectations could increase pain. Professor Fabrizio Benedetti, whose research on placebo I described in chapter 2 (see this page), demonstrated that the pain-relieving effects of our most powerful drugs—such as morphine—can be almost completely negated by delivering the drug with a negative expectation. Morphine works for acute pain, but the ritual and belief surrounding morphine works—or interferes—to an almost equal extent. The endogenous painkillers produced by our mind are just as powerful. Like most physicians trained in the 1980s, I was taught to let the patient know if what I was about to do to them was going to hurt. Before drawing blood, giving a shot, or doing a biopsy, for example, I told them, “This may hurt a little.” Then, after the stick, I would try and calm them by saying, “It will get better now” or sometimes, “Now that wasn’t so bad, was it?” This happened (and still happens) thousands of times a day in health care. It turns out that by saying this, I was increasing my patient’s experience of pain. To add insult to injury, if I tried to reassure them afterward and they were still feeling pain, this made things worse still because my attempt at reassurance was also communicating to them that they should be over it. Now I say nothing to my patients about pain before a procedure. I only describe what I will be doing and then create a mental distraction or have them use a visualization tape or music during the procedure. They can make up their own mind from my description if it will hurt them or not.

  The nocebo effect impacts more than pain. And it is also not just transmitted though the clinical encounter. It can be embedded in our cultural beliefs and social communications. Studies by Professor Winfried Rief and colleagues from the University of Marburg, Germany, demonstrate that clinical trials consistently show higher side effects in those receiving placebo when the active drug being tested has higher side effects. These adverse effects are not just from the subjects’ baseline symptoms, which they attribute to the drug—although that does happen; the adverse effects produced by giving the placebo actually mimic those of the specific drug being studied. For example, placebo-treated groups in studies of different antidepressants with different side effects will report from two to five times the rate of adverse effects specific to the drug being studied—tricyclic placebos produce tricyclic drug–like side effects, and serotonin-like side effects occur in the placebo groups of the serotonin drug studies. This is often attributed to study subjects being told the potential side effects of a drug before entering a study—part of the process of informed consent. Like Dr. Thomas’s patients, these study subjects learn that they might experience specific negative effects—and they do. Unlike Dr. Thomas’s patients, however, these side effects continue over the course of the study—often for one to two months—without further communication about the drug. A single encounter with a study coordinator obtaining their informed consent is sufficient to induce negative effects.

  The collective mind can influence not only health outcomes, but death outcomes as well. A large study by Dr. David Phillips of the University of California, San Diego, published in the prestigious medical journal Lancet, poignantly demonstrates the cultural impact of the meaning response. The study examined the deaths of 28,169 adult Chinese-Americans, and 412,632 randomly selected, matched controls coded “white” on the death certificate. Dr. Phillips showed that: “Chinese-Americans, but not whites, die significantly earlier than normal (1.3–4.9 years) if they have a combination of disease and birth year, which Chinese astrology and [traditional Chinese] medicine consider ill-fated. The more strongly a group is attached to Chinese traditions, the more years of life are lost.” He goes on to say, “Our results hold for nearly all major causes of death studied. The reduction in survival cannot be completely explained by a change in the behavior of the Chinese patient, doctor, or death-registrar, but seems to result at least partly from psychosomatic processes.” That is, the collective mind.

  Chinese astrology assigns one of five elements—fire, earth, metal, water, and wood—to each year (as well as one of the better-known twelve animals), and people born in a metal year, who are expected by the culture to have more lung diseases than people born in other years, actually do have more lung problems—and die earlier than others from lung problems. The same thing is true for lymph problems or immune system problems if people are born in an earth year—thought to be bad luck for the immune system. Major differences in the age at death from lymphatic cancer occurred between those born in earth years and those born in other years. These effects were over and above the impact of other factors, such as smoking, lifestyle, and environmental exposures. Unlike pain, the “side e
ffect” of age at death is a rather hard, objective outcome. The effect was sociocultural—an effect from the collective mind of the culture. The more distant people were generationally from the original Chinese culture, the less this finding held, so that for third-generation Chinese-American people there was no correlation whatsoever—just like non-Chinese Americans.

