They do not underestimate the beneficial effects of medications. Nevertheless, just as Viagra cannot ameliorate erectile dysfunction in the absence of desire, so antipsychotic medications often cannot ameliorate emotional and social dysfunction in the absence of a caring relationship.
And just as surely, the loss of a caring relationship can attenuate the positive effects of medication. A few years ago, for example, Robert was put on clozapine, a newer medication that has proven uniquely effective for many individuals who suffer from long-term mental illness. Within a short while, he had improved so greatly—“miraculously,” his doctors said—that he was, after four consecutive years of hospitalization, being prepared for discharge.
At this point, his social worker, whom he had known for many years, both at his present hospital and at a hospital where he lived previously, was, without warning, transferred to another location. Within a day, Robert, who had become increasingly lucid, realistic, and happy, became angry, confused, and volatile. He deteriorated rapidly into a wild state of rage, confusion, and irritability in which he once again, alas, became a danger to himself and others.
The salient question here—why did the medications that worked so well one day cease to be effective the next day?—would seem to be rhetorical.
For how different, in this, is Robert from the rest of us? What happens to any of us, especially in crisis, when those we believe we can depend upon suddenly disappear from our lives? For most of us, the presence—or absence—of such connections, as in my brother’s life, has tangible issue. We know, from numerous studies, that, following heart attacks, people who are isolated, living alone, or unmarried and lacking a confidant are at significantly increased risk for death.* We also know, to cite a familiar instance, that widows and widowers have higher mortality rates than married persons—that their death rates, when living without companions, are higher than would otherwise be expected on the basis of age.
We would seem, then, especially in difficult times, to need connections to others as dearly as we need food, air, sleep, and water. Writing this chapter during the last week of September 2001, I think of those men and women, trapped in the World Trade Center, who hold hands while they jump to their deaths. The act of joining hand in hand with another human being so as not to die alone would seem a sad instance of this human need.
“Our free will has no product more properly its own than affection and friendship,” Montaigne writes in his essay “Of Friendship.”
“It is not in the power of all the arguments in the world to dislodge me from the certainty I have of the intentions and judgments of my friend,” he states, and continues, a few lines later: “I should certainly have trusted myself to him more readily than to myself.”
At the heart of such a friendship—friendship of a kind Montaigne distinguishes from other, lesser forms of friendship that family bonds, laws, customs, erotic love, and various social and civil obligations impose upon us—is trust.
So: just as sorely as my brother’s trust was taken from him by the transfer of that person upon whom he depended more readily than to himself, so was my trust strengthened when I was fortunate enough to have doctors recommended by my friends, and in whom I could trust—for specific needs, at a critical time—in the way I have trusted in my friends, “more readily than to myself,” for many matters, large and small, through the years.
“When I give talks on clinical care for treating HIV/AIDS,” Jerry says, “I call trust ‘The Big T’—that hard-to-define but very special and most precious two-way commodity that makes it all work.”
And when, thinking of my friends, I try to understand why and how each of these friendships has become what it is, I answer, with Montaigne, that “I feel this cannot be expressed except by answering: Because it was he, because it was I.”* On the nature of this “more equitable and more equable kind of friendship,” Montaigne quotes Cicero: “Only those are to be judged friendships in which the characters have been strengthened and matured by age.”
What we want, and require, in the practice of medicine, then, has much in common with what we want, and value, in friendship: knowledge of who we are, both in our similarities to others and in our differences; constancy and loyalty over the course of time; and accessibility and reliability in times of need. When we are ill or diseased, or when we are suffering or in need, we want our doctors to be those in whom we can trust more readily than we do ourselves.
When, two weeks after the World Trade Center tragedy, Arthur suggests to a friend that he speak with me about a book he has written, Arthur’s friend, a man in his mid-thirties, says that Arthur spoke of me warmly. “He said the two of you are like brothers,” the young man tells me.
From ancient times (as in David and Jonathan) to the present (as in the film about World War II, Band of Brothers), when we want to express the strength and importance of a friendship, we often speak of friends as being like brothers.
We expect from such friends, that is, not only the loyalty that results from obligation, but a depth of feeling—of passion— we ordinarily associate with family life. In part because friendships are created and sustained freely, we may elevate them above familial relationships and come to feel, with Montaigne, that some friends, like some brothers, are very nearly interchangeable with us. “In the friendship I speak of,” Montaigne writes, “our souls mingle and blend with each other so completely that they efface the seam that joined them, and cannot find it again. If you press me to tell why I loved [my friend], I feel that this cannot be expressed except by answering: Because it was he, because it was I.”
While what we want from our friends and from our doctors has much in common, there is this difference: we would have our doctors bring to our lives medical skills and knowledge of a kind we ourselves do not possess, and that they can utilize dis-passionately. We want, that is, to be able to rely upon them, as with friends, for their constancy and their caring, but also for their competence and their judgment. And it is the joining of such qualities in them—constancy, caring, competence, and judgment—that engenders trust in us.