  We do not have to believe in astrology for this to happen; we have only to grow up with a concept that our culture accepts. Stress is often cited as bad for you in Western cultures—thanks to Hans Selye and other scientists of the last century. However, it is also often framed as good for you, as in the phrase “no pain, no gain” used by Joe and his fellow Marines. While both attitudes can harm, people who believe that stress is bad are 43% more likely to die earlier than those who interpret stress as good. Mindset influences mortality.

  When Aadi first came to the Ayurvedic hospital to treat his Parkinson’s disease, he did not believe in the use of astrology to help him heal. In fact, he had never believed in it, and he told Dr. Manu so each time he came. I think he used the word “poppycock” to describe it. Yet Dr. Manu insisted he get an astrology reading each time anyway.

  “He may not personally believe in astrology himself,” Manu explained, “but he was raised and lives in a culture that does. He cannot escape its effects, even if they are only psychologically driven. So he might as well try and use information from it to find meaning for his life.”

  I am not sure whether Aadi ever used that information consciously, but his wife and others in his family commented on how those readings seemed to make sense and described Aadi’s life accurately. They, if not he, found them meaningful.

  Humans seem to be hardwired to seek out some type of transpersonal or spiritual meaning from illness. This has happened for centuries. When patients arrived at Epidaurus, the ancient Greek center of Hippocrates’ medical school, they first consulted with an oracle, who read their spiritual lives to contextualize their illnesses with a deeper meaning before they went on to other treatments. Most indigenous cultures infuse spiritual interpretations and rituals into their diagnoses and treatments. Some of these are clearly harmful—like when a “demon extraction” is substituted for medical treatment in an epileptic. Some can be helpful—like when prayers soothe the anxiety of a patient newly diagnosed with cancer. As with drugs, herbs, lifestyle, and social relationships, our mind-set and spiritual beliefs are simply another tool to use for healing or harm. Short of being hit by a truck or a tornado or an Ebola virus, disease, suffering, and death do not have simple cause-and-effect connections. If we are going to maximize healing from our treatments, we must pay attention to the complex layers of history and traditions, cultural and family influences, and individual beliefs that make meaning in our lives. We need to attend to our collective mind. Until we incorporate an awareness of these forces into health care, they will continue to help or harm us at random, and we will not be able to tap into our full healing potential.

  But how can we do that?

  PSYKHE

  I explore specific mental and spiritual elements of healing with my patients. While there is scientific evidence for the value of each of these elements, the purpose of my exploring these with patients is not to tell them what to believe, but to help them learn how to use their mind and faith to find deeper meaning in their lives. Once we see which elements resonate with them, I look for scientifically validated ways they can enhance those elements’ healing power in their lives. This may be a specific mind-body practice, like Jake’s visualization, or it may involve helping them link healing behaviors to their spiritual life. I always seek to respect them as they are—with all their wounds and flaws—on a journey to more wholeness and healing.

  In ancient times there was no distinction made between what today we call the mind and soul. The Greek word psykhe, the root of psyche and psychology, also means “soul, mind, spirit, or the deepest experience people have of themselves.” This experience is often “transpersonal” and “transtemporal”—seeming to go beyond the normal boundaries of space and time. This is the dimension of the spirit. While psychologists, clergy, and academics often debate the differences in these terms, I find that when it comes to healing, people use them interchangeably. Those who are atheistic or humanistic will use the terms mind or psyche, while those with a spiritual or religious preference will add the term soul or spirit. Whatever they are called, these components provide valuable tools within the inner dimensions of our being for healing. Both disciplines—psychology and religion—tend to be neglected by modern medicine. Thus the role of mind and spirit for healing remains poorly used.

  Yet there is substantial evidence that people who engage in spiritual and religious practices stay healthy longer, recover faster, and die with a better quality of life than people who do not. This is, of course, provided those beliefs do not dictate specifically harmful behaviors—such as mutilation, neglect, or violence—or create excessive spiritual (and psychological) distress from guilt, doubt, and dogma. Dr. Harold Koenig, professor of psychiatry at Duke University, has studied, reviewed, and written about the health effects of spiritual and religious practices for decades. In his Handbook of Religion and Health, he reviews research showing positive health benefits from participating in faith traditions or spiritual practices. He and others report that the evidence of benefit is particularly strong for mental health conditions such as depression, substance abuse, suicide, dementia, and stress-related disorders. There are also many positive physical health correlations with spiritual and religious practices. Most of the reasons for this make sense. Those who engage in spiritual and religious practices tend to avoid harmful substances (alcohol, tobacco, drugs), engage in social service and support activities, and pray—often in a meditative state—which induces relaxation or catharsis. In addition, some religious beliefs provide soothing explanations for suffering and death accompanied by rituals of forgiveness and reconciliation—further comforting the suffering.