Again and again my friends emphasize the importance of trust in their relationships with their patients. It is trust in Jerry that enables patients to adhere to the difficult regimens of antiretroviral therapies; it is trust in Arthur that allows his patients to talk about feelings, thoughts, and experiences that lie at the root of their difficulties, dysfunction, and pain; it is trust that allows Rich’s and Phil’s patients to talk with them in ways that elicit symptoms, events, and underlying conditions that maximize chances for helpful diagnoses and treatments.
“Most of the people with AIDS whom I’ve seen have been intravenous drug users,” Jerry says, “and they have a reputation for being difficult, frustrating patients. They’re engaged in illegal stuff, they’re secretive, and they rarely have an established, ongoing relationship with a health-care provider, so they tend to elicit disapproval, and worse, from health-care workers. In turn, they become distrustful and expect judgmental treatment.
“But I’ve found that when you treat them with attention to their medical needs in a straightforward, clinical manner, most intravenous drug users can be disarmingly open about their lifestyle, and no more or less difficult than other patients. The essential point, as I see it, is that each person, intravenous drug user or otherwise, is unique, and does not comfortably conform to any stereotype.”
Moreover, trust itself—Jerry’s “Big T”—allows many conditions, physical and emotional, to resolve themselves more readily than they otherwise would for the very real reason that a doctor’s knowledge of who each of us is in our particularity enables the doctor to judge more exactly the ways specific diseases and conditions may be acting in any one of us—and because, as the history of the placebo effect, and of healing, reveals, such trust in the physician frequently aids and hastens healing processes.
We know that mental and emotional states brought on by trauma can affect us physically—witness the
paralyses and muscular contractures of arms, legs, hands, and feet; loss of sight, speech, and hearing; palsies and tics, choreas, amnesia, catatonias, and obsessive behaviors that resulted from shell shock in World War I.*
We also know that patients who adhere to treatment, even when the treatment is a placebo—and adherence to treatment, as Jerry’s studies, and others, have shown, is preeminently a function of trust in the doctor—have better outcomes than patients who adhere poorly. We know, too, that placebos are effective in reducing pain and depression. When medications known to be effective against pain are paired with a variety of neutral environmental stimuli, the environmental stimuli (a pill’s shape and color, for example) acquire analgesic potency equal to, or surpassing, that of the medications. In one survey of (sham) surgery for lumbar disc disease, for example, although no disc herniation was present in 346 patients (“negative surgical exploration”), complete relief of sciatica occurred in 37 percent of patients, and complete relief from back pain in 43 percent.*
In the relief of depression, placebo effectiveness, in a large number of studies, ranges from 30 to 50 percent, and, when compared with effective drugs, placebos are 59 percent as effective as tricyclic depressants, 62 percent as effective as lithium, 58 percent as effective as nonpharmacologic treatment of insomnia, and 54 to 56 percent as effective as injected morphine and common analgesics.*
In a 1999 study (“Listening to Prozac but Hearing Placebo: A Meta-Analysis of Antidepressant Medications”), researchers conclude that “75% of the response to the medications examined in these studies may have been a placebo response, and, at most, 25% might be a true drug effect.”* The authors explain: “This does not mean that only 25% of patients are likely to respond to the pharmacological properties of the drug. Rather, it means that for a typical patient, 75% of the benefit obtained from the active drug would also have been obtained from an inactive placebo.”
And with regard to heart attacks, studies show that emotional conditions affect survival at least as strongly as more purely medical factors—that, for example, “the presence of major depression after acute myocardial infarction increases six-month mortality more than and independent of such clinical factors as heart failure and extent of coronary disease.”* In another study, in which patients took drugs to lower their lipid levels after heart attacks, while only 15 percent of patients who took most of their prescribed medications died during the next five years, 25 percent of those who adhered less well died during the same period, and it made no difference whether the patients took active drugs or placebos.*
And just as the loss of a loved one, or the end of a relationship with someone we have loved, can bring about depression and other distressing conditions of mind and body, so falling in love and being in love can enhance our well-being. Not only do we feel better because we are happier—appreciated, known, loved—but this state of being can help relieve preexisting conditions of mind and body (depression, impotence, headaches, gastrointenstinal disorders), and, appearances not being deceiving at such times, may often lead friends to tell us we look better too.
On the cover of the January 9, 2000, issue of the New York Times Magazine, above a headline in large, bold type (“Astonishing Medical Fact: Placebos Work!”), are four pictures, each labeled—a pill (“Antidepressant”), the top of a man’s head (“Fetal-Cell Implantation”), a knee (“Arthroscopy”), and a black-capped bottle (“Cold Remedy”)—and across each picture, stamped in red ink: FAKE.* In the accompanying article, the author, Margaret Talbot, concludes “that the placebo effect is huge—anywhere between 35 and 75 percent of patients benefit from taking a dummy pill in studies of new drugs.”
Talbot surveys a substantial body of research that demonstrates the effectiveness of placebos used in place of medications and surgery (dummy pills for depression, make-believe surgery for knees, and so on). She also reports on studies that “show actual physiological change as a result of sham treatments.” In eleven different trials, for example, not only did 52 percent of patients suffering from colitis (inflammation of the large bowel), when treated with placebos, report feeling better, but “50 percent of the inflamed intestines actually looked better when assessed with a sigmoidoscope.”