  Spiritual-like discussions at the end of life are especially important when we all—regardless of whether we have a faith tradition—seek comfort as we die. Research shows that spiritual rituals and chaplain interactions for those who desire it toward the end of life increase quality of life and satisfaction. As with any medical intervention, negative effects can also occur. Harm is caused by poorly or negatively delivered religious and spiritual beliefs and behaviors, such as blaming the believer for their illness if they remain sick. I have had deeply religious patients admit to me they feel guilty that they have not “prayed deeply enough” if they do not recover. Some religious traditions state that explicitly. Harm also occurs if a religious community on which a person has had lifelong reliance fails to visit and care for the person during serious illness or hospitalization—breaching an unwritten social and moral contract. Whether or not you are religious, if you and your health care professional do not include the mind and spiritual dimension in your conversations—especially toward the end of life—you risk missing out on its use for healing.

  THE WOUNDED HEALER

  One of the most important effects of a serious illness is its impact not only on the body, but also on the soul (or spirit, or whatever you call your nonphysical inner being). Bodies often heal; souls may not. Sometimes there is a point in an illness when you are not sure if you will ever get better—or if you even want to. It is as if you have lost your will to live. There’s no modern medical disease category when a trauma or a stress penetrates your soul. But you feel it nonetheless. You can feel it in some people who suffer from PTSD produced by war, when it is not possible to elicit even a glimmer of hope. You can feel it in the chronic embodied stress of those who have had adverse childhood experiences—when they do not even have a memory of personal power. And you can feel it in the existential threat of a serious disease and its therapy—when a patient asks, “Who am I now?” Soul loss is named in some cultures, especially in Native American and indigenous cultures. They recognize it as
a distinct disability separate from any psychological or physical condition. Finding a way back out of such a state is central to recovering one’s well-being. Navigating out through that labyrinth is part of the healing journey.

  Susan’s first cancer changed her view of herself forever. Like many of her colleagues, she had taken a professional life path up to that point—with family in tow. But having cancer at such a young age, along with the triple whammy of surgery, chemotherapy, and radiation, “knocked me out of the path of a normal thirty-five-year-old lawyer,” she said. “Even though my body would recover, my spirit had to change. I could never be with my peers or myself in the same way again—pursuing both family and professional careers. After the cure, when they said they got it all, my questions went from ‘Why did I get this’ to ‘Why me?’ I realized that I didn’t really want to be a lawyer anymore. But then what was I here for, I wondered? Why had I been born?”

  For Susan, the illness brought to the forefront what is arguably the most important question in anyone’s life: why am I here? Medicine offers chemistry and biology as the answer. People need more than that. They need something more meaningful, something drawn out of the deeper dimensions of who we are—social, emotional, mental, and spiritual. And for most of us, healing requires that we try to answer that question by exploring the mind and spiritual dimensions of our soul.

  So here is the irony of healing and what makes it different than curing: the very wound from which we suffer induces the process of healing. To acknowledge and enter that wounding opens the path to wholeness. The priest, writer, and spiritual teacher Henry Nouwen called this “the wounded healer,” whereby a person, by accepting and then embracing the fact that he is flawed and wounded, can find a deep peace and joy. He called this the experience of “being beloved”—fully valuing oneself and one’s life just as they are. It is an “exceptional spiritual experience” of a different kind. This experience of deep peace and joy can come in a spiritual version, as found by Jake and Joe, or through a different pathway. Aadi found it through Ayurveda, Sergeant Martin through his friends with PTSD, Clara in nature, Mabel with her family, Jeff in running, and Gloria through teaching cooking classes. Each path is unique, yet all lead to the same place of healing and wholeness.