Placebo effects have been explained in many ways—they may work because of conditioning (as in Pavlov’s experiments); or because of the release of endorphins that stimulate the brain’s own analgesics; or because of the diminution of stress. But what all explanations have in common, Talbot writes, “is the element of expectation, the promise of help on the way that can only be imparted by another human being.”
What is clear, too, is that without the doctor who prescribes it, the placebo is powerless.
“It may seem strange to say this of a profession regularly accused of vanity and self-importance,” Dr. Leston Havens, professor of psychiatry at Harvard Medical School, writes, but the fact is “that many professional people allow themselves to come and go among patients as if their knowledge and skills were all that counted, their persons not at all.* One sees this most vividly with medical students, who cannot believe in their importance to the people they take care of. Yet we are the great placebos of our pharmacopoeia, and the power of the placebo can be measured by the results of its withdrawal.”
In talking with my friends about placebos, they make a helpful distinction between illness and disease.* For most doctors, they explain, disease is what the doctor sees and finds, whereas illness is what the patient feels and suffers. Given that what most doctors see most of the time is illness, the distinction is not insignificant. Although the two terms are, in general, used synonymously, disease can occur in the absence of illness (as in a person with hypertension—or heart disease!—who is asymptomatic), and illness can occur in the absence of disease (all those debilitating conditions of mind and body—stomach disorders, headaches, back pain, hives—that have no discernible physiological causes).
Because we have, since the end of the nineteenth century, been able to successfully treat many previously intractable diseases, we sometimes lose sight of the fact that, as Arthur Shapiro puts it, “the history of medical treatment until relatively recently is essentially the history of the placebo effect.”
Some researchers contend that the placebo effect is a myth, and many, like Shapiro, are keenly aware of “faddish exaggerations about the extent of placebo power.”* Still others, like Dr. Howard Spiro, professor of medicine at Yale, while finding “no evidence that placebos helped disease or that they changed the objective, visible, measurable aspects that we doctors regard as important,” believe that placebos do “help patients with the pain and suffering that the disease brings.”
Yet clinicians, Spiro writes, “have a hard time accepting the idea that mental events may affect physical events, that faith can ‘heal.’ That is why placebos embarrass modern doctors, for they call attention to the persistent dualism of medicine and our so recent climb out of the prescientific swamp.”
Although Spiro accepts the existence of the placebo phenomenon, he insists on the “difference between treating cancer with placebos and treating the pain that comes from cancer with them.” Nonetheless, he cautions physicians to “be humble before our ignorance of how one person can relieve the suffering of another,” and “to remember that the placebo is only a symbol of all that we do that we cannot measure.”
How measure, then, the degree to which my own attitudes and responses, before and after surgery (my persistence in pursuing the cause of symptoms, my skepticism about preliminary diagnoses, my swift recovery, the absence of common complications such as infection, memory loss, and depression), were made possible and enhanced because of the trust I placed in my friends, and in the doctors they trusted?
10
In Friends We Trust
IN REVIEWING THE HISTORY of healing practices that have been used from ancient times to our own—in China, Babylon, Egypt, and India, and in the Western world for more than two millennia—Arthur Shapiro reports
that “the astonishing total of these remedies is about 4785 drugs and 16,842 prescriptions.* Even more startling is that with only a few possible but unlikely speculative exceptions, all were placebos.”
He quotes Galen—a Greek philosopher of the second century A.D. and physician to the Roman emperor Marcus Aurelius—whose pharmacopoeia dominated treatment in the Western world for 1,500 years, and disappeared fully only near the end of the nineteenth century, as saying that “he cures most successfully in whom the people have the most confidence.” (This from a physician not lacking in self-esteem: “Never as yet have I gone astray,” Galen proclaimed, “whether in treatment or in prognosis, as have so many other physicians of great reputation.”)
In Care of the Psyche, a history of healing practices through the centuries, Stanley Jackson describes measures that people in ancient Greece and Rome developed to aid them when they found themselves helpless in the face of disease and illness—in particular, their reliance upon magicians, sorcerers, priests, and physicians. “The healer’s experience and reputation,” he writes, “his status in the particular culture, his knowledge of the proper ritual, his use of the proper words with the proper tone and in the proper manner, and his belief in the efficacy of his words and actions all came together to calm and reassure sufferers, to soothe and comfort them, and to mitigate any sense of helplessness or hopelessness. Sufferers in need, and their willingness to believe and cooperate, completed the potentially healing situation.”
While delineating the ways a healer was urged to be considerate and compassionate so as to maintain the patient’s morale and thereby increase the patient’s confidence in the physician and his treatments, Jackson, professor emeritus of psychiatry and the history of medicine at Yale, also remarks on something that reminds me of the place my friends hold in my life: “these issues were apparently addressed as aspects of being a good person and an effective physician rather than as an aspect of psychological therapeutics.”*
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